Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide privacy for a resident during hygienic care. Specifically, the bedroom and bathroom doors were not closed, exposing the resident's upper body. This deficiency was noted for 1 out of 20 residents (Resident # 38) reviewed. This deficient practice was evidenced by the following: On 01/13/2025 at 10:19 AM, the surveyor observed Resident # 38 in the bathroom sitting on the toilet, with the wheelchair positioned in front of the resident while getting dressed. The door was open, exposing the resident's upper body. During an interview with the surveyor on 01/13/2025 at 10:39 AM, the Licensed Practical Nurse #1 (LPN #1) said that she was uncertain whether the bedroom and bathroom doors should remain open during the time the resident was getting dressed. During an interview with the surveyor on 01/15/2025 at 11:40 AM, the Director of Nursing (DON) said that the bedroom and bathroom doors should have been closed while the resident was getting dressed. A review of a facility policy dated 03/2024 titled, Quality of Life -Dignity, revealed, Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. N.J.A.C. 8:39-4.1(a)(16)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to keep the call device system within reach for a resident who was dependent on staff. This deficiency was identified for 1 out of 1 resident (Resident # 32) reviewed for Accommodation of Needs. This deficient practice was evidenced by the following: On 01/13/2025 at 10:01 AM, the surveyor reviewed the electronic medical records (EMR) for Resident #32. The EMR revealed that he/she had a diagnoses of but not limited to Dementia and Alzheimer's Disease (cognitive disease). A review of the significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/20/2024 indicated that Resident #32 had severe cognitive impairment and was dependent in both self-care and mobility. On 01/13/2025 at 9:59 AM, the surveyor observed the resident in the bedroom, seated in a geriatric recliner chair (a large, padded chair designed to assist those with limited mobility) next to the right side of the bed. The call device was out of reach, hanging from the oxygen system connected to the wall on the left side of the bed. On 01/14/2025 at 10:58 AM, the surveyor observed the resident in the bedroom, seated in a geriatric chair next to the right side of the bed. The call device was out of reach, hanging from the oxygen system connected to the wall on the left side of the bed. During an interview with the surveyor on 01/15/2025 at 11:40 AM, the Director of Nursing (DON) said that the resident needs access to a call device and acknowledged that it is not appropriate for him/her to be without one. The DON indicated that she would reassess the situation and seek an appropriate solution. A review of a facility policy dated 03/2024 titled, Call System, revealed, The facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities. If a resident is physically incapable of actuating a call system, the resident shall be physically housed in a resident room close enough to the nursing station to allow for line-of-sight supervision at a frequency identified by a through individualized nursing assessment. N.J.A.C. 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set death in facility tracking record in accordance with federal guidelines. This deficient practice was identified for 1 of 2 residents reviewed for resident assessment (Resident #58). This deficient practice was evidenced by: On [DATE] at 12:07 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. On [DATE] at 12:07 PM, the surveyor reviewed Resident #58's electronic medical record. The record revealed that the resident expired on [DATE]. The electronic health record reflected that there was no death in facility tracking record completed for the resident's death date of [DATE]. On [DATE] at 12:13 PM, the surveyor interviewed the MDS Coordinator. The MDS Coordinator confirmed that the death in facility tracking record was not completed or transmitted for Resident #58. She stated it should have been completed by [DATE]. A MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. The surveyor reviewed the facility's policy entitled MDS Completion and Submission Timeframes with a revised date of [DATE]. The policy revealed that the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. NJAC 8:39-11.2

Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care plan to address an elopement alarm for 1 of 23 residents (Resident #59) reviewed. The deficient practice was evidenced by the following: On 01/12/25 at 10:00 AM, the surveyor observed Resident #59 in the room with an elopement alarm on the left ankle. The surveyor reviewed Resident #59's medical record which reflected that the resident had diagnoses which included muscle weakness and anxiety. A review of the physician orders for Resident # 59 reflected an order dated 09/10/21 for the resident to have a wanderguard. The minimum data set, an assessment tool, dated 11/8/24 Q MDS reflected that Resident #59 used an elopement alarm used daily. The surveyor reviewed the resident's care plans which revealed there was no care plan developed to address the elopement alarm which was initiated on 09/10/2021. On 01/15/25 at 10:53 AM, the surveyor interviewed the Nurse Manager who said the elopement alarm should be included in the care plan. The nurse manager and surveyor reviewed the care plans of Resident #59 together. She confirmed that there was no care plan addressing the elopement alarm. A review of the policy titled, Care Plans-Comprehensive, with a revised date of January 1, 2025 reflected 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. It further reflected 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for 2 of 3 units (South and North Units). This deficient practice was evidenced by the following: On 01/12/2025 at 10:28 AM, Surveyor #1 observed the baseboard trim in room [ROOM NUMBER] detached from the wall on the North Unit. On 01/13/2025 at 10:35 AM, Surveyor #1 observed water stains on the ceiling tiles in the shower room on the North Nursing Unit. On 01/13/2025 at 10:43 AM, Surveyor #1 observed the shower room on the North Nursing Unit, which including a portable commode, three commode buckets, a commode lid, and a non-stick food placement mat placed on a chair in the corner. During an interview with Surveyor #1 on 01/15/2025 at 9:58 AM, the Maintenance Director (MD) said that water stains could indicate condensation or a leak and if wet ceiling tiles are observed, an investigation is conducted, followed by the replacement of ceiling tiles as needed. During an interview with Surveyor #1 on 01/15/2025 at 10:14 AM, the Assistant Housekeeping Director (AHD), said that shower rooms are cleaned regularly and as needed. Housekeeping does not handle residents' personal items, emphasizing that they do not touch any private belongings. During an interview with Surveyor #1 on 01/15/2025 at 11:40 AM, the Director of Nursing (DON) said that nursing staff shares the responsibility of cleaning the shower rooms, and while they remove residents ' personal items, housekeeping conducts a thorough cleaning afterward. A review of the dated facility policy 03/2024, titled, Homelike Environment, revealed, The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Those characteristics include cleanliness and order. 3.) On 1/14/25 at 9:58 AM while touring the fifth floor, surveyor #3 observed large area of brown splatter residue on the wall to the right of Resident #52's bed behind their intravenous pole and dresser. Surveyor #3 also observed brown residue on the intravenous pole. On 1/14/25 at 10:08 AM, surveyor #3 interviewed Certified Nursing Assistant (CNA #1) who reported that all of nursing is responsible to ensure the resident's rooms are clean. When asked who would make sure that the resident's medical equipment remained clean CNA #1 responded, the nurse. On the same date at 10:48 AM, surveyor #3 interviewed Licensed Practical Nurse (LPN #1) acknowledged the large area of brown residue behind the intravenous pole and dresser. LPN #1 stated that the room is their home and it should not have brown splatter on the wall. On the same date at 11:06 AM, surveyor #3 interviewed Unit Manager Registered Nurse (UMRN# 1) who stated that the brown residue appeared to be enteral formula. UMRN #1 confirmed that the wall should not be that condition and it should have been identified by nursing or housekeeping. When asked why the wall should not look like that UMRN# 1 responded, because this is their home and we should keep it clean. On 1/16/25 at 9:59 AM, surveyor #3, interviewed the Assistant Director of Facilities who acknowledged the brown residue on Resident #52's wall and that it should have been identified by housekeeping. On 1/16/25 at 10:04 AM, surveyor #3, interviewed the Assistant Director of Environmental Services, in the presence of the Operations Manager, who confirmed that the brown residue on Resident #52's wall should have identified and should not present in that condition. On 1/16/25 at 11:35 AM, surveyor #3, interviewed the Director of Nursing, in the presence of the Licensed Nursing Home Administrator (LNHA) acknowledged brown residue on Resident #52's wall should have been cleaned to ensure homelike environment. N.J.A.C. 8:39-31.3(a) N.J.A.C. 8:39-31.4 (a) 2.) On 01/12/2025 at 10:04 AM during the initial tour of the fourth floor, Surveyor # 2 observed Resident # 84's room. At that time, the surveyor observed brown stains on the wall near the bed and on a feeding pump located on a pole in the room. The garbage receptacle had no bag in it. The bedside table adjacent to the bed was observed to have dried stains on it. On 01/14/2025 at 10:37 AM, Surveyor # 2 observed Resident # 84's room. At that time, the surveyor observed that the garbage receptacle had no bag in it. The room also emanated a strong odor of fecal matter. On 01/15/2025 at 11:35 AM during an interview with the surveyor, the Director of Nursing (DON) replied, Daily. Housekeeping is twenty-four seven but lesser on evenings and overnights. when the surveyor asked how often resident rooms are cleaned. The DON explained that cleaning entails the garbage, floors, dusting, bedside tables, and the garbage.

3.) Surveyor #3 observed a sign for enhanced barrier precautions (EBP) to the right of the door outside Resident #23's room. The sign reflected that everyone must clean hands, including before and when leaving room. Providers and staff must also wear gloves and gown for the following high contact resident care activities: dressing, bathing, providing hygiene, changing linens, changing briefs and device care. On 01/12/2025 at 10:21 AM, Surveyor #3 observed Resident #23 receiving care. Certified Nurses Aide (CNA) #2 was observed performing direct care on this resident wearing a mask and gloves. CNA #2 was not wearing a gown. When asked if she should be wearing a gown the CNA responded, oh yeah. On 01/14/2025 at 11:18 AM, Surveyor #3 observed Registered Nurse #2 at Resident #23's bedside adjusting the oxygen tubing. RN #2 was observed wearing gloves and no gown. When asked at that time if she should be wearing a gown, RN #2 responded yes. A review of the medical record reflected that Resident #23 had diagnosis which included dysphagia (a problem swallowing). A review of the quarterly minimum data set, an assessment tool, dated 11/12/2024 reflected that Resident # 23 had long and short-term memory deficits. It reflected that Resident # 23 utilized a feeding tube for nutrition. During an interview on 01/15/2025 at 10:22 AM, the infection preventionist said that when a resident is on EBP a gown should be utilized when providing care and adjusting Oxygen tubing. A review of the policy titled Enhanced Barrier Precautions with an effective date of 04/05/2024 reflected that all residents with medical devices including feeding tubes require gloves and gowns to be worn during high contact resident care. NJAC 8:39 19.4(a) 2.) On 01/13/2025 at 11:28 AM while outside of Resident # 84's room, Surveyor # 2 observed Registered Nurse (RN) # 1 in the room. RN # 1 was disconnecting the feeding tube (External tube inserted into the stomach to provide nutritional formula) that was connected to Resident # 84 from the nutritional formula hanging on a pole. RN # 1 was wearing gloves but not a disposable gown. At that time, Surveyor # 1 also observed a sign outside the doorway that was titled, Enhanced Barrier Precautions Everyone Must: The sign revealed that providers and staff must wear gloves and a gown for the following High-Contact Resident Care Activities. The sign revealed a list including Device care or use: central line, urinary catheter, feeding tube . A review of Resident # 84's Active Orders revealed an order for, Formula hang flush bag of 150,L [milliliter] ever 6 hours X 20 hours to run with feeding. Special Instructions: [Brand name redacted] at 50 mL/hour X 20 hours. Up at 2 PM and Down at 10 AM or when total volume of 1000 mL infused. Hang flush bag at 150 mL every 6 hours X 20 hours to run with feeding. Twice a day start feeing at 02:00 PM, Remove feeing 10:00 AM. A review of Resident # 84's Electronic Medical Record (EMR) revealed an order to clean a wound to left foot with normal saline solution and apply aquacel, wrap with gauze daily. A review of Resident # 84's Care Plan revealed a focus for, Impaired skin integrity, presence of: wounds : Stage III wound to sacral area. 9/11/2024 ulcer to left dorsal foot. On 1/13/2025 at 11:30 AM, Surveyor # 2 observed the sign outside the doorway of Resident # 84's room that was titled, Enhanced Barrier Precautions Everyone Must: The sign revealed that providers and staff must wear gloves and a gown for the following High-Contact Resident Care Activities. The sign revealed a list including Wound Care: any skin opening requiring a dressing. On the same date at 11:33 AM, Surveyor # 2 observed Registered Nurse (RN) # 1 with assistance from Certified Nurses Aide (CNA) # 1 perform wound care on Resident # 84. At that time, CNA # 1 did not don a gown while in the room. During the wound care at approximately 11:43 AM, RN # 1 removed the soiled dressing from Resident # 84's left foot. At that time, RN # 1 removed the disposable gloves and applied a new pair of gloves. RN # 1 did not perform any hand hygiene between changing gloves. At approximately 11:46 AM, after irrigating the wound, RN # 1 removed the disposable gloves and applied a new pair of gloves. RN # 1 did not perform any hand hygiene between changing gloves. Lastly, RN # 1 applied a gauze wrap to Resident # 84's left foot. At that time, RN # 1 removed the disposable gloves. RN # 1 did not perform and hand hygiene after removing the gloves. RN # 1 and CNA # 1 then proceeded to lift and position Resident # 84 in their bed. CNA # 1 did not wear a gown throughout the entire observation of wound care. At approximately 11:50 AM during an interview with Surveyor # 2, RN # 1 said CNA # 1 should have worn a gown in the room. RN # 1 said that he washed his hands before wound care and didn't use alcohol-based hand rub between glove changes. On 1/15/2025 at 10:20 AM during an interview with Surveyor # 2, the Infection Preventionist confirmed that staff should be performing hand hygiene between glove changes clarifying it is important to prevent transmission. On 1/15/2025 at 11:35 AM during an interview with the Director of Nursing (DON), Surveyor # 1 asked when a nurse is disconnecting a completed formula feeding for a resident with a feeding tube, should the nurse be wearing a gown if they are on Enhanced Barrier Precautions? The DON replied, yes. The surveyor then asked why would that be important. The DON replied, Because there is an opening an it could possibly transfer possible infection. During the same interview with Surveyor # 2, the Director of Nursing (DON) replied, Yes when the surveyor asked should a nurse perform hand hygiene between glove changes during wound care. The DON said it is important for infection control. A review of the facility policy titled, Handwashing/hang hygiene with a revised date of 3/24 revealed, Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: k. Before and after changing a dressing .e. Before handling clean or soiled dressing, gauze pad, etc., j. After removing gloves. Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to use appropriate infection control practices, such as hand hygiene and Personal Protective Equipment (PPE) when providing care and other high-contact care activities to 3 of 3 residents (Resident #23, #52, #84) reviewed under the Infection Control Task. The deficient practices were evidenced by the following: 1. On 1/14/2025 at 10:24 AM, surveyor #1 observed Licensed Practical Nurse (LPN#1) perform tracheostomy (a small surgical opening that is made through the front of the neck into the windpipe) care, which was identified as requiring aseptic techniques (a set of practices that prevent the spread of infection) on Resident #52 and observed the following: At 10:31 AM, following Resident #52's assessment by LPN #1 it was determined that that deep suctioning was required to clear their airway due to excessive secretions. LPN #1 removed her disposable gloves and applied sterile gloves without performing hand sanitation. Upon completion of suctioning, LPN #1 removed the sterile gloves and washed their hands with soap and water lathering under the flow of running water for fifteen seconds. At 10:39 AM, LPN #1 proceeded to apply sterile gloves in order to change Resident #52's tracheostomy inner cannula (the inner portion of the trachestomy tube which can help prevent airway obstruction). While applying the right glove, LPN#1 grabbed the thumb of the glove with the ungloved left hand which broke the sterility of the right glove. During the inner cannula change at 10:41 AM, LPN #1 recognized that she did not have the correct cannula. With sterile gloves applied, LPN #1 retrieved the proper supplies, opened the package, and continued with the change which resulted in a break of aseptic techniques. At 10:46 AM, following the inner cannula change, LPN #1 removed the sterile gloves and changed to disposable gloves without hand sanitization. At 10:51 AM, surveyor #1 interviewed LPN #1 who confirmed that handwashing was not completed for the required 15-20 seconds that there should have been hand sanitizing between glove changes. LPN #1 also acknowledged that she broke aseptic techniques and the sterility of the gloves when she touched the thumb of the right glove and when she gathered supplies in the room with the gloves on. During an interview with another surveyor on 1/15/2025 at 10:00 AM , the Infection Preventionist (IP) confirmed that hand hygiene is essential between glove changes to prevent cross contamination. During an interview with surveyor #1 on 1/16/2025 at 11:35 AM, the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) acknowledged that hand sanitation should be completed between glove changes, the hand washing length, and break in sterile technique. A review of facility policy titled, Tracheostomy Care, Revised 12/24, under section General Guidelines included: 1. Aseptic technique must be used: c. during tracheostomy tube changes, either reusable or disposable [ .] 2. [ .] Sterile Gloves must be used during aseptic procedures . A review of facility policy titled, Handwashing/Hand Hygiene, Revised 3/24, under section Policy Interpretation and Implementation included: 5. Employees must wash their hands for at least 20 seconds using antimicrobial or non-microbial soap and water ( .) 6. In most situations, the preferred method of hand hygiene is with and alcohol-based hand rub. If hands are not visibly soiled use and alcohol based rub containing 60-95% ethanol or isopropanol for the following situations ( .)b. before donning sterile gloves; ( .) j. after removing gloves.

Based on observation and interviews, it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. The deficient practice was identified on 3 of 3 units. This deficient practice was evidenced by the following: During the Resident Council Meeting on 01/15/2025 at 10:00 AM, five of five alert and oriented residents said they were not aware of the location of the State Survey results and that the facility had not spoken to them about the results. During a tour of each unit, the surveyor had to ask at the nurse's station where the State survey results binder was kept. The surveyor was told by the unit secretary or nurse that was at the desk at each unit that it was located behind the nurse's station. The surveyor was also told at each unit that if the residents asked for it, they could see it. On the 4 South unit the Registered Nurse (RN) could not locate the binder when asked. The RN said, I know it's here somewhere. There were no posted signs to direct resident's, families, and the public to the location of the survey results. These binders were not accessible to residents or visitors without asking staff. During an interview with the surveyor on 01/15/2025 at 10:34 AM, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) said that the survey results are located on the unit behind the desk. The DON then said the residents were allowed to go behind the nurse's station and ask or get look at the results if there was someone behind the desk to help them. When asked if they considered if the results binder was readily accessible to the residents or public, the LNHA stated, No. The facility was unable to produce a policy in reference to the State of New Jersey inspection results. NJAC 8:39-9.4(b)

Based on interview and record review, it was determined that the facility failed to transmit a Minimum Data Set (MDS) - Annual and Quarterly Reporting Assessment in accordance with federal guidelines. This deficient practice was identified for 13 of 13 residents reviewed for resident assessment (Resident #43, #44, #23, #5, #51, #53, #49, #20, #1, #26, #16, #65, #64). This deficient practice was evidenced by: On 8/25/23 at 11:30 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. A MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2019) under Non-Comprehensive Assessments and Entry and Discharge Reporting, page 2-32 MDS must be transmitted (submitted and accepted into the QIES (Quality Improvement and Evaluation System) ASAP system) electronically no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days). Further review of the RAI (Resident Assessment Instrument) Manual under Comprehensive Assessments, page 2-20 MDS must be transmitted (submitted and accepted into the QIES ASAP system) electronically no later than 14 calendar days after the care plan completion date (V0200C2 + 14 calendar days). 1.) Resident #43 was observed to have a Quarterly MDS completion date of 7/1/23 and was due to be transmitted no later than 7/29/23. The Quarterly MDS was not transmitted until 8/23/23. 2.) Resident #44 was observed to have a Quarterly MDS completion date of 7/5/23 and was due to be transmitted no later than 8/2/23. The Quarterly MDS was not transmitted until 8/24/23. 3.) Resident #23 was observed to have a Quarterly MDS completion date of 7/5/23 and was due to be transmitted no later than 8/2/23. The Quarterly MDS was not transmitted until 8/24/23. 4.) Resident #5 was observed to have a Quarterly MDS completion date of 7/3/23 and was due to be transmitted no later than 7/31/23. The Quarterly MDS was not transmitted until 8/23/23. 5.) Resident #51 was observed to have a Quarterly MDS completion date of 7/4/23 and was due to be transmitted no later than 8/1/23. The Quarterly MDS was not transmitted until 8/24/23. 6.) Resident #53 was observed to have a Quarterly MDS completion date of 7/17/23 and was due to be transmitted no later than 8/14/23. The Quarterly MDS was not transmitted until 8/25/23. 7.) Resident #49 was observed to have an Annual MDS completion date of 7/14/23 and was due to be transmitted no later than 8/18/23. The Annual MDS was not transmitted until 8/24/23. 8.) Resident #20 was observed to have a Quarterly MDS completion date of 7/21/23 and was due to be transmitted no later than 8/18/23. The Quarterly MDS was not transmitted until 8/23/23. 9.) Resident #1 was observed to have an Annual MDS completion date of 7/5/23 and was due to be transmitted no later than 8/8/23. The Annual MDS was not transmitted until 8/23/23. 10.) Resident #26 was observed to have a Quarterly MDS completion date of 7/10/23 and was due to be transmitted no later than 8/7/23. The Quarterly MDS was not transmitted until 8/25/23. 11.) Resident #16 was observed to have a Quarterly MDS completion date of 7/14/23 and was due to be transmitted no later than 8/11/23. The Quarterly MDS was not transmitted until 8/25/23. 12.) Resident #65 was observed to have a Quarterly MDS completion date of 7/12/23 and was due to be transmitted no later than 8/9/23. The Quarterly MDS was not transmitted until 8/25/23. 13.) Resident #64 was observed to have an Annual MDS completion date of 7/12/23 and was due to be transmitted no later than 8/16/23. The Annual MDS was not transmitted until 8/25/23. On 8/25/23 at 1:04 PM, the surveyor interviewed the facility's Registered Nurse (RN) MDS Coordinator who was responsible for completing and transmitting the MDS assessments who acknowledge that the above MDS assessments were transmitted late. No further information was provided. On 8/30/23 at 12:19 PM, the surveyor discussed the above concern with the facility's Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). No further information was provided. NJAC 8:39-11.2

**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 18 residents, (Resident #3) reviewed for accurate coding of MDS. This deficient practice was evidenced by the following: On 8/24/23 at 9:54 AM, Resident #3 was observed sitting on wheelchair in hallway, able to wheel self around unit. The Resident responded to the surveyor appropriately when spoken to stating that they were ok and had no issues with care. The Resident refused to continue the interview. The surveyor reviewed the resident's hybrid medical chart which included review of paper as well as computerized medical chart. A review of Resident #3'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 COVID 19, Urinary Tract Infection, Chronic Obstructive Pulmonary disease, Asthma with exacerbation, Type 2 Diabetes Mellitus, Schizophrenia, Depression, Essential hypertension. A review of the Progress Note dated 6/9/23 documented, Resident AAO (Awake, Alert, Oriented) x 3 stable. Resident called for help, found lying on the floor by the bedside facing up stated I fell from the bed while sleeping. Assessment done no apparent injury, denies pain. Message left for Doctor, informed family member. A review of the Progress Note dated 6/18/23 documented, At approximately 8:42 AM this writer heard loud noise in dayroom, writer ran into dayroom, upon assessment resident lying on floor in supine position, awake with confusion, slurred speech no active bleeding noted, this writer called 911 immediately. Upon assessment Blood Pressure 167/86, Pulse 97, 98% oxygen Saturation on room air, Temperature 97.3 Fahrenheit, complaining of stomach pain, denies head/neck pain. Noted resident trying to move arms and head, Re-educated resident to stay still and not move body. Resident complaining of nausea, started to vomit, resident log rolled with 2 assist to side with neck/head stabilized, airway kept clear. Emergency Medical Service arrived on scene, left with resident at 9:06 AM. Further review of the Progress Note dated 7/8/23 documented, Around 1:00 AM Resident roommate reported that resident was on the floor. Resident was assisted back to bed with 3 person assist, stated I fell when I was trying to sit on the chair. Assessment done no apparent injury, no bruise noted, complained of discomfort on their back Tylenol 650 milligrams given with effective. Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 8/4/23, indicated that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 10. This score established that Resident #3 had a moderately impaired cognition. A review of Resident #3's MDS dated [DATE], Section J1800 - Any Falls Since Admission/Entry or Reentry or Prior Assessment coded as 0, indicating that the resident had no falls since their last Annual Assessment of 5/5/23. The documentation in the MDS contradicted the resident's history of falls based on the Progress Notes dated on 6/9/23, 6/18/23, and 7/8/23. On 8/28/23 at 10:41 AM, the surveyor along with MDS Coordinator reviewed the Quarterly assessment dated [DATE] which documented 0 under J1800, indicating no falls occurred since last assessment of 5/5/23. Further review of the Progress Notes dated 6/9/23, 6/18/23, and 7/8/23 with the MDS Coordinator, revealed that Resident #3 had a fall on 6/9/23 with no injury, a fall on 6/18/23 with no injury, and a fall on 7/8/23 with injury. The MDS Coordinator stated, she missed coding the falls. No further information was provided. On 8/30/23 at 12:19 PM, the survey team met with Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the concern above. No further information was provided. NJAC 8:39-33.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C #: Covid-19 Infection Control Based on record review and staff interviews, and review of pertinent facility documents on 12/12/22 and 12/13/22, it was determined that the facility failed to ensure resident representatives were notified by 5 PM the next calendar day following the occurrence of a single confirmed COVID-19 infection. This deficient practice was identified for 3 of 3 sampled residents (Resident #1, #7 and #8) reviewed for notifications and was evidenced by the following: The surveyor reviewed the COVID-19 line list and revealed that a staff member, the Recreation Director (RD) tested positive for COVID-19 on 11/16/22. A review of the COVID-19 PCR laboratory result for the RD indicated that the specimen was collected on 11/13/22 with a Positive result. It was revealed that the result was verified and reported to the facility on [DATE]. On 12/13/22 at 8:30 AM, the Assistant Director of Nursing (ADON), provided the surveyor copies of the representative or family notification documentations for the sampled residents. The ADON stated that resident's families were notified via phone by the Social Worker (SW) and Director of Recreation (DR) and these communications were documented into the resident's Progress Notes (PN). The surveyor reviewed the phone communication documentations with the ADON, and it was revealed that Resident #1, #7, and #8's families were notified on 11/22/22 instead of 11/17/22 by 5PM following the facility's first confirmed COVID-19 positive on 11/16/22. The ADON could not explain why the resident's families or representatives were not notified timely. On 12/13/22 at 10:06 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the SW and DR were responsible for notifying resident's representatives or families when an outbreak of Covid-19 have been identified. She explained that new COVID-19 cases in the facility are discussed during morning meetings and resident's families are notified via phone call weekly. In addition, nurses would notify families of residents immediately after a confirmed positive Covid test. Furthermore, the LNHA indicated that she was unsure if resident's representatives were notified the next day by 5PM following the first confirmed COVID-19 positive on 11/16/22. However, she agreed that the timely requirements for family notifications and their facility's policy for notification were not followed and could not explain why they were not followed. Review of the facility's policy titled Infection Prevention and Control Manual under Notifications and Communication indicated that 2. Contact and inform resident, their representatives, and families of those in facilities by 5 PM, the next calendar day following occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other. NJAC: 8:39-13.1 (c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 6/23/21 at 09:49 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and the Executive Chef (EC) and observed the following: 1. In the production area, there was one bag of kaiser rolls with no identification on the bag, no opened or use by dates. 2. In the prep fridge #16, there were five small individually wrapped styrofoam plates in clear plastic that contained tomato and lettuce dated use by 6/22/21. The FSD removed them and discarded them in the garbage. There was one metal bin with individually wrapped cut onion, cut cucumber, lettuce, cut carrots, and shredded cabbage with no identification, no prepared on date or use by date. The FSD stated, these are fresh, if they are visibly not good then we throw them out. 3. In the dry storage entryway, there was an unsealed bag of 12 hamburger rolls with an orange sticker marked use by 6/19, the bag was marked with an expiration date 6/29/21. The FSD removed the bag. 4. In the dry storage room, there was a box of pumpkin seeds with an internal open to air plastic bag with seeds visible. There was no label, no opened by or use by date. The FSD removed the bag. There was a large plastic bin that contained one open bag of egg noodles that had no opened on or use by date. The FSD stated it, should be discarded and threw the pasta away. On a metal shelf, in the canned storage area, there were three dented 105 ounce (oz) cans of fruit cocktail, one dented 6 pound (lb) 8 oz can of sweet/sour red cabbage and one dented 6 lb 2 oz can of sliced jalapenos. The EC removed the cans and placed them in the dented can section. There was a large plastic bin containing tan crumbles with no identification, no label, no use by date or expiration. The EC stated that they were bread crumbs then removed the bin and stated it was going in the trash. The FSD acknowledged there was no label on the bin as required. 5. In freezer #4, there was one box of chicken tenders breast strips with the inner plastic bag unsealed and the meat was exposed. The EC stated it should have been sealed and removed the box. There was one metal tin with a sticker labeled corned beef and dated 5/26, good through 5/29 with unsealed clear plastic wrap and the meat was exposed. The EC acknowledged it should not be like that and removed the bin. 6. The meat slicer had tan and white debris. The EC acknowledged the debris should not be there and that the cleaning process was done after use with a disposable cloth and sanitizer while wearing gloves and cut gloves. The EC acknowledged it should have been covered and that the slicer gets cleaned after each use. The EC stated that cleaning records were not kept. 7. In the kosher freezer, there were two boxes of individually wrapped baked fish dinners with no sticker when they were received or opened, no dates on the individual meals. There were 6 boxes of individually wrapped baked fish dinners with a received sticker dated 3/12. There were 2 boxes of fillet of sole with a received sticker dated 2/19. The FSD stated that it should have a good through date and a date of arrival and that it is good for 3 months frozen. The FSD informed the EC to toss it. 8. In the freezer, there was a large sheet pan with no identification, that had a sticker dated 6/13 and good through 6/18 with clear plastic wrap that covered half the pan and left half exposed. The EC identified it as white cake and stated it should be good for three months and acknowledged he will toss that. There was a metal bin with no identification that had a sticker dated 6/19 and good through 8/19. The bin had clear plastic wrap that was unsealed with the patties visible. The EC identified it as beef and stated he will throw it out. The EC acknowledged the pan should have had clear wrap and foil covering it. 9. In refrigerator #3, there was an opened bag of green beans, no identification, no open date, no use by date, no label. 10. In refrigerator #2, there was one bag of tortilla wraps opened with cling wrap covering it. There was a sticker dated 5/16 good through 5/30 with a 4/1/21 printed expiration date on the bag. There were three unopened bags of tortilla wraps with a 4/1/21 printed expiration date on the bag. The FSD threw the wraps into the garbage. There was a whole defrosted wrapped pork loin with no sticker, no pull date or use by date. When asked when the pork loin was pulled the EC stated Good question, it came in on Monday. It should have a sticker that says the date it came in and an expiration date. There was a metal tray with 6 defrosted individually wrapped packages of meat sitting in a cloudy liquid with no identification, no sticker, no pull date or use by date. The EC identified them as turkey breasts and stated they are, not good, they are garbage. The EC removed them from the refrigerator then acknowledged it should have had the name of the product, the date it was pulled, an expiration date and the employee initials on an orange [NAME] label and that it should have been covered. 11. In freezer #10, there was one box of Jamaican meat patties with a received by sticker dated 6/18/21 with no opened date. The plastic inner bag was opened with the meat patties visible. The FSD acknowledged it should be covered and removed the box. There was one box of vegetarian sausage patties with a received by sticker dated 5/21 with no opened date. The plastic inner bag was opened with the sausage patties visible. The FSD stated, we will not serve them, probably discard them and the box was removed. On 6/24/21 at 10:31 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and the Executive Chef (EC) and observed the following: 1. In refrigerator #3, there were two 5 lb sealed bags of carrots with an orange sticker with a 5/24 expiration date and manufacturer marked best if used by 5/21. The FSD stated they are throwing them in the garbage and removed the bags. 2. The meat slicer had white debris on the blade. The EC acknowledged the debris and stated they need to clean and sanitize the slicer and that the process is posted on the wall in the area. The EC further stated a visual inspection tells if it is clean between uses and that they used to cover it when it was clean. 3. On the spice rack, there was one bottle of Sriracha sauce opened with no opened date, received on date or use by date. There was one bottle of ReaLemon opened with no opened date, received on date or use by date. The FSD disposed of the bottles in the garbage. During an interview with the EC at that time, the EC stated responsibility for the rotation process and that expiration dates are checked at that time. The EC also stated that supervisors are also tasked with checking coolers daily and no record of delivery is kept. The EC stated that when there is a delivery on Tuesday and Friday that the storeroom staff puts the deliveries away and it is their responsibility to mark it. The EC stated it is everyone's responsibility to put an orange sticker marked with the item product name, the date in, the good through date, and the staff member's initials. During an interview with the surveyor on 06/25/21 at 12:05 PM, the FSD stated that whoever receives the shipment, primarily the chef, is responsible for labeling the items. The FSD stated it was important to have labels so the food is served fresh and not contaminated or spoiled, and that it is a nourishing state for the residents because some may be nutritionally compromised. During an interview with the surveyor on 06/25/21 at 12:15 PM, the EC stated that he is the one that usually checked the stock and labeled the food. The EC stated it was important because you want to use the older food before the newer food and you don't want to serve expired food because freshness matters. Review of the facility's policy #B003, Food and Supply Storage with a revision date of 1/21, revealed: Policies. All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Most, but not all, products contain an expiration date. The words sell by, best-by, enjoy-by or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use-by, sell-by, best-by, or enjoy-by date should be discarded. Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label, or use the Medvantage/Freshdate or other approved labeling system. Products are good through the close of business on the date noted on the label. Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. Frozen storage: Wrap food tightly to prevent cross contamination. Food prepared in-house, and then stored frozen should be kept no longer than 3 months. Commercially produced foods may be held frozen until the manufacturer's expiration date, or for 3 months if no expiration date on the package. Once the packaging around the food has been opened, food must be used within 3 months. Review of the facility's policy #B003, Freezer storage life of foods, dated 1/21, revealed Use manufacturer's expiration date for products, BUT DO NOT EXCEED 1 YEAR. If there is no expiration date on the package, add the time listed here to the date the food is received. If a case of food is partially used, and the remaining food is exposed to the air (ex: 20# case of frozen vegetables), re-label when product is opened, to use within 3 months. Food item: prepared manufactured entrees, Unopened: +3 months. Review of the facility's policy #B003, Refrigerated storage life of foods, dated 1/21, revealed Use manufacturer's expiration date for products before they are opened. If there is no expiration date on the package, add the time listed here to the date the food is received. Add the time in the opened column to the date when the food is prepared or opened. Label when product is opened. The time listed is added to today's date. Food item: Meat/Prepared Entrees/Soups, raw meat (frozen: to thaw in refrigerator), Opened: +4 days from frozen to prepared. Raw meat (refrigerated) except top round in cryovac, Opened: poultry:+2 days; beef and pork:+3 days. Fruit, Vegetables and Desserts, cut fresh fruit and vegetables, prepared on-site, Opened: +3 days. Bags of processed produce (diced onion, etc.), Opened: no manufacturer's date: use +3 days of delivery, with manufacturer's date: use +3 days of opening, or by the manufacturer's date, whichever is sooner. Review of the facility's policy #B003, Dry storage life of foods, dated 1/21, revealed Use manufacturer's expiration date for product storage. If there is no expiration date on the package, add the time listed here to the date the food is received. The time listed is added to today's date. Expiration/use by dates are guidelines; discard products where the quality is deemed unacceptable. Food item: Seasonings, ketchup, BBQ, Tabasco, steak, mustard, horseradish, garlic in oil, Room temperature storage: +1 year unopened; +2 months opened-refrigerate. Breads, bagels, English muffins, bread, rolls, tortillas, Room temperature storage: if no expiration date: +3 days after delivery Review of the facility's policy B002, Receiving, with a revision date of 1/20, revealed Procedures: Director/Designated Associate: Date foods prior to placing in storage areas, per Policy B003. Review of the facility's undated Daily Master Cleaning Matrix, revealed Equipment/Area/Task/Comments, Cooks: All small equipment i.e., robot coupe, buffalo chopper, blender, slicer, needs to be cleaned. Free of debris and stains. Daily. NJAC 8:39 17.2(g)