Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete reference checks on employees before their start date. The deficient practice was identified for 5 of 6 employees reference checks reviewed under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by the following: On 10/15//24, the surveyor reviewed six employee files of employees hired since the last standard survey which revealed that five of the six did not have reference checks done prior to the start of employment. RN #1, date of hire 12/4/23 LPN (Licensed Practical Nurse) #1, date of hire 9/5/23 LPN #2, date of hire 8/17/23 LPN #3, date of hire 1/30/24 Housekeeper#1, date of hire 11/20/23 On 10/15/24, the surveyor requested the reference checks on the above employees. On 10/16/24 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) who stated that he was unable to provide the reference checks at this time. He further stated that they used to be handwritten but now are on an electronic system. He acknowledged that the reference checks should be readily available. On 10/16/24 at 12:32 PM, the surveyor interviewed the Human Resources Director and the Administrator, who stated that they do reference checks on newly hired employees. They use a software program that requests electronically references from the previous places of employment. They were stored in one software program but were moved to another software program. They stated that was why they couldn't retrieve the reference checks. The Administrator further stated that she understood and stated we should be able to print them out. A review of the facility's policy Employment Verifications and Backround checks reviewed 5/16/24, revealed: 4.1 Background Check Components: .Prior Employment Verificaition confirms applicant's employment with the provided companies, includeing dates of employments, position held .performance ratings, reason for departure and eligibility for rehire. This generally will be run on past two employers or past five years, which ever is most recent. N.J.A.C. § 8:39-9.3(b)

Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to notify the resident and or resident representative in writing of the reason for transfer or discharge to the hospital for 2 of 2 residents (Resident #8 and Resident #173) reviewed for hospitalization. This deficient practice was evidenced by the following: 1.) On 10/11/24 at 9:52 AM, the surveyor observed Resident #8 out of bed in a high back wheelchair in the common area with activities. On 10/11/24, the surveyor reviewed the Electronic Medical Record (EMR) which indicated that Resident #8 was admitted to the facility for long term care. Further review showed there was a Discharge/Return Anticipated MDS completed on 5/16/24 following a transfer to the hospital for treatment of a sacral wound. The surveyor review of the admission Record indicated Resident #8 had medical diagnosis which included but were not limited to; stage 4 pressure ulcer of the sacral region and osteomyelitis (an infection of the bone). A review of the annual Minimum Data Set (MDS), an assessment tool, dated 8/26/24, revealed a Brief Interview for Mental Status (BIMS) score of 9 out 15, indicating moderate cognitive impairment. The surveyor reviewed the progress notes which revealed that on 5/16/24 at 7:30PM, Resident #8 was transferred to the Hospital. On 10/15/24 at 10:13AM, the surveyor asked the Director of Nursing (DON) for the location of the family and ombudsman notification of hospitalization. He stated the family notification is in the progress notes. On 10/16/24 at 9:17AM, the surveyor was unable to locate written notifications to the resident or family for the reason of transfer in the medical records. On 10/16/24 at 9:51 AM, in the presence of the survey team, the Social Service Coordinator, and the Licensed Nursing Home Administrator (LNHA), the LNHA stated when a resident was hospitalized , a written notice goes to the hospital with the resident's transfer paperwork. The LNHA further stated in most cases the facility retains a copy; however, in this case they did not have a copy to provide to the surveyor. 2. On 10/10/24 at 11:19 AM, during the initial tour, the surveyor observed Resident #173 in bed with their eyes closed. The resident's family member was at the bedside and stated the resident had just been readmitted to the facility. The surveyor reviewed the electronic medical record (EMR) for Resident #173. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; end stage renal disease (the kidneys can no longer function properly) and dependence on renal dialysis (a renal replacement therapy that removes waste and excess fluids from the blood). A review of the progress notes revealed: 10/4/2024 08:01 COMMUNICATION - with Physician - Narrative Note Text: Nephrologist called at 7:30 AM 10/04/2024 .requested that [identifier redacted] be sent to hospital for evaluation .Dr. (doctor) and Son [name redacted] were both notified of the situation. Further review of the medical record, did not revealed written notification of reason for transfer to the resident or family. On 10/16/24 at 11:52 AM, the Director of Nursing (DON) provided a copy of Skilled Nursing Facility Notice of Transfer for Resident # 173. The letter dated was 10/4/24. The DON stated the letter was sent with the resident to the hospital. He was unable to verify if a copy was sent to the family/representative or if a copy was given to the resident. On 10/16/24 at 12:31 PM, in the presence of the survey team, the DON confirmed a written copy of the notification of hospitalization was not sent to the family or given to Resident #173. Review of facility provided policy Transfer, Discharge & Bed-Hold Notices reviewed 5/16/24,included: 4. The Social Service Coordinator/designee will complete the following steps before the community transfers or discharges a resident (voluntary or involuntary): a. Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move, in writing and in a language and manner they understand. NJAC 8:39-4.1(a) 31

Based on observation, interview, and record review, it was determined that the facility failed to obtain an admission weight for 1 of 3 residents, Resident # 173, reviewed for nutrition. This deficient practice was evidenced by the following: On 10/10/24 at 11:19 AM, during the initial tour, the surveyor observed Resident #173 in bed with their eyes closed. The resident's family member was at the bedside and stated the resident had just been readmitted to the facility. The surveyor reviewed the electronic medical record (EMR) for Resident #173. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; end stage renal disease (the kidneys can no longer function properly) and dependence on renal dialysis (a renal replacement therapy that removes waste and excess fluids from the blood). A review of the admission Minimum Data Set, an assessment tool, dated 10/8/24, revealed it was in progress. A review of the individual comprehensive care plan (ICCP) revealed: FOCUS: .resident has nutritional problem or potential nutritional problem r/t (related to) wound and current dx. (diagnosis) Date Initiated: 10/10/2024. Goal: [name redacted] will consume at least 75-100% of meals and supplements offered resulting in stable weight and wound improvement over next 30 days. Date Initiated: 10/10/2024. The surveyor reviewed both the EMR and paper chart for the resident's admission weight. There was no documented readmission weight taken by the facility in the resident's medical record. The last weight entry was 9/26/2024 at 12:28 PM. A review of the progress notes revealed the Registered Dietician's (RD) progress note: 10/10/2024 12:01 PM Type: Nutrition/Dietary Note . Resident known from previous admission .Updated weight pending . RD from dialysis center to be in contact with community dietitian .RD will continue to follow up. On 10/15/24 at 10:32 AM, the surveyor interviewed the RD, who stated a resident's weight should be obtained within 24 hours of admission. He stated he completes the nutrition section on the Service Evaluation and Health Assessment (SEHA) for all new admissions. He stated the purpose of the admission weights was for a baseline weight. The RD reviewed the SEHA for Resident #173 in the presence of the surveyor and acknowledged a new admission weight was not used. He acknowledged the weight from 9/26/24 was used. He further reviewed the EMR and confirmed he was unable to find a new admission weight for the resident. He stated if there was not an admission weight, he would ask the nurse. He stated he had told the nurse but was unable to say when or who he told. On 10/15/24 at 10:50 AM, the surveyor interviewed Resident #173's assigned Certified Nursing Assistant (CNA), who stated the residents should have been weighed yesterday (Monday) but the resident did not want to get out of bed. On 10/15/24 at 10:53 AM, the surveyor interviewed Resident #173's assigned Licensed Practical Nurse (LPN), who stated new admission should be weighed upon admission and then in 3 days. She stated weights should be done usually within 24 hours so you know the parameters. The LPN reviewed the EMR in the presence of the surveyor and acknowledged the last entered weight was 9/26/24. On 10/15/24 at 11:10 AM, the surveyor interviewed the Director of Nursing (DON) and the Assistant DON (ADON). The DON stated new admissions should be weighed within 24 hours, and then weekly x 4 weeks. He then stated all weights would be in the EMR. The DON reviewed the EMR for Resident #173 in the presence of the surveyor. He acknowledged that a new admission weight was not entered. He reviewed the SEHA, effective date 10/8/24, completed by the RD and acknowledged the RD should not have used the weight from 9/26/24. He then stated, We missed the admission weight. He stated our policy is to weigh them (the residents) ourselves and if a weight was not obtained the reason should be documented. On 10/15/24 at 1:18 PM, in the presence of the survey team, the Licensed Nursing Home Administrator and the DON were made aware of the above concerns. A review of the facility's policy Nutrition & Weight Management Program reviewed 5/16/24, revealed: Goal: The Goal of this program is to evaluate residents .prevent unanticipated weight gain or loss .Section 2: .Weight Monitoring: Ongoing weight is integral to the plan to manage the resident's weight: Residents are upon admission, weekly for 4 weeks, then monthly to evaluate trends or in accordance with physician's orders .All weights are recorded int the resident's electronic health record. NJAC 8:39-11.2(e), 17.1(c), 27.1(a)

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation performed on 10/11/24, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 27 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.41 %. This deficient practice was identified for two (2) of four (4) residents, (Resident #12 and #13), that were administered medications by one (1) of two (2) nurses (Licensed Practial Nurse (LPN #1). The deficient practice was evidenced by the following: 1. On 10/11/24 at 9:27 AM, during the medication pass, the surveyor observed LPN #1 preparing to administer five (5) medications to Resident #12 which included one 81 milligram (MG) chewable tablet of Aspirin. LPN #1 stated that the resident had a physician's order (PO) for Aspirin 81 MG according to the electronic medication administration record (eMAR). LPN #1 also stated that the Aspirin 81 MG tablets were a house stock over the counter (HS/OTC) medication, meaning that the facility purchased a bottle to be used for any resident that had a PO. LPN #1 stated that the Aspirin was a chewable tablet and was the only formulation of Aspirin 81 MG in the medication cart. On 10/11/24 at 9:32 AM, the surveyor observed LPN #1 administer the Aspirin chewable tablet to Resident #12 and told the resident to chew the tablet. On 10/11/24 at 9:46 AM, after the surveyor observed LPN #1 administer an Aspirin EC (enteric coated) 81 MG tablet to Resident #13, LPN #1, with the surveyor, reviewed the eMAR for Resident #12 which revealed a PO for Aspirin EC 81 MG which was the same PO for Resident #13. LPN #1 explained that Resident #13 had their Aspirin EC 81 MG tablets packaged by the provider pharmacy and labeled for them and had not had to use the HS/OTC. LPN #1 acknowledged that the PO for Resident #12 was for Aspirin EC 81 MG tablets and that he had administered Aspirin 81 MG chewable tablets. (ERROR #1) On 10/11/24 at 10:33 AM, the surveyor interviewed LPN #1, in the presence of the Assistant Director of nursing (ADON). LPN #1 stated that there were no bottles of Aspirin EC 81 MG in the medication room where the backup supply of HS/OTC medications were stored. The ADON stated that if the PO was for Aspirin EC 81 MG and there was not any available, then the physician had to be called and the order changed to chewable. LPN #1 stated, It was already administered. The surveyor reviewed the medical record for Resident #12. A review of the admission Record revealed diagnoses which included but not limited to; dementia and acute ischemic heart disease (heart problems caused by narrowed heart (coronary) arteries that supply blood to the heart muscle). A review of the October 2024 Order Summary Report revealed a PO with an order date of 10/1/24 for Aspirin EC tablet delayed release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for CAD (coronary artery disease)(a narrowing or blockage of the coronary arteries). A review of the October 2024 electronic medication administration record (eMAR) revealed a PO with a start date of 10/2/24 for Aspirin EC tablet delayed release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for CAD. On 10/11/24 at 11:53 AM, the surveyor interviewed the Health Information Coordinator (HIC), who stated she was responsible for ordering the HS/OTC medications. The HIC stated that she was aware of what had happened this morning, meaning that there were no Aspirin EC 81 MG tablets available. The HIC stated that she usually ordered by visualizing what was low in the medication room where the HS/OTC medications were stored or what she was told by the nurses. The HIC added that she was just given a list of what HS/OTC medications the facility were to keep on hand and would now check the list against what was on hand. A review of the facility Stock List provided by the Director of Nursing (DON) reflected that Aspirin EC 81 MG 100 ct (count) was on the list as a HS/OTC medication. On 10/11/24 at 2:00 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone, who stated that Aspirin EC and Aspirin chewable were the same drug but not the same formulation and that one could not be substituted for the other. The CP added that the chewable formulation is absorbed in the stomach and that the EC formulation was absorbed in the intestine. The CP also stated that he had completed medication observations but had not completed an inservice on medication pass. On 10/15/24 at 9:08 AM, the surveyor interviewed the DON, who stated that he had completed a Medication Skill Capability Evaluation Checklist on 12/27/23 for LPN #1 which was a comprehensive medication pass observation. The DON also stated that Aspirin EC 81 MG was a HS/OTC medication but was not available on 10/11/24 and was obtained after the surveyor performed the medication administration observation. The DON acknowledged that if the Aspirin EC was not available then the physician was to be called and asked to switch to what was on hand. The DON added that the nurses were inserviced on the specific issue of what to do if a medication was not available and to make sure the correct HS/OTC was available. On 10/15/24 at 1:29 PM, the survey team met with the Licensed Nursing Home Administrator and the DON. The DON stated that the Aspirin EC 81 MG tablets were obtained on 10/11/24 after the surveyor performed the medication administration observation. A review of the manufacturer specifications for Aspirin included, but was not limited to, Aspirin is available in different formulations such as film-coated, enteric coated and chewable. In addition, the specifications reflected that Film-coated, extended-release, or enteric-coated may be associated with less GI irritation and/or symptomatic GI disturbances than uncoated tablets. 2. On 10/11/24 at 9:34 AM, during the medication pass, the surveyor observed LPN #1 preparing to administer nine (9) medications to Resident #13 which included Polyethylene Glycol 3350 (PEG3350) (a medication used to relieve constipation). LPN #1 stated that according to the eMAR the dose of PEG3350 was 17 grams (GM). LPN #1 added that sometimes the provider pharmacy sent 17 GM packets, but that Resident #13 had a labeled bulk powder bottle that was sent by the provider pharmacy and that he had to measure the 17 GM. At that time, the surveyor observed LPN #1 pour the PEG3350 powder into a 30 milliliter (ML) medication cup. LPN #1 stated that he was filling the medication cup up to 17 ML, which was an estimate between the 15 ML mark and the 20 ML mark on the medication cup. On 10/11/24 at 10:16 AM, the surveyor interviewed LPN #1, who stated that he thought 17 GM was the same as 17 ML. LPN #1 added that it was easier to use the 17 GM premade packets. LPN #1, in the presence of the surveyor, removed the resident's bulk bottle of PEG3350 from the medication cart and reviewed the label which revealed the instructions for use were to Use the measuring line on the bottle cap to measure a single dose (about 1 heaping tablespoon). (ERROR #2) At that time, LPN #1 removed the cap of the PEG3350 bottle and stated that there was a designation for 17 GM to be measured in the cap. LPN #1 then stated that he was unsure if the 17 ML that he had measured in the medication cup would be the same as the 17 GM measurement indicated on the cap of the PEG3350 bottle. On 10/11/24 at 10:19 AM, the surveyor observed LPN #1 measure 17 GM of PEG3350 from the resident's bulk bottle in a 30 ML medication cup as he had previously done by estimating 17 ML, and poured the measured 17 ML powder into a clear plastic 8-ounce cup. Then, LPN #1 poured a 17 GM packet of PEG3350 powder into another clear 8-ounce cup and put the two cups side by side. LPN #1 stated that he was unsure if they were the same but thought the two cups were close to the same amount. On 10/11/24 at 10:26 AM, the surveyor, in the presence of another surveyor, with LPN #1, showed the two clear cups of PEG3350 that were measured by LPN #1 to the ADON. The ADON stated that the plastic cup with the 17 GM packet measured a little more than the plastic cup with the 17 ML measured PEG3350 powder. LPN #1 explained that he had measured 17 GM of the bulk PEG3350 powder in a medication cup and had to make an estimation of 17 ML between the 15 ML mark and the 20 ML mark. At that time, the surveyor with the ADON reviewed the label on the PEG3350 bulk powder bottle which revealed Use the measuring line on the bottle cap to measure a single dose (about 1 heaping tablespoon). The ADON stated that the manufacturer instructions for measuring were to be followed for an accurate dose. The surveyor reviewed the medical record for Resident #13. A review of the admission Record revealed diagnoses which included but were not limited to; gastro-esophageal reflux disease without esophagitis (stomach acid rises into the esophagus chronically), muscle weakness and difficulty in walking. A review of the October 2024 Order Summary Report reflected a PO with an order date of 10/3/24 Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)) Give 17 GM by mouth in the morning for constipation. A review of the October 2024 eMAR revealed a PO with a start date of 10/4/24 Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)) Give 17 GM by mouth in the morning for constipation. On 10/11/24 at 2:00 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone, who stated that the manufacturer instructions should be followed for measuring PEG3350 powder from the bulk bottle for an accurate dose. On 10/15/24 at 9:08 AM, the surveyor interviewed the DON, who stated that he had completed a Medication Skill Capability Evaluation Checklist on 12/27/23 for LPN #1 which was a comprehensive medication pass observation. The DON also stated he was aware that the PEG3350 was inaccurately measured using a 30 ML medication cup. A review of the manufacturers' specifications for PEG3350 reflected to Follow all directions on your prescription label. In addition, the specifications reflected to use the powder form of this medicine, measure your dose with the medicine cap on the bottle. This cap should contain dose marks on the inside of it. A review of the facility policy titled Medication Administration dated January 2023 provided by the DON revealed that Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing and principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Also, the policy revealed for the medication administration procedure that Medications are administered in accordance with written orders of the prescriber. In addition, the policy revealed for the medication administration procedure that Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart b. When dose is pulled c. Before dose is administered. NJAC 8:39-11.2(b), 29.2(d), 29.4(c)

Based on observation, interviews, and review of facility documentation it was determined that the facility failed to a.) handle, clean and sanitize dishware in a manner to prevent microbial growth and cross contamination, and b.) wear hair restraints to maintain proper kitchen sanitation. This deficient practice was evidenced by the following: On 10/10/24 at 9:22 AM, the surveyor entered the kitchen with a second surveyor. The surveyors observed a staff member at the dish machine without a hair restraint. At 9:35 AM, the surveyors began the kitchen tour with the Dining Director. The surveyors observed the same staff member (now with a hair restraint worn) load the dish machine with soiled dishware and bare hands. He then removed clean bowls from the clean side of the dish machine without performing hand hygiene and glove application. The Dining Director acknowledged that the staff member should have washed his hands and applied gloves prior to removing clean dishware from the dish machine to prevent cross contamination. She stated that there was usually one dishwasher that worked the soiled side and one dishwasher on the clean side of the dish machine. A review of the facility's policy Food Safety and Seniors - Additional Food Safety Tips dated 2015, included Restrain hair in food preparation areas. A review of the facility's policy Dishwashing Procedure dated 11/19/2019, included Objective: Participants will understand the correct dishwashing procedures .; Either two people are in the dish room, one on the dirty side, one on the clean side. If one person does both, they must wash their hands between dirty and clean areas . A review of the facility's policy Proper Handwashing dated 8/16/23, included Hands must be washed: . After contact with unsanitary surfaces i.e. soiled dishes . A review of the facility's policy Food Safety and Seniors - Facts About Handwashing dated 2015, included When to Wash Your Hands . After washing dirty dishes. A review of the facility's policy Food Safety and Seniors - Four Steps to Food Safety dated 2015, included Wash and sanitize . to prevent cross contamination. A review of the facility's policy Food Safety and Seniors dated 2015, included Objective: to recognize the consequences of unsafe food practices and identify ways to prevent foodborne illness. Be sure to: . Avoid cross contamination. A review of the Dishwasher Job Description, dated November 2023, included The Dishwasher is responsible for cleaning and janitorial duties . while adhering to all food safety and sanitation requirements and maintaining a safe and orderly kitchen. Performs dishwashing tasks to properly wash and sanitize all dishes and china, silverware, glassware, utensils and cookware. N.J.A.C 18:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to treat a resident in a dignified manner. This deficient practice was identified for 1 of 1 resident observed for pressure ulcer wound dressing change, Resident #14. On 6/19/23 at 12:27 PM, the surveyor observed Resident #14 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor further observed that the resident had a dressing to the right foot. On 6/21/23 at 9:35 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform wound care to the right heel of Resident #14. At the conclusion of the wound care, the LPN taped the dressing and then proceeded to write her initials including the date 6/21/23, on the tape after it had been applied to the resident. The LPN stated to the surveyor that it was her practice to initial the tape for the other staff to know when the wound care was performed. The surveyor reviewed Resident #14's medical record. The admission Record reflected that Resident #14 was admitted to the facility on [DATE] with medical diagnoses which included but not limited to, Atrial Fibrillation, Type 2 Diabetes Mellitus, Anemia, and Hypertension. A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 6/2/23 reflected that the resident had a Brief Interview for Mental Status of 15 out of 15, indicating that the resident was cognitively intact. A review of the June 2023 Physician Order Summary revealed a physician's order dated 6/20/23 for Santyl External Ointment 250 unit/gm (Collagenase) Apply to right heel topically two times a day for wound treatment cleansed with Daikin solution cover with dressing. A review of the facility's Policy and Procedure titled, Skin Care & Pressure Ulcer Management Program did not specifically indicate the procedures of wound dressing changes. On 6/21/23 at 2:05 PM, the surveyor met with the facility's Licensed Nursing Home Administrator, Director of Nursing, Senior Director of Nursing Services, and Associate Executive Director to discuss the above concerns. There was no additional information provided. On 6/21/23 at 2:05 PM, the surveyor met with the facility's Licensed Nursing Home Administrator, Director of Nursing, Senior Director of Nursing Services (SDNS), and Associate Executive Director. The SDNS stated to the surveyor that nurses should not sign and date the dressing on the resident once the surgical dressing has been applied on the resident. The SDNS added that the surgical dressing should be signed and dated prior to applying it on the resident. There was no additional information provided. N.J.A.C. 8:39-4.1, 12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident verbal abuse. This deficient practice was identified for 1 of 3 reportable investigations reviewed, involving Resident #31 and Resident #15. This deficient practice was evidenced by the following. On 6/22/23 at 11:30 AM, during Resident Council Interview Resident #15 informed the Surveyor that on 6/19/23 CNA #1 had dropped flowers in a vase belonging to Resident #15. Resident #15 explained to CNA #1 that the flowers had special meaning and that Resident #15 would like the flowers placed back into the vase. Resident #15 continued to explain that CNA #1 responded, Who cares they're dead anyway. Resident #15 further described that CNA #1 aggressively threw the roommate's (Resident #31) call bell onto the roommate's bed and was verbally abusive toward the roommate. Resident #15 explained to the surveyor that they felt frightened. Resident #15 informed the surveyor that on the morning of 6/20/23 they alerted the Director of Nursing (DON). On 6/22/23 at 12:15 PM, the surveyor reviewed the Electronic medical records (EMAR) for Resident #31. Resident #31's EMAR revealed diagnoses which included, but were not limited to: Alzheimer's Disease, Dementia, Depression, and Other Specified Fracture of Left Pubis. The Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 6/17/23 for Resident #31 provided a Brief Interview for Mental Status (BIMS) with a score of 0, revealing a severe impairment of cognition. On 6/22/23 at 12:20 PM, the surveyor reviewed the EMAR for Resident #15. The EMAR revealed that Resident #15 had diagnoses which included but not limited to Periprosthetic Fracture around Internal Right Hip Joint, muscle Weakness, and Aftercare following Joint Replacement Surgery. Review of the admission MDS dated [DATE], for Resident #15 documented a BIMS score of 15, revealing that the resident has a cognitively intact cognition. A review of the Progress Notes starting 6/20/23 for Resident #31 and Resident #15, did not provide any information that there was an incident reported about either resident. On 6/22/23 at 2:15 PM, the surveyor team interviewed the DON, who stated that the facility did not have any reportable events for the month of June but remembered Resident #15 informing him of an incident. The DON stated he informed the Social Worker (SW). On 6/22/23 at 3:00 PM, the survey team interviewed the DON and SW, who informed the team that this incident was investigated as a grievance. Both the DON and SW agreed that the Licensed Nursing Home Administrator (LNHA) was not informed of the incident. On 6/22/23 at 4:00 PM, the survey team interviewed the LNHA, who stated, The incident should have been reported to the New Jersey Department of Health (NJDOH), investigated, and the CNA involved should have been suspended pending the investigation. A review of the facility policy titled, Abuse, Neglect & Exploitation - prevention, Reporting and Investigation, Effective Date: 5/31/16 revealed under the Action Steps section 2, subsection a) All team members are mandated reporters and are required to report allegations or a known episode of abuse, neglect and/or exploitation to applicable state authorities within the time frame established by law. Continued review of the policy section h) Steps to take to ensure the safety and protection of residents in situations of known or suspected abuse, neglect and/or exploitation, including escalation to the Executive Director/designee. On 6/27/23 at 10:00 AM, surveyor met with the LNHA who stated that the facility should have reported the abuse to the NJDOH at the time that facility staff was informed of the allegation. NJAC 8:39-9.4(f)

Based on observation, interview, record review, and review of pertinent facility documentation, the facility failed to implement their abuse policy to investigate an allegation of verbal abuse between a Certified Nursing Assistant (CNA #1) and resident. This deficient practice was identified for 1 of 3 resident's (Resident #31) reviewed for abuse. The deficient practice is evident by the following: On 6/22/23 at 11:30 AM, during Resident Council Interview Resident #15 informed the Surveyor on 6/19/23 that CNA #1 had dropped flowers in a vase belonging to Resident #15. Resident #15 explained to CNA #1 that the flowers had special meaning and that Resident #15 would like the flowers put back into the vase. As per Resident #15, CNA #1 responded, Who cares they're dead anyway. Resident #15 further described that CNA #1 aggressively threw their roommate's (Resident #31) call bell onto the roommate's bed and was verbally abusive toward the roommate. Resident #15 explained to the surveyor that they felt frightened and alerted the Director of Nursing (DON), on the following morning 6/20/23. On 6/22/23 at 12:15 PM, the surveyor reviewed the Electronic medical records (EMAR) for Resident's #31 and #15. Resident #31 EMAR revealed the resident had diagnoses which included, but were not limited to: Alzheimer's Disease, Dementia, Depression, and Other Specified Fracture of Left Pubis. An assessment for the Resident #31 cognition called Brief Interview for Mental Status (BIMS) Skilled completed on 6/17/23 revealed that Resident #31 had a BIMS score of 0, which shows the resident has a severe impairment with mental cognition. The admission Minimum Data Set, an assessment tool, dated 6/19/23, revealed the Resident #31 was totally dependent on one person for bed mobility, transferring, toileting, dressing and personal hygiene and had no behavioral symptoms. Resident #15 EMAR revealed the resident had diagnoses which included, but were not limited to: Periprosthetic Fracture around Internal Right Hip Joint, muscle Weakness, and Aftercare following Joint Replacement Surgery. An assessment for the Resident #15 cognition called Brief Interview for Mental Status (BIMS) Skilled completed on 6/10/23 revealed that Resident #15 had a BIMS score of 15, which shows the resident is cognitively intact with mental cognition. On 6/22/23 at 2:15 PM, the surveyors interviewed the DON, who stated the facility did not have any reportable events for the month of June but remembered Resident #15 informing him of the incident. The DON stated he does not handle these investigations and informed the Social Worker (SW), who investigated the incident of abuse as a grievance. On 6/22/23 at 2:30 PM, the SW provided the survey team with a copy of the grievance report. The SW stated her investigation was not completed. The report includes a copy of statements made by Resident #15 and CNA #1 as well as a copy of CNA #1 resident assignment sheet for the 3-11 PM shift which included both Resident #15 and #31. On 6/22/23 at 3:00 PM, the survey team interviewed the DON and SW who both agreed that the Licensed Nursing Home Administrator (LNHA) was not made aware of the incident. On 6/22/23 at 4:00 PM, the survey team interviewed LNHA, who stated, The incident should have been reported to the New Jersey Department Of Health (NJDOH), investigated, and the CNA should have been suspended pending the investigation. A review of the facility policy titled, Abuse, Neglect & Exploitation - prevention, Reporting and Investigation, Effective Date: 5/31/16 revealed under the Action Steps section 2, subsection a) All team members are mandated reporters and are required to report allegations or a known episode of abuse, neglect and/or exploitation to applicable state authorities within the time frame established by law. h) Steps to take to ensure the safety and protection of residents in situations of known or suspected abuse, neglect and/or exploitation, including escalation to the Executive Director/designee. Section 8 The SNA/designee, subsection b) Removes the individual alleged to be involved in the abuse, neglect or exploitation from the area, part i. Ensures that any team member alleged to be involved in the abuse, neglect or exploitation is placed on administrative leave, pending the results of the investigation. c) Ensures that the resident's (i) physician, (ii) legal representative and (iii) family member or other individual regularly involved in the resident's day to day care are notified as soon as practicable within timeframes established within laws/regulations. On 6/27/23 at 10:00 AM, surveyor met with LNHA with stated, that the facility should have reported the abuse to the New Jersey Department of Health (NJDOH) well the allegation was made and per the facility policy an investigation should have begun as well as the CNA #1 being suspended until the outcome of the investigation was reached. The LNHA also stated the DON and SW were going through retraining on abuse and reporting. NJAC: 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to accurately code resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for one 1 of 12 residents, (Resident #21) reviewed for accurate coding of MDS. This deficient practice was evidenced by the following: On 6/20/23 at 10:01 AM, Resident #21 was observed lying in bed awake, alert, and responded appropriately to the surveyor. The surveyor observed floor mats against the wall by the window in the resident's room. Resident #21 had their call bell within reach. On 6/21/23 at 9:43 AM, Resident #21 was observed lying in bed awake, alert, and verbally responsive. The resident informed the surveyor that they were ok. The resident had no complaints of pain or discomfort. The floor mats for Resident #21 were noted against the wall by the window. The surveyor reviewed the resident's hybrid medical chart which included review of paper as well as computerized medical chart. A review of Resident #21's Face Sheet (a one-page summary of important information about the resident) documented the resident's diagnosis which included but was not limited to Unspecified Dementia Without Behavior, Major Depressive Disorder, Anxiety, History of Falls, Essential Hypertension, Type 2 Diabetes Mellitus A review of the Health Status Progress Note dated 2/19/23 documented, Patient was found sitting by the bed and asking for help. Buttock on the floor she was trying to grasp the wheelchair nearby. Further review of the Health Status Progress Note dated 3/12/23 documented, Resident was heard calling for help around 4:35 AM. The care manager went to the room and found the resident sitting on the floor, backing the bed and facing the door. Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 4/10/23, indicated that Resident #21 had a Brief Interview for Mental Status (BIMS) score of 5. This score established that Resident #21 had a severely impaired cognition. A review of Resident #21's MDS dated [DATE], Section J1800 - Any Falls Since Prior Assessment coded as 0, indicating that the resident had no falls since their last Quarterly Assessment of 1/16/23. The documentation in the MDS contradicted the resident's history of falls based on the Health Status Progress Notes dated from 1/1/23 to 6/20/23. On 6/22/23 at 11:02 AM, the surveyor along with MDS Coordinator reviewed the Quarterly assessment dated [DATE] which documented 0 falls and the Health Status Progress Notes dated 3/12/23, which revealed that Resident #21 had a fall with no injury. The MDS Coordinator reviewed her personal fall log in the presence of the surveyor, which revealed that Resident #21 had a fall on 3/12/23. The MDS Coordinator confirmed that she missed coding the fall. Further review of Health Status Notes dated 2/19/23, with the MDS Coordinator documented that Resident #21 had a fall on 2/19/23 with no injury. The MDS Coordinator reviewed her personal fall log and confirmed that she had also missed coding the 2/19/23 fall as well. No further information was provided. NJAC 8:39-33.2(d)

Based on observation, interview, and record review it was determined that the facility failed to carry out a comprehensive care plan (CP) for 1 of 12 residents reviewed for the fulfillment of a care plan, Resident #21. This deficient practice was evidenced by the following: On 6/20/23 at 10:01 AM, Resident #21 was observed lying in bed awake, alert, and verbally responsive. The surveyor observed floor mats that were leaning against the wall by the window. On 6/21/23 at 9:43 AM, Resident #21 was observed lying in bed awake, alert, and verbally responsive. The surveyor observed floor mats that were leaning against the wall by the window. The surveyor reviewed the resident's hybrid (paper and electronic) medical chart which revealed the following: A review of Resident #21's Face Sheet (a one-page summary of important information about the patient) documented the resident's diagnoses included but were not limited to Unspecified Dementia Without Behavior, Major Depressive Disorder, Anxiety, History of Falls, Essential Hypertension, Type 2 Diabetes Mellitus. A review of the Minimum Data Set (MDS), an assessment tool dated 4/10/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating that Resident #21 had severely impaired cognition. A review of Resident #21's CP with an effective date of 7/19/22 and 4/12/23 presented a goal that [Resident #21] will not sustain any fall related injury through the next review date. An intervention in the CP, dated 8/1/22 read The resident uses floor mats as ordered by MD. Ensure the device is in place at bedtime. A review of the Physician's Orders (PO) indicated an order, dated 7/20/22, for floor mats while in bed every shift for fall risk. On 6/21/23 at 9:48 AM, the surveyor interviewed the Registered Nurse (RN) assigned to Resident #21. The RN stated floor mats were used at night time only, placed on both sides of the bed, and that in the morning floor mats were not needed because the resident was being supervised. The surveyor reviewed with the RN the resident's PO, which revealed the physician order for floor mats while the resident was in bed for every shift. The RN stated that floor mats should be at both sides of the bed while the resident was in bed as per the physician's order. On 6/21/23 at 2:05 PM, the surveyor informed the Director of Nursing, Senior Director of Nursing Supervisor (DNS), Licensed Nursing Home Administrator, and Associate Executive Director, of the above concerns. The DNS stated it was expected that when the resident was in bed that the floor mats should have been in place. There was no further information provided by the facility. N.J.A.C. 8:39-11.2; 27.1 (a)

2. On 6/20/23 at 10:01 AM, the surveyor observed Resident #21 lying in bed awake, alert, and responded appropriately to the surveyor. The Surveyor observed floor mats standing against the wall by the window of the resident's room. Resident #21 had their call bell within reach. On 6/21/23 at 9:43 AM, the surveyor observed Resident #21 lying in bed awake, alert, and verbally responsive. The resident informed the surveyor that they were doing ok. Resident #21 had no complaints of pain or discomfort. Once again, the surveyor observed the floor mats standing against the wall by the window of the resident's room. A review of Resident #21's Face Sheet (a one-page summary of vital information about the patient) revealed the resident had diagnoses which included but were not limited to Unspecified Dementia Without Behavior, Major Depressive Disorder, Anxiety, History of Falls, Essential Hypertension, and Type 2 Diabetes Mellitus. Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 4/10/23, the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating that Resident #21 had a severely impaired cognition. A review of the Health Status Progress Notes revealed that Resident #21 had falls on: 7/19/22, 8/1/22, 8/12/22, 10/20/22, 12/23/22, 2/19/23, 3/12/23, and 5/7/23. Resident #21 had a total of 8 falls since admission to the facility. A review of the resident's care plan (CP) initiated on 7/19/22, identified Resident #21 was at risk for falls, which included a list of dates when Resident #21 had falls. The CP Focus section failed to include the falls that occurred on 3/12/23 and 5/7/23. Further review of the Resident #21's CP identified an initiation date of 7/19/22 for fall interventions. The CP was revised on 8/1/22, with a new documented intervention of resident uses floor mat as ordered by MD. Ensure device is in place at bedtime. The CP was again revised on 10/21/22, with a new intervention for educate resident about safety and use of any device or to request assistance as needed. The CP had the most recent revision on 5/9/23, adding a new intervention for frequent staff check. On 6/22/23 at 11:40 AM, the surveyor interviewed the Director of Nursing Supervisor (DONS) and the Director of Nursing (DON) in reference to updating fall interventions when there is a new fall. The DNS explained that all fall interventions are documented on progress notes, the task section, and/or care plans. The DNS added that interventions documented in the progress notes or task section should be included in care plan interventions. A review of the facility's policy titled, Incident and Event Reporting presented, The intent of this policy is that the community identifies each resident at risk for events/incidents and/or falls, and adequately plans care and implements procedure to prevent accidents. On 6/26/23 at 2:17 PM, the surveyor interviewed the Acting DON who confirmed that all nurses or other disciplines can update the CP. The Acting DON verified that CPs should be updated and reviewed every time a fall occurs. No further information was provided. NJAC 8:39-11.2(i) Based on observation, interview, and record review, it was determined that the facility failed to revise a comprehensive care plan for 2 of 18 residents reviewed, Resident #14 and Resident #21. This deficient practice was identified by the following: On 6/19/23 at 12:27 PM, the surveyor observed Resident #14 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor further observed that the resident had a surgical dressing to their right foot. The surveyor reviewed Resident #14's hybrid medical records. The admission Record reflected that Resident #14 was admitted . to the facility with medical diagnoses which included but were not limited to Atrial Fibrillation, Type 2 Diabetes Mellitus, Anemia, and Hypertension. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/2/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating that the resident had an intact cognition. A review of the June 2023 Physician Order Summary revealed a physician's order dated 6/20/23 for Santyl External Ointment 250 unit/gm (Collagenase) Apply to right heel topically two times a day for wound Treatment cleansed with Daikin solution cover with dressing. A review of the form titled; Wound Healing Solutions dated 6/20/23 revealed that Resident #14 had an unstageable pressure ulcer injury to the right heel due to eschar (a dry, dark scab). The surveyor reviewed the resident's care plan (provides direction on the type of nursing care for an individual) which had no documentation indicating that Resident #14 had a skin breakdown pressure ulcer to the right heel. On 6/21/23 at 10:30 AM, the Licensed Practical Nurse (LPN) who was assigned to care for Resident #14, stated that the care plan was not updated to indicate the resident's pressure ulcer. The LPN verified that Resident #14's care plan should have included the resident's pressure ulcer.

1) Based on observation, interviews, and record review, it was determined the facility failed to consistently follow standards of clinical practice with regard to a.) accurately documenting medication administration, and b.) correctly following physician's orders for 2 of 12 residents, Resident #19 and Resident #15. The deficient practice is evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. The surveyor reviewed the hybrid medical records of Resident #19, which revealed the following: The resident's admission Record listed diagnoses that included but were not limited to Alzheimer's Disease [a progressive disease that destroys memory and other important mental functions], Hypertension, and Hyperlipidemia. The Quarterly Minimum Data Set (MDS), an assessment tool dated 4/3/23, indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 00 out of 15, which indicated that the resident had severe cognitively impairment. A review of the Order Summary Report and the electronic Medication Administration Record (eMAR) indicated Resident #19 had physician orders dated 11/10/22, that read: amlodipine Besylate Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day for HTN [Hypertension] Hold SBP [Systolic Blood Pressure] below 120. A review of the June 2023, May 2023, and April 2023 eMAR for Resident #19 revealed that at the time of the administration of the amlodipine, there was no documentation of the resident's blood pressure. On 6/21/23 at 11:28 am, the surveyor interviewed LPN #1 about the amlodipine order and any special instructions for the medication. LPN #1 stated he was aware Resident #19 had parameters to hold the amlodipine medication for a SBP less than 120. LPN #1 stated he checked the resident's blood pressure (BP) prior to administering the medication. He acknowledged that he did not enter the BP result in the electronic medical record at the time of the medication's administration. On 6/21/23 at 11:57 am, the surveyor interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN) about the amlodipine medication order and documentation of the resident's BP with medication administration. The LPN/CN stated the eMAR would prompt at the time of medication administration for the nurse to document the resident's BP. LPN/CN reviewed the physician's order and the eMAR with the surveyor and stated she did not know why it was not picked up by the nurses and why the order was not clarified in the eMAR. LPN/CN acknowledged it would be expected for the nurse to enter the BP at the time of the medication administration on the eMAR. On 6/21/23 at 12:12 pm, the surveyor interviewed the Director of Nursing (DON) about the above concerns. The DON stated it was expected for the blood pressure to be checked and documented prior to the medication's administration. The DON stated that the nurses and pharmacy consultant should have caught that the BP was not being documented at the time that the medication was administered. On 6/21/23 at 2:05 pm, the surveyor informed the Administrator, Senior Director of Nursing Services, Associate Executive, and DON of the above concerns. The surveyor reviewed the facility provided policy titled Medication Administration, with a date of 01/23. Under Medication Administration, it read: 1. Medications are administered in accordance with written orders of the prescriber .2. Obtain and record any vital signs as necessary prior to medication administration. 2.) On 6/19/23 at 12:22 PM, the surveyor observed Resident #15 in the room, lying in bed, awake, alert, and verbally responsive. The surveyor reviewed the resident's hybrid medical records, which revealed that Resident #15 was admitted to the facility with diagnosis which included but were not limited to Type 2 Diabetes Mellitus, Periprosthetic fracture around the internal prosthetic right hip joint, and Hypertension. A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 6/10/23, reflected that the resident had a Brief Interview for Mental Status of 15 out of 15, indicating that the resident had intact cognition. A review of the resident's June 2023 Order Summary Report indicated a physician's order (PO) having a start date of 6/6/23 for Losartan Potassium Oral Tablet 50mg. Give 1 tablet by mouth one time a day for Hypertension. There was also another PO having a start date of 6/12/23 for Losartan Potassium Oral Tablet 50mg. Give 1 tablet by mouth two times a day for Hypertension, hold SBP (Systolic Blood Pressure) (top number of a blood pressure reading) below 110, and heart rate below 60. A review of the June 2023 eMAR revealed the PO for Losartan Potassium Oral Tablet 50mg with a start date of 6/6/23 was scheduled to be administered to Resident #15 at 9:00 AM. Further review of the eMAR revealed the PO with a start date of 6/12/23 for Losartan Potassium Oral Tablet 50 mg was scheduled to be administered to Resident #15 at 9:00 AM and 5:00 PM. On 6/22/23 at 1:43 PM, the surveyor interviewed the Licensed Practical Nurse #1 (LPN #1), assigned to care for Resident #15, regarding the two different PO for the same medication to treat Hypertension. LPN #1 explained that she administered two tablets of Losartan Potassium 50mg, totaling 100mg, for the 9:00 AM dose. LPN #1 informed the surveyor that the LPN/CN obtained the 6/12/23 PO from the physician. On 6/22/23 at 1:50 PM, the surveyor interviewed LPN/CN, who acknowledged that when she obtained the PO dated 6/12/23 for Losartan Potassium 50mg 1 tablet two times a day. LPN/CN explained that she should have discontinued the PO dated 6/6/23 for Losartan Potassium 50mg 1 tablet one time a day and not have both POs active. LPN/CN stated that both orders should not have been active and administered to Resident #15 together. On 6/26/23 at 2:00 PM, the surveyor discussed the above concern with the facility's Licensed Nursing Home Administrator and Director of Nursing, who did not provide any further information. NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were 1. stored in a secure locked environment, 2. expired medications were removed from a resident's active inventory after it had expired and/or been discontinued by the physician in accordance with professional standards of clinical practice, 3. removed expired narcotics kept in a locked backup box. This deficient practice was identified for 1 of 1 units reviewed during the facility unit inspection process. This deficient practice was evidence by the following: 1. On 6/19/23 at 10:03 AM, a surveyor along with another surveyor requested from the Unit Clerk (UC), if someone could open the medication room door for inspection. At that time the UC volunteered to open the locked medication room door, and had access to the passcode. The UC entered the keypad code unlocking the medication room door. 2. Once within the locked medication room, the surveyors noted that there were 3 cassette boxes filled with numerous non-narcotic prescription back up medications secured with zip ties on the counter of the medication room. These medications were accessible to the UC, and any other non medical person who would have the access code to the keypad locking and securing the medication room. 2. Once in the medication room, the surveyor asked if the locked refrigerator could be opened. The UC stated that she'd be right back and left the medication room. The UC returned to the medication room with the key to the refrigerator, opening the locked refrigerator for the surveyors. On 6/19/23 at 12:11 PM, the surveyor interviewed the UC in the presence of another surveyor, the UC informed the surveyor that she was given the refrigerator key by the Registered Nurse (RN), who was busy administering medications. On 6/19/23 at 12:34 PM, the surveyors interviewed the DON in the presence of the Licensed Practical Nurse in charge of the unit (LPN), who stated that only nurses should have access to the medication room. The Concierge (UC) should not have access to the medication room. The LPN added that the access keys to the medication room and refrigerator are kept in the drawer of the nursing office and only nurses should have access to the keys. The LPN stated that the UC should not have had access or knowledge of the keypad code to the medication room. An interview of the UC on 6/19/23 at 12:40 PM, stated that the RN gave her the keys to the refrigerator. On 6/19/23 at 12:40 PM, the surveyor interviewed the RN who stated that she gave her refrigerator keys to the UC. I shouldn't have done that. She shouldn't have access. 3. On 6/19/23 at 12:12 PM, the surveyors encountered the LPN who entered the medication room to help the surveyors. The surveyors inspected the refrigerator and found 2 intravenous medication bags that had expired. The surveyors found Vancomycin 1250 mg (antibiotic therapy) 262.5 milliliters (ml) that had been manufactured by the Provider Pharmacy on 6/8/23 and had a documented expiration date of 6/17/23. In the presence of the LPN, the surveyors also found Ceftriaxone 1 gm (antibiotic therapy) 50 ml that had been manufactured by the Provider Pharmacy on 5/18/23 and had a documented expiration date of 6/7/23. The LPN explained that both of these medications were discontinued and should have been immediately removed from the refrigerator by the nursing staff and discarded. The LPN added that the Consultant Pharmacist (CRPh) performs unit inspections monthly. The LPN stated that he should have picked this up. 4. On 6/20/23 at 10:10 AM, the DON in the presence of the surveyor completed a narcotic inventory of all narcotics double locked in the wall lock box located in the medication room. During the narcotic inventory review, the surveyor found #10 tablets of Lyrica (non-narcotic pain reliever) 50 mg which had expired on 4/2023 and #10 tablets of Morphine Sulfate (Opioid narcotic pain reliever) 15 mg tablets which had expired 2/2023. On 6/20/23 at 12:29 PM the surveyor interviewed the LPN who stated that all narcotics are counted every shift by nursing, and they should have noticed the expired narcotics in the wall lock box and removed them from active stock. The LPN added that the Consultant Pharmacist (CRPh) performs unit inspections monthly. The LPN stated that he should have picked this up. 5. The surveyor reviewed the Consultant Pharmacist Unit Inspection Reports received from 1/2023 to the last inspection dated June 8, 2023. There were no documentations that alerted the facility of Ceftriaxone 1 gm (antibiotic therapy) 50 ml that had a documented expiration date of 6/7/23, Lyrica (non-narcotic pain reliever) 50 mg which had expired on 4/2023 and #10 tablets of Morphine Sulfate (Opioid narcotic pain reliever) 15 mg tablets which had expired 2/2023. On 6/26/23 at 11:26 AM, the surveyor interviewed the Consultant Pharmacist (CRPh) who stated that he was not aware of backup narcotics stored in the wall lock box. The CRPH admitted that he should have removed Ceftriaxone 1 gm (expiration 6/7/23) from the refrigerator when he performed the last facility unit inspection of the refrigerator on 6/8/23. The Storage of Medication policy was reviewed, Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Continued review of the procedures of The Storage of Medication policy, 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. In addition to the above documentation of The Storage of Medication policy, 14. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy. Review of the Controlled Medication Storage policy, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations. Under, PROCEDURES 1. The director of nursing and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled medications. Continued review of the Controlled Medication Storage policy, PROCEDURES 8. The consultant pharmacist, or pharmacy designee, routinely reviews a sampling audit of controlled medication storage, records, and expiration dates during medication storage inspections. On 6/21/23 at 2:05 PM, the surveyor discussed concerns related to the unit inspection findings with the DON, Senior Director of Nuring Services, Licensed Nursing Home Administrator (LNHA), and Associate Executive Director. There was no additional information provided. On 6/26/23 at 3:43 PM, the surveyor discussed concerns related to the interview with the CRPh that had transpired, with the LNHA, the temporary replacement DON, Director of Operations and Assistant DON. There was no additional information provided. NJAC 8:39-29.4(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/20/23 at 10:01 AM, Resident #21 was observed lying in bed awake, alert, and responded appropriately to the surveyor. The surveyor observed floor mats against the wall by the window in the resident's room. The call bell was observed within reach for Resident #21's use. The surveyor reviewed the resident's hybrid chart which included a paper as well as a computerized medical chart. A review of Resident #21's Face Sheet (a one-page summary of relevant information about the patient) that documented the resident's diagnosis which included but was not limited to Unspecified Dementia Without Behavior, Major Depressive Disorder, Anxiety, History of Falls, Essential Hypertension, Type 2 Diabetes Mellitus. Review of Resident #21's Physician's orders (PO) presented active orders with start dates of 7/19/22 for Tylenol 325 milligram (mg) 2 tablets by mouth every 4 hours as needed for temperature greater than 100.2 and Tylenol 325 mg 2 tablets by mouth 2 tabs by mouth every 4 hours as needed for temperature 100 above. Review of the eMAR for the month of June 2023 and May 2023, revealed 2 separate sections for Tylenol 325 mg give 2 tablets by mouth every 4 hours as needed for temperature greater than 100.2 and Tylenol 325 mg give 2 tablets by mouth every 4 hours as needed for temperature 100 above. Documentation on the eMAR revealed that Resident #21 had not received either one of the ordered Tylenol as needed medications. A review of the Consultant Pharmacist Progress Notes revealed that the CP visited and documented comments monthly, with the last documented visit and comment on 6/8/23. A review of the initial pharmacy recommendations for Resident #21 dated 7/19/22 documented, no irregularities noted. There were no other comments or recommendations documented related to the resident's duplicate Tylenol order for August 2022 to June 2023. On 6/26/23 at 11:45 AM, the surveyor interviewed the CP who stated that he reviews all resident's medications once a month. The CP added that his review of medications includes as needed medications based on the resident's PO. The CP revealed that he does not review the eMAR. The CP identified that he would document any duplicate in his report making recommendations to discontinue one of them. During the interview with the CP about the two as needed Tylenol orders, the CP stated, I must have missed those orders based on what the order is stated. The CP agreed that he had never notified the facility of the duplicate Tylenol as needed orders. The surveyor reviewed the facility document titled, Pharmaceutical Consultant Services Contract Developed for [NAME] Gardens of [NAME] Skilled, created June 2016. The contract indicated the CP would be responsible for the general supervision of the facility's pharmaceutical services and services including: A review of all medication records on a monthly basis for the skilled subacute facility. Provide written reports to the Administrator and the Director of Nursing on a monthly basis for the skilled sub-acute facility. On 6/26/23 at 3:35 pm, the surveyor informed the Licensed Nursing Home Administrator, Acting DON, and Director of Operations of the interview with the CP. The Administrator stated that she would follow up with the CP. No further information was provided. On 6/27/23 at 9:37 AM, the surveyor along with the Registered Nurse (RN) reviewed Resident #21's PO, and the duplicate order for the as needed Tylenol 325mg. The RN explained that one of the Tylenol as needed orders should have been discontinued. The RN acknowledged that there should not have been duplicate orders for as needed Tylenol. NJAC 8:39- 29.3 Based on observation, interview, and record review, it was determined that the Consultant Pharmacist (CP) failed to identify and notify the facility of medication irregularities. These irregularities were identified for 2 of 12 residents reviewed, Resident #19, and Resident #21. The deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid medical records of Resident #19 which revealed the following: The resident's admission Record listed diagnoses that included but were not limited to Alzheimer's Disease [a progressive disease that destroys memory and other important mental functions], Hypertension, and Hyperlipidemia. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/3/23, indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 00 out of 15 which indicated that the resident had severe cognitive impairment. A review of the Order Summary Report and the electronic Medication Administration Record (eMAR) indicated Resident #19 had physician orders, dated 11/10/22, Amlodipine Besylate Oral Tablet 5 MG[milligram] .Give 1 tablet by mouth one time a day for HTN [Hypertension] Hold SBP [Systolic Blood Pressure] below 120. A review of the June 2023, May 2023, and April 2023 eMAR for Resident #19 revealed that at the time of the administration of the Amlodipine, there was no documentation of the resident's blood pressure being monitored prior to administration of the medication. A review of the Consultant Pharmacist Progress Notes revealed the CP visited and documented comments monthly. There were no comments or recommendations documented informing the facility of the lack of documentation for the Amlodipine order evaluating the BP parameters for December 2022 through to June 2023. On 6/21/23 at 11:28 AM, the surveyor interviewed LPN #1 about the Amlodipine order and any special instructions for the administration of the medication. LPN #1 acknowledged that he did not document the SBP result in the eMAR at the time of the medication's administration. On 6/21/23 at 11:57 AM, the surveyor interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN) about the Amlodipine medication order and the documentation of the resident's BP with medication administration. The LPN/CN explained that the electronic medical record has a prompt associated with the eMAR at the time of Amlodipine administration that should alert the nurse to monitor and document the resident's SBP. The LPN/CN reviewed the physician's order and the eMAR with the surveyor, revealing that the prompt to alert the nurses for monitoring SBP was not turned on when the order was entered into the eMAR. The LPN/CN could not explain why it was not picked up by the nurses and why the order was not clarified in the eMAR. The LPN/CN acknowledged it would be expected for the nurse to enter the BP at the time of the medication administration on the eMAR. On 6/21/23 at 12:12 pm, the surveyor interviewed the Director of Nursing (DON) about the above concerns. The DON stated it was expected for the blood pressure to be monitored and documented prior to the medication's administration. The DON stated that the nurses should have corrected the eMAR to alert for the documentation of the SBP. The DON also remarked that the CP should have alerted the facility staff that the SBP was not being monitored or documented on the eMAR at the time that the medication was administered. On 6/21/23 at 2:05 PM, the surveyor informed the Administrator, Senior Director of Nursing Services, Associate Executive and DON of the above concerns. On 6/26/23 at 11:26 am, the surveyor interviewed the CP about the process for reviewing medications with BP parameters. The CP explained that he did not review the eMAR for irregularities. The CP indicated that the nurses administering medication ordered by the physician with parameters, are expected to monitor and document the BP on the eMAR. The surveyor interviewed the CP asking if an accurate and comprehensive monthly medication review could be conducted without reviewing the eMAR to verify correct transcription of medication orders and that the physician orders were being administered accurately. The CP provided no verbal response. On 6/26/23 at 12:35 pm, the surveyor interviewed the Associate Executive Director (AED) who informed the surveyor that the CP had access to the electronic medical records and eMAR. The surveyor reviewed the facility document titled, Pharmaceutical Consultant Services Contract Developed for [NAME] Gardens of [NAME] Skilled, from June 2016. The contract indicated the CP would be responsible for the general supervision of the facility's pharmaceutical services and services included: .Help establish policies and procedures to ensure safe and appropriate administrations of medications .Review all medication records on a monthly basis for the skilled sub-acute facility . The surveyor reviewed the facility provided policy titled, Medication Administration, with a facility review date of 1/23. Under Medication Administration it read: 1. Medications are administered in accordance with written orders of the prescriber .2. Obtain and record any vital signs as necessary prior to medication administration.

Based on observation, interviews, and review of facility policies, it was determined the facility failed to properly label and date potentially hazardous foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following. On 6/19/23 from 09:45 AM through 10:30 AM, the surveyor completed the initial kitchen tour located in the Assisted Living (AL) section of the building with the Food Service Director (FSD) and observed the following: 1. On top of the Sandwich/Deli counter prep area, the surveyor observed multiple opened bags of assorted loaves of bread with received dates but no open and/or use-by dates: a. One loaf of Rye bread, with a received date of 6/16/23 b. One loaf of Wheat bread, with a received date of 6/16/23 c. One loaf of [NAME] bread, with a received date of 6/16/23 d. One loaf of Raisin bread, with a received date of 6/16/23 e. One bag of Hamburger buns, with a received date of 6/16/23. The FSD stated all bread is discarded 7 days after opening and have not been labeling the bread with an open and/or a use-by date. 2. In the Dry storage area, the surveyor observed multiple containers opened without opened and/or use-by dates: a. Two 1-gallon apple Cider Vinegar both with the received dates of 12/31/22 b. One 1-gallon Soy Sauce with the received date of 4/29/23 c. One 1-gallon Worcestershire Sauce with the received date 4/29/23. The FSD could not indicate the open dates of the items mentioned above were opened or the use-by date. Surveyor requested a copy of the facility's food labeling and storage policy. The FSD acknowledged having the open and use-by dates on all products are needed to ensure the facility has the information on the estimated period of time for which the product will be of best. On 6/21/23 at 9:19 AM, the FSD provided the surveyor with a facility policy titled, Labeling and Dating for Safe Storage of Food, with a revised date of 3/6/2020 which revealed, All products should be dated upon receipt. All products should be dated when opened. The Dry, Refrigerated, and Freezer Storage Charts note for staples, refrigerated, and freezer storage recommended storage time for unopened and opened products. On 6/21/23 at 2:05 PM, the survey team met with the Director of Nursing (DON), Administrator, and Associate Executive Director, who all stated that all items in the kitchen need to have received, open, and use-by dates. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices, which was identified during 1 of 1 wound treatment observation for Resident # 14. This deficient practice was evidenced by the following: On 6/19/23 at 12:27 PM, the surveyor observed Resident #14 in their room seated in a wheelchair. The resident was alert and verbally responsive. The surveyor further observed that the resident had a dressing on the right foot. The surveyor reviewed Resident #14's medical record on 6/1/23 at 12:29 PM. The admission Record reflected that Resident #14 was admitted to the facility with medical diagnoses, which included but not limited to Atrial Fibrillation, Type 2 Diabetes Mellitus, Anemia, and Hypertension. A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 6/2/23, reflected that the resident had a Brief Interview for Mental Status of 15, indicating that the resident was cognitively intact. A review of the June 2023 Physician Order Summary revealed a physician's order dated 6/20/23 for Santyl External Ointment 250 unit/gm (Collagenase) Apply to Rt heel topically two times a day for wound Tx cleansed with Daikin solution cover with dressing. On 6/21/23 at 9:45 AM, the surveyor observed the Licensed Practical Nurse (LPN) gather all the needed supplies for the wound treatment of Resident #14 and placed it on top of the resident's bedside table without using a clean drape or any barrier in between. At the conclusion of the wound care, the LPN discarded the supplies she used for the wound treatment and placed the bedside table next to the resident without disinfecting the table. The surveyor interviewed the LPN, who acknowledged that she did not sanitize the bedside table where she placed all the supplies for the wound treatment. On 6/21/23 at 2:05 PM, the surveyor met with the facility's Licensed Nursing Home Administrator, Director of Nursing, Senior Director of Nursing Services, and Associate Executive Director to discuss the above concerns. There was no additional information provided. A review of the facility's Policy and Procedure titled Skin Care & Pressure Ulcer Management Program did not specifically indicate the procedures for wound dressing changes. NJAC 8-39-19.4 (a)