Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen equipment in a clean, safe, and sanitary manner and was evidenced by the following: On 12/16/24 at 09:45 AM, in the presence of the Food Service Director (FSD) the surveyor observed the ice machine which had a black sediment on the interior of the ice machine dispenser shoot. When the surveyor asked the FSD what it was, the FSD responded it was Black Mold and he would have it cleaned immediately. On 12/16/24 at 10:20 AM, the surveyor interviewed the FSD who stated the ice machine was cleaned quarterly but it seems to be needed more often. The FSD acknowledged that the interior of the dispensing shoot had black sediment in it. The FSD further stated that the ice machine is responsible for the food tray line and the ice coolers on the nursing units that provide ice to the residents. The FSD stated he would have all the ice chests pulled from the nursing units to be cleaned. On 12/17/24 at 9:50 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss the ice machine findings. The LNHA acknowledged the black sediment in the surveyors findings. On 12/20/24 at 10:09 AM, the surveyor interviewed the LNHA, who confirmed that the ice machine was cleaned quarterly and had just been done in the beginning of November. After reviewing the pictures, the LNHA acknowledged the black sediment found on the interior of the dispensing shoot. On 12/20/24 at 10:30 AM, the survey team met with the LNHA and DON and both acknowledged the surveyors findings. A review of the Ice Machines and Ice Storage Chests, dated revision January 2024, revealed . Policy: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy Interpretation and Implementation: 1) Ice making machines, ice storage chests/ containers, and ice can all become contaminated by: c) colonization by microorganisms. 2) To help prevent contamination of ice machines, ice storage chest/containers or ice, staff shall follow these precautions: Clean and sanitize the tray and the scoop daily. 3) cleaning interior according to manufacture instructions. A review of the manufacturers cleaning, sanitation and maintenance user manual, date 12/2018, revealed . The ice machine requires 3 types of maintenance: 1) remove the buildup of mineral scales from the ice machine's water system and sensors. 2) Sanitize the ice machines water system and the storage bin or dispenser. 3) Clean or replace the air filter and clean the air cooled condenser It is the user's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Without humane intervention, sanitation will not be maintained. Ice machines also require occasional cleaning of their water systems. NJAC 8:39-17.2(g)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to follow professional standards of clinical practice with medication administration for 1 of 8 residents (Resident #93) observed for medication pass. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing a medical regimen as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 10/27/23 at 8:16 AM, the surveyor observed as the Registered Nurse (RN) prepared medications to be administered via a gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach) to Resident # 93. The RN removed the resident's medication bingo cards (a multidose card containing individually packaged medications) from the medication cart and checked them against the Medication Administration Record (MAR). The RN removed the tablets from the bingo cards, put them in a small plastic bag, and crushed the three tablets together. The RN administered the 3 crushed medications together via the Gastrostomy tube (g-tube). During an interview with the surveyor on 10/27/23 at 12:07 PM, the RN stated that it was her regular practice to crush and administer all the tablets together via a g- tube. The surveyor asked the RN what the facility's policy was for administering medications via a g-tube. The RN replied she wasn't sure. The surveyor asked the RN if she had received a medication administration in service and competency. The RN replied she had received both but wasn't sure who provided the training or completed the competency. On 11/2/23 at 11:25 AM, the surveyor team met with the Regional Administrator, Licensed Nursing Home Administrator (LNHA), Administrator in training, Director of Nursing (DON), Regional Nurse, and Infection Preventionist Nurse to discuss the above observations and concerns. The DON stated that the facility's policy was to administer medications individually one at a time via the g-tube. Review of the facility's Administering Medications policy, revised April 2023, did not address the administration of medications via a gastrostomy tube. Review of the Facility's Competency Validation for Medication Administration reflected .Respect resident's right to privacy .when administering medication through a g-tube do not mix several medications together .flush tube between each medication with at least 5 ccs of water. Review of the RN's Competency Validation for Medication Administration reflected that the Infection Prevention Nurse (IPN) had completed a competency with the RN during her orientation on 9/13/23. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to perform proper hand hygiene for 1 of 3 nurses who administered medications to 1 of 8 residents (Resident # 93) observed during medication administration. This deficient practice was evidenced by the following: On 10/27/23 at 8:16 AM, the surveyor observed the Registered Nurse (RN) administer insulin and medications via a gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach) to Resident # 93. The surveyor then observed the RN remove her gloves to wash her hands. The RN applied soap and lathered her hands for seven seconds out of the stream of running water. She rinsed her hands and turned off the faucet with her bare hands then dried her hands with a paper towel. The surveyor reviewed the medical records of Resident #93 which revealed the following: Resident #93 was admitted with diagnoses which included but were not limited to Type 2 diabetes mellitus and aphasia following a cerebral infarction (stroke) and Gastrostomy Status. Review of Resident #93's Quarterly MDS dated [DATE], revealed that Resident #93 had a BIMS of 3 out of 15 which indicated that the resident's cognition was severely impaired. During an interview with the surveyor on 10/27/23 at 12:07 PM, the RN stated that the process for handwashing included lathering hands together with soap and water for 20 seconds and that the whole process should take 30 seconds. The RN stated that the importance of handwashing was to prevent the spread of infection. On 11/2/23 at 11:25 AM, the surveyor team met with the Regional Administrator, Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Nurse, and Infection Preventionist Nurse to discuss the above observations and concerns. During an interview with the Infection Preventionist Nurse (IPN) on 11/2/23 at 1:36 PM, the IPN stated that the RN should have washed her hands following the facility handwashing policy which instructed to vigorously lather hands with soap and scrub them for at least 20 seconds. The IPN further stated that the RN should have turned the faucet off with a clean paper towel. A review of the facility's Handwashing/Hand Hygiene policy, revised December 2022 reflected .this facility considers hand hygiene the primary means to prevent the spread of infections .Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions:before and after direct resident care; before and after performing any invasive procedure (e.g., fingerstick blood sampling) .vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least 15-20 seconds covering all surfaces of the hands and fingers .rinse hands thoroughly under running water .dry hands thoroughly with paper towels and then turn off faucets with a clean dry paper towel. A review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. NJAC 8:39:19.4 (a)(n),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 provide privacy and promote dignity during medication administration for 3 of 8 residents observed (Residents #16, #34 and #93) on 1 of 2 nursing units and for 1 of 3 nurses observed. This deficient practice was evidenced by the following: During the medication administration observation of the A unit on 10/27/23 at 7:39 AM, the surveyor observed the Registered Nurse (RN) administer medications to Resident #16. The surveyor observed the resident awake and seated in their wheelchair in the doorway of their room. The RN sanitized their hands, donned gloves, and without providing Resident #16 with privacy the RN cleaned Resident #16's finger with an alcohol swab and performed a capillary blood glucose test (finger prick to obtain a blood sugar level using a glucometer). The door to the resident's room remained opened and the resident continued to be visible from the hallway as the RN performed the test. The surveyor reviewed the medical records of Resident #16 which revealed the following: Resident #16 was admitted with diagnoses which included but were not limited to: Type 2 diabetes mellitus (DM) and mood disorder. Review of Resident #16's Quarterly Minimum Data Set (MDS), an assessment tool, dated August 20, 2023, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 11 out of 15 which indicated that the resident's cognition was moderately impaired. Review of Resident #16's October 2023 Physician Order Summary (POS) Report reflected a physician order (PO) for Humalog Solution 100 units/milliliter (ml) (Insulin Lispro) Inject as per sliding scale: if 201-250 give (=) 2 units; 251-300=4 units; 301-350=6 units; 351-400=8 units; 401-450=10 subcutaneously before meals for DM; if blood glucose monitoring (BGM) is less than 70 or greater than 400 notify the MD. On 10/27/23 at 8:09 AM, the surveyor observed Resident #34 seated in their wheelchair in the hallway outside of their room. The RN asked Resident #34 to go to their room. The RN put gloves on, cleaned Resident #34's fingertip with an alcohol pad and performed a capillary blood glucose test. The door to the resident's room remained opened and the resident continued to be visible from the hallway as the RN then administered Artificial Tears 1 drop (gtt) to each eye and then used an eye scrub pad to each eye. The surveyor reviewed the medical records of Resident #34 which revealed the following: Resident #34 was admitted with diagnoses which included but were not limited to: Type 2 diabetes mellitus and Alzheimer's disease. Review of Resident #34's Quarterly MDS, dated [DATE], revealed that Resident #34 had a BIMS of 14 out of 15 which indicated that the resident's cognition was intact. Review of Resident #34's October 2023 POS reflected a PO for Novolog Solution 100 unit/ml for BGM if less than 70 or greater than 400 notify the MD; PO for Artificial Tears Solution 1.4% instill one gtt in both eyes two times a day for allergies; Provide Privacy; Eye Scrub External Pad apply to both eyes topically two times a day for redness/swelling. On 10/27/23 at 8:16 AM, the surveyor observed the RN enter Resident # 93's room. Resident #93 was awake in bed. The RN stated that the resident was aphasic but communicated by using a communication board and using thumbs up and thumbs down. The RN put gloves on, cleaned Resident #93's fingertip with an alcohol pad, and performed a capillary blood glucose test. The RN pulled up Resident #93's gown exposed his/her adult brief, gastrostomy tube, urinary catheter tubing, and administered 8 units of Insulin subcutaneously to Resident #93's abdomen in the upper right quadrant. The door remained open and the resident continued to be visible from the hallway. At that time, the surveyor asked the RN to step out of Resident #93's room and asked the RN if she should have provided the resident with privacy by pulling the resident's curtain and closing the door. The RN replied, yes, but [the resident] is so far back and nobody is usually back here. The surveyor reviewed the medical records of Resident #93 which revealed the following: Resident #93 was admitted with diagnoses which included but were not limited to Type 2 diabetes mellitus, aphasia following cerebral infarction (stroke), and Gastrostomy Status (a tube inserted through the belly that brings nutrition directly to the stomach). Review of Resident #93's Quarterly MDS dated [DATE], revealed that Resident #93 had a BIMS of 3 out of 15 which indicated that the resident's cognition was severely impaired. Review of Resident #93's October 2023 POS reflected a PO dated 9/9/23 for Humalog Injection Solution 100 units/ml (Insulin Lispro) inject per sliding scale: if 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 =10 units, subcutaneously three times a day for DM call MD if less than 70 or greater than 400. During an interview with the surveyor on 10/27/23 at 12:07 PM, the RN stated that she should have provided privacy by closing the residents' door during care, capillary blood glucose testing, administration of eye drops, eye scrubs, insulin, and medications given via the gastrostomy tube. The RN acknowledged that she did not provide privacy during those times. On 11/2/23 at 11:25 AM, the surveyor team met with the Regional Administrator, Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Nurse, and Infection Preventionist Nurse to discuss the above observations and concerns. The DON stated that the RN should provide privacy during care, treatments, and medication administration. Review of a facility policy titled, Resident Rights, dated January 2023, included but was not limited to; Employees shall treat all Residents with kindness, dignity, and respect. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include .privacy and confidentiality. Residents are entitled to exercise their rights and privileges to the fullest extent possible. NJAC 8:39-4.1(a)(12)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident received treatment and services to promote healing of a chronic stage two (Stage II) pressure ulcer. This deficient practice was identified for 1 of 3 residents, (Resident #19) reviewed for pressure ulcers and was evidenced by the following: On 08/2/21 at 07:11 PM, the surveyor observed Resident #19 sitting upright and asleep in his/her bed on a fully inflated and functioning pressure reducing air mattress. On 08/5/21 from 10:03 AM to 10:17 AM, the surveyor in the presence of another surveyor and the Registered Nurse/Unit Manager (RN/UM) observed the Licensed Practical Nurse (LPN) perform the wound treatment to Resident #19's sacral (lower back) wound. The following observations were made: At the treatment cart, the LPN gathered the required supplies which included island dressing (a sterile gauze bandage which is centered in a square adhesive pad), wooden tongue depressor (for medication application), and squeezed medihoney (a paste which aids in wound healing) into a small medication cup. The LPN, while at the treatment cart used her ungloved hand to open and date the outside of the island dressing. At 10:08 AM, the LPN performed hand hygiene using soap and water and laid a dry clean pad on the bedside table and placed the supplies. The LPN proceeded to turn Resident #19 with the assistance of the RN/UM exposing a clean, oval shaped, reddish-pink, healing Stage II pressure ulcer (opening in the skin that is superficial, not reaching the full thickness of the skin) on his/her sacrum. The LPN then performed hand hygiene using alcohol based hand rub and put on clean gloves. The LPN dampened a clean gauze with normal saline solution and cleaned the wound. The LPN then disposed of the soiled gauze and immediately grabbed new, clean, dry gauze and patted the wound dry. There was no observed glove change or hand hygiene performed after the disposal of the soiled gauze and the application of the clean gauze. The LPN using the same gloves, then applied the medihoney with the tongue depressor to the resident's wound. Then the LPN without any observed glove change or hand hygiene applied the clean pre-dated island gauze dressing to the resident's wound and then removed her gloves and preformed hand hygiene. The surveyor reviewed Resident #19's medical record. A review of the admission Record reflected that the resident was re-admitted to the facility in June 2021 with diagnoses which included pressure ulcer of sacral region, unspecified open wound of the right and left knees, acute kidney failure (kidneys suddenly stop working properly), peripheral vascular disease (a slow and progressive circulation disorder), and unspecified dementia with behavioral disturbance. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 05/21/21, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated that the resident had moderately impaired cognition. A further review of the MDS Section M - Skin Conditions, reflected that the resident had no active pressure ulcers. A review of a telephone physician's order dated 7/30/21, for medihoney wound/burn gel; to cleanse wound with normal saline solution, apply medihoney to wound bed and cover with clean dry dressing daily for fourteen days. A review of the Progress Notes reflected a Skin/Wound Note dated 8/3/21, that the resident had a deep tissue injury that evolved into a stage II pressure ulcer measuring 2x2.5x0.2 centimeters (cm) in size. The plan was clean wound with normal saline solution and apply medihoney with clean dry dressing daily and as needed if soiled. A review of the resident's individualized care plan reflected that the resident had a focus area dated 6/27/21, for the potential for skin breakdown related to compromised skin integrity on admission and comorbidities: anemia (decrease in red blood cells), kidney failure, gout, arthritis, incontinence (lack of voluntary control over bowel and/or bladder), scar tissue to sacrum and bilateral (both) knees. Interventions included; to administer treatment per physician orders. On 08/5/21 at 11:53 AM, the surveyor interviewed the LPN who stated that the process to perform wound care would be to remove the dressing off the wound, assess the wound for any sign of infection, clean the wound as ordered, remove gloves, sanitize hands, put on new clean gloves and then apply medication and new dressing as ordered. When the surveyor asked the LPN if she missed any of these steps during the wound care, the LPN replied that she could not remember. On 08/5/21 at 12:07 PM, the surveyor interviewed the RN/UM who stated to that the procedure for wound care after gathering supplies and checking physician orders was to remove the dirty dressing and assess for signs of infection, remove gloves and wash hands, put new gloves on, apply ointment or medication and dressing. When the surveyor asked the RN/UM if the LPN had missed any of these steps, the RN/UM replied that she could not remember. On 8/5/21 at 12:54 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the procedure for wound care would be to wash hands, put on clean gloves, remove dressing already in place, dispose of dirty dressing and dirty gloves, perform hand hygiene, put on new gloves, clean wound site as ordered, dispose of gloves and perform hand hygiene, and apply treatment medication and clean dressing. On 08/6/21 at 09:23 AM, the [NAME] President (VP) in the presence of the DON, Licensed Nursing Home Administrator, and the survey team stated that, The nurse who forgot to change her gloves, she should have. She knew what to do, but she got scared. A review of the facility's Wound Care Procedure for Major Wounds policy dated revised 2009, included the procedure for wound care is to remove soiled dressing, remove gloves and discard, wash hands, clean the wound according to the order, place soiled gauze used for cleaning in (trash) bag, remove gloves, put on new gloves, apply clean dressing as ordered, remove gloves, and initial, date and time dressing. NJAC 8:39-27.1(e)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to provide the correct consistency of diet according to physician's orders. This deficient practice was identified for 1 of 4 residents (Resident #58) reviewed for nutrition and evidenced by the following: On 8/4/21 at 11:45 AM, the surveyor observed the Certified Nursing Aide (CNA) place a lunch meal tray in front of an unsampled resident. The meal ticket on the tray identified the meal was for sampled Resident #45 and contained a peanut butter and jelly sandwich, jello, creamed celery, health shake (nutritional supplement) and thin liquids (consistency) of water and gingerale. The CNA set-up the meal by placing a spoon in the soup, opened all three beverage containers, and cleaned the resident's hands. The surveyor observed no identification on the resident so they asked the resident what his/her name was. The resident had not responded and the CNA told the resident to tell the surveyor his/her name. The resident identified him/herself as Resident #58 and the CNA confirmed this. At this time, the CNA left the resident alone with the meal tray to eat and drink. On 8/4/21 at 11:50 AM, the surveyor asked the Licensed Practical Nurse/Unit Manager (LPN/UM) to identify Resident #58, which the LPN/UM confirmed that the resident was Resident #58. At this time, the surveyor asked the LPN/UM to accompany them to the resident's tray and identify whose lunch tray this was. The LPN/UM confirmed that the tray was Resident #45's and not Resident #58's. The LPN/Um immediately removed the lunch tray and put it at the nurse's station. The LPN/UM stated that it had not appeared that the resident had eaten or drank from the lunch tray. At this time, the surveyor observed a list on the cabinet entitled Residents with Thickened Liquids/Fluid Restrictions Ordered dated revision 8/4/2, which indicated that Resident #58 was on nectar thick liquids (consistency slightly thicker than thin liquids) and not the thin liquids he/she was served on Resident #45's lunch tray. On 8/4/21 at 11:53 AM, the surveyor observed Resident #58's lunch tray which contained chopped carrots and cheese blintz, pudding, cream of celery, health shake, and nectar thick cranberry juice and nectar thick lemon beverage. On 8/4/21 at 11:54 AM, the surveyor interviewed the CNA who stated that he was given Resident #45's lunch tray and was told to give it to Resident #58. When asked who the person was, the CNA responded that he could not remember, but confirmed that he was suppose check the tray as well to ensure that correct resident received the correct tray. The CNA confirmed that Resident #58 drank nectar thick liquids, but he was unsure the liquid consistency that he/she received on the other resident's tray. The surveyor reviewed the medical record for Resident #58. A review of the admission record reflected that the resident was admitted to the facility in April of 2021, with diagnoses which included dementia with behavioral disturbance, protein-calorie malnutrition, heart failure, anorexia (lack or loss of appetite for food), and gastro-esophageal reflux disease (acid reflux). A review of the admission Minimum Data Set, an assessment tool dated 7/9/21, reflected a Brief Interview of Mental Status (BIMS) score of 0 out of 15 which indicated cognitive impairment. A further review of the MDS in Section G - Functional Status, indicated that the resident required extensive assistance of one person physical assistance for eating. A review of the active Order Summary Report dated 8/4/21, reflected a physician's order dated 7/15/21, for nectar thick liquids. A review of the Progress Notes reflected a Nursing Progress Note dated 7/15/21, that the Speech Therapist (ST) stated that the resident was coughing during session (speech therapy) so diet was downgraded to mechanical soft (food texture) with nectar thick liquids. A review of the resident's individualized care plan reflected a focused area dated 7/6/21, that the resident has a nutritional problem or potential nutritional problem with regards to dementia and at risk for varied by oral intake. Interventions included to feed self after tray set up; staff will monitor for sign and symptoms of dysphagia (difficulty swallowing); and staff will provide and serve diet as ordered. On 8/4/21 at 12:29 PM, the surveyor re-interviewed the CNA who stated that the resident was able to feed him/herself, but required assistance with the set-up. The CNA stated that staff observed the resident eating to ensure that the resident took small bites and drank plenty of liquids to prevent pocketing of food or aspiration (when something such as food or liquids enters your airway or lungs by accident). On 8/4/21 at 12:36 PM, the surveyor re-interviewed the LPN/UM who confirmed that the resident fed him/herself, but it had not appeared that the resident had touched anything on Resident #45's lunch tray. On 8/4/21 at 1:09 PM, the surveyor interviewed the ST via telephone who stated that Resident #58 was currently receiving speech therapy. The resident arrived to the facility with a diet order of regular texture food and thin liquids. The ST stated that she had observed the resident two weeks later eating poorly and he/she seemed congested so she put the resident in speech therapy and changed the diet order to mechanical soft food texture with nectar thick liquids with a goal to return back to regular texture food and thin liquids. The ST stated that thin liquids were not dangerous to the resident, and if the resident were to receive, they would not be at risk for choking or death. On 8/5/21 at 1:11 PM, the surveyor in the presence of the Licensed Nursing Home Administrator, Director of Nursing, Regional Nurse, and survey team addressed this concern. A review of the facility's undated Meal Tray Policy and Procedure which included that staff passing trays will check the meal ticket to identify the correct resident before passing each tray and special or altered diets listed on the meal ticket will be verified before the resident begins eating. NJAC 8:39-17.4(a)(1,2); 27.1