Complaint #: NJ183456 Based on observation, interview, and record review, it was determined that the facility failed to accommodate resident preferences with specific food items that were documented on the resident's meal tickets. This deficient practice was identified for 4 out of 6 sampled residents, Resident #1, #2, #4, and #5 and was evidenced by the following: According to the admission Record (an admission summary), Resident #2 was admitted with diagnoses that included but were not limited to Hypertension (high blood pressure) and Abnormalities of Gait and Mobility (changes in walk pattern). According to the Minimum Data Set (MDS), an assessment tool dated 2/4/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. The Order Summary Report (OSR), received on 2/26/25, revealed Resident #2 was on a NAS (No Added Salt) thin consistency, Regular texture, Lactose intolerance with a start date on 2/12/25. Review of the Care Plan (CP) for Resident #2, initiated on 1/29/25, revealed a focus that Resident #2 was at risk for malnutrition related to (r/t) recent acute illness, variable intake. The Goal included maintain adequate nutritional status as evidenced by maintaining weight within 180-190 pounds (#) . Interventions included but was not limited to provide, serve diet as ordered. During the interview with the surveyor on 2/26/25 at 10:37 a.m., Resident #2 stated, No, I am not getting my food preference . During an interview with the surveyor on 2/26/25 at 11:29 a.m., Resident #1 stated, Most of the time I ordered something, I do not get it. I usually request coffee for breakfast, and I would check for creamer and sugar, and sometimes I do not get it. I usually requested tea for lunch and dinner, and sometimes I do not get it. Residents have been complaining about the food in the Resident Council Meetings. During an interview with the surveyor on 2/26/25 at 12:29 p.m., the Dietician revealed that she was made aware that Resident #2 had complaints about incorrect and missing items on her tray. The Dietician stated that she observed Resident #2's lunch tray delivered and she confirmed that Resident #2 did not receive what was ordered. The Dietician stated that she sent an email to the Diet Aide, Food Service Director (FSD), Unit Manager (UM #1), and Social Worker (SW). During an interview with the Surveyor on 2/26/25 at 12:54 p.m., the Food Service Director (FSD) stated that he was made aware via telephone from Resident #2 that he/she did not receive eight sugar packets as requested. The FSD stated that he personally brought the additional sugars to Resident #2. FSD stated that when he delivered the extra sugars, he looked on Resident #2's menu slip and acknowledged that he/she did request eight sugars and only received six sugars. When surveyor asked what he did, the FSD stated that he went back to the kitchen and made all the staff aware to check the menu slips. When surveyor asked if he documented the education of all staff, he stated, I need to work on that. FSD stated that he should have documented it for paper trail. FSD stated that he did not remember the date it happened. During interview with the surveyor on 2/26/25 at 1:45 p.m., the Licensed Nursing Home Administrator (LNHA) stated that she was aware that Resident #2's tray was delivered to his/her previous room. The LNHA further stated that it should not have been delivered to Resident #2's previous unit, it should have been delivered at his/her current unit. During meal tray observation on 2/27/25 at 9:07 a.m., Resident #5's meal ticket indicated that the resident should have received two juices, but the resident received one juice with his/her breakfast tray. Resident #5 stated, I ordered two juices, and I got one. I get the Select Menus. Everyday there was always something I am not getting. Resident #5 stated that he/she told the Certified Nursing Assistant (CNA) about the juice. The surveyor interviewed the CNA, and she stated that she told Resident #5 that she would see what she could do when breakfast was over. The CNA stated that she was done giving out the trays and had not brought the juice to Resident #5 yet. The CNA stated that she got sidetracked because another resident had requested care. The surveyor asked the CNA what she should have done, and she acknowledged that she should have given Resident #5 the juice because he/she had asked for it. The surveyor interviewed UM #2, and she stated that Resident #5 should have received the two juices as stated on the meal ticket. UM #2 further stated that the CNA should have brought the second juice to Resident #5 or asked someone else if she was unable to get it, because that was the resident's preference. On 2/27/25 at 9:57 a.m., the Dietician stated that she mis-spoke and that she observed Resident #2's lunch tray on 2/5/25 and sent an email on 2/6/25 to LNHA, Director of Social Services (DSS), FSD, and UM. During interview with the surveyor on 2/27/25 at 10:23 a.m., the LNHA stated that Resident #5 should have gotten his/her preference because it was the resident's rights. During interview with the surveyor on 2/27/25 at 10:32 a.m., the DSS stated that she was aware of Resident #2's food concerns and his/her preferences shortly after Resident #2 was admitted . The DSS stated that she sent email to the FSD, Dietician, and UM, copied the LNHA, and discussed in morning meeting. During interview with the surveyor on 2/27/25 at 11:04 a.m., the DSS stated that what should have happened was that the Dietitian should have addressed the concerns directly with the resident and then collaborated with the FSD and ensured that the requests were fulfilled. She stated, It was important that Dietician takes these measures because nutrition played a vital role, the overall performance and rehabilitation treatment, patient experience and recognize resident's rights regarding his/her dietary needs and preferences. During interview with the surveyor on 2/27/25 at 11:57 a.m., the LNHA stated, The Dietician should have notified the dietary department regarding the inaccuracy, and she should have ensured that Resident #2 received the items requested if available. It is important that these steps are taken because it is the resident's rights and preference. On 02/27/25 at 12:30 a.m., the surveyor entered the Main Dining Room on the first floor along with UM #2 and observed the following: 1. Resident #1 had a select menu on his/her tray and Resident #1 did not receive the tomato juice as ordered. This item was circled on the select menu. 2. Resident #5 had a select menu on his/her tray and did not receive one out of two juices and garlic spinach as ordered. These items were circled on the select menu. Review of the Dietary Department policy dated 03/2020, on Resident Trays revealed that Resident will be provided with meal trays as ordered. The Food Services Manager or supervisor will check trays routinely. Nursing staff shall check each food trays routinely before serving residents. Review of the Department of the Dietary Department policy dated 03/2020, on Menu Standards revealed, Tray tickets print specific to the physician order and patient preferences. NJAC 8:39-17.4 (a)1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to keep all areas clean specifically the hallways by leaving linen bundled up outside the linen cart and in the soiled-utility rooms by leaving trash bags on the floor, stacked up, and untied. The deficient practice was identified on 2 of 4 units reviewed under the Environment Task. The deficient practice was evidenced by the following: On 12/03/2024 at 11:08 AM in the St. [NAME] hallway, the surveyor observed linen including towels and blankets unfolded and piled onto the outside handle of the linen cart. On the same date at 12:15 PM in the St. [NAME] Soiled Utility room, the surveyor observed linens overflowing and not bagged from the receptacle, two trash bags were placed on top of the trash receptacle also. On the same date at 12:19 PM in the St. Mary's soiled utility room, the surveyor observed linens in an untied trash bags left on the floor. On 12/04/2024 at 11:07 AM during an interview with the surveyor, the Infection Preventionist said soiled utility rooms should not be piled up. She confirmed that she makes sure nothing is on the floor. On 12/05/2024 at 1:10 PM during an interview with the Licensed Nursing Home Administrator (LNHA) said soiled utility rooms are to checked twice during the day shift however, they did ask housekeeping to make additional checks. At that time, the LNHA confirmed trash bags should be in receptacles and not on the floor. § 8:39-19.7 (a), (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint: NJ170170; NJ169828 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for a resident that had repeated falls. This deficient practice was identified for 1 of 2 Residents (Resident #347) reviewed for falls and was evidenced by the following: On 12/03/2024 at 11:40 AM, the surveyor requested all accidents and/or investigations from the facility for Resident #347 during the year of 2023. The facility provided fall investigations for incidents that occurred on 2/27/23, 4/23/23, and 4/28/23. Upon review of document titled, Incident Audit Report (IR) dated 2/27/2023 at 4:00 PM revealed under Nursing Description: Called to room [ROOM NUMBER] by CNA [Certified Nursing Assistant] and noted resident sitting on floor next to bed. Identified under Resident Description revealed: Resident said [they were] getting up from [their] bed to go the bathroom and fell to the floor. The IR contained a signed conclusion by the Unit Manager, and a handwritten signed statement from the identified CNA that identified the fall as unwitnessed. Upon review of IR dated 4/23/2023 at 10:30 PM, it revealed under Nursing Description: Resident sitting on the floor next to [their] bed, and [their] wheelchair behind [them]. Identified under Resident Description revealed: Resident said [they're] trying to get up from bed to go to the bathroom but slid down to the floor. Identified under Description of Action Taken revealed: Resident helped up from the floor and assisted to the bathroom. Attached to the IR was an undated and unsigned document dated 4/23/23 at 10:30pm that included, Resident found by CNA during rounds sitting on the floor next to his bed. Prior [to] the incident, resident was in [their] wheelchair which was behind [them]. Resident stated [they were] attempting to go to the bathroom and slid to the floor. No injuries noted upon assessment. Denies hitting [their] head. Resident assisted back to wheelchair and then assisted to the bathroom. Resident was wearing non-skid socks. Wheelchair cushion was inspected with no issues noted. Anti-roll back breaks applied to wheelchair. The IR did not include statements from the identified CNA, vital signs, and did not specify if the fall was witnessed or unwitnessed. The surveyor reviewed the IR dated 4/28/2023 at 1:15 PM that revealed under Nursing Description: This writer summoned to resident room at [approximately 1:15 PM] by Certified Nursing Assistant (CNA) assigned who stated, [the resident] fell to the floor. Identified under Description of Action taken indicated: Resident assisted into wheelchair with the assist of one staff member-unit manager in to evaluate. [Neurological] checks initiated. [Range of Motion] unchanged to upper/lower extremities. Message with [doctor] . Attached to the IR was an undated and unsigned document dated 4/28/23 at 1:15pm indicated, Resident found on the floor next to [their] wheelchair in [their] room. Prior to the incident, resident was sitting in [their] wheelchair after eating the room meal. Denies hitting [their] head and upon assessment, no visible injuries. Resident was assisted back to wheelchair and assessed by Unit Manager. [Neurological] checks were [within normal limits]. Resident has not been feeling well. [Doctor] ordered labs which are pending. Post incident, resident [complained of] back pain. Call placed to [doctor] with order for x-ray of spine. Results noted with age-indeterminate compression fracture of L2. Resident sent to [emergency department]. admitted to facility with hyponatremia. The Incident Audit Report did not include statements from the identified unit manager or CNA, did not specify if the fall was witnessed or unwitnessed, and did not have documentation of vital signs. The surveyor reviewed the medical record for Resident #347. A review of the admission Record face sheet (an admission summary) reflected that Resident #347 was admitted to the facility with diagnosis that included, but not limited to cardiomegaly (enlarged heart), hypomagnesemia (low magnesium), and repeated falls. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/13/2023, reflected a brief interview for mental status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. On 12/4/2024 at 12:16 PM, the surveyor interviewed CNA#1 who reported that following a resident fall, whether it is witnessed or unwitnessed, the CNA complete a handwritten report of everything that they they did and saw during the incident. On 12/4/2024 at 12:21 PM, the surveyor interviewed Licensed Nurse Practitioner (LPN #1) who advised that following a resident fall, the cart nurse and supervisor/unit manager work together complete a thorough fall investigation. LPN#1 confirmed that nursing is responsible for ensuring that statements are obtained from nursing as both a progress note and risk management assessment in the EMR (electronic medical record), and any witnesses (including the CNA) will be on paper. LPN #1 further explained that the nursing progress note should include the resident assessment, including the resident's vital signs, environmental concerns, resident presentation, where they were found in the room, etc. On 12/5/2024 at 9:18 AM, the surveyor interviewed Licensed Nurse Practitioner Unit Manager (UM/LPN #1) who advised that nursing works together to complete the fall investigation. UM/LPN #1 confirmed that statements are obtained from everyone that witnessed or was involved in the fall. UM/LPN #1 advised the CNA would fill out a form since they do not have access or the EMR progress notes. The UM/LPN #1 advised that the nursing documentation should include vital sings, if the resident is prescribed any blood thinners, reports of pain, etc. UM/LPN #1 confirmed that the Director of Nursing would review the fall investigation to ensure completeness. UM/LPN #1 reviewed the IR completed for 4/23/23 and 4/28/23 and confirmed that were no statements obtained, no vital signs documented, and no name, title, or date of the investigation summary. On 12/5/2024 at 11:12 AM, the surveyor interviewed the Director of Nursing (DON) who reviewed the 4/23/23 and 4/28/23 IRs and confirmed that statements were not obtained and that she could not identify who completed the IR conclusion summary since it was not signed. The DON also acknowledged that thorough nursing documentation was not completed since there were not vitals signs documented on the IR. When asked if the two IRs were thoroughly completed, the DON stated no. On 12/5/202 at 10:09 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, and Regional Clinical Nurses acknowledged that the facility does not require handwritten statements or names of witnesses in their fall investigations but could not speak to the facility policy. A review of the facility's policy titled, Fall Prevention/ Management, with an effective date of 6/2017 and revised date of 3/2023, documented under Procedure: An incident report will also be initiated for any unwitnessed or witnessed fall . A review of the facility's policy titled, Accident and Incident Investigation, with an effective date of 10/2018 and revised date of 1/202, documented under Policy Interpretation and Implementation: The following data, as applicable, shall be included on the Report of Incident/Accident Form: E. The name(s) of witnesses and their accounts of the accident or incident; I. The condition of the injured person, including his/her vital signs; M. The signature and title of the person completing the report. NJAC 8:39-9.4(f)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that facility staff failed to use appropriate infection control practices, specifically by failing to wear a gown during high-contact activity in a resident's room who was under Enhanced Barrier Precautions. The deficient practice was identified for 1 of 3 residents (Resident # 190) reviewed for Respiratory Care. The deficient practice was evidenced by the following: A review of Resident # 190's Order Summary located in the Electronic Medical Record (EMR) revealed an order for, Enhanced Barrier Precautions every shift for [catheter]/wound. The order continued, Enhanced Barrier Precautions (EBP) adherence during high contact resident activities. Must wear Gown & Gloves during: Dressing, Bathing, Transfers, Linen changes, Providing hygiene, Brief changes, toileting assistance, indwelling medical device care, and wound care. DON/DOFF and cleanse hands before and after care . A review of Resident # 190's Care Plan located in the EMR revealed an intervention to, Maintain Enhanced Barrier Precautions-Utilize PPE when performing high-contact resident care. The date initiated was 11/07/2024. On 12/04/2024 at 12:04 PM, the surveyor observed Certified Nurse Aide (CNA) # 1 in Resident # 190's room with the door open and curtain partially drawn. On the door of the room was an Enhanced Barrier Precautions sign indicating that staff are to wear a gown when performing high-contact activities including but not limited to providing hygiene and dressing. At that time, the surveyor was able to see a clean, incontinence brief unfolded near the foot of the resident's bed. At that time, the surveyor observed CNA # 1 in the room providing care to Resident # 190 with gloves and a mask on. CNA # 1 was not wearing a gown. At that time, in the presence of the surveyor, the Unit Manager/Licensed Practical Nurse (UM/LPN) # 1 observed CNA # 1 in the room. UM/LPN # 1 confirmed CNA # 1 was performing incontinence care without wearing a gown. On 12/04/2024 at 11:07 AM during an interview with the surveyor, the Infection Preventionist confirmed Resident # 190 is under Enhanced Barrier Precautions. Further, she confirmed that if the CNA is providing incontinence care, they are expected to wear a gown. On 12/05/2024 at 1:10 PM during an interview with the surveyor, the Director of Nursing (DON) confirmed staff should be wearing a gown and gloves when a resident is on Enhanced Barrier Precautions and incontinence care is being provided. During the same interview, the DON stated, It's Enhanced Barrier Precautions, so it's infection control. A review of the facility policy titled, Enhanced Barrier Precautions dated 3/2024 revealed under, General Overview that, Enhanced Barrier Precautions (EBP) utilizes targeted gown and glove use during high-contact resident care activities to reduce the transmission of MDROs [Multiple-Drug Resistant Organisms]. Further, the policy revealed, Examples of high-contact resident care activities requiring gown and gloves for EBP include but are not limited to: Dressing, Bathing/Showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting . N.J.A.C. § 8:39-19.4 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/02/2024 from 9:35 until 10:00 AM, the surveyor, accompanied by the Dietary Director (DD) observed the following in the kitchen: 1. In the walk-in refrigerator, on an orange tiered cart, 15 bags of hot dog rolls with a received by date of 11/11/24. The DD stated he will get rid of them. 2. In the walk-in refrigerator on the second shelf, an opened plastic container of prepared cucumber salad with a received by date of 11/21/24. The DD stated he will get rid of the cucumbers. 3. In the walk-in freezer on top of an opened box, an opened clear plastic bag with pizza dough with no label and no date. The DD stated the pizza dough should have been labeled and dated. The DD threw the pizza dough in the trash. 4. In the prep area, a large container of food thickener and large container of flour were opened and exposed to air. The DD stated the containers should be covered. The DD closed the containers. On 12/04/2024 at 01:49 PM, the surveyor, accompanied by the Nurse Manager #1 observed an unlabeled, covered plate with fish, pork, and fries in the St. [NAME] unit pantry refrigerator. The Nurse Manager #1 stated the plate should be labeled and dated and removed the plate from the refrigerator. On 12/04/24 at 02:00 PM, the surveyor, accompanied by the Nurse Manager #2 observed a plastic container of fresh blueberries dated 11/23/2024 in the [NAME] Garden pantry refrigerator. A few of the blueberries appeared to be dry. The nurse manager was not aware of the expiration date of fresh fruit. The Nurse Manager #2 removed the blueberries from the refrigerator. A review of the facility policy titled Food Storage, revised 2/2024, reflected that refrigerated and ready to eat food shall be held at a temperature of 40 degrees Fahrenheit or less for a maximum of 7 days and refrigerated bread increases shelf life to 14 days. A review of the facility policy titled Freezer with a revised date of 10/2022 reflected that items that require dates in freezers will be dated per industry standards and when items are open or not labeled in freezers items will be discarded. A review of the facility policy titled Foods Brought by Family/Visitors dated 01/02/2024 reflected that perishable foods must be stored in re-sealable containers with tightly fitted lids in the refrigerator/unit pantry. Containers will be labeled with the resident's name, the item and the use by date. A review of the facility policy titled Dietary Practices with a revised date of 02/2024 reflected that all foods are to be protected from other sources of contamination and after food preparation is completed, food items should be stored and covered appropriately. NJAC 18:39-17.2(g)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to explicitly contain any language to inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at the facility and failed to contain any language allowing the resident or anyone else to communicate with federal, state, or local officials. The deficient practice has the potential to affect all residents that signed the binding arbitration clause. The deficient practice was evidenced by the following: A review of the the facility admission packet included an Arbitration Agreement, titled, Voluntary, Binding Arbitration. The arbitration agreement at no time contained any language that explicitly informs the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at the facility. Further review of the facility Arbitration Agreement located in the admission Packet did not reveal any language that allowed the resident or anyone else to communicate with federal, state, or local officials and a representative of the Office of the State Long Term Care Ombudsman. On 12/02/2024 at 10:16 AM during the Entrance Conference, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that the facility includes Arbitration Agreements in the facility admission Agreement. The LNHA informed the surveyor that no residents have entered into binding arbitration or resolved disputes through binding arbitration on or after 09/16/2019. On 12/05/2024 at 12:30 PM during an interview with the Admissions Director, the surveyor asked does the arbitration agreement state that neither the resident or his or her representative is required to sign the binding arbitration. The admission Director replied, The document is titled voluntary. On 12/06/2024 at 9:29 AM during an interview with the Licensed Nursing Home Administrator (LNHA), the surveyor asked if the arbitration agreement explicitly says neither the resident nor his or her representative is required to sign this agreement as a condition of admission to, or as a requirement to continue to receive care at the facility. The LNHA replied, I don't see it in this section. On the same date at 10:01 AM during an interview with the LNHA, the surveyor asked does the binding arbitration agreement allow the resident or anyone else to communicate with federal state, or local officials such as federal and state surveyors, other federal or state health employees and representatives of the Office of the State Long Term Care Ombudsman. The LNHA replied, Not in the arbitration agreement but we have the Ombudsman notification form in the admission agreement. The surveyor then asked does the arbitration agreement explicitly state neither the resident nor his or her representative is required to sign this agreement as a condition of admission to, or as a requirement to continue to receive care at the facility. The LNHA replied, No, it does not state in there. N.J.A.C. § 8:39-4.1 (8)

2. On 10/03/23 at 11:50 AM, the surveyor observed Resident #55 in bed watching TV. The resident stated they did not get out of bed that day. A review of the admission Record indicated the resident had the following diagnoses: major depressive disorder, mood affective disorder, weakness, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, and a contracture of their left hand. A review of Resident #55 Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/16/2023 revealed resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #55 was cognitively intact. A review of the Resident #55's care plan dated 04/6/23 reflected the resident enjoyed and benefited from involvement in activities. A review of the October Treatment Administration Record (TAR) reflected an order to apply the left leg brace when the resident was out of bed every day shift. The TAR had been signed by the nurse from 10/01/23 to 10/11/23. A review of the Activities Consult/Recommendation dated 04/28/23, 07/11/23, and 10/10/23/2023 reflected that Resident #55's preference as to attend activities including activities held in the day room. On 10/04/23 at 11:26 AM, the surveyor observed Resident#55 in bed watching TV who stated, they did not get me out of bed today. On 10/05/23 at 11:50 AM, the surveyor observed Resident #55 in bed watching TV who stated, I did not get out of bed today. On 10/13/23 at 10:09 AM, the surveyor observed Resident #55 in bed watching TV. Resident #55 stated that they used to get transferred to the reclining chair and brought to the dayroom for bingo activities. Resident #55 stated it had been a month since they had gotten out of bed. On 10/13/23 10:24 AM, the surveyor interviewed the resident's routine Registered Nurse (RN#3) who stated Resident #55 got out of bed 3-4 days ago but varied at times according to the resident's mood. On 10/13/23 10:30 AM, the surveyor interviewed Unit Manager/Licensed Practical Nurse (UM/LPN #2) who stated that the resident did not like to get out of bed. UM/LPN #2 further explained that Resident #55 would be transferred by Hoyer lift, but once in the chair would want to go back to bed right away. UM/LPN #2 stated the resident refused to get out of bed and that the physician and family were aware. UM/LPN #2 stated Resident #55's refusal was documented in progress notes and being signed in the Treatment Administration Record (TAR). The surveyor reviewed the TARs for September and October 2023 which did not indicate that the resident refused to get out of bed. The surveyor reviewd Resident # 55's progress notes from June 2023 - October 13, 2023. There was no documentation that indicated that the resident refused to get out of bed. On 10/13/23 at 10:38 AM, the surveyor interviewed the resident's regular Certified Nursing Assistant (CNA#6). CNA #6 stated Resident #55 refused to get out of bed all the time. CNA #6 further stated if the resident refused to get out of bed, they would notify the unit manager and the nurse. On 10/13/23 at 11:00 AM, after surveyor inquiry, the surveyor observed the resident in a gerichair being transported out of their room and to the hallway by 2 CNAs and in the presence of the UM. The resident's left leg brace was on the resident. The resident told the surveyor that they were happy. A review of the facility's Resident Rights policy and procedure, revised 12/31/22 reflected, employees and staff will treat all residents with kindness, dignity, and respect the rights of each resident .Resident Rights to independent choices are outlined and explained .residents are entitled to fully exercise their rights and privileges possible. NJAC 8:39-4.1 (a) (12)(21)(24)(28) Based on observation, interview, and record review, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promoted his/her quality of life for a.) a resident whose preference was to attend church services and was not provided their breakfast tray in a timely manner for 1 of 35 residents (Resident #108) and b.) a resident whose preference was to get out of bed was not honored 1 of 35 residents, (Resident #55) reviewed for Resident Rights. This deficient practice was evidenced by the following: 1. On 10/4/23 at 12:34 PM, during the lunch meal observation on the second floor day room, Resident #108 stated that they didn't receive their breakfast tray until 9:30 AM yesterday morning, which made them late for church. Resident #108 stated that they were uncomfortable going into church late and felt bad holding up the transportation staff. A review of the resident's admission Record revealed that the resident had diagnoses that included but were not limited to Atrial Fibrillation, hypertension, and difficulty walking. A review of Resident #108's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 7/13/23, reflected the resident has a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating Resident #108 had an intact cognition and required the assistance of one staff for locomotion off the unit. On 10/5/23 at 12:10 PM, during the lunch meal observation, Resident #108 told the surveyor that they did not have breakfast this morning because it wasn't delivered until 9:30 AM, and the resident didn't want to be late for church again. On 10/10/23 at 9:51 AM, the surveyor observed Resident #108 in their room waiting for breakfast. At that time, the activity coordinator announced that they were there to transport Resident #108 to church. Resident #108 stated that they were hungry but didn't want to hold up the transporter and did not want to be late for church so the resident left for church without having eaten breakfast. On 10/11/23 at 9:15 AM, the surveyor observed Resident #108 in their room waiting for breakfast to be delivered. The resident stated that they were so hungry yesterday that the resident ate every last bite of their lunch. On 10/11/23 at 9:25 AM, the surveyor observed Certified Nursing Assistant (CNA) #9 deliver the breakfast tray to Resident #108. The resident told CNA #9 and the surveyor that they would like their breakfast earlier so that they could attend church services which began at 10:00 AM and that the transporters arrived between 9:30 AM and 9:50 AM. On 10/11/23 at 9:38 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that she expected all residents to have their breakfast trays delivered by 9:00 AM. The surveyor asked the LPN/UM #2 if she had a list of residents who attended church services or any other morning activities to ensure these residents received their trays with enough time to eat before attending the activities. LPN/UM #2 replied, no. LPN/UM #2 further stated that she should have had a system in place so that residents who leave for church at 9:30 AM receive their trays first. On 10/11/23 at 11:37 AM, the surveyor interviewed the Food Service Director (FSD) who stated that all residents should have their breakfast trays by 9:00 AM, and further stated that he was not provided with a list of any residents who attended morning church services/ activities or medical appointments nor was he aware of any residents who require early breakfast trays. On 10/18/23 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing and Regional Clinical Nurse to discuss the above observations and concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 159668 Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to maintain the call bell within reach for two of thirty-five residents (Resident #19) and (Resident #82) reviewed for accommodation of needs and was evidenced by the following: 1. A review of Resident #19's admission Record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, dementia, diabetes mellitus, bipolar disorder, and unsteadiness on feet. A review of Resident #19's Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/12/23, indicated Resident #19 was cognitively impaired, and required supervision of one staff for bed mobility and transfers. On 10/11/23 at 9:01 AM, the surveyor observed Resident #19 seated in a wheelchair by the left side of the bed with the call bell wrapped around the upper right side rail. On 10/11/23 at 10:26 AM, the surveyor observed Resident #19 in their wheelchair with the call bell wrapped around the upper right side rail. On 10/11/23 at 11:55 AM, the surveyor and Nursing Assistant (NA) observed Resident #19 lying in bed. The surveyor observed the call bell wrapped around the upper right side rail. The NA stated that she had assisted Resident #19 into the wheelchair sometime before 9:00 AM. At that time, the NA told Resident #19 it was lunch time, assisted Resident #19 back into their wheelchair, and left the resident's room with the call bell still wrapped around the upper right side rail. On 10/11/23 at 11:59 AM, the surveyor asked the NA to enter Resident #19's room and the surveyor showed the NA the call bell wrapped around the upper right side rail not within Resident #19's reach. The NA stated that she should have put the call bell within the resident's reach first thing that morning when she assisted Resident #19 into their wheelchair but she forgot, it wasn't intentional. On 10/11/23 at 12:02 PM, the surveyor interviewed LPN/UM #2 in the presence of the NA. The LPN/UM #2 stated that the NA received an in-service on keeping call bells within residents' reach, beds in the lowest position, and providing [NAME] every shift. The NA acknowledged that she had received that information during orientation. On 10/12/23 at 9:26 AM, the surveyor observed Resident #19 seated in chair of the left side of the bed, eating breakfast meal with the call bell wrapped around the right upper side rail. On 10/12/23 at 9:49 AM, the surveyor interviewed CNA #8 who stated that she provided morning care to Resident #19 and assisted her/him to the chair before 8:00 AM that morning. On 10/12/23 at 9:50 AM, the surveyor showed LPN/UM #2 and CNA #8 Resident #19's call bell which was wrapped around the right upper side rail. The LPN/UM #2 stated that CNA #8 had not been present for the speech she gave to all the CNAs reminding them that all call bells should be kept within residents' reach when in or out of bed but acknowledged CNA #8 should have already known this. CNA #8 acknowledged the call bell should be kept within the resident's reach. 2. On 10/3/23 at 11:42 AM, the surveyor observed Resident # 82 seated in a wheelchair positioned on the right side of the bed, with the call bell on the left side of the bed not within Resident #82's reach. A review of Resident #82's admission Record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, depression, anxiety, difficulty walking, and repeated falls. A review of Resident #82's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/1/23, indicated Resident #82 had a moderate cognitive impairment, and required extensive assistance from staff for bed mobility and was dependent on staff for dressing, toilet use and personal hygiene. On 10/16/23 at 9:07 AM, the surveyor observed Resident #82 in bed with the call bell hanging down of the left side of the bed towards the floor. The surveyor asked the resident how they contacted staff for assistance. Resident #82 replied, I push the button on the call bell when I can reach it. Resident #82 further stated that when the resident couldn't reach it, their roommate would use their call bell to call for them. The surveyor asked Resident #82 how often they were unable to reach the call bell. Resident #82 replied that they were not sure but stated that the roommate helped a lot. On 10/16/23 at 9:14 AM, the surveyor interviewed the resident's alert and oriented roommate who stated that Resident #82 asked the resident to call nursing staff at least two times a day. On 10/16/23 at 10:22 AM, the surveyor observed Resident #82 seated in their wheelchair with their call bell within reach. Resident #82 stated with a big smile on their face, I can reach my call bell now! On 10/16/23 at 10:38 AM, the surveyor interviewed CNA #7 who stated that she had recently answered the call light for Resident #82's roommate. When CNA #7 answered the call light, the roommate stated that it was actually Resident #82 that needed assistance. Resident #82 told CNA #7 that they were unable to find their call bell. CNA #7 stated she picked Resident #82's call bell up off the floor and handed it to the resident. CNA #7 further stated that she had not had a chance to make rounds that morning, so she was not sure how long Resident #82's call bell was on the floor. On 10/16/23 at 10:45 AM, the surveyor interviewed LPN/UM #2 who stated that her expectation was that the unit Nurses and CNAs made rounds every morning making sure all residents are okay, call bells are within reach and the beds are in the lowest positions. On 10/16/23 at 10:53 AM, the surveyor interviewed RN #1 who stated that she did not make morning rounds so she had not been aware that Resident #82's call bell was on the floor. RN #1 further stated that she had not gone into Resident #82's room until after breakfast but should have made rounds to ensure the resident was okay and that the call bell was within reach. On 10/18/23 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing and Regional Registered Nurse to discuss the above concerns. Review of the facility's policy and procedure titled Call Bell Response, revised on 12/2021, reflected . staff is to ensure that the call bell is within reach for ease of use. NJAC 8:39- 31.8 (c) (9)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to inform, and provide written information to all adult residents concerning the right to formulate an advance directive. This deficient practice was identified for 1 of 35 residents reviewed (Resident #19) and was evidenced by the following: 1. On 10/11/23 at 9:01 AM, the surveyor observed Resident #19 seated in a wheelchair next to the left side of the bed. The resident greeted the surveyor with a smile. On 10/11/23 at 11:55 AM, the surveyor and Nursing Assistant (NA) observed Resident #19 lying in bed with their eyes closed. On 10/12/23 at 9:26 AM, the surveyor observed Resident #19 seated in a chair eating breakfast. A review of the resident's admission Record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, dementia, diabetes mellitus, bipolar disorder, and unsteadiness on feet. A review of Resident #19's Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/12/23, indicated Resident #19 was cognitively impaired, and required supervision of one staff for bed mobility and transfers. On 10/11/23 at 12:33 PM, the surveyor interviewed the Director of Social Services who stated that the facility's policy was to discuss Advance Directives on admission and then quarterly but for some reason Advance Directives were not discussed for Resident #19. On 10/12/23 at 10:50 AM, the surveyor interviewed the Social Worker who stated that after the surveyors inquiry the Social Worker sent an email to Resident #19's family with information regarding Advance Directives. On 10/18/23 at 12:16 PM, the survey team met with the Administrator, Director of Nursing and Regional Clinical Nurse to discuss the above observations and concerns. No further information was provided. A review of the facility's policy and procedure titled Advanced Directives, revised 11/2020 reflected . on admission the facility will determine whether the resident has an advance directive, and if not, determine whether the resident wishes to formulate an advance directive. .If an adult individual is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility will give advance directive information to the individual's resident representative. NJAC 8:39 - 4.1 (a); 9.6(a) (e)

Based on interviews, medical record review (MR), and other pertinent facility documentation, it was determined that the facility failed to report an an injury of unknown origin to the New Jersey Department of Health (NJDOH) for 1 of 2 residents reviewed for accidents and incidents (Resident # 57). This deficient practice was evidenced by the following: On 10/3/23 at 11:42 AM, the resident was observed sleeping in bed with face partially covered by blanket. Resident #57 did not acknowledge surveyor's presence. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted with diagnosis which included Atherosclerotic Heart Disease (buildup of fats, cholesterol, and other substances in and on the artery wall). A review of Resident #57's Quarterly Minimum Data Set (MDS), an assessment tool, dated 9/15/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) of score of 6 out of 15, which demonstrated severe cognitive impairment. A review of the care plans for Resident #57 identified that the resident had a history of falls with interventions included but not limited to: call bell within reach, encourage resident to ask for assistance, have commonly used items within reach, remind resident to use call bell for assistance. A review of Resident #57's Incident Report (IR) dated 6/21/2023 at 2:09 PM, revealed that the Licensed Practical Nurse (LPN) was notified by the Nurse Practitioner (NP) that the resident had bruising on their chest area. The LPN assessed the resident and observed bruising on the resident's chest, and left side of their stomach. Additional review of the IR revealed, under Incident Description that the resident was unable to provide a description of the incident. Attached to the IR was an undated typed summary included On 6/21/2023 at 2:04 PM observed resident had bruising on [resident's] left chest and left side of stomach. Resident unable to state how it occurred. Statements obtained. Monitor until resolution. Intervention: Monitor until resolution. Call MD if needed. Family/MD notified. No statements were provided as part of the IR investigation. During an interview with the surveyors on 10/6/23 at 12:28 PM, the Director of Nursing (DON) advised that the Department of Health was to be notified if there was any injury or harm to the resident and the cause was not able to be determined. The DON stated that the Department of Health was to be notified within 2 hours. The DON acknowledged that the resident was not able to explain that happened as evidenced by BIMS 3/15. The DON further explained that the resident had a fall on 6/13/2023 and the implication might be bruising from that but no timeline to tie that together. The DON added that this should have been a reportable because it was not determined how the resident got the bruise. During an interview with the surveyor on 10/13/23 at 1:49 PM, the Administrator stated that the injury was not reported to the NJDOH because the facility did not feel it was abuse. A review of the facility's Abuse and Neglect Policy and Procedure, with an effective date of 1/15/2020, documented that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made.[ .] to the Administrator of the facility, the Department of Health [ .] A review of the facility's policy titled, Investigation and Reporting, with an effective date of 4/2017 and revised date of 6/2021, documented under the Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident [ .] g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident [ .] j. Review all events leading up to the alleged incident. NJAC 8:39-4.1(a)(5)

Based on interviews, record review, and other pertinent facility documentation, it was determined that the facility failed to timely and thoroughly investigate an injury of unknown origin for 1 of 2 residents reviewed for accidents and incidents (Resident # 57). This deficient practice was evidenced by the following: On 10/3/23 at 11:42 AM, the resident was observed sleeping in bed with face partially covered by blanket. Resident #57 did not acknowledge surveyor's presence. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted with diagnosis which included Atherosclerotic Heart Disease (buildup of fats, cholesterol, and other substances in and on the artery wall). A review of Resident #57's Quarterly Minimum Data Set (MDS), an assessment tool, dated 9/15/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) of score of 6 out of 15, which demonstrated severe cognitive impairment. A review of the care plans for Resident #57 identified that the resident had a history of falls with interventions included but not limited to: call bell within reach, encourage resident to ask for assistance, have commonly used items within reach, remind resident to use call bell for assistance. A review of Resident #57's Incident Report (IR) dated 6/21/2023 at 2:09 PM, revealed that the Licensed Practical Nurse (LPN) was notified by the Nurse Practitioner (NP) that the resident had bruising on their chest area. The LPN assessed the resident and observed bruising on the resident's chest, and left side of their stomach. Additional review of the IR revealed, under Incident Description that the resident was unable to provide a description of the incident. Attached to the IR was an undated typed summary included On 6/21/2023 at 2:04 PM observed resident had bruising on [resident's] left chest and left side of stomach. Resident unable to state how it occurred. Statements obtained. Monitor until resolution. Intervention: Monitor until resolution. Call MD if needed. Family/MD notified. No statements were provided as part of the IR investigation. During an interview with the surveyors on 10/6/23 at 12:28 PM, the Director of Nursing (DON) advised that the Department of Health was to be notified if there was any injury or harm to the resident and the cause was not able to be determined. The DON stated that the Department of Health was to be notified within 2 hours and a follow-up with conclusion, including everything we did in the investigation was to be provided within 24 hours. When inquired about what was included with an investigation for discovery of a new bruise the DON stated that an investigation will go back 24 hours prior to the discovery along with written statements, progress notes, etc. The surveyor reviewed the IR dated 6/21/23 with the DON who responded, this is not even close to a full investigation. The DON acknowledged that the resident was not able to explain that happened as evidenced by BIMS 3/15. The DON further explained that the resident had a fall on 6/13/2023 and the implication might be bruising from that but no timeline to tie that together. On 10/18/23 at 8:15 AM, the surveyor was provided with an additional copy of the IR for 6/21/23. Review of the IR included undated statements from staff, and an undated, unsigned summary that was indicated as revised. Review of the statements revealed that all the statements were not dated with Today's Date. In addition, the revised bruise investigation did not contain an author and was also undated. The LPN statement revealed, [left side of chest bruising, 1x1 size purple/yellow coloring. Also a bruise on the [left] side of stomach 1.5x1.5 size, purple/yellow coloring. The conclusion documented, based on previous fall, location of bruises and healing stages of bruises, it is deduced that the bruises were noted were a result of the fall on 6/13/23. No abuse suspected. During an interview with the surveyor on 10/18/23 at 10:25 AM, the Administrator stated the investigation for 6/21/23 was not complete, and that she had staff complete statements on 10/17/23 (for the incident on 6/21/23) and she had completed the revision of the summary on 10/17/23 (for the incident on 6/21/23). A review of the facility's policy titled, Investigation and Reporting, with an effective date of 4/2017 and revised date of 6/2021, documented under the Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident [ .] g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident [ .] j. Review all events leading up to the alleged incident. NJAC 8:39-4.1(a)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care for 2 of 35 residents, (Resident's #79 and #249) reviewed resident assessment. This deficient practice was evidenced by the following: 1.A review of Resident #79's admission Record reflected that the resident had diagnoses which included but were not limited to; dementia and nutrtional deficiency. A review of Resident #79's progress notes written by a wound care Nurse Practioner on 8/15/2023 at 12:38 PM revealed that the resident was seen for a sacral area wound that was identified as moisture associated skin damage MASD. A review of Resident #79's Quarterly MDS dated [DATE] revealed that on Section M1040 (other ulcers wounds and skin problems) M1040H, MASD was not checked as coded. According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Asessment Intstrument (RAI) 3.0 user's manual dated October 2019, section M1040 includes the following: Steps for Assessment 1. Review the medical record, including skin care flow sheets or other skin tracking forms. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review. 3. Examine the resident and determine whether any ulcers, wounds, or skin problems are present Coding Instructions Check all that apply in the last 7 days. 2. A review of Resident #249's admission Record reflected that the resident was admitted with diagnoses which included but were not limited to; heart failure and obesity. A review of resident #249's wound assessment dated [DATE] at 11:44 AM indicated that the resident had a wound that was acquired during the resident's stay at the facility. A review of Resident of Resident #249's discharge MDS dated [DATE], revealed that on Section M0100 (determination of pressure ulcer risks/injuries) M0300 (current number of unhealed pressure ulcers/injuries at each stage) reflected that the resident had a stage 3 pressure that was present upon admission/entry or reentry. According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Asessment Intstrument (RAI) 3.0 user's manual dated October 2019, Section M0300 included the following: Coding Instructions for M0300C M0300C1. Enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is Stage 3.Enter 0 if no Stage 3 pressure ulcers are present and skip to M0300D, Stage 4. M0300C2. Enter the number of these Stage 3 pressure ulcers that were first noted at Stage 3 at the time of admission/entry AND-for residents who are reentering the facility after a hospital stay, enter the number of Stage 3 pressure ulcers that were acquired during the hospitalization (i.e., the Stage 3 pressure ulcer was not acquired in the nursing facility prior to admission to the hospital). Enter 0 if no Stage 3 pressure ulcers were first noted at the time of admission/entry. During an interview with the surveyor on 10/11/23 at 11:42 AM, the MDS Coordinator stated that one of his responsibilities was to ensure the MDS was completed, and the computer software would let him know if an MDS was missing. The MDS Coordinator added that he would base the coding of the MDS by reviewing nursing evaluations, progress notes and going to the nursing units and asking questions. At that time, the surveyor asked the MDS Coordinator to review Resident #79 and Resident #249. The MDS Coordinator confirmed that Resident #79's quarterly MDS dated [DATE] was not coded correctly indicating that the resident had MASD and would need to complete a modification. The MDS Coordinator reviewed Resident #249's discharge MDS which indicated that the resident developed pressure ulcer that was present on admission and stated that if it was not present on admission, then the MDS was not correct. The MDS Coordinator stated that he was not sure if miscoding affected anything but may affect billing. The MDS Coordinator added that the MDS Coordinator's signature on the MDS ensured that the MDS was accurate. During an interview with the surveyor on 10/11/23 at 12:53 PM, the MDS Coordinator stated that Resident #79 and Resident #249's assessments were incorrectly coded by human error and should be corrected. A review of the MDS Coordinator job description revised 5/13, included that the MDS Coordinator's job responsibilities were to ensure that the MDS was completed in a timely and accurate manner, and was responsible for timely submission to the appropriate regulatory agencies. A review of a facility policy with subject MDS Completion and Submission revised on 8/2020 included that the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. Timeframe for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. NJAC 8:39-11.1

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident's preferred gender and name. This deficient practice was identified for 1 of 35 residents (Resident #146) reviewed for care plans and was evidenced by the following: On 10/3/2023 at 12:03 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager(LPN/UM #3), who reported that Resident #146 had a preferred gender and name. On 10/4/2023 at 12:14 PM, the surveyor observed the resident seated in a reclining chair at a table identified as Table 2, which identified Resident #146 with their non-preferred name. On 10/10/23 at 11:26 AM, a surveyor overheard a staff member repeatedly calling Resident #146 by their non-preferred name. On 10/11/23 at 9:08 AM, the surveyor observed that the name tag outside Resident #146's room identified their non-preferred name. The surveyor reviewed the medical record for Resident #146: A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Malformation Syndrome associated with Short Stature. A review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 08/11/2023, reflected a brief interview for mental status (BIMS) score of 3 out of 15, which demonstrated severely impaired cognition. A review of an Initial Social Services Note, dated 5/10/2022, documented that Resident #146 reported a preferential name and gender. At that time, a BIMS was conducted and returned as 12/15, that established the resident moderately impaired cognition. A review of the individualized comprehensive care plan (ICCP) failed to include a focus area along with interventions that identified Resident #146's preferred gender and name. On 10/11/23 at 9:33 AM, the surveyor interviewed Certified Nursing Assistant (CNA #2), who acknowledged that they were unaware of any nicknames or personal preferences for Resident #146. When asked if they were to receive this information when would the information be relayed CNA #2 responded, in the AM meeting. On 10/11/23 at 10:31 AM, the surveyor interviewed Social Worker #1 (SW #1) and Director of Social Services (DOSS), who acknowledged that as part of the LGBTQI+ training the facility is to honor resident preferences, including resident gender and identifiers. When asked to discuss Resident #146, the DOSS confirmed Resident's preferred gender and name was established prior to their cognitive decline. DOSS also indicated that family also verified the resident's preferences. When asked to review Resident #146 care plan, the DOSS advised that the focus area stated their preferred name. The surveyor inquired if the resident's preferred gender was identified. The DOSS responded that the name should be an identifier of the preferred gender based on the spelling. The surveyor questioned if the resident's specified preferences should care planned so all staff was made aware. The DOSS confirmed. When asked if the resident's preferred name should be identified at the room door and at the dining table the DOSS responded, I'm not sure, that is a good question [ .] It should be based on the resident's preference. A review of the facility provided LGBTQI+ Senior [NAME] of Rights, that was signed and dated by the DOSS, document identified that a violation of these rights would be Repeatedly failing to use a resident's chosen name or pronouns despite being informed. A review of the document LGBTQI+ Affirming Assessment Worksheet for Healthcare and Long-Term Care Environments, which was part of the LGBTQI+ Training Program, included .2. All forms seeking personal information about clients (from screening through discharge) include LGBTQI+ terminology. For example, [ .] a. Chose name option if difference from their legal name [ .] gender pronouns preferred: he/him/his; she/her/hers or they/them/theirs. A review the facility's Care Plans, which effective date of 12/2015 and revised date of 6/2022, included [ .] Care plans will include measurable objectives with interventions based on the resident's care needs and be individualized as able. NJAC 8:39-11.2(e) thru (i); 27.1(a), (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # 159668 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to obtain a physician's order (PO) for a resident who was transferred to the hospital. This deficient practice was identified for 1 of 4 residents reviewed for hospitalization (Resident #249) 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 regimes 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 state: 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. The surveyor reviewed the medical record for Resident #249. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Atrial Fibrillation. A review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 5/17/23, reflected a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which demonstrated moderately impaired cognition. The MDS also identified Resident #249 as receiving Hospice Services. A review of the Nursing Progress Notes included a note dated 11/20/2022 at 2:57 PM that indicated, Power of Attorney (POA) (granddaughter) of resident approached this writer at [2:25 PM], requesting that [the resident] be sent to [hospital] for evaluation of status. Supervisor made aware of family request at [2:30 PM]. [Hospice] contacted and message left for nurse at [2:35 PM]. Hospice Nurse returned call at [2:45 PM]-notified of resident transfer. [Transport Company] contacted to arrive at [5:50 PM]. Oncoming nurse notified of resident status- need to contact POA [related to] transport. A review of the Discontinued Physician Summary Report did not include an order for the resident to be transferred for the emergency room on [DATE]. During an interview with the surveyor on 10/6/23 at 9:02 AM, Licensed Practical Nurse Unit Manager (LPN/UM #3) reviewed the above referenced Nursing Progress Note and Discontinued Physician Summary Report. LPN/UM #3 stated that it was not documented if facility physicians were made aware of the resident's condition and did not observe orders in the Physician Summary Report to send the resident to the hospital. LPN/UM #3 further stated, even though [the resident was] hospice, the [physicians] should be made aware and there should be orders to send out to the hospital. During an interview with the surveyor on 10/10/23 at 11:20 AM, the author of the Nursing Progress Note, Licensed Practical Nurse (LPN #4) stated that considering the circumstances, I don't recall what was going on at the time [ .] I'm not even sure if I endorsed it to the unit manager. When specifically asked if a PO should have been obtained to send the resident to the hospital LPN #4 stated, I don't know. During an interview with the surveyor on 10/12/23 at 11:01 AM, the Director of Nursing (DON) confirmed that a PO, along with a reason, was required for resident transport to the hospital. During an interview with the surveyor on 10/13/23 at 11:30 AM, a Nurse Practitioner (NP #1) reported that there was an expectation that orders are to be received for any resident requiring transportation to the hospital. When asked who has the responsibility for entering the PO NP #1 stated, the nurses will put in the orders. During an interview with the surveyor on 10/13/23 at 1:49 PM, Licensed Nursing Home Administrator (LNHA) confirmed that there was no PO for the resident to be transported to the hospital. A review the facility's Hospital Transfer Process document dated 8/2017, included .An order should be obtained from the physician for the transfer. A review the facility's Change in Resident Condition policy, with an effective date 5/2018 and revised date of 2/2022, included 1. The nurse will notify the resident's physician when there has been a (an): a. accident or incident involving the resident; [ .] d. significant change in the resident's physical/emotional/mental condition that impact their current pan of care; [ .] e. need to alter the resident's medical treatment significantly; [ .] g. need to transfer the resident to hospital/treatment center . A review the facility's Physician Orders-Obtaining/Transcribing policy with an effective date 10/2018 and revised date 9/2020, included .13. All orders will be identified as telephone, verbal, or prescriber written. Orders will be repeated and verified with physician or practitioner, and transcribed into record as quickly as practicable to when order has been received. A review the facility's Job Description- LPN document, with a revision date 5/13, included .Communicate change in resident status, test results and any other pertinent resident information to Physicians, Physicians Assistants, and Consultants in a timely and a professional manner. Document such communication in the Medical Record [ .] Transcribe and implement physicians orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review it was determined that the facility failed to a.) document and monitor a resident that had an external defibrillator life vest (an external device worn on the chest to stop an abnormal heart rhythm), and obtain physician orders for monitoring of a resident's life vest and b.) follow a physicians order for daily wound dressing changes. This deficient practice was identified for Resident #396, 1 of 1 resident reviewed for life vests and Resident #398 1 of 3 residents reviewed for wound care and was evidenced by the following: 1.On 10/03/23 at 10:35 AM, during the initial tour of the facility the surveyor observed Resident #396 in the bed. Resident #396 told the surveyor he/she came to the facility for therapy following angioplasty (unblocking of a blood vessel) for the leg. During the observation the surveyor noticed a small cardiac monitor on the nightstand. A review of the admission Record revealed the resident was recently admitted to the facility with medical diagnoses which included but were not limited to diabetes (high blood sugar), heart failure, and ventricular tachycardia (an abnormal heart rhythm). A review of the admission Minimum Data Set, an assessment tool (MDS) dated [DATE] indicated Resident #396 had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. On 10/05/23 at 09:51 AM, the surveyor reviewed physician progress notes that were completed on admission to the facility. The physician documented that the resident was wearing a life vest for diagnosis of V-tach (an abnormal heart rhythm). At the same time the surveyor reviewed all of the nursing progress notes and a life vest was not mentioned in the progress notes since Resident #396 physician admission note. On 10/05/23 at 09:57 AM, the surveyor reviewed the admission Nursing Assessment which did not include the resident was wearing a life vest. On 10/05/23 at 10:02 AM, the surveyor reviewed Resident #396 hospital discharge records which revealed that the resident had been discharged from the hospital with a life vest. On 10/05/23 at 10:30 AM, the surveyor reviewed the residents care plan. The care plan was initiated on 09/30/23 and had a focus of cardiac status and heart failure. The care plan did not include that the resident was wearing a life vest or interventions pertaining to a life vest. On 10/05/23 at 12:03 PM, the surveyor asked the Unit Manager/Licensed Practical Nurse (UM/LPN) if the resident had a life vest and the UM/LPN stated, Yes that resident has a life vest. The UM/LPN stated the resident came with the life vest. The surveyor asked if something like a life vest should be included on the care plan and the UM/LPN stated, I believe it is. At that time the UM/LPN went into the Electronic Medical Record (EMR) to check the residents care plan and stated to the surveyor, It isn't, but it definitely should be on the care plan. During the interview with the UM/LPN the Clinical Regional Nurse (CRN) was present who stated, I don't even see a life vest in the physician orders. The surveyor reviewed the physician orders and could not locate any orders pertaining to a life vest or monitoring. On 10/05/23 at 12:16 PM, the surveyor went to see Resident #396. The resident told the surveyor he/she had a life vest. The surveyor asked who charges the vest and resident stated, I do. On 10/10/23 at 12:29 PM, the surveyor interviewed CNA #4 who was caring for Resident #396. The surveyor asked CNA #4 how she washed the resident with the life vest and CNA #4 stated, She was all done when I came in today, so I didn't have to. The surveyor asked if she knew the resident had a life vest and if she received any education on the vest when she received her assignment in the morning, and CNA #4 stated, No. On 10/12/23 at 10:55 AM, Resident #396 was observed sitting on the side of bed fully clothed. The resident told the surveyor he/she was going home and was awaiting discharge instructions. The surveyor asked the resident if, during the stay at the facility did the staff check the life vest and the resident replied, Not at all, not once. I did everything and when the alarm would go off, I would hit a button and the machine would tell me what to do. On 10/17/23 at 09:30 AM, the surveyor reviewed the policy titled, Wearable Cardioverter Defibrillator, the policy had an effective date of 03/2020. Under the procedure section of the policy, it indicated the facility will verify the use of the defibrillator, the clinical team will monitor the use of the device routinely, and the residents wearing one will be placed close to the nursing station for monitoring when possible. 2. On 10/03/23 at 11:18 AM, during the initial tour of the facility the surveyor observed Resident #398 in the room. The surveyor observed that Resident #398 had a white gauze dressing to the left lower leg. During the interview the surveyor asked the resident how often the staff change the leg dressing and the resident said, It should be changed every day, but they don't do it every day. Resident #398 then said, It's not getting infected though. During the observation of the leg dressing the surveyor observed a date on the dressing of 09/30 with a staff member initials on the dressing. A review of the admission Record revealed that Resident #398 was recently admitted to the facility with medical diagnoses which included but were not limited to diabetes (high blood sugar) with foot ulcer, heart failure, and anemia (low blood count). A review of the admission Minimum Data Set (MDS), an assessment tool dated 09/20/23 which indicated the resident had a Brief Interview of Mental Status of 14, meaning Resident #398 was cognitively intact. On 10/03/23 at 11:24 AM, the surveyor interviewed a Licensed Practical Nurse (LPN #3) who was caring for the resident. LPN #3 along with the surveyor entered the room and the surveyor showed LPN #3 the date on the dressing, LPN #3 said, September 30th, but the wound nurse is coming today. The surveyor asked LPN #3 that if it was a daily dressing what should the date on the dressing be and LPN#3 said, October second. The LPN #3 then told the surveyor, there may have been some confusion because sometimes the wound nurse gets pulled to a medication cart when they are short staffed. On 10/04/23 at 01:35 PM, the surveyor reviewed the physician orders which showed on 09/13/23 there was an order for a wound consult as needed. It was an active order. Further review of the physician orders showed an order dated 09/15/23, an active order to Clean left leg and left toe wound with normal saline solution and pat dry, apply Xeroform (a gauze dressing with petroleum), cover with a pad, and wrap it daily. On 10/04/23 at 02:01 PM, the surveyor reviewed the Treatment Administration Record which showed that the nursing staff signed the wound care as completed on October 1st, 2nd, and 3rd. The third was the day of the observation with the wound dressing dated 09/30. On 10/04/23 at 02:11 PM, the surveyor further reviewed the MDS dated [DATE], section M skin conditions, which indicated that the resident had two venous/arterial (open wounds caused by damaged veins or arteries) ulcers of the foot and leg. On 10/04/23 at 02:23 PM, the surveyor reviewed Resident #398 care plan that was initiated on 09/14/23. The focus of the care plan was actual skin breakdown related to peripheral vascular disease. Interventions included but were not limited to administer treatment per physician orders and consult wound specialist for further treatment and recommendations. On 10/17/23 at 09:31 AM, the surveyor interviewed the Director of Nursing (DON) regarding residents with wound treatment orders. The DON told the surveyor that when a resident had a wound, the nurse would look for the current treatment orders in place and transcribe the orders onto the Treatment Administration Record (TAR). The surveyor asked who was responsible to complete the wound care treatments and the DON responded, Ninety-nine percent of the time the nurse on the cart (medication cart) who does the wound treatment. If there is an extra nurse on duty, we assign them to the wound cart. The DON told the surveyor the Charge Nurse was responsible to ensure that wound treatments were done, and the assigned nurse was also responsible to ensure the wound treatment was done, even if the facility had a wound nurse. The surveyor questioned the DON regarding the date of Resident #398's dressing, and she stated that obviously the wound treatment was not done if not dated 10/3. The DON stated that she knew that Resident #398's wound treatment was not done, and that the resident even said it. The DON stated that the issue was identified upon surveyor inquiry. She stated that if the nurse documented the wound treatment was completed on the TAR and it was not done that was false documentation. The DON further stated that the treatment would still need to have been done on 10/3/23, as the wound consultant would just assessed the wound and would not redress the wound. On 10/18/23 at 11:22 AM, the surveyor reviewed the policy titled, Physician Orders, the policy had a revision date of 07/2017. The policy read that the facility was to assure that medication/treatment orders are implemented accurately, timely, and in accordance with the State of New Jersey and Federal Government regulations. NJAC 8:39-27.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # 159668 Based on record review, staff interviews, and facility policy review, the facility failed to ensure a newly identified area of skin breakdown was assessed and treated in a timely manner for 1 of 3 residents (Resident #249) reviewed for pressure ulcers and was evidenced by the following: The surveyor reviewed the medical record for Resident #249. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Atrial Fibrillation. A review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 5/17/23, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which demonstrated moderately impaired cognition. The MDS also identified Resident #249 as receiving Hospice Services. A review of the individualized comprehensive care plan (ICCP) for Resident #249 identified a significant change secondary to end stage disease hospice, with an initiation date of 9/13/2022, and interventions that included, but not limited to: hospice visits, no invasive procedures, and report skin breakdown, lack of analgesia effectiveness, and unexpected weight loss. The care plan also identified that the resident was at risk for skin breakdown, with initiation date of 9/8/2022, and interventions that included, but not limited to: barrier cream to perianal area/buttocks as needed, anti-pressure mattress for preventions of wounds. The care plan identified the Resident #249 with refusal of medication related to cognitive impairment, with initiation date of 10/27/2022 and interventions that included, but not limited to: if resisting care, leave (if safe to do so) and return later, provide non-care related conversation proactively before attempting ADLs. A review of the Hospice care plan with start date of 9/13/2022 identified skin integrity and interventions included: educate caregiver on barrier ointment application for every incontinent episode. The Hospice care plan also identified for stage 1 or 2 wounds- incontinent patient- apply zinc based protective ointment daily and after each incontinent episode. A review of the Hospice Nursing Clinical Note, dated 11/9/2022 and signed at 12:24 PM, detailed the following summary note: arrived to [resident] in bed unresponsive with granddaughter at bedside [ .] collaborated with staff nurse concerning [end of life care], [social work] made aware. A review of the facility Body Check assessment dated [DATE] at 7:00 AM, under the Section titled: Body Check, the boxes next to Skin Intact and Open Lesions was checked. Under the section titled Body Diagram, the following was entered: Site- Sacrum; Description: dime size stage 2 opening noted to sacral/coccyx area. Unit manager/hospice made aware/ treatment in progress. A review of the facility Nursing Progress Notes included a note dated 11/10/2022 at 10:00 AM, indicated: Cart/floor nurse notified this RN that resident had MASD [Moisture Associated Skin Damage] to sacral area: MASD noted with redness and small opening approx. 0.25cmx0.25cm to sacral area. Cart/floor nurse to follow up and place order for treatment. A review of the facility Wound Assessments dated 11/10/2022 at 11:44 AM, revealed under Wound location/Type, Site: Sacrum; Type: Pressure; Length:1cm; Width 0.5cm; Under the Section titled: Other Ulcers, Wound & Skin Problems the box MASD was checked, along with following interventions: Air Mattress and Preventative Skin Care. Under the Section titled: Treatment/Evaluation, the current treatment plan is entered: Zinc Oxide. Under the Section titled: Comments/Interventions, the following was entered: 11/10/2022-First Observation. A review of the facility Nursing Progress Notes included a note dated 11/10/2022 at 12:15 PM, that indicated: Resident received in bed with head of bed elevated in fowlers position, call bell within reach, safety measures in place/functioning. Vital signs taken/charged. Resident took Ativan/Morphine sublingual-no adverse reaction noted thus far. Resident noted to have dime-size open area to sacral/coccyx. Treatment in place. Unit manager notified/in to eval at approx. 0930. Hospice nurse notified during facility rounds at approx. 1030. Nursing to monitor. A review of the facility Nursing Progress Notes included a note dated 11/16/2022 at 3:14 PM, that indicated: Tech in- air mattress applied as recommended by hospice services. A review of the facility Body Check assessment dated [DATE] at 7:00 AM, under the Section titled: Body Check, the boxes next to Skin Intact was checked and under Other the following was entered: MASD area noted to sacrum. Under the section titled Body Diagram, the following was entered: Site- Sacrum; Description: MASD area under treatment-air mattress applied 11/16/22. A review of the facility Wound assessment dated [DATE] at 11:35 AM, revealed under Wound location/Type, Site: Sacrum; Type: Pressure; Length: 2.5 cm (centimeters); Width 2cm;. Under the Section titled: Other Ulcers, Wound & Skin Problems the box MASD is checked, along with following interventions: Air Mattress, Preventative Skin Care, Preventative Skin Care. Under the Section titled: Treatment/Evaluation, the following is checked under Response to Treatment: the current treatment plan is entered: Clean with NSS [Normal Saline Solution], apply MediHoney and cover with dry dressing daily and PRN (as needed) for soilage. Under the Section titled: comments/Interventions, the following was entered: 11/18/22- pink to area, no drainage, no odor, no [sign/symptom] of infection. A review of the Practitioner Note included an entry, dated 11/18/2022 at 3:42 PM, that indicated: Notified by nursing patient has a sacral wound- will consult wound nurse [ .]. A review of the Order Summary Report revealed the following orders: Air Mattress for comfort/ Hospice with start date 11/16/2022. Consult Wound Nurse for sacral wound one time only for 1 day with start date 11/18/2022. Consult Wound Nurse for sacral wound one time only for 4 days with start date 11/18/2022. Clean with NSS [Normal Saline Solution], apply MediHoney and cover with dry dressing daily and PRN for soilage with start date of 11/21/2022, (3 days after the 11/18/22 wound assessment). Zinc Oxide to redness on sacral area every shift for skin integrity with start date of 11/21/2022, (11 days after the 11/10/22 wound assessment). A review of November 2022 Treatment Administration Record (TAR) revealed the following: Clean sacral wound with NSS, apply MediHoney and cover with dry dressing every day and evening shift for sacral wound, with a start date of 11/21/2022 at 1522 (3:22 PM) and D/C Date of 11/21/2022 at 1807 (5:07 PM); Zinc Oxide to redness on sacral area every shift for skin integrity with start date of 11/21/2022 with a start date of 11/21/2022 at 1522 (3:22 PM) and D/C Date of 11/21/2022 at 1807 (5:07 PM). The review of the TAR revealed that the start dates of the orders were three days after the wound assessment identified the order on 11/18/2022. The month of November contain an X, which indicated that the treatments were not administered. During an interview with the surveyor on 10/6/23 at 9:02 AM, Licensed Practical Nurse Unit Manager (LPN/UM #3) reviewed the Nursing Progress Notes, Physician Orders, Body Check Assessments, and Wound Assessments. LPN/UM #3 confirmed that there was no documentation of physician being contacted upon initial discovery of the injury. When asked if there should have been a delay the LPN/UM #3 responded, absolutely not [ .] treatment should have been in place right away. During an interview with the surveyor on 10/10/23 at 11:20 AM, the author of the Nursing Progress Note Licensed Practical Nurse (LPN #4) confirmed that nurses were responsible for any type of follow ups and the end of their shift. When inquired about the status of the physician notification for Resident #249's wounds LPN #4 responded, I endorsed it to [unit manager] and it was up to them. LPN #4 concluded the interview and stated, considering the circumstances, I don't recall what was going on at the time and would not elaborate. During an interview with the surveyor on 10/12/23 at 11:01 AM, the Director of Nursing (DON) advised that when a wound/pressure ulcer is observed, the nurses are to notify the physician, family, and wound care team and obtain a treatment order. The DON advised that the wound care team can be contacted at any time. When asked what the expected timeframe for a wound intervention the DON responded, immediately [ .] it can deteriorate and become infected. During an interview with the surveyor on 10/12/23 at 1:37 PM, the Licensed Nursing Home Administrator (LNHA) acknowledged that the nurse missed the treatment and no treatment was put into place. The LNHA further explained that the nurses staging of the wound may not be accurate based on the measurement and the overall description of the injury. The LNHA also acknowledged that the resident was hospice and declining significantly. During an interview with another surveyor on 10/16/23 at 8:51AM, the LNHA provided written acknowledgement that there was a failure to place treatment in place post finding of wound. A review the facility's Change in Resident Condition policy, with an effective date 5/2018 and revised date of 2/2022, included .1. The nurse will notify the resident's physician when there has been a (an): a. accident or incident involving the resident; [ .] d. significant change in the resident's physical/emotional/mental condition that impact their current pan of care; [ .] e. need to alter the resident's medical treatment significantly . A review the facility's Skin Management policy, with an effective date 12/2018 and revised date of 10/2021, included under the title Monitoring, 1. The staff will examine the skin of a resident with ulcerations or alterations in skin routinely. A review the facility's undated Skin Assessment document included under the title policy: skin assessments will be completed by the nurse upon admission and weekly thereafter. The aides will also monitor skin integrity during routine care, and will notify the nurse should they find any changes in the resident's skin. The document further relayed, the assessment should note any signs of redness, rash, bruises, abrasions, lacerations or breakdown. If found by the nursing assistance, they shall report their findings to the nurse immediately. The nurse will then assess the resident, and if warranted, notify MD for appropriate interventions. Documentation of the findings or lack thereof, will be documented in the resident's record. A review the facility's Job Description- LPN document, with an revision date 5/13, included .assess, monitor and evaluate the residents' physical and emotional status for significant changes on a continual basis and document such in the medical record [ .] take temperature, pulse, blood pressure and other vital signs to detect deviations from normal and assess condition of residents. NJAC 8:39-27.1(e)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order. This deficient practice was identified for 1 of 1 resident (Resident #137) reviewed for respiratory care, and was evidenced by the following: On 10/03/23 at 10:41 AM, the surveyor observed Resident #137 resting in bed watching television (TV). The resident was receiving humidified oxygen by nasal cannula (NC) from a concentrator, which the surveyor observed to be set to 1.5 liters per minute (lpm). On 10/04/23 at 11:19 AM, the surveyor observed Resident #137 sitting in a wheelchair in their room watching TV. The resident was receiving oxygen by nasal cannula with the oxygen concentrator set to 1.5 lpm. The resident informed the surveyor that they did not adjust the oxygen setting themselves, and that the facility nursing staff check on it every now and then. On 10/11/23 at 9:20 AM, the surveyor observed the resident eating breakfast in bed with the oxygen concentrator set to deliver oxygen at a rate of 1.5 lpm. On 10/13/23 at 9:05 AM, the surveyor observed the resident eating breakfast with the oxygen concentrator set to a rate of 1.5 lpm. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis which included but not limited to chronic obstructive pulmonary disease (COPD, respiratory disease), and chronic respiratory failure with hypercapnia (long term respiratory failure with excessive carbon dioxide in the bloodstream typically caused by inadequate respiration). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 7/3/2023, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which indicated the resident had moderate cognitive impairment. A further review reflected the resident was on oxygen therapy at the time of this assessment. A review of the resident's individualized resident-centered Care Plan included a focused care area indicating the resident's use of oxygen related to their medical diagnosis of COPD and chronic respiratory failure which was initiated on 3/30/2021 and included an intervention to administer oxygen as ordered. A review of the resident's physician's orders (PO) included an active order started on 9/20/2023 for oxygen at 3 liters per minute by nasal cannula continuous every shift related to COPD, and a second order with a start date of 10/11/2023 for oxygen 3 liters by nasal cannula as needed (PRN) to maintain blood oxygen saturation level (SpO2) greater than 92% every shift related to COPD. On 10/13/23 at 9:12 AM, the surveyor interviewed Licensed Practical Nurse #2 (LPN #2) who stated that oxygen concentrators should be set to deliver oxygen to the residents per the physician's order, and that she checked the concentrator's setting when rounding approximately every two hours. On 10/13/23 at 10:25 AM, the surveyor asked the Registered Nurse/Unit Manager (RN/UM) to check Resident #137's oxygen concentrator setting. The RN/UM accompanied by the surveyor went to the resident's room at which point the RN/UM confirmed that the concentrator was incorrectly set to 1.5 lpm and the PO was for 3 lpm. At that time, the RN/UM stated she should have caught that error during her rounds, and the nurse's assigned to the resident were responsible for ensuring the setting to be adjusted to the ordered setting. The RN/UM also confirmed that the setting should be to the level ordered even if it is ordered to be PRN. On 10/13/23 at 10:59 AM, the surveyor interviewed the Director of Nursing (DON) who stated that oxygen concentrator settings should be checked by the nursing staff every shift to ensure the oxygen is being administered to the residents as ordered. Review of the facility's Oxygen Therapy policy with a revision date of 12/2021 included: verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration . Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate ordered. Place appropriate oxygen device on the resident. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. NJAC 8:39 - 27.1(a)

Complaint # NJ 155924 Based on observation, interview, and review of facility documents, it was determined that the facility failed to ensure: a.) the accurate documentation of the administration of controlled medication for one unsampled resident (unsampled Resident #4) identified upon inspection of 1 of 8 medication carts (Rose Garden cart #1), b.) the shift to shift controlled medication count record was completed for 1 of 8 medication carts, (Rose Garden cart #2), c.) accurate documentation for the destruction of controlled medication for one unsampled resident (unsampled Resident #5) identified upon inspection of 1 of 8 medication carts (Rose Garden cart #2), and d.) medication was received timely from the provider pharmacy 1 of 35 residents (Resident #246) reviewed. These deficient practices were evidenced by the following: 1. On 10/12/23 at 11:10 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #4) inspected the [NAME] Garden cart #1. The surveyor and LPN #4 reviewed the controlled medications located in the secured and locked controlled medications box. When the controlled medication inventory was compared to the corresponding patient-controlled substance record, a declining inventory sheet, the surveyor identified the following concerns: Unsampled resident #4's morphine sulfate 30 milligrams (mg) tablets, a medication used for pain, did not match the declining inventory sheet quantity. The blister pack contained 44 tablets and the declining inventory sheet indicated there should be 45 tablets remaining. LPN #4 stated that the night supervisor and Registered Nurse #1 (RN #1) had counted the narcotics at change of shift, that she was not present at that time. LPN #4 further stated she was not made aware there was a discrepancy in the controlled medication count prior to taking over the cart and acknowledged she should have done her own narcotic count with the nurse before she had taken over the cart. LPN #4 stated two nurses, the outgoing and incoming nurse should count and then sign the narcotic log to ensure accuracy. On 10/12/23 at 11:29 AM, the surveyor interviewed RN #1 in the presence of the [NAME] Garden Licensed Practical Nurse Unit Manager (LPN/UM). RN #1 stated she had counted the narcotics for [NAME] Garden cart #1 with the night supervisor that morning and the night supervisor told her the evening nurse on 10/11/23 had not signed the declining inventory sheet when she had administered the morphine to unsampled resident #4. At that same time, the LPN/UM stated she had not been made aware there was a discrepancy identified. On 10/17/23 11:02 AM, the surveyor interviewed the Director of Nursing (DON) who stated she was aware of the discrepancy in the declining inventory sheet for unsampled resident #4. The DON further stated that two nurses must count and sign the narcotics at the start and at the end of every shift. 2. On 10/12/23 at 11:29 AM, the surveyor, in the presence of Registered Nurse (RN#1), reviewed the October 2023 Record of Narcotic Sedative Barbiturates Abuse Drug Count, a shift-to-shift record accounting for the accuracy of each individual resident's controlled medication declining inventory sheet, for [NAME] Garden medication cart #2 and observed the following blank areas: 10/6/23 11:00 PM, no signature or initials- Column 1 for incoming nurse. 10/7/23 7:00 AM, no signature or initials- Column 2 for outgoing nurse. 10/7/23 11:00 PM, no signature or initials- Column 1 for incoming nurse. 10/9/23 3:00 PM, no signature or initials- Column 1 for incoming nurse. 10/9/23 11:00 PM, no signature or initials- Column 1 for incoming nurse. 10/12/23 7:00 AM, no signature or initials- Column 1 for incoming nurse. 10/12/23 3:00 PM, no signature or initials- Column 2 for outgoing nurse. On 10/12/23 at 11:29 AM, the surveyor interviewed RN #1 regarding the discrepancies in the controlled medication count record. RN#1 stated the incoming nurses must count the controlled medications with the outgoing nurses and both nurses must sign the narcotic log. 3. On 10/12/23 at 11:29 AM, the surveyor, in the presence of RN #1 reviewed the alprazolam, a medication used for anxiety declining inventory sheet, for unsampled Resident #5 which revealed on 9/07/23 at 9:00 AM, a dose of alprazolam 0.25 mg tablet, a medication that had been documented as wasted. There was no nurse signature to account for who had wasted the medication. RN #1 stated when wasting controlled medications there should be two nurses who witness the destruction and disposal of the medication and once finished, they both signed the declining inventory sheet as witness. On 10/17/23 11:02 AM, the surveyor interviewed the DON who stated she was aware of the entries that were not documented. The DON further stated that two nurses must count and sign the narcotics at the start and at the end of each shift. She further stated when a controlled medication needed to be wasted two nurses needed to destroy the medication and then both must sign the declining inventory sheet. 4. On 10/17/23 at 10:40 AM, the surveyor conducted a review of medical records for Resident #246 which revealed the following: A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis which included but not limited to opioid dependence and restless leg syndrome (RLS). A review of the resident's physician orders (PO) included an order dated 6/15/22 for methadone hcl 10 milligrams (mg) tablets, a narcotic medication used to treat pain give one tablet by mouth at bedtime for RLS. Another order dated 6/18/22 for methadone hcl 5 mg give two tablets by mouth at bedtime for RLS. A review of the June 2022 Medication Administration Record (MAR) revealed the resident received their first dose of the ordered methadone medication on 6/19/22 at 9:00 PM. A review of the resident's individualized resident-centered Care Plan included a focused care area which an indicated the resident was at risk for pain, and included interventions which included to administer pain meds as ordered and document effectiveness and observe and document if pain med was effective and notify doctor (MD) if needed. A review of nursing and provider (doctor and nurse practitioner) progress notes included the following: 6/19/2022 at 9:30 PM the nurse practitioner (APN) noted has chronic pain syndrome for which (resident) takes methadone nightly. Scripts done on evening of admission, but patient has not yet received any methadone here since it has not been delivered from pharmacy . has not yet received delivery of methadone here, although scripts have been written since day of admission. Per staff, pharmacy didn't have 10mg tabs, so they requested new Rx for 5mg ii tabs. Nursing staff has reportedly been in touch with pharmacy again today. 6/27/2022 at 3:00 PM, the APN noted will continue other meds as they are. Son suspects some of changes/mood issues initially could have been due to missing methadone for about 4 days or so, which is certainly possible. On 10/18/23 at 10:35 PM, the surveyor interviewed Licensed Practical Nurse/ Unit Manager #1 (LPN/UM #1) who informed the surveyor that typically medications can be ordered and delivered from the pharmacy quickly. She informed the surveyor that with narcotic medications, the doctor (MD) was notified, and usually they sent the written prescription to the pharmacy by fax the same night and the pharmacy delivered it the next day. She also added that the pharmacy had multiple deliveries per day and sometimes overnight. LPN/UM #1 also stated that if a medication was not available and the pharmacy recommended another available strength, then the MD was notified, and they usually were able to send a new script to the pharmacy right away. On 10/18/23 at 10:56 AM, the surveyor interviewed the DON, who confirmed that the pharmacy had scheduled deliveries at approximately 6:00 AM, 4:00 PM, and 11:00 PM daily and if necessary, STAT (immediate) deliveries were available. The DON also stated that four (4) days was not an appropriate or acceptable time frame for ordered medication to be delivered and administered to the resident. She stated that it was expected that if the nurse had a situation where medication was unable to be delivered and administration was delayed that they relay that information to the unit manager who would stay on top of it in order to receive the medication timely. On 10/18/23 at 11:25 AM, the surveyor called and spoke with the pharmacist (RPh) at the provider pharmacy utilized by the facility. The RPh stated that going through the documentation on their end, she was able to locate one script for methadone 5 mg #2 tablets every night dated 6/15/22, and a second one with the same order dated 6/19/22. The RPh confirmed that the prescription dated 6/15/22 was filled and delivered on 6/19/22, and the prescription dated 6/19/22 was filled and delivered on 6/20/22. The RPh was unable to locate any further documentation or reason why there was a delay in delivering the medication for four days. On 10/19/23 at 11:50 AM, in the presence of the survey team, the facility's Licensed Nursing Home Administrator (LNHA), DON, and the Regional Nursing Coordinator (RNC) confirmed the four-day delay in obtaining the methadone for Resident #246. When asked if it was acceptable to wait that long for medication, the RNC replied of course not, no and the DON informed the team that the primary provider pharmacy had a backup pharmacy if they could not provide a medication. The administrative team stated they don't disagree, there should not have been a delay that long for the resident to have received their medication from the pharmacy. A review of the facility's Controlled Substance Medication Policy and Procedure revised 10/1/2018 . When CDS medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials. An inventory count of all CDS medications stored on each nursing unit shall be performed at each change of each shift by both the incoming and outgoing nurse. Both nurses are responsible for the count and must sign the inventory count form. A review of the facility's Delivery of Medications from Satellite (Back-up) Pharmacy with revision dated 10/1/2018 and included . Purpose: to provide medications in a timely manner by utilizing satellite (back-up) pharmacies to dispense medications that are needed by a facility sooner than the regularly scheduled delivery. Under the section labeled Policy it included the pharmacy strives to provide all medications in a timely manner that is acceptable by the facility and more importantly by the resident . The section labeled Procedure included: if a medication is needed by a facility within a time frame that is unreasonable to be dispensed . the facility may call the pharmacy and request a STAT delivery . has a 2-3-hour window to deliver a medication as a STAT from our main location. If a medication is needed in a more immediate time frame, the medication may be processed via a back-up pharmacy closer to the location of the facility. NJAC 8:39-29.2(d); 29.7(c)

Complaint # 159668 Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident was provided water consistent with the need to maintain resident hydration. This deficient practice was identified for 1 of 1 resident (Resident #59) reviewed for choices and was evidenced by the following: On 10/03/2023 at 11:08 at 10:56 AM, the surveyor observed the resident seated in a wheelchair by the doorway. Resident #59 stated that they were not offered water and had to request water that day. When asked if water was offered throughout the day, Resident #59 denied. On 10/04/2023 at 11:46 AM, the surveyor observed the resident sitting by the doorway of their room. There was no water cup at the resident's bedside. The resident stated that they had requested water and did not get any that day. 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 with diagnosis that included failure to thrive, muscle wasting, and atrophy (partial or complete wasting away of a part of the body). A review of the most recent Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 8/31/23, reflected a Brief Interview for Mental Status (BIMS) score of 11 out of 13, which demonstrated moderately impaired cognition. The MDS also identified Resident #59 as enrolled with Hospice Services. A review of the individualized comprehensive care plan (ICCP) included a focus area initiated on 10/03/2023, that the [Resident] had a Hospice Care need due to muscle wasting and atrophy, with a goal that stated [the resident] would be free of hunger, thirst and dry mouth. Another focus area included that the [Resident] was at risk for malnutrition related to to Hyponatremia [ .]. Interventions included: Honor food and beverages preferences. On 10/05/2023 at 12:10 PM, the surveyor interviewed Certified Nursing Aide (CNA #1) who acknowledged that water was one of the first things that they were to check and ensure that it was available for the resident at the beginning of the shift. On 10/11/2012 at 9:33 AM, the surveyor interviewed CNA #2, who also confirmed that water is offered in the overnight shift and is usually still icy in the morning so water was given around 10-11am. However, CNA #2 confirmed that water was still checked to make sure the cup was full. When asked what happens if there was no cup visible around the resident CNA#2 responded that they were to offer another cup of water. On 10/12/2012 at 11:01 AM, the surveyor interviewed the Director of Nursing (DON) who reported that water was offered every shift to those that had the proper hydration orders. The DON confirmed that the CNAs should check on the water during their morning rounds. The DON also confirmed that residents should always have a fluid cup readily available and that not having proper fluids nearby could be a concern for their hydration status. A review the facility's undated Resident Hydration and Prevention of Dehydration document included 6. Fresh water will be provided at bedside to those residents who are permitted [ .] 7. Nursing will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care . NJAC 8:39-17.4(c), (e)

Complaint # 159668 Based on interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practice by not documenting pertinent clinical documentation on the resident's medical record for a resident who was transferred to the hospital. This deficient practice was identified for 1 of 4 residents (Resident #249) reviewed for hospitalization and was evidenced by the following: The surveyor reviewed the medical record for Resident #249. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Atrial Fibrillation. A review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 5/17/23, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which demonstrated moderately impaired cognition. The MDS also identified Resident #249 as receiving Hospice Services. A review of the Nursing Progress Notes included a note dated 11/20/2022 at 2:57 PM that indicated, Power of Attorney (POA) (granddaughter) of resident approached this writer at [2:25 PM], requesting that [the resident] be sent to [hospital] for evaluation of status. Supervisor made aware of family request at [2:30 PM]. [Hospice] contacted and message left for nurse at [2:35 PM]. Hospice Nurse returned call at [2:45 PM]-notified of resident transfer. [Transport Company] contacted to arrive at [5:50 PM]. Oncoming nurse notified of resident status- need to contact POA [related to] transport. There was no documented evidence of the resident's clinical condition, including patient condition, vital signs, and physician notification, for Resident #249's transfer to the hospital. A review of the New Jersey Universal Transfer Form (UTF) documented the incorrect date of transfer (11/24/2022) and time of transfer (12:00 AM). The UTF further failed to indicate the reason for transfer, code status, isolation precaution, sensory, intravenous access, and personal items sent with patient. During an interview with the surveyor on 10/6/23 at 9:02 AM, Licensed Practical Nurse Unit Manager (LPN/UM #3) reviewed the referenced Nursing Progress Note. LPN/UM #3 confirmed that the progress note was not a complete assessment. LPN/UM #3 further explained that the following information was missing: cognitive status, documentation as to whether the resident is stable, physician notification, vital signs, and body checks. During an interview with the Licensed Nursing Home Administrator (LNHA) on 10/6/23 at 11:17 AM, the surveyor questioned if the provided UTF was correct. The LNHA responded, that is what the Director of Nursing (DON) gave me. When asked about the date of transfer identified on the UTF the LNHA stated, oh [the resident] was out of the building by the 22nd, I believe. During an interview with the surveyor on 10/10/23 at 11:20 AM, when questioned regarding the patient condition, the author of the first Nursing Progress Note, Licensed Practical Nurse (LPN #4), stated that considering the circumstances, I don't recall what was going on at the time and would not elaborate further. During an interview with the surveyor on 10/12/23 at 11:01 AM, the Director of Nursing (DON) confirmed that a change in condition required a full assessment including lung sounds, vitals, and possible neurological. The DON further confirmed that the UTF dated 11/24/2022 was not the correct form. During an interview with the surveyor on 10/13/23 at 11:30 AM, Nurse Practitioner (NP #1) reported that there was an expectation that an assessment for change in status included vital signs and a description of how the change presented. When asked if this information should be entered in the electronic charting system NP #1 stated, Yes all this information is to be in there. During an interview with the surveyor on 10/13/23 at 1:49 PM, the LNHA stated that they had requested a copy of the UTF from the hospital. When asked if the UTF was part of the patient's medical record and to be kept in the facility the LNHA confirmed and stating yes. During an interview with another surveyor on 10/17/23 at 10:21 AM, the LNHA provided written acknowledgement that there was no documentation of Resident #249's clinical status in the progress notes. A review the facility's Hospital Transfer Process document dated 8/2017, included .When it is necessary to transfer a resident to the hospital, an assessment should be completed by the charge nurse. A review the facility's Transfer Process document dated 10/2019, included .when a resident requires transfer to the hospital or another facility a New Jersey Universal Transfer Form is to be completed and sent with the resident. A copy of the New Jersey Transfer Form is to be kept in the resident chart. A review the facility's Change in Resident Condition policy, with an effective date 5/2018 and revised date of 2/2022, included .2. prior to notifying the Physician/healthcare provider, and authorized representative, the nurse will gather relevant and pertinent information. A review the facility's Job Description- LPN document, with an revision date 5/13, included .assess, monitor and evaluate the residents' physical and emotional status for significant changes on a continual basis and document such in the medical record [ .] take temperature, pulse, blood pressure and other vital signs to detect deviations from normal and assess condition of residents. NJAC 8:39-35.2(d)6,16(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to monitor and document the amount of fluids administered on a resident on hemodialysis with fluid restriction. This deficient practice was identified for 1 of 2 residents reviewed for dialysis, Resident #171, and was evidenced by the following: On 10/04/23 at 12:09 PM, the surveyor observed Resident #171 in their room and observed an unmarked white cup with a lid on the overbed table. The resident stated the cup contained water and would drink the water but not too much. The resident opened the cup and showed surveyor the contents of the cup. The resident further stated that they received hemodialysis three times a week and was also on a fluid restriction. The surveyor observed a picture of a water pitcher taped next to Resident #171's room number and name on the door. On 10/04/23 at 12:12 PM, the surveyor interviewed the Certified Nurses Aide (CNA #5) who stated the water pitcher on the resident's door meant the other resident in the room was on water with thickener. On 10/04/23 at 12:24 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #5) outside the resident's room, who stated Resident #171 received hemodialysis and was on a fluid restriction. LPN #5 stated the resident was on a fluid restriction of 800 milliliters (ml) for the 7-3 shift, 500ml for the 3-11 shift, and 200 ml for the 11-7 shift. At that time, the LPN saw the white cup with water on the resident's overbed table. LPN #5 stated residents on fluid restrictions were not supposed to have a water cup at their bedside and removed the cup. On 10/05/23 at 11:37 AM, the surveyor observed a white cup with dark liquid with ice in it on top of Resident #171's overbed table. On 10/10/23 at 7:54 AM, the surveyor observed a white cup half-filled with water on the resident's bedside table. According to the admission Record, Resident #171 had diagnosis which included but were not limited to End Stage Renal Disease, Anemia, Heart Failure, Type 2 Diabetes Mellitus. A review of the resident's Annual Minimum Data Set (MDS) dated [DATE] revealed resident had a Brief Interview of Mental Status (BIMS) of 15 which indicated that the resident's cognition was intact. A review of the resident's care plan initiated 07/27/2022 revealed resident was on 1500ml Daily Fluid Restriction which included; Nursing-7-3 800ml, 3-11 500 ml, 11-7 200 ml with fluid preferences of water and coffee. A review of the resident's Physician's Orders (PO) dated 01/25/23 revealed an order for: 1500 ml Fluid Restriction, Nursing serve (7-3 800 ml, 3-11 500 ml, 11-7 200 ml) fluid preferences of coffee, water. A review of the resident's Medication Administration Records (MAR) revealed the aforementioned PO with following dates that Resident #171's fluids per shift were not documented: July 2023 MAR from 07/01/23 to 07/31/23; August 2023 MAR from 08/01/23 to 08/31/23; September 2023 MAR from 09/01/23 to 09/30/23; and October 2023 MAR from 10/01/23 to 10/03/23 On 10/10/23 at 8:21 AM. the surveyor interviewed the Unit Manager LPN (UM/LPN #3) who stated Resident #171 was on hemodialysis with a fluid restriction of 1500ml a day. She further stated nurses would give the resident fluids in the amount scheduled for the shift and then would document the amount of fluid that was given in the resident's electronic Medication Administration Record (eMAR) at the end of their shift. On 10/10/23 at 9:45 AM, the surveyor interviewed the Director of Nursing (DON). who stated residents who were on fluid restriction must have an order from the physician. The DON further stated staff would know if residents were on fluid restriction because of the water pitcher picture next to a resident's name on the door. The DON stated only nurses would give fluids to residents who have a fluid restriction and that residents should not have water cups at their bedside. The DON stated nurses would document the amount of fluids the resident had at the end of their shift in the eMAR. DON stated the nurses of resident #171 should have documented the amount of fluids in the medication administration record. A review of the facility's Policy & Procedure on Restricting/Encouraging Fluids General Policy Guidelines with revised date of 04/2021, #4 stated to record fluid intake in milliliters (ml) in the eMAR, #8 when resident is placed on restricted fluids, remove the water pitcher and cup from the room, and #6 document the amount in mls of fluids consumed by the resident during the shift. NJAC 8:39-2.9

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to a.) properly label, date and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and dishware in a manner to prevent microbial growth and cross contamination and c.) ensure activity staff were wearing hair nets when entering the kitchen. This deficient practice was observed and evidenced by the following: 1. On 10/03/2023 at 09:45 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the Assistant Food Service Director (AFSD) attempt to remove two boxes of croissants that were not properly labeled with open or discard dates. The first box contained 7 unwrapped croissants and the second box was unopened and did not include a received or a discard date. The surveyor interviewed the AFSD, who confirmed that the 2 boxes of croissants were being discarded because they were not properly labeled. In the walk-in refrigerator, there was a large cart full of sandwiches that not properly labeled. The FSD stated the items were taken from the boxes that were labeled and placed in the cart that they use daily. The FSD confirmed that the sandwiches should have been dated. In the walk-in freezer, there were three large silver trays that contained unwrapped food exposed to the air. The AFSD placed a piece of paper over the top of the trays with a date of 10/03/2023 which was the date of the tour. The FSD confirmed that the trays should have been thoroughly wrapped, labeled, and stored properly. Upon exiting the walk-in refrigerator, the surveyor observed the AFSD with a black marker writing on large containers from the spice rack. The surveyor observed 13 large bottles of spices and sauces to include soybean oil, barbeque sauce, and soy sauce that were not properly labeled with received, opened, or discard dates. The FSD confirmed that the spices and sauces should have been dated when they were received and should include an expiration date. On that same day at 9:57 AM, the surveyor observed two boxes of white coffee filters that were open, uncovered and exposed to air in the paper product storage area. The FSD stated that the coffee filters should have been covered to prevent dust, debris, and any dirt from coming in contact with them. The surveyor observed a dented can in the non-dented can area in the dry storage area. The FSD confirmed the dented can should not be with the non-dented cans. On 10/03/2023 at 10:06 AM, the surveyor observed two tall food warming carts that had buildup of a black, greasy substance on the inside doors, on three trays that were inside, and on the warmer bottoms. The FSD stated the warmers were used for breakfast and acknowledged there were lunch items in the warmers. The FSD confirmed there was debris in the warmers and stated the warmers should have been cleaned between each meal preparation to prevent cross contamination. On the same day at 10:12 AM, the surveyor observed an uncovered mixing bowl exposed to the air. The FSD stated that the mixing bowl was clean and should have been covered. On 10/03/2023 at 10:17 AM, the surveyor observed the dumpster area which had debris on both sides of the compactor to include used face masks, wooden sticks, 2 broken florescent bulbs, plastic bags, newspapers, a juice cup, and a milk carton. The FSD acknowledged the debris. 2. On 10/04/23 11:18 AM, the surveyor observed 18 place settings for lunch meal in the main dining room. The place settings included an inverted plastic blue mug, two clear plastic cups, utensils, and a napkin. The surveyor observed the inside of the mugs. Two of the mugs had a brown powder like debris, one had a brown powder like debris and a piece of a wet white substance, one had a brown powder like debris and several white spots. The surveyor interviewed a cook who acknowledged that the mugs were not clean and stated, Not at all, I'm sorry. Upon further interview the cook stated there was no specific staff member who was responsible for the place settings. On 10/11/23 at 11:01 AM, the surveyor observed 18 place settings for lunch meal in the main dining room which included inverted plastic blue mugs. Two of 18 mugs had a brown powder like debris and one mug also had two brown particles. On 10/12/23 at 10:39 AM, the surveyor interviewed a dietary staff member (DS) regarding the table settings. The DS told the surveyor that the task of setting the tables was rotated among staff, and it changes daily. She stated, I haven't done this in four months. The DS further stated that the staff check the cups for cleanliness. She also described the cleaning process for the mugs as follows: They get soaked every Sunday only, we can't do it every day because if it's lunch time and we would be behind because there are only so many cups, and we only have enough cups for one meal setting. If cups are soiled, we would remove it and sometimes we have an extra staff person who can soak a few cups on that day. On 10/13/23 at 11:52 AM, the surveyor interviewed the Food Service Director (FSD) regarding the cleaning process of the plastic mugs. The FSD stated the mugs were de-stained on Sundays, Every Sunday, we soak them in an urn with cleaner, then each one gets hand wiped on the inside and then sent through the dish machine. The FSD stated, I notice a few of them have not been completely clean and they should be checked before they put them out. 3. On 10/4/23 at 12:03 PM, the surveyor was conducting a dining observation in the main dining room. The surveyor observed a sign by the entrance to the kitchen that read, Hair nets All staff members are required to wear a hairnet prior to entering the kitchen. Located below the sign was a mounted bin that contained hair nets. On 10/04/23 at 12:26 PM the surveyor observed Activity Aide (AA) #1 enter the kitchen, walk around, exited and reentered the kitchen. AA #1 had long hair and was not wearing a hair net. At 12:26 PM, the surveyor observed AA #2 enter the kitchen walked around kitchen, left the kitchen, entered the kitchen again and exit the kitchen. AA #2 had visible hair on his head and was not wearing a hair net. During an interview with the surveyor on 10/04/23 at 12:28 PM, AA #2 stated that she was getting cups and was not sure if she needed to wear a hair net. The surveyor showed the sign by the kitchen entrance to AA #2. AA #2 replied that she didn't know. During an interview with the surveyor on 10/04/23 at 12:55 PM, AA #1 stated he was not aware he needed to wear a hair net when entering the kitchen. During an interview with an additional surveyor on 10/13/23 at 10:29 AM, the FSD stated that hair nets need to be worn before entering the kitchen so there's no hair or foreign debris in the food and also for the plates and the cups. The surveyor reviewed the facility's revised policy dated 10/18/2023 titled, Received on Date/Expired Items which revealed the facility would follow established methods for dating items that were delivered and discarding out of date items immediately. Procedure: 1. When receiving any food items from the vendors, each item will have a Received on Date written on the packaging. If an item is removed out of the packaging (i.e. Apple Pie) the received on date will be written on the individual item, using the original date. 2. During opening and closing rounds, the management team or designee will check to make sure all appropriate dating is found and accurate. The surveyor reviewed the facility's revised policy dated for 10/18/2023 titled, Labeling and Dating of Pulled Frozen Items, which revealed the purpose was to safely and correctly label and date frozen foods being thawed. Procedure: 1. Any item that is pulled from the freezer to the refrigerator for thawing shall have the following information listed on the parchment paper/label a. item description, b. pulled on date, c. amount pulled for thawing, d. which meal the item is for, e. use by date, f. employee initials. 2. Parchment paper/label will be replaced when soiled using the same information listed above. The surveyor reviewed the revised policy dated for 10/18/2023 titled, Dented Cans which revealed the facility will ensure that no dented cans were utilized in daily production. Procedure: Any employee that comes across a dented can must remove said can and place on the dented can rack which is clearly labeled and visible in the kitchen. 2. The employee shall alert a manager who will then take the appropriate actions. The surveyor reviewed the policy dated for 05/30/2022 titled, Cup Destaining. The purpose of the policy was to maintain a clean and stainless hot beverage cup. Under the section titled process, it included the process for the cup destaining and that the cups were destained every Sunday. The policy did not have a process to destain if needed on any day other than a Sunday. A review of a facility policy with a subject titled, Hair Covering and [NAME] Covering revised on 1/14/2019 included that the facility would follow established methods for use of hair nets and beard covers. The purpose was to ensure no foreign items specific to bodily hair, are to contaminate not only food items, but also other equipment. The procedure indicated that any employee or guest entering the food and nutrition department, kitchen or tray line service area will be required to wear at all times a hair covering for the head. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/04/23 at 1:19 PM, during dining observation in the 1st floor day room, the surveyor observed Activities Aide #2 (AA #2), pick up a cup that had fallen on the floor and without performing hand hygiene continued to assist with passing lunch trays to the residents. On 10/13/23 at 11:05 AM, the surveyor interviewed AA #2, who stated that when assisting with meal service, if something fell on the floor he would pick it up and put it to the side, so it was not used. He stated he was unaware of the need for hand hygiene after picking up an object off the floor; however, he verbalized the need to perform hand hygiene. 3. On 10/03/23 at 10:41 AM, the surveyor observed Resident #137 resting in bed watching television (TV). The resident had an indwelling catheter for urine collection. The collection bag was observed to be resting on the floor under the resident's bed without a privacy bag and with no protective barrier between it and the floor. The resident informed the surveyor that they have had an indwelling catheter for a couple years and had experienced multiple urinary tract infections in the past, with the most recent being approximately a couple months ago. On 10/11/23 at 9:22 AM, the surveyor observed the resident eating breakfast in bed with the indwelling catheter's urine collection bag resting on the floor under the bed with no privacy bag or barrier between it and the floor. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis which included but not limited to retention of urine, neuromuscular dysfunction of bladder (miscommunication between the nerves and muscles), benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous prostate enlargement), and urinary tract infection. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 7/3/2023, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which indicated the resident had moderate cognitive impairment. A further review reflected the resident had an indwelling catheter. A review of the resident's individualized resident-centered Care Plan included a focused care area with an initiation date of 11/23/2021 indicating the resident had an indwelling urinary catheter, with interventions including but not limited to providing catheter care as ordered. A review of the resident's physician's orders (PO) included an active order started on 5/31/2023 for catheter care every shift. On 10/13/23 at 9:36 AM, the surveyor interviewed Certified Nurse Aid #3 (CNA #3) who stated that indwelling urinary catheter bags should be hanging from the side of the bed below waist level in a privacy bag and not on the floor, stating the reason it should not be on the floor is for infection control, since residents can get an infection through the tubing if it was on the floor. On 10/13/23 at 10:38 AM, the surveyor interviewed Licensed Practical Nurse #2 (LPN #2) who stated that indwelling catheter urine collection bags should never be unprotected on the floor and should be in a privacy bag hanging from the side of the bed below waist level. LPN #2 further added that if the bag was on the floor, it was definitely an infection control issue and it should be changed. On 10/13/23 at 10:48 AM, the surveyor interviewed the Infection Preventionist nurse (IP) who stated that indwelling catheter collection bags should not be on the floor due to infection control, and that having the bag on the floor was not appropriate. On 10/13/23 at 10:59 AM, the surveyor interviewed the DON who confirmed that having the catheter bag on the floor was not acceptable and was an infection control concern. On 10/18/23 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing and Regional Clinical Nurse to discuss the above observations and concerns. Review of the facility's Handwashing/Hand Hygiene policy and procedure with an revised date 06/10/2022, revealed the following: The facility considers hand hygiene the primary means to prevent the spread of infections. The policy reflected that .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, soap (antimicrobial or non-antimicrobial) and water . Review of the facility's Urinary Catheter Care policy with a revision date of 3/2021 under the section labeled Infection Control included: Be sure the catheter tubing and drainage bag are kept off the floor. NJAC 8:39-19.4 (a)1(m)(n);27.1(a) Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) practice appropriate hand hygiene between residents after direct contact with residents during meal service on 1of 2 units (day room [ROOM NUMBER]) b.) perform hand hygiene when handling a contaminated item from the floor on 1 of 2 units (day room [ROOM NUMBER]) and c.) ensure that a urinary catheter drainage bag was stored in a manner to prevent the spread of infection forone of five residents reviewed for urinary catheters and urinary tract infections (UTIs), Resident #137. This deficient practice was evidenced by the following: 1. On 10/4/23 at 12:13 PM, the surveyor observed meal service on the second floor day room [ROOM NUMBER]. At 12:13 PM, the surveyor observed the food truck arrived on the second floor day room [ROOM NUMBER]. At 12:14 PM, the surveyor observed a certified nurses aide (CNA) #6 assisting 4 unsampled residents with hand hygiene using hand wipes. CNA #6 proceeded to cleanse the hands of each unsampled resident without sanitizing or performing hand hygiene between the 4 residents. At 12:18 PM, CNA #7 entered day room [ROOM NUMBER] and began cleansing the hands of Resident # 80, Resident #108 and two unsampled residents with hand wipes without performing hand hygiene between residents. On 10/13/23 at 12:05 PM, the food truck arrived on the second floor in day room [ROOM NUMBER]. At 12:09 PM, the surveyor observed CNA #6 use hand wipes to clean the hands of 8 unsampled residents. The surveyor observed that CNA #6 did not perform hand hygiene between residents. At 12:15 PM, the surveyor interviewed CNA #6 who acknowledged that she had not performed hand hygiene before and after cleaning the residents hands because she was rushing today. The surveyor explained to CNA #6 that during meal service on 10/4/23 she observed CNA #6 using hand wipes to clean residents hands and did not observe CNA #6 perform hand hygiene after touching and cleaning each residents hands. CNA #6 stated that she was also rushing on that day but acknowledged the importance of performing hand hygiene in order to prevent the spread of infection. On 10/16/23 at 9:43 AM, the surveyor interviewed CNA #7 in the presence of the Licensed Practical Nurse Unit Manager (LPN/UM) #2. The surveyor asked CNA #7 her process for providing hand hygiene for residents prior to meals. CNA #7 stated she used hand wipes to clean the residents hands. The surveyor asked CNA #7 what she did after cleaning the hands of one resident before assisting another resident. CNA #7 replied, dry their hands. The surveyor asked LPN/UM #2 if it was her expectation that the CNA performed hand hygiene between residents. LPN/UM replied, of course. CNA #7 acknowledged that she should be performing her own hand hygiene between residents but stated that she had not been doing that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REPEAT DEFICIENCY Complaint # NJ 159503, NJ 160417, NJ 162667 Based on observation, interview, and review of facility documentation it was determined that the facility failed to consistently serve foods at safe and appetizing temperatures. This deficient practice was identified for 2 of 2 units reviewed and was evidenced by the following: 1. On 10/05/23 At 12:25 PM, the surveyor observed large stainless trays with lunch food arrive to the day room one steam table. There were 13 residents seated in day room one waiting for lunch to be served. All of the other unit residents from the first floor had lunch in their rooms. The food service staff began making lunch trays from the steam table. As the trays were being prepared for the residents some trays were handed to the residents in day room one and other trays were placed on a silver open tray cart to be distributed to resident rooms. Trays were placed on the cart for delivery to rooms prior to all of day room one residents receiving their trays. On 10/05/23 at 12:45 PM, the open cart with the resident trays left the dining room and was placed in the hallway on the unit. On 10/05/23 at 12:49 PM, the unit staff began handing out the seven trays for the first-floor wing being observed. At 01:05 PM, just prior to the final tray being handed to the resident the surveyor requested the FSD to obtain food temps on that selected tray. The temperatures were as follows: Cheeseburgers @ 121.5 degrees Fahrenheit (F), Onion rings @ 101.3 degrees F Green bean salad (warm salad per FSD) @ 111.6 Four ounce carton of milk @ 58 degrees F. The tray was discarded after temperatures were obtained. Immediately following completing the temperature checks, the FSD responded, I know none of them meet temp. 2. On 10/10/23 at 7:58 AM, the surveyor observed large stainless trays with breakfast food arrive to the second floor day room [ROOM NUMBER] steam table. There were no residents in day room [ROOM NUMBER]; all residents who reside on the second floor were served breakfast in their rooms. The Dietary [NAME] (DC) in the presence of the surveyor took food temperatures with his calibrated thermometer. The following temperatures were obtained: Strawberries with syrup @ 100 degrees Fahrenheit (F) Pureed French toast @ 138 degrees F Boiled eggs @132 degrees F At that same time, the DC stated that he would have to bring the above items back to the kitchen because the temperatures needed to be at least 145 degrees F and that all other food temps were above 145 degrees F. On 10/10/23 at 8:07 AM, the DC brought the above items back to the kitchen. On 10/10/23 at 8:19 AM, the DC returned to day room [ROOM NUMBER] with the aforementioned foods and again sampled the temperatures. The following temperatures were obtained: Boiled eggs @ 155 degrees F Pureed French Toast @145 degrees F Strawberries with syrup @ 130 degrees F On 10/10/23 at 8:28 AM, the surveyor observed the following: At 8:28 AM, the first meal was plated. At 8:34 AM, the first silver open food cart was brought to the Ivy Unit for distribution. At 9:40 AM, the Food Service Director (FSD) arrived to day room [ROOM NUMBER] with an additional large stainless tray with cream of wheat which he placed on to the steam table. At 9:41 AM, the last meal was plated. At 9:42 AM, the last open cart was brought to the [NAME] Garden Unit for distribution. At 9:43 AM, the surveyor asked the DC to temp the french toast, strawberries with syrup and sausage patty. The DC stated he misplaced his thermometer. At 9:46 AM, the DC dumped all the bowls out of a large box and discovered the thermometer. The DC told the surveyor that he still couldn't take temps with that thermometer because it was, acting up. The FSD stated that he would go get a new calibrated thermometer. On 10/10/23 at 9:59 AM, the surveyor observed the last tray served which contained french toast, ground sausage patty and coffee. At that time, the surveyor requested the DC to again sample the food temperatures. Then with a new calibrated thermometer the following temperatures were obtained: french toast with strawberries in syrup @ 127 degrees F ground sausage patty @ 111 degrees F. The DC stated that the temperatures were not within regulation. The DC further stated that meal service should have been completed within one hour, not two hours and that he didn't know what happened. On 10/10/23 at 10:30 AM, the surveyor interviewed the Food Service Director (FSD). The FSD stated that hot foods should be above 140 degrees F and cold foods should be below 41 degrees F in order to prevent food-born bacteria. The FSD agreed that the temperatures were not maintained at appetizing temperatures for the residents. The FSD stated that meal service should take no more than an hour, definitely not two hours. On 10/11/23 at 9:36 AM, the surveyor observed the last breakfast tray delivered to the room of an unsampled resident. On 10/11/23 at 9:38 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager ( LPN/UM) #2, who stated that meal service should be completed within one hour and that all available staff were expected to help pass out trays. The LPN/UM #2 further stated that she did not have a list of residents, nor was she aware of which residents preferred to receive early meal trays so that they could attend activities of their choice including church services. On 10/18/23 at 12:16 PM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional Clinical Nurse. The DON stated that when the DC removed the trays of food from the steam table they should have been placed back into the heated truck and transported back to the kitchen. No further information was supplied. A review of a facility policy titled, Food Temperatures, with an effective date of 11/30/17 indicated that the foods are stored, prepared, and served at proper temperatures. Under the process section of the policy, it revealed that all time/temperature control for safety food must maintain an internal temperature of 41 degrees Fahrenheit or lower for cold foods and 140 degrees Fahrenheit or higher for hot foods while being held for service, internal cooking temperature, and holding temperatures of foods. NJAC 8:39-17.4(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of pertinent facility documentation, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement Program's (QAPI) sources of quantitative data was being analyzed to evaluate program effectiveness and implement new processes. This deficient practice was identified during the standard survey and was evidenced by the following: Refer to F 804 F During the standard survey, the surveyors conducted meal observations on 10/5/23 and on 10/10/23. On 10/5/23 beginning at 12:25 PM, the surveyor observed the lunch service in day room one. The surveyor observed the lunch tray preparation begin at 12:25 PM, and ended with the last lunch tray served at 1:05 PM. During the observation, some trays were handed to the residents in the day room one, and some tray were placed on an open tray cart to be delivered to the resident rooms. On that same day at 12:45 PM, the open food cart contained the resident lunch trays and left the day room and were placed in the hallway. On that same day at 1:05 PM, as the last tray was to be hand to the resident, the surveyor requested the FSD to obtain food temperatures on that tray. The FSD obtained the food temperatures which were not within acceptable ranges. The FSD stated that none of the hot and cold food items met acceptable food temperatures. On 10/13/23 beginning at 7:58 AM, the surveyor observed breakfast service on the second floor day room two. At 7:58 AM, the breakfast arrived to day room two. The Dietary [NAME] (DC) obtained the temperatures of the breakfast food, and returned the food to the kitchen because the food was not hot enough. On that same day at 8:19 AM, the Dietary [NAME] (DC) returned to dayroom two with the breakfast food, and obtained the temperatures. The surveyor observed the that the first tray was plated at 8:28 AM. The last tray was plated at 9:41 AM and was served at 9:59 AM. At that time, the surveyor requested the FSD to obtain food temperatures on the last tray. The FSD obtained the food temperatures and none of the hot and cold food items met acceptable food temperatures. The FSD stated the temperatures taken were not with in regulation and that the breakfast should not have taken more than one hour to be served. A review of the resident council minutes revealed the following concerns regarding food temperatures: January 2023- Food did not stay hot, waited too long for dinner to be served. Administrator stated dietary department was working to correct that by using insulated lids, plate warmers, and putting trays on fewer carts. The Administrator acknowledged tray delivery time must be improved. February 2023-food was cold at breakfast- Administrator stated measures had been taking including insulated lids, fewer trays on a cart, plate warmers, hot boxes, additional staff handing out trays, and cart covers to keep food hot. Resident stated only a few trays were delivered as soon as the cart arrived, and the rest were left sitting in the hallway. March 2023 - a resident stated the steam table or plate warmer was not plugged in day room [ROOM NUMBER], and there were concerns with tray pass and roommates not being served at the same time. June 2023- the eggs were often cold. A resident stated plate warmers were not plugged in early enough to get the food warm. July 2023- plated food was sometimes cold tray passing must be a priority. Food plated in the day room was usually cold by the time it was served. September 2023- food often cold at night. A resident asked if tray cart covers could be purchased to keep the food hotter. During an interview with the surveyor, in the presence of the survey team on 10/18/23 at 1:16 PM, the Administrator stated that QAPI was held monthly, and all department heads attended. The Administrator stated the QAPI was held for tracking and logging with a current focus on meal temperatures and ticket tray accuracy. The Administrator stated that they set goals and see what can be put into place to reach the goals. At that time, the surveyor explained the deficiency regarding food temperatures from the prior survey, the resident council concerns regarding food temperatures and the temperature and tray pass observations on survey. The surveyor asked what the facility's QAPI plan was and how it was reviewed for effectiveness. The Administrator stated that the facility always looks to see what may need to improve and they are currently thinking outside of the box. The Administrator stated that the temperatures were not met during the meal observation on on survey because the hot box was not being utilized. The surveyor was provided with the facility's documentation for their QA on the dietary concerns. A review of an undated document titled, Resident Tray Distribution revealed that the challenge was to ensure that all resident meal trays were passed in a timely manner (with in 7 minutes) once the trays have been delivered to the unit. The goal was to have trays passed in less than 7 minutes from the time the trays are delivered to the unit, until the time the trays were in front of the residents. The plan was to have weekly audits of resident meal tray distribution, with a minimum of 8 per month. The evaluation included monthly meeting with the Administrator, Unit Managers, Director of Nursing, Assistant Director of Nursing, Food Service Director, and Assistant Food Service Director to review the audits and create a plan of action if required. The findings would be reported to the quarterly QA meeting. A review of a document, titled, Food and Nutrition Tray Distribution Audit completed and signed by the FSD included the following questions: What time trays start getting made for test tray cart; What time trays get to unit/hallway; What time did the first tray get passed from the cart, on the unit/hallway; What time was the last tray passed from the cart, on the unit/hallway and What was the time elapsed from beginning the trays were being made to the last tray delivered on unit/hallway. There was no documented evidence on what unit or hallway the trays were observed. A reviewed of the FSD's monthly Dietary Focused QA Summary from January 2023 to September 2023 revealed, trays are not always being delivered in a timely manner to residents. A review of an undated document titled, Food Temperature & Ticket Accuracy 2023 revealed that the challenge was ensuring all foods were at the correct temperature. The goal was to strive for 90% or better meal temperature. The plan was to conduct weekly audits of resident meal trays with a minimum of 16 per month. The evaluation included weekly meeting with Administrator, Dietician, Department Heads, FSD, AFSD, to review audits and create a plan of action if required. The findings would be reported to the quarterly QA meeting. A review of the audits revealed that in January 2023, nine (9) trays for food temperature were audited, February 2023, eight (8) trays for temperature were audited, June 2023, eight (8) trays for food temperatures were audited, August 2023, eight (8) trays for food temperatures were audited, and in September 2023, nine (9) trays for food temperatures were audited. For the aforementioned audits, tray temperatures came back with a score of 90%. Those that did not have correct temperatures, lid covers were placed, plates were placed in the plate warmer, and insulated bases were implemented each time. During an interview with the FSD in the presence of the survey team on 10/19/23 at 9:33 AM. The FSD stated he completed his own in-services for his staff. He stated he attended QAPI every quarter and had a QAPI in place due to a deficiency the prior survey. He stated his QA was to take test trays of food temperatures and the temperatures came back fairly well with a score of greater than 90%. The surveyor reviewed the FSD's audits in the presence of the FSD who stated that there was no way to identify which unit the audit was completed on his documentation. The FSD stated that the audits should have included the unit where the temperatures where taken to be able to identify. When asked what process had changed, the FSD stated that they had opened up the dining rooms and fallen short and it had not been effective. The surveyor reviewed the FSD's monthly Dietary Focused QA Summary with the FSD which indicated from January 2023 through September 2023, trays are not always being delivered in a timely manner to residents. The FSD stated he had notified the Director of Nursing and the Administrator during the monthly QA meeting and explained that trays were not passed in a timely manner which make the residents wait and the food was losing temperature. The FSD stated that he reports his concerns during the monthly QA meeting and was not provided feedback on his findings to remedy the problem. During an interview with the survey team on 10/19/23 at 10:19 AM, the Assistant FSD stated he attends as many resident council meetings as he could and the residents generally complain of cold food. He stated the cold food complaints were reported to the Administrator. He stated hot boxes were purchased, and once the trays go to the cart, they sit for at least twenty minutes before they were passed. During an interview with the survey team on 10/19/23 at 11:55 AM, the surveyor reviewed the dietary audits with the Administration. The audits did not identify a location of where the audits were conducted. The surveyor reviewed the January 2023 through September 2023, summary of QA dietary department which revealed that every month, trays are not always being delivered in a timely manner to residents and asked how this was addressed. The Administrator replied, I understand, I understand. The Administrator stated dietary should not be doing the audits. The Administrator added, we changed service areas, we have to think outside of the box, either it's not coming hot enough off steam table. When asked about data collection monitoring, root causes analysis to monitor the effectiveness of their QAPI, the Administrator responded, I have never done it like that. Review of an undated facility's QAPI Purpose Statement included the facility strived to provide high quality of life for the residents, improved quality measures by evaluating present time data collected, and taking action when needed. Guiding principles included, Our organization uses quality assurance and performance improvement to make decisions and guide our day to day operations the outcome of QAPI in our organization is the quality of care and quality of life of our residents .QAPI focuses on systems and processes, rather than individuals. The emphasis is on identifying system gaps rather than on blaming individuals .Our organization makes decisions based on data, which includes the input and experience of caregivers, residents, health care practitioners, families and other stakeholder .sets goals for performance and measures progress towards those goals .The goals of QAPI are to improve the quality of life, care and services for individuals in nursing homes. The QAPI philosophy is to ensure a systemic, comprehensive, data-driven approach to care. The results of QAPI may prevent adverse events, promote safety and quality and reduce risks for residents and care givers. NJAC 8:39-31.6 (g); 33.1 (d); 33.2 (a)(b)(c)

Based on observation, interview, and record review, it was determined that the facility failed to a.) obtain a physician order (PO) for a low air loss mattress (an air mattress designed to prevent and treat pressure wounds), and b.) ensure that an air mattress was functioning properly and adequately inflated for a hospice (sick or terminally ill) resident with a history of wounds. This deficient practice was identified for 1 of 6 residents (Residents #52) reviewed for hospice and was evidenced by the following: 1.) During the initial tour of the Saint Mary's Unit on 06/07/22 at 10:47 AM, the surveyor observed Resident #52 lying in bed with eyes closed. The surveyor observed the resident on an air mattress; however, the pump that inflated the air mattress was not on and functioning. Review of Resident #52's admission Record revealed that the resident was admitted to the facility with diagnoses which included, but were not limited to, Asperger's Syndrome (neurodevelopment disability that affects the ability to effectively interact and communicate with people), Type 2 Diabetes Mellitus, cerebral infarction (brain lesion in which a cluster of brain cells die when they don't get enough blood) due to unspecified occlusion or stenosis of right posterior cerebral artery, palliative care, and epilepsy. Review of Resident #52's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 04/01/22, reflected that Resident #52 was severely cognitively impaired and required extensive assistance to total dependence with Activities of Daily Living. The MDS further revealed that the resident was incontinent of bowel and bladder and was at risk for developing pressure ulcers. Review of Resident #52's Braden Scale, an evidenced-based tool that predicts the risk for developing a hospital- or facility-acquired pressure ulcer or injury, dated 03/28/22, revealed Resident #52 had moderate risk for the development of pressure ulcers. Review of Resident #52's Interdisciplinary Care Plan revealed that the facility's Interdisciplinary Team identified a Focus that the resident was at risk for skin breakdown due to incontinence and limited mobility. Interventions included, but were not limited to, an air mattress initiated on 04/01/22. Review of an Interdisciplinary Team progress note dated 04/20/22 revealed that Resident #52 was being treated for a sacral wound, a treatment was in place to the resident's wound, and an air mattress was in place on the bed. Review of the Order Summary Report for Active Orders as of 06/14/22 did not reflect a physician's order for an air mattress. Review of the 06/01/22 - 06/30/22 Treatment Administration Record did not reflect a physician's order for an air mattress or accountability for the functioning and placement of the air mattress. On 06/15/22 at 10:10 AM, the surveyor interviewed the DON who confirmed that the nurses should have obtained a physician's order for an air mattress and to check function/placement of the air mattress every shift. 2.) On 06/08/22 at 10:17 AM, the surveyor observed Resident #52 with eyes opened lying in bed. The surveyor further observed an air mattress on the resident's bed with an alarm that was sounding. The Hospice Health Aid (HHA) entered the room and silenced the audible alarm on the air pump. The surveyor interviewed the HHA, at that time, who stated that she would notify the nurse concerning the air mattress pump alarm that was sounding. On 06/09/22 at 10:30 AM and at 12:08 PM, the surveyor observed Resident #52 lying in bed with eyes closed. The surveyor observed that the air mattress pump alarm was sounding. The surveyor further observed a red-light indicator on the air mattress pump which reflected low pressure. On 06/09/22 at 1:21 PM, the surveyor observed Certified Nursing Assistant #1 (CNA) entering Resident #52's room. The surveyor observed that Resident #52's bed was positioned at a 45-degree angle with an audible alarm for the air mattress pump sounding. |The surveyor interviewed CNA #1 who stated that the air pump alarm was sounding and attempted to adjust the alarm by turning the air pump for the air mattress on and off. On 06/09/22 at 1:27 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that nobody mentioned to her that the air pump alarm for the air mattress was beeping but that she would put in a maintenance work order in to have the air mattress pump inspected. On 06/09/22 at 1:39 PM, the surveyor interviewed the Registered Nurse/Regional Clinical Nurse who stated that she would replace the malfunctioning air mattress. On 06/09/22 at 1:44 PM, the surveyor observed the air mattress pump was powered on, however there was a red-light illuminating on the air pump which indicated low pressure. On 06/14/22 at 12:16 PM, the surveyor interviewed CNA #2 who stated that maintenance sets up the air mattress and that any issues with the air mattress were reported to maintenance. On 06/15/22 at 10:10 AM, the surveyor interviewed the Director of Nursing (DON) who stated that it was the nurse's responsibility to check the placement and function of the air mattress every shift; and that if there was no alarm sounding, that the air mattress was working fine. However if an alarm was sounding, the nurses should reset the alarm to see if that corrected the issue. She added that the alarm sounding could indicate that there was an imbalance of the air pressure. The DON further stated that if the alarm continued to sound, then the nurse should have contacted the maintenance department. The DON confirmed that the functioning of an air mattress was important in preventing pressure ulcers. The DON further stated that it was important to assure that a resident's air mattress was functioning properly, because if it was not functioning correctly, that it could put the resident at risk for developing pressure ulcers. Review of the facility's Support Surfaces Guidelines policy, with the revision date of 07/21, reflected that support surfaces would be used as a guideline for the assessment of appropriate pressure reducing and relieving devices for residents at risk for skin breakdown. General Guidelines included that redistributing support surfaces were to promote comfort for all bed or chair bound residents, prevent skin breakdown, promote skin circulation, and provide pressure relief or reduction. NJAC 8:39- 11.2 9 (a), 27.1(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 06/14/22 at 12:00 PM a review of the facility's DEA Form-222 revealed the facility did not complete the number of packages received and the date the medication was received in Part 5, as instructed on the face of DEA Form-222, within each section and in the directions on the back of the form itself. The inaccuracies were as follows: Order Form Number: 220317355, dated 03/03/22 did not indicate the number received or the date received for Items 1, 2, 3, 4, 5, 6, 7, or 8. During an interview with the surveyor and team on 06/14/22 at 1:07 PM, the Director of Nursing (DON) and Administrator confirmed that they obtained a copy of the finalized DEA-222 Form from the provider pharmacy staff. They acknowledged that the provided copy of the DEA Form-222 was incomplete, specifically as related to the number of items received upon delivery and the date on which the referenced items were received. In addition, the DON and Administrator confirmed that the directions on the front and back of the form should be part of the reconciliation process and that a copy of the completed form, as described, should have been retained in the facility's records. During an interview with the survey team and administrative staff on 06/15/22 at 1:22 PM, the DON and Administrator reiterated they understood the surveyor's concerns regarding the incomplete DEA-222 Form and the absence of retaining a copy of the form for their records. Review of instructions titled, INSTRUCTIONS FOR DEA FORM 222 obtained from facility records, revealed directions in Part 5, that indicated the actions that must be completed upon controlled substance receipt. These include the purchaser filling out this section on its copy of the form, including the number of items received and date received upon delivery of such items. Review of the facility's policy titled, 6.0 Inventory Control of Drugs revealed an effective and revised date of 10/01/2018. According to the policy, it is necessary for controlled drugs to be inventoried and documented under proper conditions with regards to security and state/federal regulations. NJAC 8:39-29.6(a) and 8:39-29.7 Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to a.) ensure that 1 of 2 nurses on 1 of 4 units ([NAME] Unit) properly disposed of one medication during medication pass, and b.) ensure accurate completion of a Drug Enforcement Agency (DEA) Form-222 (a federal narcotic requisition form), to enable accurate reconciliation of controlled-dangerous substances (medications, that due to their high potential for abuse, are tracked with detail) for 1 of 1 DEA Form-222 reviewed . The deficient practice was evidenced by the following: 1. On 06/08/22 at 8:50 AM, the surveyor observed the Registered Nurse (RN) prepare a resident's medication. She placed a bingo card (a method of packaging medications in an enclosed blister pack with a cardboard backing) that contained one Farixga (a medication used to treat Type 2 Diabetes) 10 milligram (mg) tablet directly over a plastic medication cup. When she pressed on the bingo card to dispense the medication, the pill fell from the bingo card and landed on top of a sheet of paper on top of the medication cart instead of inside of the medication cup. The RN stated, That was the last one I had. She placed the tablet in a separate medication cup and locked it in the medication cart while she attempted to replace the dosage. At 9:12 AM, the surveyor accompanied the RN to the first-floor medication room where she confirmed with the Registered Nurse/Unit Manager #2 that there were no additional quantities of Farixga available for immediate dosage replacement. At 9:15 AM, the surveyor observed the RN as she removed the Farixga tablet from the locked medication cart and discarded it directly into the sharp's container (a needle and sharp instrument disposal unit) that was attached to the side of the medication cart. When interviewed, the RN stated that was how she normally discarded medications. At 9:35 AM, in a later interview with the RN, she stated that there was supposed to be a chemical solvent or medication disposal system that was used for the destruction of medications available on her medication cart. She stated that she disposed of the Farixga in the sharps container since there was no chemical solvent available on the medication cart at that time. She stated that there was a storage closet down the hall where additional quantities of chemical solvent were stored, and she did not have a key to access it. She further stated that there were also additional quantities of chemical solvent available in the first-floor medication room. On 06/10/22 at 11:02 AM, the surveyor interviewed the Director of Nursing (DON) who stated that there were drug disposal systems available on each medication cart to waste medications. She stated that the RN should have thrown the medication to be wasted into the drug disposal system. She stated in past practice, we utilized the sharp's container. She further stated that, sharps containers were for sharps only. On 06/14/22 at 11:39 AM, the surveyor interviewed Licensed Practical Nurse #4 (LPN) who stated that she worked at the facility for six years and the drug disposal system had been available since she started working at the facility. She stated that if she dropped a medication, she discarded it in a drug disposal system. She then opened the bottom drawer of her medication cart and demonstrated the availability of the medication disposal system. LPN #4 stated that if it were not available on her cart, she would phone the supervisor to obtain another. She further stated that the drug disposal systems were plentiful and were available in the first-floor medication room and in the storage closet to which not everyone had access to. The surveyor reviewed the undated facility policy, Discarding and Destroying Medications which revealed the following: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA (Environmental Protection Agency) recommends destruction and disposal of the substance with other solid waste following the steps below: .Mix medication either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, drug buster or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. If an undesirable substance is not accessible, medication may be discarded in a locked sharps container.

2. On 06/09/2022 at 8:40 AM, the surveyor observed LPN #3 prepare medications for Resident #143. Afterwards, the LPN entered the resident's room to administer the medications without locking the medication cart. While in the resident's room, the nurse turned her back to the medication cart and washed her hands in the resident's sink. On 06/09/2022 at 8:50 AM, the surveyor observed LPN #3 prepare medications for Resident #121. Afterwards, the LPN entered the resident's room to administer the medications without locking the medication cart. While in the resident's room, the LPN turned her back to the medication and the resident's privacy curtain was between the nurse and the medication cart. During an interview with the surveyor on 06/09/2022 at 9:05 AM, the LPN stated the medication cart should be locked when not within eyesight of the nurse to prevent residents from going into the medication cart. During an interview with the surveyor on 06/09/2022 at 9:10 AM, LPN/UM #1 stated the medication cart should be locked before going into a resident's room to prevent anyone from accessing the medication cart. During an interview with the surveyor on 06/10/2022 at 11:40 AM, the Director of Nursing stated the nurse should lock the medication cart any time the nurse turns his/her back to the medication cart to prevent anyone from taking anything from the medication cart. Review of the facility's Administering Medications policy, revised 03/2019, included, During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse. Review of the facility's Storage of Medications policy, revised 10/2021, included, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. NJAC 8:39-29.4(h) Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to a.) store medications within acceptable temperature ranges for 1 of 2 medication storage areas (Rosegarden Unit) reviewed as part of the medication storage and labeling task and b.) properly secure medication within the nursing cart for 1 of 2 nurses observed on 1 of 2 units (Rosegarden Unit) during medication administration. This deficient practice was evidenced by the following: 1). On 06/10/22 at 11:47 AM, the surveyor entered the Rosegarden Unit (RU) medication room and observed the refrigerator temperature at ranges between 31.8 and 35.4 degrees Fahrenheit (F), in the presence of the Licensed Practical Nurse #1 (LPN) over the course of approximately 10 minutes. In addition, there was a fluorescent orange sign on the door of the refrigerator, indicating to maintain the temperature between 36-46 F and a temperature refrigerator log on top of the refrigerator. During an interview with the surveyor on this date and time, the surveyor questioned LPN #1 regarding the observed temperature on the thermometer. LPN #1 referred the surveyor to the Licensed Practical Nurse/Unit Manager #1 (LPN/UM). During an interview with the surveyor on 06/10/22 at 12:00 PM, LPN/UM #1 stated that the thermometer in the refrigerator was replaced earlier on the same day, approximately 40 minutes prior to the surveyor's observation. LPN/UM #1 further stated that the surveyor's observation of the out of range temperature may have been the result of the new thermometer being incorrect, rather than an actual problem with the refrigerator itself. LPN/UM #1 further stated that she would continue to monitor the situation as a result of the surveyor's observation and follow-up with any additional action that may be needed. During the same interview, the surveyor asked LPN/UM #1 who was responsible for checking the refrigerator temperatures. LPN/UM #1 stated temperature checks for the refrigerator were checked and recorded by staff on the 11:00 PM-7:00 AM (overnight) shift. If, however, there was a problem with the refrigerator in the interim, any nurse or staff member could report the problem to a nursing unit manager to initiate corrective actions. On 06/10/22 at 1:33 PM, the surveyor observed a temperature of 34.3 F on the thermometer in the RU medication room refrigerator, in the presence of the LPN #1. During an interview with the surveyor at this time, LPN #1 stated that that LPN/UM #1 was looking into the matter but was not aware of further details regarding the current process. On 06/13/22 at 11:28 AM, the surveyor observed a temperature reading of 44.1 F on the thermometer, in the medication room of the RU, in the presence of LPN/UM #1. The surveyor referred LPN/UM #1 to the surveyor log, on top of the refrigerator, which revealed temperature readings with days, dates, and temperatures as follows: Friday (06/10/22) at 30 F, Saturday (06/11/22) at 30 F, Sunday (06/12/22) at 31 F, and Monday (06/13/22) at 30 F. During an interview with the surveyor at this time, LPN/UM #1 stated that the referenced temperatures, over the weekend, were recorded by two per-diem (staff that work on an as needed basis) LPN staff members and the temperatures were incorrect. When asked about this further, LPN/UM #1, confirmed that she was not present and did not work in the building during the weekend. When asked how she would know that the recorded temperatures were incorrect, LPN/UM #1 clarified that she was assuming that the recorded temperatures were incorrect. As a result, LPN/UM #1 stated that she will check the items in the refrigerator. She stated that she would remove the medications, dispose of them in accordance with policies, and replace them with new medications, if necessary. When the surveyor asked LPN/UM #1 if the process described should have already occurred, LPN/UM #1 acknowledged that the process described should have already been completed, due to the deviations in temperature. During the referenced time and date, the surveyor, in the presence of LPN/UM #1, observed that the following items were present in the referenced refrigerator: -two, 2.5 milliliter (mL) bottles of Latanoprost 0.005% Eye Drops for Glaucoma -two, 1 mL bottles of Tuberculin 5TU/0.1 mL for Tuberculosis skin testing -one, 3 mL pen of Ozempic 4 mg/3 mL for Diabetes Mellitus (DM) -one, 3 mL pen of Basaglar 100-units/mL for DM -one, 3 mL pen of Lantus 100-units/mL for DM -one, 10 mL bottle of Lantus 100-units/mL for DM -one, 3 mL bottle of Humalog 100-units/mL for DM -seven capsules of Dronabinol 2.5 mg for appetite stimulation -12 syringes of Lorazepam 0.5 mg/0.5 mL gel for agitation/anxiety During the same interview, LPN/UM #1 stated that medication replacement, as described, did not occur because the refrigerator temperatures were checked again on Friday, 06/10/22 in the afternoon, and were within acceptable range. Finally, LPN/UM #1 stated she understood the surveyor's concerns regarding these matters. During an interview with the survey team and administrative staff on 06/15/22 at 1:17 PM, the Regional Clinical Manager stated that further action and replacement of the medications should have occurred at the time that the refrigerator temperature deviations were observed. The facility's administrative staff indicated they understood the surveyor's and team's concerns regarding the referenced matter. Review of a policy titled, Policies and Procedures for the subject of Storage of Medications revealed an effective date of 03/17 and a revision date of 10/21. The policy indicated a need for the facility to store all drugs and biologicals in a safe, secure, and orderly manner. In addition, the policy indicated that nursing staff shall be responsible for maintaining medication storage in a clean, safe, and sanitary manner but did not specify any guidance regarding appropriate temperature ranges.

Based on observation, interview, and review of other facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot and cold food and drink was served to the residents. This deficient practice was identified for 6 of 6 residents interviewed during the Resident Council Meeting and confirmed during the lunchtime meal service on 06/10/22 for 1 of 4 nursing units (St. Mary's Unit) tested for food temperatures and was evidenced by the following: On 06/09/22 at 10:35 AM, the surveyors met with the residents for the Resident Council Meeting. Six out of six residents stated that they were displeased with the food temperatures and that hot food items were not consistently served hot enough. On 06/10/22 at 12:41 PM, the surveyor observed an open food truck arrive on the first floor. The surveyor pulled two trays from the food truck. The surveyor observed that the trays were not on warming plates, and the uninsulated dome food lids did not fit securely over the plates. The surveyor further observed Certified Nursing Assistants (CNAs #1 and #7) started to deliver meal trays to residents at 12:44 PM. On 06/10/22 at 12:52 PM, the Food Service Director (FSD) arrived to the St. Mary's Unit with his calibrated thermometer. After the last meal tray was delivered to a resident at 1:21 PM, the FSD took the temperatures of the following items in the presence of the surveyor: Puree consistency: 2-ounce (oz) cup of [NAME] sauce - 99.8 degrees Fahrenheit (F) 4 oz cup of fortified mashed potatoes - 99.1 degrees F 4 oz green beans - 102.8 degrees F 4 oz pineapple tidbits - 68.2 degrees F 4 oz super pudding - 66 degrees F 6 oz nectar thick coffee - 119.5 degrees F Regular consistency: 6 oz soup of the day - 124.2 degrees F 4 oz shrimp [NAME] - 94.6 degrees F 4 oz pasta linguini - 95.4 degrees F 4 oz green beans - 90.1 degrees F 4 oz pineapple tidbits - 61.2 degrees F 4 oz whole milk - 63.0 degrees F 6 oz coffee decaf - 114.1 degrees F On 06/10/22 at 1:28 PM, the surveyor interviewed the FSD. The FSD stated that hot foods should be above 140 degrees F and cold foods should be below 41 degrees F in order to prevent food-borne bacteria. The FSD agreed that the temperatures of the food were not maintained at appetizing temperatures for the residents. The FSD acknowledged that the facility should be using properly fitted insulated dome covers but stated that many had broken seals and the facility needed to order new ones. The FSD stated that Timeliness in passing trays has been an ongoing issue. It usually takes about 15 minutes, never 40 minutes. The FSD further stated that the dietary staff kept a food temp (temperature) log when foods were taken out of the oven and refrigerator and again before the food truck left the unit. The FSD ensured that those temperatures were accurate on the tray-line to avoid food temp danger zones. On 06/10/22 at 1:47 PM, the surveyor interviewed Registered Nurse/Unit Manager #1, who stated that all available staff was expected to help with the meal service and acknowledged that it should not have taken 40 minutes to pass the lunch trays. On 06/10/22 at 1:53 PM, the surveyor interviewed CNA #7 who stated that, Today's meal service was a disgrace. I was embarrassed by how long it took to pass out trays and feed residents. On 06/15/22 at 1:00 PM, the survey team discussed the above observations and concerns with the Administrator, Director of Nursing, Regional Clinical Nurse, and Regional Administrator. No further information was supplied. Review of the facility's policy Food and Nutrition Services Policies and Procedures dated 11/30/17, reflected that cold foods should be maintained at a temperature of 41 degrees F or below and hot foods should be maintained at a temperature of 135 degrees F or higher. Review of the Food and Drug Administration guidelines for maintaining foods at safe temperatures reflected at or below 41 degrees F (for cold foods) or at or above 135 degrees F (for hot foods). NJAC 8:39-17.4(e)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident's preference for milk was honored while on fluid restrictions. This deficient practice was identified for 1 of 2 residents (Resident #86) reviewed for choices and was evidenced by the following: On 06/07/22 at 11:08 AM, the surveyor observed, from the hallway, Resident #86's name outside the resident's room with a picture of a pitcher near the resident's name, and the surveyor further observed Resident #86 in his/her room sitting in a gerichair speaking with another resident. Review of the admission Record (an admission summary) reflected that the resident had been admitted with diagnoses which included, but were not limited to, Type 2 Diabetes without complications, chronic pulmonary edema (swelling), and congestive heart failure (CHF). Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 04/28/22, reflected that the resident was cognitively intact, and was able to eat independently with meal set-up by staff. Review of the Initial Nutrition Risk Assessment, dated 01/20/22, revealed the Registered Dietician (RD) was able to interview the resident. The evaluation included food preference: wants free milk, coffee with honey. The RD's recommendations included to continue Resident #86's diet and fluid restrictions as ordered. Review of Resident #86's Interdisciplinary Care Plan revealed a Focus for nutrition and fluid restriction. The surveyor observed the Care Plan did not address the resident's fluid preferences. Review of the Nutrition Note dated 01/27/22 revealed that Resident #86 spoke with the dietitian and requested low far milk with his/her meals. The Nutrition Note further reflected that resident was educated to ask the nurse for low fat milk because the nurse was recording the resident's fluid intake, and Resident #86 verbalized an understanding. The Nutrition Note further reflected that the RD documented that the nurse was made aware of the resident's preference. Review of the Order Summary Report for Active Orders as of 06/13/22, did not include the resident's fluid preferences in the fluid restriction order. Review of the June 2022 Medication Administration Record (MAR) did not include the resident's fluid preferences in the fluid restriction order. On 06/13/22 at 10:39 AM, during an interview with the surveyor, Certified Nursing Assistant #3 (CNA) stated that she was aware that the resident was on fluid restrictions because there was a sign of a pitcher on the resident's door by the resident's name, and that she would ask the nurse what to fluids give to the resident. On 06/13/22 at 10:41 AM, during an interview with the surveyor, Licensed Practical Nurse #2 (LPN) stated that she reviewed the MAR to determine the amount of fluid to offer a resident on fluid restrictions. LPN#2 added that she would offer the resident four ounces of water during the medication pass. On 06/13/22 at 10:45 AM, during an interview with surveyor, the Registered Nurse/Unit Manager #3 (RN/UM) confirmed there were no fluids on the meal tray of Resident #86 and that the fluid was passed by the nurse or CNA as instructed by the nurse. The RN/UM #3 also stated that the nurse would review the fluid restriction shift amounts in the physician order and on the MAR. She further stated that a picture of a pitcher on the door meant a resident was on fluid restriction. On 06/13/22 at 11:55 AM, during an interview with surveyor, Resident #86 stated that he/she does not receive fluid with meals but wants milk in the morning and at night. Resident #86 confirmed that breakfast did not include milk for that meal although he/she wrote it on the breakfast meal ticket. On 06/13/22 at 12:45 PM, the surveyor observed Resident #86's lunch meal tray in the dining room which contained the meal without any fluid. On 06/14/22 at 11:27 AM, during a follow-up interview with surveyor, Resident #86 stated that every meal does not include drinks on the meal tray and that he/she only received water throughout the day. Resident #86 also stated that meals were brought by staff and that he/she had to ask staff for a drink. On 06/14/22 at 11:43 AM, the surveyor observed Resident #86's overbed table with a note affixed on the corner. The note contained Resident #86's name with the handwritten message, Milk, please. At this time, the RN/UM #3 came into the room. The resident told the RN/UM #3 that he/she would like to have milk with his/her breakfast and the RN/UM #3 replied that the resident would have to ask the nurse for the milk. On 06/14/22 at 12:10 PM, during an interview with surveyor, LPN #2 stated that Resident #86 did not ask for any fluids today and admitted that she was unfamiliar with the policy for food preferences. On 06/14/22 at 01:47 PM, during an interview with surveyor, the Regional Dietician stated that fluid preferences were obtained through resident interview and the dietary aids and nursing staff were informed of the resident's preferences. She further stated that the care plan would be updated with the resident's preferences and a physician order would be obtained for the resident's preferences. The Regional Dietician confirmed that a resident with a food preference should not have to ask for what they want every day, provided that it is something dietary has available. On 06/15/22 at 10:20 AM, during an interview with surveyor, the Director of Nursing (DON) stated that when a resident was on fluid restrictions, the physician order reflected the amount of fluid the resident should receive on each shift and a picture of a pitcher would be placed outside of the resident's room. The DON further stated that dispensing of fluid to a resident on fluid restrictions was the responsibility of the nurses. The DON acknowledged that residents informed the dietitian of their food preferences and the preferences should have been incorporated in the physician orders and included on the meal ticket. The DON confirmed that the staff should have asked the resident for their preferred fluid with their meal, as food preferences are a resident's right and should be honored. Review of the facility's 10/19 Fluid Restriction policy included that Fluids are defined as beverages offered to residents and that Nursing will be responsible for providing the entire amount of fluids as ordered by the physician. Review of the facility's undated Food Preference Policy reflected that it is the policy of the facility to allow residents to make choices that reflect individualized, day-to-day meal preferences. NJAC 8:39-17.4 (c), (e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to minimize the potential spread of infection to residents during medication administration for 1 of 2 nurses observed during the medication pass on 1 of 2 units ([NAME] Unit). This deficient practice was observed and evidenced by the following: On 06/08/22 at 8:42 AM, the surveyor observed the Registered Nurse (RN) prepare medications for one resident. The RN opened the top drawer of the medication cart and stated that there was no enteric coated aspirin available for administration. She stated that she needed to go to the first-floor medication storage room to obtain the medication. At 8:50 AM, the surveyor accompanied the RN to the elevator where she pressed the button with her index finger to signal the elevator; and once inside the elevator, she pressed the button with her same index finger to go to the first-floor medication storage room. The RN informed the Registered Nurse/Unit Manager #2 (RN/UM) who was present, that she needed a bottle of enteric coated aspirin. The RN/UM #2 went into the medication room and obtained the medication and handed it to the RN. The surveyor and the RN returned to the elevator and the RN pressed the button with her same index finger to signal the elevator; and once inside, she pressed the button with her same index finger to return to the second floor. The surveyor observed the RN did not perform hand hygiene when she returned to the medication cart before she began to prepare the medications. The surveyor observed the RN as she opened the bottle of enteric coated aspirin, broke the seal with the tip of a pen, and pulled out a piece of cotton that was contained within the bottle with her bare hand and discarded it. She began to prepare additional medications that were contained within the bingo cards (a method of packaging medications via an enclosed blister pack with a cardboard backing) from the medication cart. When she attempted to press on the bingo card that was placed over a plastic medication cup to release the pill (Farixga, a medication used to treat Type 2 Diabetes), the pill fell onto a piece of paper on top of the medication cart. She stated, That was the last one I had. The RN then donned a single glove, picked up the pill and placed the pill into a second medication cup and locked the medication cup in the medication cart. She doffed (removed) the glove and did not perform hand hygiene before she continued to prepare other medications for administration. At 9:01 AM, the RN entered the resident's room and handed the resident the cup of medication. She then picked up a disposable cup that contained water that was on the overbed table with the same bare hand and handed it to the resident. She stated that the cup was sweating and felt wet, as the facility no longer utilized insulated Styrofoam cups. The RN did not perform hand hygiene after she administered the medications to the resident. She returned to the medication cart and utilized the computer, as she signed out the medications that were administered in the electronic medical record. At 9:12 AM, the RN stated that she needed to return to the first floor medication room to obtain Farixga to replace the pill that she dropped on the medication cart. The RN did not perform hand hygiene before she left the nursing unit via the elevator and went to the first floor medication room. At 9:18 AM, the RN returned to the second floor via elevator and did not perform hand hygiene before she pushed the medication cart down the hall and placed it in front of a resident's room who was due for medications. At that time, she used alcohol-based hand rub (ABHR) prior to accessing the medication cart. At 9:24 AM, the surveyor observed the RN as she washed her hands in a resident room prior to medication administration. She turned on the faucet, wet her hands, obtained soap and began to lather and wash her hands out of the stream of running water for 10 seconds and then continued to rub her hands together under the stream of running water for an additional 10 seconds before she rinsed her hands that were already under the stream of running water, dried them off with a paper towel, discarded the paper towel, and obtained an additional paper towel to turn off the faucet before she discarded it. At 9:38 AM, during a follow-up interview with the RN, she stated that she thought that she performed hand hygiene prior to the medication administration but she must have been nervous. The RN stated that she sang happy birthday twice to determine the appropriate amount of time to wash her hands. She stated that she was required to wash her hands out of the stream of running water for 20 seconds. The RN confirmed that she had both ABHR and sanitizing hand wipes available on top of her medication cart. She further stated that by not washing her hands or performing hand hygiene prior to and after medication administration and after she touched the elevator buttons, she risked the spread of infection. On 06/08/22 at 12:11 PM, the surveyor interviewed the RN/UM #2 who stated that the RN was required to perform hand washing prior to medication administration and could have used hand sanitizer up to three times before she was required to wash her hands again. She stated that cross-contamination could result if hands were not washed prior to handling medications, the computer keyboard and the medication cart. She stated that the RN was required to wash her hands out of the stream of running water for 20 seconds in accordance with the facility policy. On 06/09/22 at 11:25 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that she expected that nursing would have utilized ABHR in between each resident during medication pass. She stated that nursing was also required to wash their hands prior to donning and after doffing gloves. The IP stated that if nursing had come into contact with high touch surfaces such as the elevator buttons and did not perform hand hygiene prior to medication pass, it could have exposed the resident to bacteria. The IP described the process for hand washing: Turn on the faucet, wet hands, get soap, rub vigorously for 20 seconds or more out of the stream of water, then rinse from the wrist down, get a paper towel, dry hands, and obtain a second paper towel to turn off the faucet. She further stated that the nurse was required to wash her hands out of the stream of running water for a full 20 seconds because if the process was not followed, bacteria and germs could remain on the hands. On 06/10/22 at 11:02 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she expected nursing to wash their hands or use ABHR prior to handling medications, as it was an infection issue if hand hygiene was not performed first. The DON stated that nursing should also sanitize their hands after they left the resident's room, after medication administration, and before they did anything else. She stated that staff were instructed to sanitize their hands after they doffed their gloves to ensure that both staff and residents were safe from infection. The DON further stated that her expectation for handwashing was to lather and rub out of the stream of running water for 20 seconds, and stated that if the RN only rubbed her hands out of the stream of running water for 10 seconds, it was not enough time to ensure that the bacteria were removed from the hands for best practice. The surveyor informed the DON that the facility handwashing/hand hygiene policy was reviewed and indicated that handwashing was required to be performed under running water for 20 seconds. The DON stated that our policy should not have indicated that washing hands under running water for 20 seconds was permissible and agreed to furnish the surveyor with an updated policy. The surveyor reviewed the facility policy, Handwashing/Hand Hygiene, with an effective date 01/2019, which revealed the following: This facility considers hand hygiene the primary means to prevent the spread of infections. The policy reflected that .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before and after direct contact with residents; before preparing or handling medications; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; after removing gloves; and the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The policy further reflected the Procedure Washing Hands: Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water . The surveyor reviewed the Hand Hygiene policy (revised 06/10/22) which revealed the following: Washing Hands. Turn on faucet and run water until desired temperature is achieved . and to Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) . The surveyor reviewed the facility policy, Administering Medications (Revised 3/2019) which revealed the following: Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. NJAC 8:39-19.4 (a)

Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to ensure the dining experience was provided in a manner to promote dignity and respect. This deficient practice was cited during the last standard survey dated 01/31/20. This deficient practice was identified for 1 of 14 residents (Resident #123) observed for dining and evidenced by the following: On 06/07/22 at 10:47 AM, during the initial tour of the facility, the surveyor observed Resident #123 in their room being cared for by a Certified Nursing Assistant (CNA). The Resident was not responsive to the surveyor's greeting. The CNA, with the assistance of two other nursing staff members, transferred the resident from the bed to a recliner chair using a mechanical lift. Review of the admission Record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, vascular dementia, nutritional deficiency, hemiplegia and hemiparesis (paralysis of one side of the body), and dysphagia (difficulty or discomfort in swallowing). Review of Resident #123's Annual Minimal Data Set (MDS), an assessment tool used to facilitate the management of care, dated 05/27/22, indicated Resident #123 was cognitively impaired and totally dependent on staff for feeding assistance. On 06/09/22 at 1:02 PM, the surveyor observed CNA #4 bring Resident #123's meal tray to the room and began feeding the resident their meal while standing alongside the resident's recliner chair. At that time, the surveyor asked CNA #4 if standing alongside the resident was appropriate while assisting with feeding the resident, and CNA #4 responded, I don't like to sit because I get lazy, and I like to stand to see them chew their food. On 06/13/22 at 1:11 PM, the surveyor observed CNA #5 bring Resident #123, who was resting in a recliner chair, into his/her room and began to set up the resident's meal tray in preparation to assist feeding the resident. CNA #5 proceeded to feed Resident #123 while standing alongside the resident. On 06/14/22 at 12:21 PM, the surveyor interviewed CNA #6 regarding the proper procedure when providing feeding assistance to residents, and CNA #6 stated that the proper technique was to sit alongside the resident, facing them; and if need be, the staff would re-arrange the furniture to fit a chair to allow staff to sit, to ensure residents are comfortable during their meal. On 06/14/22 at 12:38 PM, the surveyor interviewed CNA #5 regarding standing while feeding Resident #123 the previous day, and CNA #5 stated that they didn't want to kill time to get a chair because they have so many other things to do. On 06/14/22 at 12:44 PM, the surveyor interviewed the Unit Manager/Registered Nurse #2 (UM/RN #2) who informed the surveyor that to preserve resident dignity, staff must follow procedure and always sit alongside the residents while providing feeding assistance. UM/RN #2 also stated that, if necessary, staff should move furniture, or bring residents to the day room/dining room to allow more space to fit a chair along side the resident to sit while providing feeding assistance. On 06/15/22 at 10:09 AM, the surveyor interviewed the Director of Nursing (DON) who stated that all staff, including agency, full time, and part time were expected to follow proper procedure when providing feeding assistance, which included sitting next to the resident. The DON informed the surveyor that this was to preserve resident dignity. When the surveyor informed the DON of the staff observations, the DON stated, That is not appropriate at all, they should have found a chair and fed the patient. I understand they are busy, but we still have to do what's right by the patient. Review of the facility's policy and procedure titled Assistance with Feeding, revised on 2/2021, reflected .2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity for example: a. Not standing over residents while assisting them with meals . NJAC 8:39-4.1 (a)(12)

Based on observation, interview and review of other facility documents, it was determined that the facility failed to a.) properly store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment in a manner to prevent microbial growth and cross contamination and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 06/07/22 from 09:48 AM-11:03 AM, the surveyor toured the kitchen in the presence of the Director of Dietary (DD) and observed the following: 1. The surveyor observed the DD with facial hair was not wearing a beard restraint. The DD acknowledged that he wore a surgical mask and was not wearing a beard restraint. He stated it was important to wear hairnets to prevent contamination of the food. 2. In the walk-in refrigerator, there were two opened packages of American cheese wrapped with clear plastic wrap that had no open or use by dates. The DD acknowledged that the packages should have been dated to determine if they were expired or spoiled. The DD removed them from the refrigerator. 3. In the walk-in freezer, there was a large silver tray containing unwrapped light pink frozen pieces of meat that were exposed to air. The DD identified them as fish filets and acknowledged they should have been wrapped and that they were not stored correctly. 4. On the drying rack, there were three white cutting boards with black smudges. The DD stated they were clean and sanitized after each use. He stated that they just needed to be sanded down. 5. In the paper product storage area, there were three opened boxes with plastic bags containing spoons, forks and knives that were opened and exposed to air. The DD stated that the plasticware was used in the red and yellow zones (isolation areas) and that they should have been covered to prevent debris, dust and dirt exposure. 6. In the top convection oven, there was black, greasy debris on the inside doors and black and orange debris on the floor of the oven. The DD acknowledged the debris and stated the oven needed to be cleaned to prevent cross contamination and allow proper heating temperatures. 7. On the spice rack, there was one opened 16 ounce jar of Spanish paprika marked 03/04/12, one opened 16 ounce jar of celery seed with no dates, one opened 16 ounce jar of ground cumin with no dates, one opened 5 ounce jar of dill weed with no dates, and one opened 23 ounce jar of Montreal steak seasoning with no dates. The DD stated that spices got dated when they were delivered and that he was unsure when they were opened. He further stated that it was important to date them to know how fresh they were. 8. On 06/14/22 at 12:21 PM, the surveyor observed the new Food Service Director (FSD) with facial hair wearing a surgical mask as he served food to residents in the main dining room. The FSD was not observed wearing a facial hair restraint. The surveyor interviewed the FSD at that time, and the FSD explained to the surveyor that if facial hair was one inch or shorter that no beard cover was needed and that it was the responsibility of the DD or FSD to measure and monitor beard length. The FSD was unable to state the process for staff members who entered the kitchen with facial hair, nor was he able to indicate if there was a beard measurement record log kept. On 06/14/22 at 12:32 PM, the Administrator and the Director of Nursing (DON) were made aware of the surveyor's observations of the FSD. The Administrator acknowledged that if a kitchen staff member had facial hair that a surgical mask did not do the same job as a beard net and that a beard net should be worn to prevent food contamination. She further stated that she would have to review the policy on beard length. 9. On 06/15/22 at 10:04 AM, the surveyor observed in the sink area of the kitchen, a pot washer (PW) with facial hair who wore a surgical mask. The PW was not observed wearing a facial hair restraint. The surveyor interviewed the PW at that time who acknowledged that he should have worn a beard net and that a beard net was required to be worn for any facial hair to prevent hair from falling into the food. He further stated he was unsure how long his facial hair was and that no one measured his beard length. 10. On 06/15/22 at 10:08 AM, the surveyor observed a cook (food preparer) in the kitchen with facial hair wearing a surgical mask and a white beard guard over his mask. The surveyor interviewed the cook at this time and the cook stated that no one measured his beard. On 06/15/22 at 11:51 AM, the surveyor interviewed the DD who stated the beard length guidance was a standard and that the DD, FSD or a supervisor was responsible for measuring beard length of staff members and that no log was kept. The DD further stated that if facial hair measured more than one inch long, then that was when a beard net was needed. On 06/15/22 at 12:59 PM, the surveyor interviewed the Administrator, in the presence of the DON, the Regional Clinical Nurse, and the Regional Administrator, who stated that she was unsure where the beard length policy guidance came from and that facial hair was measured by looking at the facial hair. The surveyor reviewed the facility's undated policy titled, All food items must be labeled and dated, which revealed Procedure: 1. All food items must be labeled with either a manufacturer label or handwritten label. 2. All food products, upon receiving, must be dated with receiving date. The surveyor reviewed the facility's policy titled, Labeling and Dating, dated 11/28/17, which revealed Process: 1. All food products, upon receiving, must be dated with the receiving date cold and dry storage items, this includes, bulk items (BBQ sauce, Mayo, Spices, Bases). 2. All food items must be labeled with either a manufacturer label or handwritten label. The surveyor reviewed the facility's policy titled, Refrigerated/Frozen Storage, dated 11/30/17, which revealed Process: 1. Refrigeration: 1.4 All foods are labeled with name of product and the date received and use by date once opened. Manufacturer use by dated are used until opened. 2. Freezer: 2.4 Food is dated when received and with use by date when opened. Manufacturer use by dates are used until opened. 2.5 Foods are kept in original container. If removed from original container, foods are completely covered and labeled with the name of product and use by date. The surveyor reviewed the facility's policy titled, Dry Storage, dated 11/30/17, which revealed Process: 3. Supply Storage: 3.1 Disposable products intended for food service are stored in a sanitary manner using covered, closed, sanitary containers or enclosed food quality plastic bags. The surveyor reviewed the facility's policy titled, Personal Hygiene, dated 11/28/17, which revealed Process: 7. Hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. Facial hair coverings are used to cover all facial hair. NJAC 8:39-17.2(g)