**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the administration of a resident's enteral tube feeding (allows liquid food to enter the stomach or intestine through a tube) was consistently documented to indicate if it were administered or held on the Medication Administration Record. This deficient practice was identified for 1 of 1 resident, (Resident #27) reviewed for tube feedings. This deficient practice was evidenced by the following: During the initial tour of the facility on 09/03/24 at 8:38 AM, the surveyor observed Resident #27 lying awake in bed. The resident stated that their tube was clogged four to five weeks ago. A review of Resident #27's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but was not limited to: other pneumonia (lung infection), and dysphagia, pharyngeal phase (problems in the throat during swallowing). A review of Resident #27's admission Minimum Data Set (MDS), an assessment tool, revealed that the resident had Brief Interview for Mental Status Score (BIMS) of 15 out of 15, which indicated that the resident was fully cognitively intact. Further review of the MDS indicated that the resident had a swallowing disorder with coughing or choking during meals or when swallowing medications and complaints of difficulty or pain with swallowing. The MDS specified that the resident experienced no significant weight loss and had a feeding tube (PEG, percutaneous endoscopic gastrostomy, a feeding tube inserted through the skin and the stomach wall for people who can not obtain nutrion by mouth). A review of Resident #27's Care Plan revealed an entry dated 07/09/24, that had a Focus of: I have a nutritional problem or potential nutritional problem, risk for malnutrition r/t (related to) abnormal nutrition-related labs, EN (enteral nutrition) via PEG, dysphagia, MASD (moisture associated skin damage) at sacrum (a triangular bone in the lower back) partial thickness, add MVI (multivitamin), 1) Possible unintentional weight loss 2) Enteral nutrition support. Goals included but were not limited to: I will tolerate TF (tube feeding) 100% by next review date, .I will be free from s/sx (signs and symptoms) of dehydration through next review date .My skin integrity will be improved or maintained by next review date and My abnormal nutrition-related labs will show improvement by next review date. Interventions included but were not limited to: Provide and served diet as ordered: NPO (nothing permitted orally): Jevity 1.2 at GR (rate) of 75 ml/hr x 20 hr, TV (total volume) to provide 1800 kcal (calories), 83 gm (grams) pr (protein),1215 ml free water .via peg to meet 100% ENN (enteral nutritional needs) fluid needs, monitor and record intake at meals . A review of Resident #27's Order Summary Report revealed an order dated 08/13/24 for NPO diet. A second order dated 09/03/24, for Enteral Feed Order in the afternoon Enteral: Jevity 1.2 .liquid feeding tube every shift, feeding pump set at 75 ml/hr for 20 hours, total volume 1,500 ml A review of Resident #27's August 2024 Medication Administration Record (MAR) revealed an entry for an Enteral Feed Order in the afternoon Enteral: Jevity 1.2 Cal liquid via feeding tube every shift, feeding pump set at 75 ml/hr for 20 hours, total volume 1500 ml, 100 ml flush after medication start date 08/11/24. Further review of the entry revealed that on 08/25/24, 08/27/24, 08/28/24, and 08/29/24 at 1400 (2:00 PM) the order was not signed out to indicate whether the tube feeding was admininistered or held and the fields that were allotted for charting were left blank. A review of Resident #27's Progress Notes within the electronic health record (EHR) from 08/25/24 through 08/29/24, did not indicate that the resident left the facility or experienced difficulties with tube feeding administration. On 09/05/23 at 10:09 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated that the resident went out to the hospital on [DATE], and the entry for tube feeding administration on the MAR was left blank but there was documentation on the MAR on 08/13/24, that the entry was signed out as held on that date. The LPN/UM stated that the entry should have been charted as not administered if the resident were not here. The LPN/UM reviewed the August MAR and stated that on 08/27/24, 08/28/24, and 08/29/24, the patient was in the building and the nurse did not properly document. The LPN/UM stated there was no excuse why she was not documenting. The LPN/UM further stated that even on 08/25/24, 08/27/24, 08/28/24, and 08/29/24 blanks were noted on the MAR. The LPN/UM stated that she did not know why it was not signed out, but the patient was in the building and I think it was missed. The LPN/UM stated that there were no orders in place to indicate that the tube feeding was held for any reason. On 09/05/24 at 11:44 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she would not expect to see blanks on the MAR. The DON stated that a lack of documentation was a problem. The DON stated that sometimes care was given and provided, but they just did not sign. The DON further stated, In nursing, if you did not document, you did not do it. A review of the facility policy, Enteral Tube Feeding via Continuous Pump (Revised November 2018) revealed the following: .Documentation: The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. .9. The signature and title of the person recording the data. A review of an undated facility policy, Administering Medications revealed the following: .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. NJAC 8:39-29.2(d), 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food to prevent food borne illness. This deficient practice was evidenced by the following: On 09/03/24 at 8:46 AM, during the initial tour of the kitchen, the surveyor observed the following in the walk-in meat freezer in the presence of two (2) Food Service Directors (FSD #1 and FSD #2). 1. An opened slab of roast beef on the top shelf was not labeled or dated. 2. An opened bag containing six (6) salisbury patties was not labeled or dated. At that time, during an interview with the surveyor, FSD #1 stated, everything that is in the freezer should have dates. Once it is opened, it should be dated. FSD #2 discarded the roast beef and salisbury patties. On 09/05/24 at 1:15 PM, during an interview with the surveyor, the Licensed Nursing Home Administrator stated, when food packages are opened, it should be labeled and dated with the use by date. A review of the facility policy titled Food Receiving and Storage (revised November 2022) revealed, Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). NJAC 8:39-17.2 (g)

Based on interview and review of pertinent facility documentation, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement Program's (QAPI) sources of quantitative data was being analyzed to evaluate program effectiveness and implement new processes. This deficient practice was identified during the standard survey and was evidenced by the following: Refer to S1410 On 09/03/24 at 08:32 AM, during the entrance conference the surveyor requested the facility's QAPI book. On 09/06/24 at 08:45 AM, the Licensed Nursing Home Administrator (LNHA) provided the QAPI book. A review of the QAPI book revealed that the facility started a QAPI in January of 2024 on the two-step tuberculosis (TB) skin test (a procedure that helps determine if a person has a recent TB infection or a boosted reaction to an old infection) for employee health and that the Infection Preventionist (IP) and Human Resources (HR) were responsible to audit the active employee files which was ongoing. Further review of the QAPI book revealed that in April 2024 the two-step TB skin test QAPI was still ongoing. On 09/06/24 at 09:37 AM, the LNHA provided an audit that was completed only for the newly hired employees for January 2024. There was no documented evidence that an audit was completed for active employees from January 2024 to August 2024. During an interview with the surveyor on 09/06/24 at 09:52 AM, the LNHA stated, in the presence of the survey team, that QAPI was the process to monitor the improvement of the identified concerns. She further stated that if there was no improvement, then the QAPI committee reviewed why it was not improving and what interventions could be put into place. When asked about the provided audit, the LNHA stated that the January audit that was provided for the employee health two-step TB skin test was completed for the newly hired employees and not the active employees. She further stated that the expectation would be to audit all of the active employees as indicated by the QAPI plan. The LNHA confirmed that the audits from February to August 2024 were not completed. The LNHA acknowledged that since there was a QAPI on it, there should have been audits completed from January to August 2024 on the active employees and the information should have been presented at the QAPI meetings. During an interview with the surveyor on 09/06/24 at 10:22 AM, the infection Preventionist (IP) stated in the presence of the survey team, that she started the QAPI on employee health two-step TB skin tests for active employees because she was trying to put a system in place to have the files in order. The IP further stated that she started with the newly hired employees in January because it would be easier. When asked about the ongoing audits, the IP stated it fell by the way side. The IP emphasized the plan was to review all the active employees, but they started with the newly hired employees first. The IP confirmed there were no other audits completed for the active employees related to the employee health two-step TB skin test. She further stated that the expectation was that all active employees should have been reviewed since it was brought to QAPI. A review of the facility's undated Quality Assurance and Performance Improvement (QAPI) Program policy, included, 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include a. tracking and measuring performance. 3. The committee meets at least quarterly (or more often as necessary) to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. NJAC 8:39-33.1(a)(e); 33.2 (a)(b)(c)(d)

Based on interview and review of other pertinent facility documentation, it was determined that the facility failed to ensure full implementation of the antibiotic stewardship program, including ongoing monitoring and use of a nationally recognized surveillance criteria prior to consulting the prescriber. This deficient practice was identified for 1 of 1 resident reviewed for antibiotic stewardship, (Resident #27). This deficient practice was evidenced by the following: On 09/04/24 at 9:38 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the facility Antibiotic Stewardship Program (efforts to ensure that antibiotics are used only when necessary and appropriate). The IP stated that she had worked at the facility for nearly one year and had worked as an IP since 2019. When the surveyor asked the IP to describe how the Antibiotic Stewardship Program worked she stated, With a prayer. The IP stated that she monitored residents on antibiotics. When the surveyor requested to view the Antibiotic Stewardship documentation, the IP stated that she would need to run a report in order to do so. When the surveyor asked the IP to run the report, the IP stated that she would have to get back to the surveyor at a later time with that information. The IP stated that she reviewed the Antibiotic Stewardship Program recently with both the Medical Director and Administrator at a Quality Assurance Performance Improvement. (QAPI) meeting. At that time, the IP stated that she used the McGeer Criteria [used for retrospectively counting true infections, with more diagnostic information (positive laboratory testing often used to meet the criteria for definitive infection)]. The IP stated that there was a tool in the computer system, but the nurses did not always complete it. The IP stated that if she had time, she went into the computer and completed the tool. When the surveyor asked the IP to demonstrate use of the tool within the computer that was on her desk in front of her, she stated that the report would need to be ran from the electronic health record. The surveyor asked the IP to identify a resident who was currently being monitored for the antibiotic stewardship and the IP stated, I cannot tell you right now. The IP stated that she ensured the appropriate usage of a prescribed antibiotic was met with the McGeer Criteria Assessment. The IP stated that if the McGeer Criteria was not met, she reached out to the doctor and asked if changes could be made. When the surveyor asked the IP to provide a list of residents who currently received antibiotics at the facility, or an example of the McGeer Criteria Assessment template in her computer or elsewhere, the IP was unable to provide the surveyor with documented evidence of completion of any component of an Antibiotic Stewardship Program. On 09/04/24 at 1:05 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that Antibiotic Stewardship was reviewed during QAPI meetings. The LNHA stated that the IP should have been able to provide evidence of the facility Antibiotic Stewardship Program when requested. The LNHA stated that she would look within the QAPI Binder. On 09/05/24 at 9:29 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that when a resident demonstrated signs and symptoms of an infection she first evaluated the signs and symptoms of the infection and then notified the doctor. LPN #1 stated that if the resident had a cough or wheeze, the doctor may order a chest x-ray or a COVID test, or if the resident were confused the doctor may order a urine culture. LPN #1 stated if an antibiotic was ordered, she started it as soon as possible and informed both the resident and the resident's family. LPN #1 stated that no additional documentation or notification were required when a new antibiotic treatment was ordered. On 09/05/24 at 11:22 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the facility reviewed resident antibiotic usage at QAPI Meetings and clinical meetings. The DON stated that when an antibiotic was ordered, the nurse should document, review signs and symptoms, see why the antibiotic was ordered, and then update the resident's care plan. The DON stated that the IP did the McGeer Criteria and there must be two symptoms present. The DON stated that she was unsure if the nurses were required to complete the McGeer Criteria. The DON stated that she would have expected that the IP would have shown the surveyor her Antibiotic Stewardship when requested and should have known of at least one resident who received an antibiotic when asked. The DON stated the IP should have had a binder with the information requested in her office. The DON further stated that she was not an IP, but she knew who the residents were who received antibiotics. On 09/05/24 at 12:06 PM, the LNHA stated that she was ultimately responsible for oversight of the IP's work, and agreed to furnish the surveyor with a binder used for Antibiotic Stewardship. On 09/05/24 at 1:17 PM, in a later interview with the LNHA, she provided the surveyor with a binder used for Antibiotic Stewardship and stated that the information was used during QAPI meetings. When the surveyor asked why the binder only contained laboratory data and reports that were obtained from the electronic health record (EHR) that pertained to antibiotic usage and failed to contain documented evidence of McGeer Criteria Assessments, the LNHA stated that there was more education that needed to be done with the IP. On 09/06/24 at 10:01 AM, in the presence of the survey team, the DON stated that after an antibiotic was started, the nurse filled out the infection screening evaluation. The DON explained that the Medical Doctor provided an order for antibiotics, and the Infectious Disease (ID) Doctor did the screening and confirmed that the antibiotic was appropriate and there was no resistance to the antibiotic. The DON stated that the IP was responsible for reviewing the Antibiotic Stewardship and she should have been documenting in the EHR and also should have been tracking antibiotic usage. The DON stated that the monthly tracking that was provided within the binder was completed by the laboratory. On 09/06/24 at 10:07 AM, the LNHA stated that the facility reviewed antibiotic usage both daily and monthly. When asked how the facility ensured appropriate antibiotic usage, the LNHA stated that labs and symptoms were reviewed. The LNHA stated that documentation of daily tracking was not maintained and only monthly tracking provided by the lab was kept. On 09/06/24 at 10:13 AM, the IP stated that she was tracking antibiotic usage in the EHR that were prescribed both from the hospital and in house. The IP stated that she spoke with the nurses to track changes if any changes were identified during the daily meeting. The IP stated the staff nurse would complete the assessment form and determine if the McGeer criteria was met within three days of a resident starting an antibiotic. The IP stated that if the antibiotic criteria was not met, then the doctor was notified and the the antibiotic was discontinued. When the surveyor asked if antibiotic stewardship should have been reviewed prior and what the process was to determine if an antibiotic were appropriate prior to administration, the IP stated that she reviewed Antibiotic Stewardship in daily clinical meetings. The IP stated that she reviewed the information prior to presenting. When the surveyor asked the IP how she could have explained resident information fully if there was missing documentation on the assessment forms that were provided to the survey team, the IP stated, I will go off memory to try and fill out the information that was missing. The IP further stated that she did not document daily when the daily meetings were held, as they just discussed it. At that time, the IP stated the importance of Antibiotic Stewardship was to identify infections and how we can discuss whether the antibiotics that were used were effective or not. On 09/06/24 at 4:42 PM, the LNHA provided the surveyor with a list of residents who received antibiotics in-house for the past three months. The surveyor reviewed the list and noted that Resident #27 was included on the list. The surveyor reviewed the Medication Administration Record (MAR) within the resident's EHR which revealed that on 08/04/24 at 9:00 AM, the resident was ordered and received Amoxicillin-Pot Clavulanate Tablet 875-125 mg (milligrams) Give 1 (one) tablet via PEG (percutaneous endoscopic gastrostomy, feeding tube inserted through the skin and the stomach wall, directly into the stomach) Tube every 12 hours for bacterial infection for 2 (two) days. On 08/04/24 at 1644 (4:44 PM), the order was discontinued and revised for the same dosage and the indication of Pneumonia was replaced the indication of bacterial infection which was omitted. The order had a start date of 08/04/24 at 2100 (9:00 PM) and an end date of 08/06/24 at 23:59 (11:59 PM). A review of the MAR indicated that the resident received a dosage of the medication at 9:00 PM as ordered and on 08/05/24 at 9:00 AM. Further review of the MAR revealed that there were blanks on the MAR on 08/05/24 at 9:00 PM , and there were also blanks for the medication administration times that pertained to 08/06/24 at both 9:00 AM and 9:00 PM, with no documentation provided into the allotted spaces to indicate the status of antibiotic administration through the end date of 08/06/24 at 23:59 (11:59 PM). A review of Resident #27's Physician Progress Note dated 08/04/24 at 1517 (3:17 PM) revealed a First Docs readmission Note, which indicated .the resident was readmitted to the facility after he/she was sent out to acute care on 7/30/24 for worsening shortness of breath .IV (intravenous Rocephin (antibiotic) administered for penumonia [sic] . Further review of the Progress Notes (PN) failed to contain a notation that referred to an order for Amoxicillin-Pot Clavulanate Tablet 875-125 mg (milligrams) Give 1 (one) tablet via PEG (percutaneous endoscopic gastrostomy, feeding tube inserted through the skin and the stomach wall, directly into the stomach) Tube every 12 hours for bacterial infection for 2 (two) days. A review of a PN dated 08/05/24 at 1458 (2:58 PM) resident was sent to the hospital. On 08/05/24 a 22:54 (10:54 PM), a Discharge Summary note revealed that .was told by ER Nurse patient admitted with Heart Failure .Further review of the EHR revealed that on 08/08/24 at 23:56 (11:56 PM), an admission Summary note revealed that the resident arrived back to the facility from the hospital via stretcher . Review of the facility policy, Antibiotic Stewardship (Revised 12/2016) revealed the following: Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. .When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. Discharge or transfer medical records must include all of the above drug and dosing elements . .As soon as clinically appropriate, the prescriber will be asked to review converting parenteral (administered elsewhere in the body other than the mouth) antibiotics to an oral formulation. Review of the facility policy, Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes (Revised 12/2016) revealed the following: Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide the decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection Preventionist, or designee. The IP, or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if: the organism is not susceptible to antibiotic chosen; the organism is susceptible to narrower spectrum antibiotic; therapy was ordered for prolonged surgical prophylaxis; or Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics . All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form . NJAC 8:39-19.4(c) (d)

Based on interview and review of other pertinent facility documentation, it was determined that the facility who had been in an active COVID-19 (potentially, deadly virus) outbreak since 08/21/24, failed to conduct complete and thorough contact tracing (method used to identify COVID-19 exposure and prevent transmission) upon the identification of a single new case of COVID-19 in a resident or staff member in accordance with the facility policy, Centers for Disease Control (CDC), Local Health Department, State Health Department and all current guidance related to infection control. This deficient practice was identified for 1 of 1 resident, (Resident #21) reviewed for COVID-19. This deficient practice was evidenced by the following: On 09/03/24 at 7:26 AM, the surveyor entered the facility and was informed by the Registered Nurse Night Supervisor (RNNS) that the facility was in an active outbreak and the last positive resident (Resident #21) was expected to complete isolation precautions that day. There was signage posted on the front door of the facility and at the receptionist desk that informed visitors that the facility was in outbreak and mask usage was required. On 09/03/24 at 8:48 AM, the surveyor observed Licensed Practical Nurse (LPN) # 1 outside of Resident #21's room during the medication pass. The surveyor observed that there was no signage or PPE (personal protective equipment, equipment worn to protect the body from injury or disease) to indicate that the resident was on isolation precautions for COVID-19. When interviewed, LPN #1 stated that Resident #21 was assigned to her and she did not have any residents who had COVID-19 on her assignment. On 09/03/24 at 9:15 AM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #21 was cleared of COVID-19 and isolation precautions were discontinued. A review of Resident #21's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: interstitial pulmonary disease (lung disease), and cognitive communication deficiency. The Diagnosis section of the form was later updated on 08/24/24, to include a diagnosis of COVID-19. A review of Resident #21's admission Minimum Data Set (MDS), an assessment tool, revealed that the resident had a Brief Interview for Mental Status score of 15 out of 15 which indicated that the resident was fully cognitively intact. A review of Resident #21's Care Plan revealed an entry dated 08/25/24, with a Focus of: I have COVID-19 (resolved 09/03/24). Interventions included but were not limited to: COVID-19 testing per the Federal, State, and local recommendations/regulations . A review of Resident #21's Health Status Note in the Electronic Health Record (EHR) revealed an entry dated 08/26/24 at 10:14 AM that was documented by the DON, revealed: The patient tested with COVID positive (+). The resident is on isolation precaution for positive COVID, he/she is in a single room by his/herself, all services provided in the room. The patient is made comfortable. Will continue plan of care. On 09/04/24 at 9:38 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that the first resident who tested positive for COVID-19 on 8/11/24, resided on the second floor in a private room. The IP stated that she checked to see if the resident had visitors or who the resident had contact with. The IP stated that she confirmed that the resident had visitors often. When the surveyor asked the IP if she completed contact tracing, the IP stated that she documented notes on the comment section of the line listing (describes an outbreak in terms of person, place and time and allows for quick identification of trends, missing information and errors). The IP stated she normally used the CDC Checklist and completed contact tracing, but I have not done it for this outbreak yet. The IP stated she had to put it together, as her contact tracing is in the comment section of the line listing. The IP stated, we are not out of outbreak, so I have not put it together yet. I just document on my line listing. At that time, the IP stated that on 08/16/24, a resident on the second floor tested positive. The IP stated the resident had frequent visitors from the outside and had since been discharged to home. The IP stated on 08/17/24, she was texted at home over the weekend by a nurse and was informed that there were three residents who tested positive for COVID-19. The IP stated that Transmission Based Precautions TBP (isolation), and droplet precuations (necessary when a patient infected with a pathogen, is within three to six feet and a mask or respirator is required to be worn) and contact precautions (precautions intended to prevent transmission of infectious agents spread by direct or indirect contact with the patient or the patient's environment) were instituted. The IP stated that an N 95 mask (filters out 95% of particles), face shield, goggles, gloves and gown were required to be worn into the affected resident's room. The IP further stated that she notified the local health department official on either Sunday or Monday of the positive cases. The IP stated the official was not available, and someone else responded in her absence. They informed her of a need to start a line list. The IP stated that she usually did contact tracing and symptoms but the outbreak stayed in one hallway. She stated, it may have been from that, it was hard. No one else was sick except for the three residents. The IP stated that a fourth resident who was a room mate of a positive resident, then tested positive four days later. The IP stated in all, she had eight positive residents and one staff member (a house keeper who did not work on either of teh sub-acute units located on the second or fifth floor). The IP stated there was another staff member, who does not come to the clinical units and was placed under the other tab on the line listing. At that time, the IP stated that a Certified Nursing Assistant (CNA) who worked on the second floor tested positive on 08/12/24. The IP stated when interviewed, the CNA stated that she took care of someone who was ill at home, but did not report that their loved one had COVID. The IP stated that the CNA came into work early and stated that she felt like she was getting a cold and requested to be tested and was sent home early before her shift. The IP stated the CNA's last day worked was on 8/10/24. When the surveyor asked if any staff or residents were tested in response to the positive CNA the IP stated that she would have to look and see what assignment the CNA had. The IP stated the nurses would notify her if any residents displayed signs and symptoms of COVID-19 and nobody was symptomatic at that time. When asked when do you test residents and staff? The IP stated, I only test if symptomatic. The IP further stated I ask who they were with. At that time, the IP stated, We talk, but it is not documented. It is me yelling at them, where were you, who at home is sick? No testing is done, only residents who were symptomatic were tested and no mass testing was done. The IP stated, the previous outbreak (ended on 07/16/24), we tested everybody, because it was out of control. The IP stated the only contact tracing performed was on the line list and has not been transferred onto my notes yet. The IP stated rapid tests were done and the results were documented on the resident's charts in the progress notes. The IP stated right now there are no active cases. The IP stated the last case was Resident #21, who tested positive on 08/24/24, and was removed from isolation on 09/03/24, on day 11. The IP explained that residents were maintained on isolation for 10 (ten) days. The IP stated that she had not spoken with Resident #21 about it to determine possible exposure. At that time, the surveyor asked the IP if she completed staff or resident education in response to the outbreak? The IP stated no education that pertained specifically to COVID-19 was completed for this outbreak. On 09/04/24 at 11:09 AM, the surveyor interviewed the Executive [NAME] President (EVP) who stated that if signs and symptoms of COVID-19 were exhibited, testing was completed and and the IP reached out to the Local Health Department (LHD), Outbreak Coordinator, who directed for Contact Tracing. The EVP stated that her expectation was for the IP to pull the staff schedules and review for possible exposure. The EVP stated that she was not IP certified and relied on the IP to work out the details with the LHD. The EVP stated that contact tracing may be documented on the line list. On 09/04/24 at 12:40 PM, the surveyor reviewed the facility line listing provided by the IP in her presence, which included eight (8) residents and one (1) staff member (from acute care). The CNA who the IP stated worked on the second floor and tested positive for COVID-19 on 08/12/24, was not included on the line list. Two (2) of the resident's comment sections which the IP stated was where she documented contact tracing were blank with no documented evidence that contact tracing was completed. When the surveyor asked the IP why there were blanks on the line listing she stated, It should have been done. The IP further stated that the comment section was intentionally not filled in because a common denominator of exposure was not found. The surveyor noted that Resident #21 was not included on the line list provided. The IP stated that was because the resident had a lot of visitors, and was placed under the other tab. At that time, the IP stated that on Monday 08/19/24, she sent the line list to the LHD. When the surveyor asked why she waited until 08/19/24 to inform the LHD, the IP stated, It took three residents to form an outbreak. The IP further stated, The definition of an outbreak was: two or more staff or residents with similar symptoms. At that time, the surveyor reviewed an email correspondence between the IP and the Health Department dated 08/21/24 at 9:39 AM, which included the following guidance for the IP to institute: .Conduct contact tracing on all resident and staff cases, Conduct testing of close contacts (someone who is within six feet of a COVID-19 case for a cumulative total of 15 minutes or more over a 24-hour period during the COVID-19 case's infectious period) as appropriate (on days 1, 3, and 5), If the facility is unable to perform contact tracing, broad based testing of the unit/wing/facility can be conducted (every 3-7 days until no new cases are found for 14 days), Be sure to follow all applicable federal and state directives. Outbreak Documentation: .Template: COVID-19 Facility Line List Template Include only residents and staff associated with this current outbreak. Be sure to add non-facility onset cases to the other cases tab on the line list after consulting with the LHD. At that time, the surveyor asked the IP to define close contact, she stated, Anyone who spent more than five minutes with a resident with care within a three to five feet distance. There was no documented evidence reflected on the line listing in the comment section to indicate that the IP interviewed both staff and residents who tested positive for COVID-19 or, visited or rendered care to the affected individuals to determine any close contacts who may have been exposed to the positive individuals to prevent the further spread of COVID-19. On 09/04/24 at 1:05 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the IP's documentation of contact tracing that was noted on the comment section of the line list. The LNHA stated, I would expect more information to have been provided. The LNHA stated that she would have included: known or potential exposures, additional test results, contact tracing and findings, activities, underlying conditions etc. The LNHA stated that the IP can document contact tracing on the line list, but it has to be more comprehensive. The LNHA stated, If proper contact tracing was not done, there could be spread of COVID-19. On 09/04/24 at 11:22 AM, the surveyor interviewed the DON who stated, I expect the line list to be comprehensive and include all residents with COVID. The DON stated that if the IP did contact tracing and did not document it, that was an issue. On 09/04/24 at 3:49 PM, the LNHA provided the surveyor with a copy of the line listing via e-mail. The surveyor reviewed the line listing and noted that Resident #21 was added to the line listing after surveyor inquiry. The surveyor reviewed Resident #21's comment section of the line listing which revealed the following: possible exposure from an unsampled resident, (who was also on the line listing as positive for COVID-19), residents observed conversing prior days. A review of the facility policy, Contact Tracing-Residents (Updated 07/2023) revealed the following: Contact tracing is a method of identifying those who may have been exposed to COVID-19, to help track and prevent the transmission of COVID-19. Close contact (exposure) is defined by the CDC as being within 6 (six) feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period. Procedure: Identify the infectious period for the resident. An infectious period begins 2 (two) days prior to symptom onset, if symptomatic. If asymptomatic, the infectious period is calculated as 2 (two) days prior to the COVID-19 specimen collection date. Add 10 (ten) days from the start of the identified infectious period, to determine the end date of the infectious period. For each day of the infectious period, identify all locations the resident visited within the facility (e.g., resident room, dining room, activity room) or if the resident was hospitalized or in another facility (e.g., hospital and unit, dialysis facility). For each location, make notes about each person that could have been in contact with the resident including visitors, other residents, staff, and volunteers. Identify contacts at each location for each day during the infectious period. For each person exposed, investigate the interaction between the case-person and the exposed contact. Was the resident wearing a mask?, Was the resident able to wear the mask consistently? , Was the resident coughing?, What was the nature of the interaction?, How close were the case-person and the exposed person?, For any of the interactions, was the exposed person wearing a mask or other appropriate PPE? Determine if exposed persons meet the definition of a close contact. A person in close contact with the case-patient during the symptomatic period would be considered exposed. Notify all exposed persons of their exposure and the required monitoring and quarantine restrictions. A COVID-19 Resident Contact Tracing Tool and Contact Tracing Location Tracker were attached to the policy. Also attached to the policy was a COVID-19 Resident Contact Tracing Tool which was not utilized by the IP to determine potential exposures that may have occurred at the facility. A review of the facility policy, CDC Guidance-New Infection in Healthcare Personnel or Resident (Revised 09/24/22) revealed the following: The facility will review and implement recommendations by the CDC. Regulatory guidance and/or directives provided by the State and or CMS (Centers for Medicare and Medicaid Services) may supersede the CDC recommendations. A single new case of SARS-CoV-2 infection in any healthcare personnel (HCP) or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad based approach; however, a broad-based (e.g., unit, floor, or other specific areas of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (one) (where day of exposure is day 0), day 3 (three) and day 5 (five). NJAC 8:39-19.4 (a)(d)(f)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility documents, it was determined that the facility failed to maintain a clean/homelike and sanitary environment for the residents. This deficient practice was identified on 1 of 2 nursing units and was evidenced by the following: During the initial tour of the 2nd floor unit on 05/22/23 from 10:06 AM to 01:35 PM, the following was observed by the surveyors: 1. In room [ROOM NUMBER] (double occupancy room): -the wall behind A bed (bed closest to the door) had multiple areas of white substance with multiple open holes and scrape marks -the wall on the opposite side of the room had multiple areas of white substance with multiple open scrapes 2. In room [ROOM NUMBER] (listed as a private room): -the wall behind A bed had multiple areas of white substance with multiple open holes and scrape marks -the same wall as A bed (beyond the bed headboard) but in an open area above the electrical outlet there were multiple areas of white substance with multiple open holes and black scrape marks 3. In room [ROOM NUMBER] (listed as a private room): -the wall to the right side behind the recliner had multiple areas of a white substance with multiple scrape marks -the same wall behind the occupied B bed there were multiple areas of white substance with multiple open holes and scrape marks 4. In room [ROOM NUMBER] (listed as a private room): -the wall to the right side, open space, there were multiple open holes and scrape marks On 05/22/23 at 01:24 PM, during an interview with the surveyors, when asked if the room was a homelike environment, Resident #248 stated not like my home, the room is not appealing. On 05/31/23 at 10:54 AM, during an interview with the surveyors, CNA#3 stated if a room needed maintenance, she would tell the unit clerk, who called the maintenance department to fix it. CNA#3 stated her assignment was room [ROOM NUMBER] to 230 and she did not notice anything that needed maintenance. On 05/31/23 at 11:01 AM, during an interview with the surveyors, the Unit Clerk (UC) stated if something needs to be fixed, staff tells her and she fills out an order form for plant services, and placed it sideways in the maintenance bin. She then would call the operator for maintenance and let them know what needed to be fixed. She then stated maintenance usually fixed things right away. On 05/31/23 at 11:04 AM, during an interview with the surveyors, the 2 floor Unit Manager (UM) stated she addressed concerns or complaints every day. She stated she would call maintenance or fill out a work order if something needed to be repaired. The UM accompanied the surveyors to room [ROOM NUMBER]. She stated she should have noticed the plaster work before the patients were brought into the room. She then stated the resident should probably be moved to another room until the work was done. The UM then accompanied the surveyors to room [ROOM NUMBER] and 228. She stated I should have noticed the holes and let maintenance know before a new admission came in. The UM then stated, as far as I know, no request had been made to environmental services. The UM stated that the purpose of maintaining the walls in the room was to maintain a holistic, safe, and clean environment. She stated she would expect her staff to report the holes and scrapes on the walls to maintenance. On 05/31/23 at 11:27 AM, during an interview with the surveyors, the Division Director (DD) stated that they do daily rounds checking on rooms for discharges and admissions, which included disinfections and electronics maintenance. He stated monthly rounds of the facility are done with the administrator checking the floors for cleanliness. The DD accompanied the surveyors to room [ROOM NUMBER], 224, 227 and 228. He stated that it was not OK to have resident's walls look that way. While in room [ROOM NUMBER], Resident #250 asked the DD if the room was going to be repaired and painted. On 05/31/23 at 11:49 AM, during an interview with the surveyors and in the presence the DD, the Facility Director (FD) stated that they do daily rounds every morning checking to make sure everything is working and that work orders from the night before were completed. On 05/31/23 at 11:53 AM, the surveyors, the DD and the FD toured rooms 222, 224, 227, and 228. The FD identified the white substance on the walls as spackle but could not tell the surveyors when the spackling had been completed. The FD acknowledged the walls with the white substance, holes and scrape marks in all the rooms mentioeds above. He the stated that it was Not OK, it doesn't look like your home. The FD then stated openings in the walls could lead to rodents or bugs coming in. On 05/31/23 at 02:24 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator, the Acting Director of Nursing, and the [NAME] President of Growth and Transition (VPGT), the above findings were presented. The VPGT stated that pests could certainly come in through open holes. A review of the facility's Room Preparedness Checklist revealed under Housekeeping: Walls: dust and clean, if visibly soiled (bed and bathroom). It did not include a check for intact walls. A review of the undated facility policy Maintenance Service revealed: Policy statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 2. a. maintain the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards. i. providing routinely scheduled maintenance service to all areas. NJAC 8:39 - 31.2

**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 a.) maintain the necessary care and services for residents who were receiving oxygen (O2) treatment according to standards of practice and b.) ensure a physician's order was obtained for a resident receiving O2. This deficient practice was identified for two (2) of two (2) residents (R # 146 and R # 145) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 5/24/23 at 12:00 PM, the surveyor observed Resident #146 awake and seated in a wheelchair across from the nurse's station. Oxygen was in use via a nasal cannula (consisting of two hollow prongs projecting from a hollow face piece) at two liters per minute (LPM). The oxygen was attached to a portable oxygen tank attached to the back of the wheelchair. The O2 tubing was undated. On 5/25/23 at 12:18 PM, the surveyor observed the resident awake and seated in a wheelchair inside his/her room with oxygen in use at two LPM via nasal cannula. The oxygen was attached to a portable oxygen tank attached to the back of the wheelchair. The oxygen tubing was undated. The surveyor reviewed the medical record of Resident #146. Review of the admission Record (an admission summary) reflected that the resident was readmitted to the facility on [DATE] with diagnoses which included but was not limited to; respiratory disorder, unspecified and pleural effusion. Review of a handwritten physician's order (PO), dated 5/19/23, for O2 at 2 L/min [liters per minute] via nasal canula. Review of the May 2023, Monthly Treatment [NAME] Continuation record reflected the above corresponding PO. Review of the resident's comprehensive care plan reflected a focus area for requiring supplemental oxygen related to respiratory failure initiated on 5/17/23. The goal was for the resident to remain free of symptoms and complication of low oxygen levels. The interventions reflected to change tubing as per facility protocol dated 5/17/23. 2. On 5/23/23 at 12:00 PM, the surveyor observed Resident #145 awake and seated in a wheelchair inside his/her room. The resident was observed with oxygen in use at 2 LPM via nasal cannula. The oxygen tubing was undated. On 5/24/23 at 12:09 PM, the surveyor observed the resident awake, seated in a wheelchair inside his/her room. Oxygen was in use at 2 LPM via nasal cannula. The oxygen tubing was undated. The surveyor reviewed the medical record of Resident #145. Review of the admission Record reflected that the resident was admitted to the facility on [DATE], with diagnoses which included but was not limited to; acute and chronic respiratory failure with hypoxia, bronchopneumonia, unspecified organism, acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral, and personal history of pneumonia (recurrent). Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/22/23, reflected that the resident had oxygen therapy while a resident. Review of the physician's orders reflected an order dated 5/25/23, for Patient on 2 liters oxygen via nasal cannula continuous for acute hypoxia. There was no documented physician's order for the oxygen until 5/25/23. Review of the May 2023 Treatment Record reflected the above corresponding PO dated 5/25/23. There was no care plan developed or implemented for the oxygen use. On 5/25/23 at 1:11 PM, the surveyor interviewed the 5th floor Registered Nurse who stated that when a patient was admitted a physician's order was obtained along with pulse ox orders and the oxygen tubing was dated and changed once a week. She stated the tubing(s) should have been dated and she could not speak to why they weren't. Review of the facility's undated Oxygen Administration policy provided by the Licensed Nursing Home Administrator (LNHA) included to verify that there is a physician's order for this procedure. The policy did not include procedure(s) regarding the frequency of changing or replacing the oxygen tubing. On 6/1/23 at 2:01 PM, the surveyor discussed the above observations and findings with the administrative staff. On 6/2/23 at 1:32 PM, the Director of Nursing (DON) stated that she spoke with the Unit Manager of the 5th floor who stated she observed the resident wearing oxygen but did not have a physician's order, so she obtained and wrote an order for the oxygen on 5/23/23. NJAC 8:39-11.2(e)(1)(2)

Based on observation, interview, and record review, it was determined that the facility failed to properly secure medications in 1 (one) of 2 (two) emergency crash carts inspected. This deficient practice was evidenced by the following: On 5/31/23 at 11:30 AM, the surveyor inspected the 2nd-floor emergency crash cart that contained the facility's Emergency-Kit (E-Kit) in the presence of a Licensed Practical Nurse/Unit Manager (LPN/UM#1). The surveyor observed the crash cart which was covered and secured by Velcro straps. The surveyor observed LPN/UM #1 remove the covering and then move a handle on the top portion of the crash cart from the locked to unlocked position. The surveyor then observed LPN/UM#1 open each drawer of the crash cart and the surveyor observed the third drawer contained syringes and the 4th drawer contained a E-Kit box that contained 14 medications. The surveyor inspected the E-Kit box that contained the following medications: 1. Albuterol 0.083% nebulizer solution (5 nebulizers) 2. Aspirin 81 mg chewable tablets (4 tablets) 3. BD POSIFLUSH INJ 0.9% (two) 4. Dextrose 50% injection (two) 5. Diazepam 5mg/ml injection (two) 6. Diphenhydramine injection 50 mg (two) 7. Epinephrine 0.3 injection (two) 8. Furosemide Injection (three) 9. Glucagon Kit 1 mg (one) 10. Glucose-15 40% gel (three) 11. Naloxone injection 0.4 (two) 12. Nitro-Bid ointment 2 % (three) 13. Nitroglycerin 0.4 mg sublingual tablets (one bottle of 25 tablets) 14. Solu-Cortef (two). The surveyor inspected the contents of the E-Kit in the presence of LPN/UM#1 and observed no missing medication and everything was accounted for inside the E-Kit. At that time, the surveyor interviewed LPN/UM#1, who acknowledge that the handle on the crash cart was not a secure lock. She acknowledged that there was nothing stopping anyone from moving the handle from the locked to the unlocked position. She showed the surveyor red-tied locks that were inside the crash cart. She stated that after the nurses do their daily checks of the crash cart, they are required to sign off that the cart was checked and make sure that the crash cart is secured with two tied locks. LPN/UM#1 acknowledge that whoever checked this crash cart did not properly secure it with the red-tied locks. On 6/1/23 at 1:30 PM, the surveyor discussed the above observations and findings with the Administrative team which included the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA), and the Regional [NAME] President. There was no additional information provided. A review of the facility's policy for Storage of Medications that were undated and provided by the LNHA included that compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended NJAC: 8:39-29.4 (a) (h) (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and other pertinent facility documentation, it was determined that the facility failed to maintain proper infection control practices by ensuring a.) appropriate personal protective equipment (PPE) was worn in a room where a resident was on contact precautions (contact precautions are intended to prevent transmission of infectious agents and microorganisms, which are spread by direct or indirect contact with the patient), this was identified on one (1) of two (2) units, b.) housekeeping staff wear gloves appropriately on 1 of 2 units, c.) disposable PPE was appropriately contained in rooms where residents were identified as COVID - 19 positive, this was identified for two (2) of three (3) rooms on the fifth floor unit, and d.) one (1) of (1) resident (Resident #196) identified as exposed to COVID-19 positive nurse staff member was tested in accordance to Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was evidenced as follows: 1.On 5/22/23 at 10:02 AM, the surveyor started the initial tour on the fifth-floor unit. The surveyor interviewed the LPN/Unit Manager (LPN/UM) who stated that there was one resident who was on transmission-based precautions (TBP) [infection control precautions in healthcare] which was Resident #35. She stated that the resident had a wound with Methicillin-resistant Staphylococcus aureus (MRSA) [which is a group of gram-positive bacteria that are genetically distinct from other strains of Staphylococcus aureus. MRSA is responsible for several difficult-to-treat infections in humans]. At that same time, the surveyor observed the resident's room. There was a stop sign posted and a sign which identified that the resident in the room was under transmission-based precautions. The surveyor also observed a PPE bin outside the resident's room that contained PPE and hand sanitizer. On 5/23/23 at 10:45 AM, the surveyor observed Resident #35's room with a sign posted which identified the resident was on contact precaution and there was a bin at the door with disposable gowns and gloves available as well as disinfectant wipes and antibacterial hand rub (ABHR). On 5/24/23 at 12:52 PM, two surveyors observed Resident #35's room with a sign posted which identified the resident was on contact precaution and there was a bin at the door with disposable gowns and gloves available as well as disinfectant wipes and antibacterial hand rub (ABHR). The surveyors observed a staff member enter the residents room wearing a surgical mask and did not apply a gown or gloves prior to entering the room. She exited the room and walked across the hall to a handwashing sink and washed her hands appropriately. At that time, the surveyor interviewed the LPN in the presence of the second surveyor. The LPN acknowledged that the resident was on contact precautions and stated that she did not need to apply PPE because she was not in direct contact with the resident and that she only asked if he/she finished lunch. The LPN further stated that she started working at the facility on 2/27/23 and had not received infection control training. She stated that she did not have to wear a gown and glove and that I got that from my own knowledge. On 5/31/23 at 12:42 PM, the surveyor interviewed the Infection Preventionist Nurse (IPN) #1 and the IPN #2 in the presence of the survey team and the [NAME] President of Growth and Transitions (VP). IPN #2 stated that she was assisting in the transition of IPN #1. IPN #1 stated that there were isolation carts outside of TBP rooms that contained gowns, gloves, surgical masks, N95 masks and face shields. She stated that PPE was required to be worn when entering a room identified as TBP. IPN #1 stated that she conducted infection control rounds on the units to ensure staff were following the proper protocols and procedures and provided reminders and on the spot education if needed. She stated that the facility followed CDC guidelines. On 5/31/23 at 1:20 PM, the survey team reviewed the above noted concern with the administrative team. On 6/02/23 at 2:33 PM, the survey team met with the facility's administrative team and no additional info was provided. Review of the facility policy Isolation - Categories of Transmission-Based Precautions with a revised date of 9/2022, included Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection. It also included, Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. It further included Contact precautions are also used in situations when a resident is experiencing wound drainage or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission. In addition, it included that staff and visitors should wear disposable gowns and gloves before entering the room. 2. On 5/23/23 at 11:54 AM, the surveyor observed two housekeepers on the fifth-floor unit walking in the corridor wearing gloves. Housekeeper (HSK) #1 was pushing a housekeeping cart. The surveyor observed HSK #1 and HSK #2 enter a resident's room wearing the same gloves. The surveyor then observed HSK #1 exit the residents room wearing the same gloves and touch items on the housekeeping cart. HSK #1 acknowledged that she wore gloves in the hallway, stated that she was not supposed to. She stated that she received infection control training that spoke to the proper use of gloves. On 5/25/23 at 10:31 AM, the surveyor observed HSK #1 wearing gloves while sweeping a hallway on the fifth-floor unit. HSK #1 removed gloves immediately when she saw the surveyor. Upon interview, she again stated that she had infection control training and that she should not wear gloves in the hallway. On 5/31/23 at 12:42 PM, the surveyor interviewed the IPN #1 and the IPN #2 in the presence of the survey team and the VP. IPN #2 stated that she was assisting in the transition of IPN #1. The surveyor requested the facility policy's related to proper glove use. On 5/31/23 at 1:20 PM, the survey team reviewed the above noted concern with the administrative team. On 6/02/23 at 2:33 PM, the survey team met with the facility's administrative team and no additional info was provided. 3. On 5/30/23 at 10:41 AM, the survey team met with IPN #1 who stated that a resident who resided in room [ROOM NUMBER] became COVID-19 positive yesterday on 5/29/23. She stated that the resident did not have a roommate but would be moved to the designated COVID-19 positive area (the end of the fifth-floor unit hallway) in room [ROOM NUMBER]P. On 5/30/23 at 12:34 PM, the surveyor interviewed the LPN/UM in the presence of a second surveyor. She stated that the residents in room [ROOM NUMBER]P and 529 P were COVID-19 positive. In addition, she stated that the resident in room [ROOM NUMBER] (no roommate) became COVID-19 positive and would be moved to room [ROOM NUMBER]. At this same time, the surveyor observed room [ROOM NUMBER]P and 529P. The surveyor observed a small beige open garbage receptacle with no lid or means of containment overflowing with blue disposable PPE in both rooms. On 5/30/23 at 12:41 PM, the surveyor interviewed the LPN/UM in the presence of a second surveyor. She acknowledged that there were open garbage receptacles in the rooms and stated that it had always been that way. She further stated that in other facilities, she had seen garbage receptacles with lids to cover for soiled PPE in TBP rooms. The LPN/UM stated that the purpose of keeping the soiled PPE covered was to prevent cross contamination. On 5/31/23 at 12:42 PM, the surveyor interviewed the IPN #1 and the IPN #2 in the presence of the survey team and the VP. IPN #2 stated that she was assisting in the transition of IPN #1. IPN #1 and IPN #2 stated that all trash is disposed of in open garbage receptacles and that there was no dedicated garbage for soiled PPE in COVID-19 positive rooms. They further stated that they follow CDC guidelines. On 5/31/23 at 1:20 PM, the survey team reviewed the above noted concern with the administrative team. On 6/02/23 at 2:33 PM, the survey team met with the facility's administrative team and no additional info was provided. 4. On 5/22/23 at 11:30 AM, the surveyor observed Resident #196 in his/her room. The resident offered no concerns. Medical Record Review: Review of the admission Record (an admission summary) reflected that the resident had diagnoses that included but were not limited to stomach cancer, moderate protein-calorie malnutrition, and muscle wasting. Review of the admission Minimum Data Set (MDS), a tool used to facilitate the plan of care, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which reflected an intact cognition. Review of the Progress Notes dated 5/23/23 at 12:54 PM and written by IPN #1, included Patient exposed to a positive staff member who had more than 15-minute contact time with patient. Patient tested for Covid today and is negative. Will test again in 48 hours and another 48 hours and instructed patient to wear a mask . Review of the undated Treatment Record included that Resident #196 tested negative for COVID-19 on 5/23/23, 5/25/23 and 5/27/23. On 5/30/23 at 12:34 PM, the surveyor interviewed IPN #1 who stated that anyone who was in close contact which would be 15 minutes or more with a staff member that was COVID-19 positive would be tested 24 hours after exposure, if negative again in 48 hours, and if negative then they are tested again after an additional 48 hours. On 5/31/23 at 12:42 PM, the surveyor interviewed IPN #1 and IPN #2 in the presence of the survey team and the [NAME] President of Growth and Transitions (VP). IPN #1 stated that she could not speak to whether or not Resident #196 was immunosuppressed and if the resident had been exposed to COVID-19. They stated that the facility followed CDC guidelines. On 6/1/23 at 1:45 PM, during a follow-up interview with IPN #1 in the presence of the survey team and the VP. IPN #1 stated that Resident #196 was identified as exposed to a COVID-19 positive nursing staff member on 5/19/23 not on 5/23/23. She further stated that the resident should have been tested on [DATE]. She further stated, I missed [him/her], that's why there was a delay. Review of the undated facility's Outbreak Response Plan included that staff and residents were tested for COVID-19 in accordance with current state and federal guidance and CDC recommendations. NJAC - 8:39-5.1(a), 19.4(a)2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 5/22/23 at 11:10 AM, during the initial tour, the surveyors observed a staff member enter the room of Resident #244, who was sitting in a wheelchair wearing a hospital gown. The resident's Power of Attorney (POA) and a friend were in the room. The staff member asked the resident why they were not dressed, Resident #244 stated because his/her clothes had not been washed. At that time, the staff member transported Resident #244, in the wheelchair, out of the room. During an interview, at that time, with the surveyors, Resident #244's POA stated they took the resident to physical therapy wearing a hospital gown. The POA stated that the resident had not had a shower until today, which was the first time since the resident was admitted . She stated the resident uses the call bell but has to wait a long time and usually loses control of bowel or bladder before the staff gets there so the residents goes through a lot of clothes. The POA stated she was unable to do the resident's laundry because she does not live nearby. She stated that she spoke to the Case Manager (CM) last Tuesday and made her aware. The POA stated that the CM was supposed to make sure the resident's clothes were washed but today there were bags of soiled clothes. She stated she had already complained to the staff at desk and they said the laundry would be done. On 05/22/23 at 01:02 PM, during a follow up interview, Resident #244 stated I have to use my call bell because I need help with the bathroom, but it takes so long for them to come and I cannot hold it, so I have an accident. The surveyor reviewed the medical record for Resident #244. A review of the admission Record (an admission summary) for Resident #244 revealed the resident was admitted to the facility in May of 2023 with a diagnosis which included but were not limited to; Chronic Heart Failure (CHF), (the heart doesn't pump blood as well as it should) Muscle wasting and atrophy (loss of muscle mass), and Difficulty in walking. A review of the Care Plan for Resident #244 revealed a Focus, dated 05/08/23: I have an ADL (activities of daily living) Self Care Performance Deficit r/t generalized weakness with an Intervention, dated 05/08/23, Encourage me to use call bell for assistance. Monitor/record/report PRN changes in ADL ability, potential for improvement, and /or inability to perform ADLs. Encourage me to participate in ADLs to the fullest extent possible. A review of the Inpatient Physician Order Sheet Sub-Acute revealed Treatments: a check placed on the line next to Shower Patient, signed by the physician on 05/08/23 at 5:10 PM. A review of the Shower Schedule for Subacute located in the Certified Nursing Assistant (CNA) assignment book, revealed Resident #244 should receive a shower on Saturdays, 3 to 11 PM shift. A review of Progress Notes *NEW* from 05/08/23 to 06/01/23, for Resident #244, did not reveal a note that the resident refused to be showered. A review of the facility provided POC Response History, Did the resident receive a Shower or Bed Bath? for Resident #244 from 05/08/23 to 05/31/23 revealed that the resident was given a bed bath every day except for 05/27/23 at 9:56 PM, in which, the resident received a shower. On 05/22/23 at 01:25 PM, the surveyor observed the resident's POA at the nurse's station being handed five (5) clear bags of the resident's clean clothes. On 05/23/23 at 10:39 AM, the surveyor observed the POA getting on the elevator, who stated she brought additional clothes today. On 5/25/23 at 10:45 AM, a surveyor conducted a resident council meeting with five (5) alert and oriented residents. The surveyor asked if they were receiving showers when scheduled or do you have to ask to get a shower? 3 of 5 residents stated that they do not get showers. On 05/25/23 at 10:46 AM, during an interview with the surveyor, CNA#4 stated that her assignment today was rooms 222 to 230, which included Resident #244. She stated that she did not have any showers in her assignment today but there was a shower list at the nurse's station. CNA #4 stated if they (residents) want a shower and I can fit it in, I will do it. She stated that the families usually laundered the resident's clothes and as far as I know, no one here gets their laundry done by the facility. She stated that there was a washer and dryer on the unit. On 05/31/23 at 10:54 AM, during an interview with the surveyors, CNA #3 stated that resident's dirty clothes were placed in a clear plastic bag and put in the resident's cabinet for the families to take home and launder. She stated that Resident #244 was in her assignment today and she thinks that their clothes needed to be laundered by the facility. CNA#3 stated that the 3 PM to 11 PM CNA would be responsible to do the laundry. On 05/31/23 at 11:35 AM, during an interview with the surveyors, the Director of Social Services/Case Manager (DSS/CM) stated she did meet with Resident #244 and that the POA made her aware that the resident's clothes needed to be laundered by the facility. She stated she made nursing aware of the request. The DSS/CM stated she usually would follow up to make sure the requests were done. She stated she did not have supporting documentation of the requests or the follow up. She then stated that it was not acceptable that the resident did not have clean clothes. On 05/31/23 at 12:00 PM, during an interview with the surveyors, the 2nd floor Licensed Practical Nurse/Unit Manager (LPN/UM) stated that we do not do laundry, the families are supposed to but if no one can do the laundry, we have a washer and dryer on the unit. She stated that the 3 PM to 11 PM CNA would do the laundry twice a week. She also stated that they did not keep clothes washing logs/records. The surveyor made the LPN/UM aware of the above concerns and she stated, as far as I knew the laundry was being done. A review of the undated facility's policy, Laundry Charges/Pick Up, revealed Policy Interpretation and Implementation: 1. Resident's personal laundry will be laundered by our facility at no cost. However, each resident/representative may choose whether or not he/she wishes this service. 3.Sufficient clothing must be maintained on premises to keep the resident clean and dry at all times. 4. Should the resident's representative not pick the laundry up, or not return adequate articles to keep the resident in clean clothes, our facility will launder such articles as outlined in the resident contract. A review of the undated facility's policy, Bathing and Showering, revealed Policy Statement: the facility will offer showers and tub baths to residents in accordance with their preferences. Policy Interpretation and Implementation: 1. The facility will offer showers and tub baths to residents at least weekly. 2. The facility will make reasonable efforts to provide more frequent showers or tub baths as requested. 3. Residents may be provided with either a shower or a tub bath as per their preference. 4. Provision and refusals of showers and/or tub baths will be documented in the medical record by the certified nursing assistant and/or licensed nurse. NJAC 8:39-4.1(a)3 Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a) ensure that meals were consistently delivered on time as per resident's preferences for seven (7) of 21 residents (Resident #5, #18, #147, #199, #202, #203 and #204) which represented two (2) of two (2) units reviewed for mealtime preferences and b) make reasonable accommodation of needs and preferences for 1 of 21 residents reviewed, (Resident #244). This deficient practice was evidenced as follows: 1.On 5/23/23 at 10:10 AM, a resident council meeting was conducted with five residents. Five out of five residents stated that the meals were not delivered on time and were consistently late. On 5/23/23 at 12:00 PM, the surveyor observed Resident #147 seated in a wheelchair in his/her room and was agreeable to be interviewed. During the interview at 12:15 PM, the Certified Nurse's Aide (CNA) #1 brought the resident his/her lunch tray. The resident stated that he/she had been at the facility since April. The resident stated that the tray should have arrived by 12 PM. The resident then stated that breakfast had been up to 20 minutes late almost daily since he/she had been here, and it has affected therapy appointments. On 5/24/23 at 11:35 AM, the surveyor observed Resident #18 in his/her room in a wheelchair with the overbed table awaiting the lunch meal. The resident stated that food services were spotty and that meals were typically late. On 5/24/23 at 12:20 PM, the surveyor interviewed Resident #147, in the presence of a second surveyor, during lunch. The resident stated that meals were served at least 20 minutes late and that . there has been improvement in the last two (2) days, and further stated that someone must have told them. Medical Record Review: Resident #5 Review of the admission Record (an admission summary) included that the resident was admitted with diagnoses that included but were not limited to; chronic kidney disease and nutritional anemia. Review of the admission Minimum Data Set (MDS) dated [DATE], a tool used to facilitate the management of care, which reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected that the resident had an intact cognition. Resident #18 Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; hypertension and gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of the admission MDS dated [DATE], included that the resident had a BIMS score of 15 out of 15, which reflected that the resident had an intact cognition. Resident #147 Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; hypertension, heart failure and gastro-esophageal reflux disease. Review of the admission MDS dated [DATE], included that the resident had a BIMS score of 15 out of 15, which reflected that the resident had an intact cognition. Resident #199 Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; hypothyroidism (a condition that can slow down the metabolism and contribute to fatigue and unexplained weight gain) and gastro-esophageal reflux disease. Review of the Medicare -5-day MDS dated [DATE], included that the resident had a BIMS score of 15 out of 15, which reflected that the resident had an intact cognition. Resident #202 Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to, diabetes and congestive heart failure. Review of the admission MDS dated [DATE], included that the resident had a BIMS score of 15 out of 15, which reflected that the resident had an intact cognition. Resident #203 Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; muscle wasting and Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors). Review of the admission MDS dated [DATE], included that the resident had a BIMS score of 14 out of 15, which reflected that the resident had an intact cognition. Resident #204 Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; diabetes and muscle wasting. Review of the admission MDS dated [DATE], included that the resident had a BIMS score of 14 out of 15, which reflected that the resident had an intact cognition. On 5/24/23 at 12:15 PM, the surveyor observed CNA #1 delivering lunch trays. She stated that breakfast and lunch meals were frequently late, sometimes by 20 minutes. On 5/31/23 at 10:25 AM, the surveyor interviewed the Food Service Director (FSD). He stated that when meals were delivered, they have a schedule to follow, and this was tracked to ensure meals were delivered on time. He stated the form was an accountability method and showed the form to the surveyor who requested copies from 4/1/23 through present. On 5/31/23 at 11:03 AM, the surveyor interviewed the Registered Dietitian (RD) and the Regional RD. Both stated that they had not heard of meals being delivered late and that there was a schedule to follow which should have been posted. On 6/02/23 at 10:39 AM, the surveyor interviewed the FSD in presence of the survey team. The FSD stated that the purpose of the meal delivery schedule was keep a time log of when food left the kitchen. He stated that the form being used did not indicate the time the food was supposed to arrive onto the units. He stated that he was working with the unit coordinators to ensure that trays were passed out timely since he identified that when food trucks were being dropped off to the units, there was a delay in meal tray delivery by nursing. The FSD stated that the previous meal delivery schedule was unrealistic, so he changed the mealtimes. He provided the surveyor with the meal delivery forms for April and May 2023 and acknowledged there were omissions in accountability. He stated that he was responsible to ensure that meals were delivered on time. In addition, he stated that a Quality Assurance Performance Improvement (QAPI) plan was initiated on 5/11/23 to address this concern (he provided a copy to the surveyor). The FSD was unable to state why the QAPI was dated 5/11/23 when a delay in meal delivery was identified as early as 4/4/23. He also could not speak to or provide accountability that units were notified about late meal delivery by the kitchen as per instructed on the meal delivery form. He stated on the days the meal deliveries were late that foods may not have been prepared on time or it could have been related to other issues and could not speak to specifics. Despite the fact that the FSD stated he felt the new system was working, he could not speak to why there was still inconsistent mealtime deliveries after the QAPI was implemented. On 6/02/23 at 11:50 AM, the surveyor interviewed CNA #1 who stated the meal delivery schedule was not posted on the unit and that food services did not call if the meal was late. She further stated that we just know lunch was supposed to come around 12 noon. On 6/02/23 at 12:00 PM, the surveyor interviewed the Licensed Practical Nurse/ Unit Manager (LPN/UM) who stated that the meal delivery schedule was not provided by food services and it was not posted on the unit. She stated that sometimes they would call when a meal was 30 minutes late or more. The RN/UM could not speak to how often this occurred and stated, but it does happen. On 6/2/23 at 12:17 PM, the lunch trays arrived on the fifth floor. CNA #2 and a Licensed Practical Nurse (LPN) acknowledged the arrival time. On 6/02/23 at 1:10 PM, the [NAME] President of Growth and Transitions (VP) in the presence of the Licensed Nursing Home Administrator (LNHA), the Acting DON and the survey team, stated that she was aware that the food service department was conducting their own QAPI plan. On 6/02/23 at 2:33 PM, the surveyor met with the facility's administrative team and no additional information was provided. Review of the Food Truck Time Sheet - [NAME] Campus dated 6/2/23, reflected that the lunch food trucks for rooms 501-530 was scheduled for 12:00 PM, left the kitchen at 12:08 PM and reached the unit at 12:13 PM. Review of the 56 Food Truck Delivery Schedules from 4/4/23 through 5/30/23 provided by the FSD on 5/31/23 at 2:00 PM reflected that 54 out of 56 were not filled out consistently, and there were no Food Truck Delivery Schedules provided for 4/7/23 and 4/13/23. The Food Truck Time Sheet - [NAME] Campus with a revised date of 5/2023, was implemented on 5/23/23 and included an area to record the time the food truck arrived to the unit. Random review of these forms included the following: On 5/23/23, for dinner: -the food trucks for rooms 205-230 was scheduled for 4:15 PM, left the kitchen at 4:30 PM and reached the unit at 4:34 PM -the food trucks for rooms 501-530 was scheduled for 5:15 PM, and there were no times recorded for what time the food trucks left the kitchen or reached the unit. On 5/24/23, for dinner: - the food trucks for rooms 205-230 was scheduled for 4:15 PM, left the kitchen at 4:30 PM and reached the unit at 4:33 PM - the food trucks for rooms 501-530 was scheduled for 5:15 PM, and there were no times recorded for what time the food truck left the kitchen or reached the unit. On 5/25/23, for dinner: - the food trucks for rooms 205-230 was scheduled for 4:15 PM, left the kitchen at 4:26 PM and reached the unit at 4:28 PM - the food trucks for rooms 501-530 was scheduled for 5:15 PM, and there were no times recorded for what time the food truck left the kitchen or reached the unit. On 5/26/23, the breakfast food trucks for rooms 205-230 was scheduled for 7:05 AM, left the kitchen at 7:25 AM and reached the unit at 7:28 AM. The lunch food trucks for rooms 205-230 was scheduled for 11:15 AM, left the kitchen at 11:40 AM and reached the unit at 11:44 AM. The dinner food trucks for rooms 501-530 was scheduled for 5:15 PM, left the kitchen at 5:37 PM and reached the unit at 5:42 PM. On 5/27/23, the breakfast food trucks for rooms 205-230 was scheduled for 7:05 AM, left the kitchen at 7:30 AM and reached the unit at 7:32 AM. The lunch food trucks for rooms 205-230 was scheduled for 11:15 AM, left the kitchen at 11:30 AM and reached the unit at 11:35 AM. The dinner food trucks for rooms 501-530 was scheduled for 5:15 PM, and there were no times recorded for what time the food truck left the kitchen or reached the unit. On 5/28/23, the dinner food trucks for rooms 501-530 was scheduled for 5:15 PM, left the kitchen at 5:30 PM and reached the unit at 5:35 PM. On 5/29/23, the breakfast food trucks for rooms 501-530 was scheduled for 8:05 AM, left the kitchen at 7:43 AM and reached the unit at 8:45 AM. There were no times recorded for the times the food trucks left the kitchen or arrived to the unit for the dinner meal for rooms 205-230 and 501-530. On 5/30/23 the breakfast food trucks for rooms 205-230 was scheduled for 7:05 AM, left the kitchen at 7:30 AM and reached the unit at 7:35 AM. Review of the Quality Assurance Performance Improvement (QAPI) Plan for the [NAME] Campus Kitchen Operations dated 5/11/23 and provided by the FSD on 5/31/23 at 2:00 PM included that Dietary operations to function properly in accordance with local, state, and federal regulations. In addition, a concern identified was Food trucks not arriving to unit on time. Notes on the QAPI plan included Food items need to be prepared in a timely fashion. Revised truck times to reflect current operations. Review of the undated facility policy Food and Nutrition Services, included Reasonable efforts will be made to accommodate resident's choices and preferences. In addition, it included Meals are scheduled at regular times . and Meal times are posted in facility common areas. Review of the undated facility policy Resident Self Determination and Participation, included Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. In addition, it included that each resident was allowed to choose his/her daily routine including eating schedules. Review of the undated facility policy Resident Rights included that a resident has a right to self-determination. Review of the facility's Food Service Director job description included Monitor food services to assure that all residents food services needs are being met. Review of the facility's Dining Supervisor job description included to ensure that all meals were prepared and served on time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** i. On 05/25/23 at 11:03 AM, the surveyor reviewed the medical record for Resident #248 which revealed the following: A review of the MARs for May 2023 POS revealed 12 medications that were prescribed for routine use that did not contain a corresponding medical indication and were transcribed to the May 2023 MAR as listed: 1. Xanax 0.25 mg (milligram) PO (by mouth) q (every) HS (hour of sleep) 2. Lipitor 20 mg PO q HS 3. Coreg 12.5 mg PO q 12 hrs (hours) 4. Cymbalta 30 mg PO q 12 hrs 5. Ergocalciferol (Vit D2) 1.25 mg PO q Monday 6. Levothyroxine 88 mcg (micrograms) PO daily 7. Mirapex 0.5 mg PO q HS 8. Zoloft 50 mg PO daily 9. Triamcinolone 0.1% topically BID (two times a day) 10. Zyrtec 10 mg PO HS 11. Celebrex 200 mg PO BID X 7 days 12. Celebrex 100 mg PO BID start 5/31/23 j. On 05/25/23 at 01:30 PM, the surveyor reviewed the medical record for Resident #249 which revealed the following: A review of the MARs for May 2023 POSs revealed 8 medications that were prescribed for routine use that did not contain a corresponding medical indication and were transcribed to the May 2023 MAR as listed: 1. Enalapril 5 mg PO 2q 12 hrs 2. Metformin 500 mg PO BID 3. Mirtazapine 7.5 mg PO q HS 4. MVI-Mineral-iron-lutein tab 1 PO daily 5. Nadolol 80 mg PO daily 6. Zocor 10 mg PO q HS 7. Aldactazide 25-25 mg PO q day 8. Nadolol 40 mg PO daily On 05/31/23 at 02:21 PM, during a meeting with the survey team, the [NAME] President of Growth and Transition, the Acting Director of Nursing (ADON), the Licensed Nursing Home Administrator (LNHA) were made aware of the above findings. The ADON acknowledged that a medical indication should be listed on the POS and the MARs. On 6/1/23 at 2:15 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional [NAME] President and discussed the surveyor's concerns. No further information was provided. A review of the facility's policy for Administration Medications and Medication Orders that were undated and provided by DON does not address any of the concerns brought forward in this deficiency. NJAC 8:39-11.2 (b), 29.2 (d) c. On 06/02/23 at 11:05AM, a review of the MARs for Resident #5's May 2023 POS revealed seven (7) medications that were prescribed for routine use that did not contain a corresponding medical indication and were transcribed to the May 2023 MAR as listed: 1. Aspirin low tab 81 mg EC(Ecotrin) give 1 tablet by mouth daily 2. Colchicine tab 0.6 mg give 1 tablet by mouth daily 3. Levothyroxine tab 112 mcg give 1 tablet by mouth daily 4. Pantoprazole tab 40 mg give 1 tablet by mouth daily 5. Oxycodone 10 mg PO @ (at) 8 am and 12 pm 6. Retacrit 40,000 units sq (subcutaneous) X 1 dose today 7. Amoxicillin 1000 mg by mouth BI d. On 06/02/23 at 11:15 AM, a review of the MARs for Resident #18's April and May 2023 POS revealed 12 medications that were prescribed for routine use that did not contain a corresponding medical indication and were transcribed to the May 2023 MAR as listed: 1. Meloxicam 7.5 mg PO q daily 2. Fluticasone 50 mcg/inh 1 inhalation q 12 hours 3. Folic Acid 1 mg PO q day 4. Montelukast 10 mg po q HS 5. Protonix 40 mg PO q daily 6. Prednisone 5 mg PO q day 7. Vit B12 1000 mcg PO daily 8. Vit D3 25 mcg PO a day 9. Lasix 40 mg PO q daily x 3 days, dated 4/15/23 10. Lasix 20 mg PO q daily x 3 days, dated 5/19/23 11. Lasix 40 mg PO BID x 3 days, dated 5/24/23 12. Lasix 40 mg PO q daily, dated 5/24/23 e. On 06/02/23 at 11:40 AM, a review of the MARs for Resident #35's April and May 2023 POS revealed eight (8) medications that were prescribed for routine use that did not contain a corresponding medical indication and were transcribed to the May 2023 MAR as listed: 1. Remeron 30 mg PO q HS 2. Megace 40 mg PO BID 3. Miralax 17 mcg PO daily 4. Atorvastatin 40 mg PO q HS 5. Metoprolol XL 50 mg PO daily 6. MVI 1 PO daily 7. Tamsulosin 0.4mg PO daily 8. Metformin 500 mg PO BID f. On 06/02/23 at 11:00AM, a review of the MARs for Resident #147's May 2023 POS revealed 11 medications that were prescribed for routine use that did not contain a corresponding medical indication and were transcribed to the May 2023 MAR as listed: 1. Amiodarone 200 mg PO daily 2. Lipitor 40 mg PO q HS 3. Bupropion XL 250 MG PO daily 4. Plavix 75 mg PO daily 5. Farxiga 10 mg PO daily 6. Fluticasone 50 mcg PO spray each nostril q AM 7. Lasix 80mg PO q AM 8. Ipratropium 0.06% spray-2 sprays each nostril q HS 9. Lutein plus 20 mg PO daily 10. Primidone 100 mg PO BID 11. Entresto 24-26 q 12 hours NJ00161372 Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards a.) accurately transcribe a physician order, for 1 of 2 residents observed during medication pass (Resident #150), b.) ensure that residents' medications were available for medication administration for 2 of 2 residents observed during medication pass (Resident #149 and Resident #150) and c). ensure that all routine medications on the physician order's sheet (POS), and medication administration record (MAR) had a corresponding medical indication for 10 of 21 residents reviewed (Residents #150, #149, #5, #18, #35, #147,#145, #146, #248 and #249). The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 5/31/22 at 9:30 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN #1) in the room of Resident #150. The surveyor observed LPN #1 checking the resident's identification bracelet and informing Resident #150 that she will be administering the resident's medications. On 5/31/23 at 9:35 AM, during the medication administration observation, the surveyor observed LPN #1 preparing to administer nineteen (19) medications to Resident #150 which included Vitamin D3 250 mcg (micrograms) (a vitamin supplement). The surveyor observed LPN #1 checked her medication cart for Vitamin D3 250 mcg but she was only able to find Vitamin D3 25 mcg. LPN#1 told the surveyor that she was going to hold this medication because she needed to clarify this order with the physician. On 5/31/23 at 11:15 AM, the surveyor interviewed LPN#1 who stated that the physician changed Resident #150's Vitamin D3 from 250 mcg to Vitamin D3 25 mcg. LPN #1 further stated that she didn't know why the order was transcribed as Vitamin D3 250 mcg and that could have been a transcription error. She acknowledges that the other nurses were probably administering Vitamin D 25 mcg since it was the only available Vitamin D3 in the medication cart. The surveyor reviewed the medical record for Resident #150. A review of the admission Record (an admission summary) revealed diagnoses that included but were not limited to; Nondisplaced comminuted fracture of the shaft of the humerus, right arm (break in the lower end of the upper arm), spinal stenosis (a condition that narrows the amount of space in the spine) and anemia (a condition in which the blood doesn't have enough healthy red blood cells). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 5/31/23, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the May 2023 POS reflected a physician's order (PO) with a start date of 5/24/23 for Vitamin D3 250 mcg 1 tablet by mouth once daily. A review of the May 2023 MAR revealed a PO with an order date of 5/24/23 for Vitamin D3 250 mcg given 1 tablet by mouth once daily. The MAR indicated that Vitamin D3 250 mcg was to be administered at 9:00 AM (0900). A review of the MAR revealed that Vitamin D3 250 mcg was documented as being given from 5/25/,5/26, 5/27, 5/28, and 5/30/23. 2) a. On 5/31/23 at 9:05 AM, the surveyor observed LPN #1 preparing to administer nineteen (19) medications to Resident #150 which included Ranitidine 150 mg (medication for the stomach) and Prevagen capsules (supplement for memory). LPN #1 told the surveyor that she was unable to locate these medications inside her medication cart. She told the surveyor that she will need to check the back-up box but she was not sure if Prevagen and Ranitidine would be available. The surveyor observed LPN#1, alerting Resident #150 that some of the resident's medications were unavailable and that she would notify the resident's physician. After the medication pass, the surveyor and LPN#1 reviewed the resident's POS and MAR. After reviewing the MAR, LPN#1 acknowledge that since the resident was admitted to the facility that the resident never received either Ranitidine or Prevagen. LPN#1 pointed out and acknowledge to the surveyor that from 5/25/23 through 5/30/23 the nurses were circling their initials which meant that the medications were not administered. She further stated that the medications were probably never received from the pharmacy and that she would call the pharmacy, to find out what was going on with these two medications. When the surveyor asked LPN #1, what the procedure was when a resident's medication was unavailable. LPN #1 stated that the nurse must inform the physician and then call the pharmacy. She also stated that the nurse must document both of these interactions with the pharmacy and the physician in the progress notes. A review of the May 2023 POS reflected a PO with a start date of 5/24/23 for Prevagen 1 capsule by mouth once daily; Ranitidine 150 mg 1 tablet by mouth once daily. A review of the May 2023 MAR revealed that on 5/25/23, 5/26/23, 5/27/23, 5/28/23, 5/29/23, and 5/30/23 the resident had not been administered either Prevagen capsules or Ranitidine 150 mg tablets. The surveyor looked at the backside of the corresponding MAR and noted one entry from 5/26/23, that indicated that the medication was not available. A review of Resident #150's progress notes from 5/24/23 until 5/30/23 revealed no notes regarding the unavailability of both Ranitidine and Prevagen capsules. There were no notes that the pharmacy was called or any documentation showing that the resident's physician was made aware that Resident #150 was not receiving either Ranitidine 150 mg or Prevagen capsules. On 5/31/23 at 11:10 AM, the surveyor interviewed LPN#1 who stated that the physician called in two new medications for Resident #150. LPN #1 showed the surveyor the two orders and stated that Ranitidine was discontinued by the manufacturer. On 6/1/23 at 12:10 PM, the surveyor interviewed Resident #150's regular nurse, Registered Nurse (RN#1). RN#1 stated that she was aware that both Prevagen and Ranitidine were unavailable and when asked by the surveyor if she documented that these two medications were unavailable, she stated that she can't recall. She stated that she probably documented it on the backside of the MAR. When the surveyor asked RN#1 if she notified the physician that Resident #150's medications were unavailable, she stated that she probably told the physician when she was at the nursing station but acknowledged that she did not document that she spoke with the physician in the progress notes. On 6/1/23 at 12:30 PM, the surveyor interviewed Resident #150 who confirmed that they were not receiving a few of their medications. Resident #150 stated that the nursing staff told them that a few medications were unavailable from the pharmacy and to their knowledge that they never received a replacement. b. On 6/1/23 at 9:05 AM, during the medication administration observation, the surveyor observed RN#2 in the room of Resident#149. The surveyor observed Resident #149 being upset that they did not receive their Brilinta (medication to prevent stroke and other heart problems) the previous day (5/31/23). The surveyor observed RN#2 assuring the resident that their medication was available. On 6/1/23 at 9:10 AM, the surveyor observed RN#2 preparing to administer Brilinta for Resident #150 which consisted of three half-tablets of Brilinta 60 mg equals 90 mg. The surveyor observed RN#2 administered the medication in apple sauce. The surveyor reviewed the medical record for Resident #149. A review of the admission Record revealed diagnoses that included but were not limited to; atrioventricular block (slow heart rate that occurs because of a malfunction with the heart's electrical system), syncope, and collapse (sudden change of blood flow to the brain that could lead to fainting and passing out) and anemia (a condition in which the blood doesn't have enough healthy red blood cells). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 5/23/23, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the May 2023 Physician's Orders sheet (POS) reflected a physician's order (PO) with a start date of 5/22/23 for Brilinta 90 mg tablet given 1 tablet by mouth every 12 hours (9:00 AM and 9:00 PM). A review of the May 2023 MAR revealed that on 5/23/23, 5/24/23, 5/25/23, 5/26/23, 5/27/23,5/28/23, 5/29/23, and 5/30/23 the resident had been administered Brilinta at 9 AM and 9 PM. The surveyor noted that at 9 AM on 5/31/23 that Resident#149 did not receive Brilinta 90 mg. The surveyor reviewed the backside of the corresponding MAR which revealed that the resident's Brilinta was not administered because the medication was unavailable from the pharmacy. On 6/1/23 at 9:15 AM, the surveyor interviewed RN#2 who stated that the resident did not receive Brilinta because the 90 mg tablet was on backorder. She stated that the pharmacy sent Brilinta 60 mg and they were now giving the resident three-half tablets of Brilinta twice daily, the three-half tablets are equal to 90 mg. She stated that the resident only missed one dose. On 6/1/23 at 12:40 PM, the surveyor interviewed the resident who stated that the medication they missed was for their heart. The resident felt that the facility knowing the importance of this medication should have gotten the medication earlier to prevent them from missing a dose. The resident stated that they had been on this medication since being admitted on [DATE] and the facility had ample time to get the medication earlier. On 6/1/23 at 2:15 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional [NAME] President and discussed the surveyor's concerns, in particular the concerns of Resident #149. Resident #149 felt that the facility had the ability and the responsibility to get their medication earlier so they wouldn't have missed a dose. The Regional [NAME] President confirmed that the facility could get medication earlier. 3) a. On 5/31/22 at 9:30 AM, while observing the above-mentioned medication administration with LPN#1 for Resident #150, the surveyor observed the following: A review of Resident #150's May 2023 POS revealed 23 medications that were prescribed for routine use that did not contain a corresponding medical indication and were transcribed to the May 2023 MARs as listed: 1. Ferrous Sulfate 325 mg give 1 tablet po (by mouth) daily 2. Lasix 40 mg give 1 tablet po daily on Monday, Wednesday, and Friday 3. Lasix 40 mg give 2 tablets po daily on Tuesday, Thursday, Saturday, and Sunday 4. Gabapentin 200 mg give 1 capsule po every 8 hours 5. Xalatan 0.005% Instill 1 drop in both eyes at bedtime 6. Mepolizumab 100 mg subcutaneously every 4 weeks 7. Toprol Xl 25 mg give1 tablet po daily 8. Nurtec 75 mg give 1 tablet po every other day 9. Nystatin 5 (milliliters) ml swish and swallow three times daily 10. Senakot S give 2 tablets po at bedtime 11. Ecotrin 81 mg give 1 tablet po daily 12. Bupropion XL 150 mg give 1 tablet po daily 13. Calcitriol 0.25 mcg give 1 capsule po daily 14. Cyanocobalamin 1000 mcg give 1 tablet po daily 15. Cholestyramine 4-gram powder once daily 16. Protonix 40 mg give 1 tablet po twice daily 17. Febuxostat 40 mg give 1 tablet po daily. 18. Zoloft 25 mg give 1 tablet po daily 19. Crestor 10 mg give1 tablet po daily 20. Aldactone 25 mg give 1 tablet po daily 21. Trelegy inhale 1 puff daily 22. Vitamin D3 give 1 tablet po daily 23. Mucinex 600 mg give 1 tablet po twice daily On 5/31/23 at 10:00 AM, the surveyor and LPN#1 reviewed Resident #150's POS and MAR. The surveyor asked LPN#1 if anything was missing in the POSs and MARs and she stated that they were no medical indications for all the routine medications. LPN#1 stated that having the medical indication could help avoid any confusion especially since a lot of medications have multiple uses. On 6/1/23 at 12:15 PM, the surveyor interviewed RN#1 regarding routine medications not having medical indications on the POS, and MARs. RN#1 stated that having the medical indication could be useful and helpful. On 6/1/23 at 9:05 AM, during the above medication administration observation with RN#2 for Resident #149, the surveyor observed the following: b. A review of Resident #149's May 2023 POS revealed that the resident had 17 medications that were prescribed for routine use that did not contain a corresponding medical indication and were transcribed to the May 2023 MARs as listed: 1. Aspirin low-dose tablet 81 mg 1 tablet by mouth daily 2. Dymista 1 spray in both nostrils two times daily 3. Brilinta 90mg give 1 tablet by mouth every 12 hours 4. Cosopt eye drops Instill 1 drop in each eye two times daily 5. Ferrous Sulfate 325 mg 1 tablet by mouth two times daily 6. Finasteride 5 mg 1 tablet by mouth daily 7. Advair Inhaler 1 puff by mouth every 12 hours 8. Hydrocortisone 10 mg give 1 tablet by mouth in the morning 9. Hydrocortisone 5 mg 1 tablet by mouth at 4 PM 10. Levothyroxine 100 mcg give 1 tablet by mouth in the morning 11. Midodrine 2.5 mg give 3 tablets by mouth three times daily 12. Singulair 10 mg give 1 tablet by mouth in the morning 13. Crestor 5 mg give 1 tablet by mouth at bedtime 14. Spiriva inhale the contents of one capsule by mouth daily 15 .Senakot-S give 1 tablet by mouth at bedtime 16. Flomax 0.4 mg give 1 capsule by the mouth at bedtime 17. Travatan Z instill 1 drop in each eye at bedtime. On 6/1/23 at 9:20 AM, the surveyor and RN#2 reviewed Resident's #149 POSs and MARs. The surveyor asked RN#2 what was missing on both the physician's orders and the MAR. RN#2 stated that they were no medical indications for any of the routine medications. She further stated that it's important to have the medical indication because some medications had multiple indications. g. On 5/23/23, the surveyor reviewed the medical record for Resident #145 which revealed the following: A review of the MARs for May 2023 and POS revealed (9) nine medications that were prescribed for routine use that did not contain a corresponding medical indication and were transcribed to the May 2023 MAR as listed: 1. Eliquis 2.5 mg PO [by mouth] q [every] 12 hours dated 5/15/23 2. Lantus Insulin 20 units SQ [subcutaneous] q HS [hour of sleep] dated 5/15/23. 3. Novolog Insulin 8 units SQ with meals TID [three times a day] dated 5/15/23. 4. Furosemide 20 mg PO daily dated 5/15/23. 5. Levothyroxine 0.175 mg dated 5/15/23. Metoprolol 75 mg PO BID [twice a day] dated 5/15/23. 6. Lisinopril 10 mg PO q 12 hours dated 5/15/23. 7. Sertraline 100 mg PO daily dated 5/15/23. 8. Januvia 100 mg PO daily dated 5/15/23. 9. Vesicare 10 mg PO daily dated 5/29/23. h. On 5/25/23, the surveyor reviewed the medical record for Resident #146 which revealed the following: A review of the MARs for May 2023 and POS revealed 10 medications that were prescribed for routine and as needed use that did not contain a corresponding medical indication and were transcribed to the May 2023 MAR as listed: 1. Aspirin 81 mg PO daily dated 5/17/23. 2. Furosemide 40 mg PO daily dated 5/17/23. 3. Metoprolol tartrate 12.5 mg PO daily dated 5/17/23. 4. Miralax 17 grams PO daily dated 5/17/23. 5. Sertraline 25 mg PO daily dated 5/17/23. 6. Albuterol 2.5 mg/3 ml nebulizer treatment every six hours as needed dated 5/17/23. 7. Januvia 25 mg PO daily dated 5/19/23. 8. Vitamin C 500 mg PO daily dated 5/26/23. 9. Zinc 220 mg PO daily for two weeks dated 5/26/23. 10. Multivitamin one tablet PO daily dated 5/26/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot and cold food and drink served to the residents. This deficient practice was identified for four (4) of five (5) residents interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 6/2/21 for 2 of 2 nursing units tested for food temperatures by four surveyors and was evidenced by the following: On 5/23/23 at 10:10 AM, the surveyor met with five (5) residents for council meeting. Four out of five residents stated that they were displeased with food temperatures and that hot food items were not served hot. 06/02/23 11:36 AM, the Registered Dietitian (RD) surveyor calibrated two state issued digital thermometers via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the survey team. On 6/02/23 at 11:53 AM, the surveyors observed the Certified Nurse's Aide (CNA) #1 delivering lunch meals to residents from the first food truck delivered to the second-floor unit. CNA #1 stated that there were only two food trucks for the second-floor unit, and both were on the unit. The surveyor chose a regular consistency diet lunch tray to test after the last tray was served. The staff immediately called the kitchen for a replacement tray. After the last meal tray was delivered to a resident at 12:15 PM, the surveyor took the temperatures of the following items, in the presence of two addition surveyors: Baked Fish Fillet: 133 degrees F Scalloped Potatoes: 132 degrees F Pears: 71 degrees F Coffee eight ounces: 128 degrees F Cranberry Juice Cocktail four ounces: 65 degrees F Reduced Fat Milk 2% four ounces: 62 degrees F On 6/2/23 at 12:17 PM, the surveyor observed food truck arrive to the fifth floor in the presence of CNA #2 and a Licensed Practical Nurse (LPN). The surveyor chose a regular consistency lunch tray to test after the last tray was served. The LPN immediately called the kitchen for a replacement tray. After the last meal tray was delivered to a resident at 12:27 PM, the surveyor took the temperatures of the following items in the presence of a Registered Nurse (RN), who acknowledged and verified the temperatures: Baked Fish Fillet: 141.2 degrees F Scalloped Potatoes: 148 degrees F Pears: 70.6 degrees F Coffee eight ounces: 139 degrees Reduced Fat Milk 2% four ounces: 59.3 degrees F Chocolate Magic Cup: 12.2 degrees F On 5/31/23 at 11:03 AM, the surveyor interviewed the RD and Regional RD both of which stated that they were unaware of any concerns or resident complaints related to hot and cold food temperatures. On 6/02/23 at 10:39 AM, the surveyor interviewed the Food Service Director (FSD) in presence of the survey team. He stated that there have been issues with food temperatures but could not speak to specifics. He stated that he started a Quality Assurance Performance Improvement (QAPI) plan which included inconsistent food temperatures and stated that he performed test trays and would provide the surveyor with copies. Review of the QAPI Plan for the [NAME] Campus Kitchen Operations dated 5/11/23 and provided by the FSD on 5/31/23 at 2:00 PM, included Dietary operations to function properly in accordance with local, state and federal regulations. In addition, it identified a concern that food temperatures were inconsistent. The Notes on this form included that test tray audits would be randomly conducted at different mealtimes to ensure all food temperatures were within range. Review of the Test Tray audits provided to the surveyor by the FSD on 6/2/23 at 2:00 PM included 10 audits ranging from 3/22/23 to 5/28/23. The audit form included acceptable temperature ranges for soup, hot beverages and entrees to be at or above 135 degrees F, and for desserts, fruit, milk, cold beverages and potentially hazardous foods to be at or below 41 degrees F. On 3/22/23, the breakfast test tray audit indicated that oatmeal was 128.7 degrees F, pancakes were 121.4 degrees F and sausage was 133.4 degrees F. On 3/27/23, the lunch test tray audit indicated that turkey was 129.8 degrees F, bread dressing was 126.4 degrees F, and green beans were 123.6 degrees F. On 4/5/23, the lunch test tray audit indicated that chicken was 128.6 degrees F, mashed sweet potatoes were 123.4 degrees F, and cauliflower was 123.6 F degrees F. On 4/12/23, the lunch test tray audit indicted that mashed sweet was 132.8 degrees F and cauliflower was 127.2 degrees F. On 4/20/23, the lunch test tray audit indicated that eggplant parmigiana was 129.7 degrees F, pasta was 133.4 degrees F, and green beans were 131.2 degrees F. On 5/1/23, the lunch test tray audit indicated that potatoes were 133.4 degrees F and green beans were 127.6 degrees F. On 5/15/23, the lunch test tray audit indicated that the chicken sandwich was 130 degrees F. On 5/28/23, the breakfast tray audit indicated that the toast was 110 degrees F. Review of the undated facility policy Food and Nutrition Services included that food and nutrition services staff will ensure that meals would be served at a safe and appetizing temperature. NJAC 8:39-17.2(g), 17.4(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently identified and implemented for eight (8) of eight (8) residents (Resident #5, #18, #145, #147,#199, #202, #203 and #204) which represented two (2) of two (2) units reviewed for dietary preferences. This deficient practice was evidenced as follows: On 5/23/23 at 10:10 AM, a resident council meeting was conducted with five residents. Five of five residents stated that they did not receive food that they ordered from the menu and that items were missing from their meal trays. In addition, five of five residents stated that someone brings them menus to fill out, but the menus are often not picked up. Resident # 202 stated that the following occurred: I asked for rice crispy cereal and a banana and for some reason they gave me pancakes and other things I don't want, and he/she also stated that they received cereal without milk and that he/she asked for sausage and toast but also did not receive it. Resident #199 stated that they received only angel hair pasta and a roll recently for dinner. Resident #203 stated that he/she only received a hard-boiled egg and a box of cereal for breakfast. On 5/23/23 at 12:00 PM, the surveyor observed Resident #147 seated in a wheelchair in his/her room and was agreeable to be interviewed. During the interview at 12:15 PM, the Certified Nurse's Aide (CNA) #1 brought the resident his/her lunch tray. The resident stated that he/she had been at the facility since April and that it was the first time the meal ticket that he/she filled out with preferences (titled Selection Sheet) was attached to the generic meal ticket. The resident stated that typically it was only the generic ticket that was on the tray and that he/she does not receive what was ordered. In addition, the resident stated that no one provided instructions as to how to fill out the menus and that someone just leaves it on the overbed table, and he/she did the best I can to fill it out. The resident stated that he/she did not recall if they were seen by a Registered Dietitian (RD) and that no one ascertained his/her food preferences. The resident stated that they were visited by a patient advocate but she did not deal with dietary issues. The resident also stated that they would prefer to have two cups of coffee on the meal trays but I don't know how to make that happen. The resident stated that they had tried to write two (2) cups on the meal ticket but they never received it. The resident also stated that one morning there was a coffee mug on the breakfast tray, but it was empty. Upon review of the lunch meal ticket, there was a section where Beverages, Dislikes and Prefers could have been addressed and NO PREFERENCES was indicated next to beverages and prefers and NONE was indicated next to dislikes. On 5/24/23 at 11:35 AM, the surveyor observed Resident #18 in his/her room in a wheelchair with the overbed table awaiting the lunch meal. The resident stated that food services were spotty and that he/she did not always get what was ordered. At this same time a second surveyor joined the interview. The resident stated that the menus (Selection Sheets) were left about a week ahead of time and that he/she filled them out but frequently did not receive what was marked off and was not notified as to why. The resident stated that he/she was not seen by an RD and that no one ever visited him/her to discuss or ascertain food preferences or dislikes. On 5/24/23 at 12:09 PM, the surveyor observed Resident #145 in his/her room in a wheelchair and visiting with their son. The lunch tray was delivered by CNA #2. The resident did not receive the yellow cake as per the meal ticket. The resident stated that this was not unusual and that there was always something missing from the trays every day. The resident stated that no one, including an RD ever asked what he/she liked or disliked and stated that I just get what they give me. The resident stated that they preferred to receive ginger ale but did not receive this consistently. Upon review of the lunch meal ticket there was a section where Beverages, Dislikes and Prefers could have been addressed and NO PREFERENCES was indicated next to beverages and prefers and NONE was indicated next to dislikes. The surveyor observed Selection Sheets dated 5/18/23 through 5/25/23 on the resident's overbed table and were not filled out. The resident stated that no one came to help him/her fill out the menus and no one came to pick them up. On 5/24/23 at 12:14 PM, Resident #18's lunch tray arrived and what was on the meal ticket matched what was on the tray. The resident stated, that is rare and also stated it was the first time he/she saw the meal ticket stamped confirmed in red. Upon review of the lunch meal ticket there was a section where Beverages, Dislikes and Prefers could have been addressed and NO PREFERENCES was indicated next to beverages and prefers and NONE was indicated next to dislikes. On 5/24/23 at 12:20 PM, the surveyor interviewed Resident #147 in the presence of a second surveyor during lunch. The resident was in his/her room and the lunch tray was on the overbed table. The resident stated that it was the first time they saw the meal ticket stamped confirmed in red. The resident stated that they received what they ordered today and that has only been happening for the last two (2) days, and since I have been here there are frequently items missing . there has been improvement in the last two (2) days. The resident further stated that someone must have told them. The surveyors observed a four-ounce apple juice on the resident's trays which the resident stated that he/she had not ordered. The resident stated that he/she preferred orange juice especially for breakfast but never received it. Medical Record Review: Resident #5: Review of the admission Record (an admission summary) included that the resident was admitted with diagnoses that included but were not limited to; chronic kidney disease and nutritional anemia. Review of the admission Minimum Data Set (MDS) dated [DATE], a tool used to facilitate the management of care, included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected that the resident had an intact cognition. Review of the Physician's Orders included an order for a Regular diet dated 4/19/23. Review of the Nutritional Risk Assessment form dated 4/28/23, reflected that the Registered Dietitian (RD) documented food preferences addressed, however no specific food preferences were noted within the assessment. Review of the nutrition care plan dated 4/28/23, did not reflect any documented food preferences. Resident #18: Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; hypertension and gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of the admission MDS dated [DATE], included that the resident had a BIMS score of 15 out of 15, which reflected that the resident had an intact cognition. Review of the Physician's Orders included an order for a Regular diet dated 4/15/23. Review of the Nutritional Risk Assessment form dated 4/18/23, did not reflect any documented evidence that food preferences were addressed by the RD. Review of the nutrition care plan dated 4/18/23, did not reflect any documented food preferences. Resident #145: Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; diabetes, hypertension and adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition). Review of the admission MDS dated [DATE], included that the resident had a BIMS score of 15 out of 15, which reflected that the resident had an intact cognition. Review of the Nutritional Risk Assessment form dated 5/16/23, reflected that the RD liberalized the diet to Regular. It also included that the resident reported that he/she did not get the menu to fill out. In addition, the RD documented the following: does not like spaghetti and tomato sauce and rice, provide menu, likes mashed potatoes, and RD communicated to the diet office to provide menu and honor resident's food preferences. Review of the nutrition care plan dated 5/16/23, did not reflect any documented food preferences. Resident #147: Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; hypertension, heart failure and gastro-esophageal reflux disease. Review of the admission MDS dated [DATE], included that the resident had a BIMS score of 15 out of 15, which reflected that the resident had an intact cognition. Review of the Physician's Orders included an order for a Cardiac diet dated 4/26/23. Review of the Nutritional Risk Assessment form dated 4/27/23,, reflected that the RD documented monitor food preferences, however no specific food preferences were noted within the assessment. Review of the nutrition care plan dated 4/27/23, did not reflect any documented food preferences. Resident #199: Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; hypothyroidism (a condition that can slow down the metabolism and contribute to fatigue and unexplained weight gain) and gastro-esophageal reflux disease. Review of the Medicare - 5-day MDS dated [DATE], included that the resident had a BIMS score of 15 out of 15, which reflected that the resident had an intact cognition. Review of the Nutritional Risk Assessment form dated 5/17/23, reflected that the resident was prescribed a Regular diet and that the Resident has no food preferences. Review of the nutrition care plan dated 5/17/23, did not reflect any documented food preferences. Resident #202: Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; diabetes and congestive heart failure. Review of the admission MDS dated [DATE], included that the resident had a BIMS score of 15 out of 15, which reflected that the resident had an intact cognition. Review of the Physician's Orders included an order for a Cardiac Consistent Carbohydrate Diet (CCD) [used for diabetics] dated 5/13/23. Review of the Nutritional Risk Assessment form dated 5/14/23, reflected that the RD documented food preferences addressed, however no specific food preferences were noted within the assessment. Review of the nutrition care plan dated 5/14/23, did not reflect any documented food preferences. Review of the residents breakfast, lunch and dinner meal ticket's dated 5/30/23, reflected in the section where Beverages, Dislikes and Prefers could have been addressed, however NO PREFERENCES was indicated next to beverages and prefers and NONE was indicated next to dislikes. Resident #203: Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; muscle wasting and Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors). Review of the admission MDS dated [DATE], included that the resident had a BIMS score of 14 out of 15, which reflected that the resident had an intact cognition. Review of the Physician's Orders included an order for a Regular diet dated 5/22/23. Review of the Nutritional Risk Assessment form dated 5/24/23, reflected that the RD documented likes cranberry juice, dislikes fish, and RD communicated to the diet office regarding food preferences. Review of the nutrition care plan dated 5/24/23, did not reflect any documented food preferences. Review of the residents breakfast, lunch and dinner meal ticket's dated 5/30/23, reflected in the section where Beverages, Dislikes and Prefers could have been addressed, however NO PREFERENCES was indicated next to beverages and prefers and NONE was indicated next to dislikes. Resident #204: Review of the admission Record included that the resident was admitted with diagnoses that included but were not limited to; diabetes and muscle wasting. Review of the admission MDS dated [DATE], included that the resident had a BIMS score of 14 out of 15, which reflected that the resident had an intact cognition. Review of the Physician's Orders included an order for a No Concentrated Sweets (NCS) [used for diabetics] diet dated 5/9/23. Review of the Nutritional Risk Assessment form dated 5/8/23, did not reflect any documented food preferences. Review of the nutrition care plan dated 5/8/23, did not reflect any documented food preferences. On 5/24/23 at 12:15 PM, the surveyor observed CNA #1 delivering lunch trays to residents on the fifth floor. She stated that when she delivered the trays that the residents often stated, that is not what I ordered. She stated that the meals do not always match the menu and that the kitchen did not notify the residents or the nursing staff of the changes. CNA #1 stated that she had never seen the meal tickets stamped confirmed in red before today. She stated that last year these things rarely occurred and that if there was a change on the meal tray verse what the resident ordered, the food services department would have put a label on it the meal ticket which indicated sorry for the inconvenience but we needed to make a substitution. On 5/31/23 at 10:25 AM, the surveyor interviewed the Food Service Director (FSD), who stated that they had a new food service software system as of 5/1/23 that was used for the resident's meal tickets and selection sheets. He stated that he, or a member of his staff, visited residents to ascertain food preferences, it would be added to the software system and would have been indicated on the meal tickets. Together with the surveyor, the FSD reviewed some meal tickets from the fifth floor which had no preferences noted. He then stated that they started adding preferences to the second-floor residents meal tickets but could not speak to when that process started. The FSD stated that nursing communicated food preferences to the kitchen via an electronic fax (eFax) through email rather than the fax machine since some fax machines were broken. He stated that the information would be entered into the software system, and he would print those out and retained copies for his records. He stated that since this new system, they were able to provide residents with a selective menu. The FSD stated that these menus were provided a week in advance to the residents and that his staff would give them out and pick them up. In addition, the FSD stated that the residents were given instruction on how to fill out the selective menus. He stated that if a resident did not fill out the menu, they would have received a default regular meal ticket on their tray and that it was not the responsibility of his staff to have provided assistance to the residents to fill out the menus. The FSD could not speak to if there have been any menu changes nor what that process would entail. On 5/31/23 11:03 AM, the surveyor interviewed the RD and the Regional RD. They stated that it was the responsibility of the RD and sometimes the food services department to ascertain resident's food preferences on admission and as needed. They both stated that they communicated food preferences to the kitchen using a dietary recommendation form and verbally as well. In addition, they stated that as of two weeks ago, they both had access to enter food preferences into the food service software system as well. The RDs stated that they were not involved with giving selective menus to the residents and they would assist residents upon request if they happen to be in the residents' room. They stated that they were unaware of any menu changes or resident's not receiving their selected or preferred foods and fluids. The RDs stated that they should have been notified if there was a menu change because they were required to approve it. They stated they were not sure if this needed to be communicated to the residents or the nursing staff. On 6/02/23 at 10:39 AM, the surveyor interviewed the FSD, in presence of the survey team. He stated that the food service software was the system in place to ensure meeting the resident's food preferences. He then stated that they were still in the process of entering food preferences into the system. He stated that the residents can also call the kitchen to request an item from the always available list (he provided a copy to the surveyor) but could not speak to when this process was implemented. The FSD further stated that the new food service software system was implemented the week of 5/2/23 and that the contract for the previous software system was going to lapse and they did not have advanced warning or time to prepare for the new software system. He stated that it took time to get staff trained on how to use the new software system and that he was responsible to oversee and ensure that residents received their preferred meals. In addition, he stated that a Quality Assurance Performance Improvement (QAPI) plan was initiated on 5/11/23 to address this concern (he provided a copy to the surveyor). The FSD stated that he had identified concerns from 2/1/23 through 5/11/23 and could not speak to why the QAPI has not been effective. On 6/02/23 at 12:00 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that it was not nursing's responsibility to ascertain food preferences from the residents nor enter that information on the resident's care plan. She stated that when there was a new admission, they communicated the diet and any supplementation to the diet office on a communication slip (she provided a copy to the surveyor) via fax. She was unaware of what an eFax was. She stated that they provided the kitchen extension to the residents or would call for them if they did not receive what they wanted at mealtime. The RN/UM stated that there were times that residents did not receive what they ordered or that what was on the tray was not reflected on their meal ticket. She stated that food services dropped of the selective menus four to seven days in advance in a black plastic bin at the nursing station and that nursing gave them out and placed them back in the bin for food services to pick up. In addition, she stated that if a resident verbalized a food preference, they would call the diet office to let them know. On 6/02/23 at 1:10 PM, the [NAME] President of Growth and Transitions (VP) in the presence of the Licensed Nursing Home Administrator (LNHA), the Acting DON and the survey team, stated that she was aware that the food service department was conducting their own QAPI plan. And at 2:14 PM, the VP stated that there was a supervisor at the end of the tray line now to ensure that the trays were accurate. On 6/02/23 at 2:33 PM, the survey team met with the facility's administrative team and no additional info was provided. Review of the QAPI Plan for Kitchen Operations dated 5/11/23, included a goal of Dietary operations to function properly in accordance with local, state and federal regulations. It also included the following concerns: (1) Diet communication sheets not being provided consistently to the kitchen, (2) Resident requests not being placed into the system properly, (3) Tray line accuracy . and (4) [name redacted - new dietary software system] rollout For each concern there were corresponding notes as follows: (1) Identified fax machines and telephone lines were working intermittently. Plan in place to email diet orders for new admissions and changes to Diet Office email. Dietary staff will make daily rounds to units in the morning, afternoon and evening shifts, (2) Identified that the [name redacted - previous dietary software] system was not fully operating due to a network change. Diet office to round the floors to take orders and input into system manual, (3) Identified items on ticket missing. Staff to ensure food items are prepared according to the menu and resident requests. Supervisor at the end of the tray line to double check trays for accuracy . Food par levels adjust to ensure products are in house ., and (4) Transition to new menu and tray card system. In service and educate staff about the new system. Input resident diet card information . from the old to new system. Review of the undated facility policy Resident Food Preferences, included Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. It also included that upon admission the RD or nursing staff would identify a residents food preferences and when possible, would interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. In addition, the policy included that nursing staff would document the resident's food and eating preferences in the care plan. Review of the undated facility policy Nutritional Assessment included that the nutritional assessment should include the resident's usual meal and snack patterns, food preferences and dislikes and preferred portion sizes. It also included that individualized care plans should address resident's personal preferences. Review of the undated facility policy Food and Nutrition Services, included that Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. It also included that the RD should assess each residents' nutritional needs, food likes, dislikes and eating habits; that a resident-centered diet and nutrition plan should be based on this assessment; reasonable efforts should be made to accommodate resident choices and preferences; and food and nutrition services will inspect food trays to ensure that the correct meal was provided to each resident. Review of the undated Food Service Job description included Participate in maintaining records of the resident's food likes and dislikes, as well as Monitor food services to assure that all residents food service needs are being met as part of the FSDs listed duties and responsibilities. NJAC - 17.4(a)1,(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ00161372 Based on observations, interviews, and review of facility provided documentation, the facility failed to a.) ensure call bells were answered timely for 4 of 21 residents reviewed (Residents #151, #204, #244 and #246) and b.) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 32 of 48-day shifts and 2 of 48 evening shifts reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. 1. During the initial tour on 05/22/23 of the 2nd floor unit the surveyors observed the following: At 10:06 AM, the surveyors interviewed Resident #246 regarding call bells being answering in a timely manner. Resident #246 stated that he/she has to wait a long time to use the bathroom, one night he/she had to wait 2 hours. At 11:10 AM, the surveyors observed a staff member enter the room of Resident #244, who was sitting in a wheelchair wearing a hospital gown. The resident's Power of Attorney (POA) and a friend were in the room. The staff member asked the resident why they were not dressed, Resident #244 stated because his/her clothes have not been washed. At that time, the staff member transported Resident #244 in the wheelchair out of the room. During an interview with the surveyors, Resident #244's POA stated they took the resident to physical therapy wearing a hospital gown. The POA stated The resident uses their call bell but has to wait a long time before it gets answered causing the resident to lose control of their bowel or bladder. On 05/22/23 at 01:02 PM, during a follow up interview, Resident #244 stated I have to use my call bell because I need help with the bathroom, but it takes so long for them to come and I cannot hold it, so I have an accident. On 05/23/23 at 11:10 AM, during a follow up interview with Resident #246, he/she stated, I waited an hour for help last night. The surveyor reviewed the medical record for Resident #246. A review of the admission Record (an admission summary) for Resident # 246 revealed the resident was admitted to the facility in May of 2023 with a diagnosis which included but were not limited to; cellulitis of left lower limb (a bacterial skin infection) and Chronic Obstructive Pulmonary Diseases (difficulty or discomfort in breathing) and Difficulty in walking. A review of the Care Plan for Resident #246 revealed a Focus, dated 05/17/23: I am at risk for falls r/t (related to) cellulitis with an Intervention, dated 05/25/23, of Be sure call light is within reach, and provide reminders to use call for assistance as needed and a Focus, dated 05/16/23: I have an ADL (activities of daily living) Self Care Performance Deficit r/t generalized weakness with an Intervention, dated 05/16/23, Encourage me to use call bell for assistance. The surveyor reviewed the medical record for Resident #244. A review of the admission Record (an admission summary) for Resident # 244 revealed the resident was admitted to the facility in May of 2023 with a diagnosis which included but were not limited to; Chronic Heart Failure (CHF), (the heart doesn't pump blood as well as it should) Muscle wasting and atrophy (loss of muscle mass), and Difficulty in walking. A review of the Care Plan for Resident #244 revealed a Focus, dated 05/08/23: I am at risk for falls r/t bilateral lower extremity weakness with an Intervention, dated 05/08/23, of Be sure call light is within reach, and provide reminders to use call for assistance as needed, a Focus, dated 05/08/23: I am on diuretic therapy r/t CHF: with an Intervention, dated 05/08/23 of I am on diuretic therapy and may need to void frequently and quickly. Routinely check and offer/provide me toileting assistance and a Focus, dated 05/08/23: I have an ADL Self Care Performance Deficit r/t generalized weakness with an Intervention, dated 05/08/23, Encourage me to use call bell for assistance. On 05/25/23 at 10:29 AM, the surveyor exited the elevator on the 2nd floor and observed the call bell light illuminated over the door of rooms [ROOM NUMBERS]. At 10:30 AM, the surveyor observed the 2nd floor Manager (UM) with another staff member walk past room [ROOM NUMBER] and press the button for the elevator. The illuminated call bell lights for room [ROOM NUMBER] and 218 were visible from where the UM and the staff member were looking at the staff member's phone. The surveyor could also hear the centralized call bell system alarming at the nurses' station. The surveyor did not observe neither staff member go to either room to check to see what the residents needed. On 05/25/23 at 10:32 AM, the surveyor observed Certified Nursing Assistant (CNA #1) enter room [ROOM NUMBER] and say yeah. The surveyor heard the resident say I was waiting a long time before CNA#1 closed the door. On 5/25/23 at 10:45 AM, a surveyor conducted a resident council meeting with five (5) alert and oriented residents. When the surveyor asked, how long does it take for staff to answer you call light? Resident #151 answered, once or twice I had to wait a while and a number of times I had to go in my diaper .number 1 (urine). Resident #204 stated, I told the nurse, 'I'm going to call 911 next time.' When the surveyor asked, do you receive assistance for either the bedpan or toilet timely? 3 of the 5 residents stated, staff do not come timely. On 05/25/23 at 10:46 AM, during an interview with the surveyor, CNA #2 stated if you hear a call bell, answer it, even if it isn't on your side because everyone is supposed to answer the call bells. On 05/30/23 at 12:32 PM, the surveyor exited the elevator on the 2nd floor and observed the call bell light illuminated for room [ROOM NUMBER]. The surveyor observed a staff member get off the elevator and walk past the illuminated call bell light. The staff member did not look in room or ask what the resident needed. At 12:33 PM, the surveyor observed the Acting Director of Nursing (ADON) get off elevator and walk past room [ROOM NUMBER]. The ADON did not look in room or ask if the resident needed assistance. At 12:39 PM, the resident in room [ROOM NUMBER] started calling out for help. At that time, CNA #3 and the Licensed Practical Nurse (LPN) entered room and closed the door. On 05/31/23 at 10:54 AM, during an interview with the surveyor, CNA#3 stated that it was everyone's responsibility to answer call bells, even housekeeping, because it could be something small. On 05/31/23 at 11:04 AM, during an interview with the surveyor, the 2nd floor UM stated call lights are everyone's responsibility. We can all answer them, even social workers. It is never OK to walk by call lights. On 05/31/23 at 2:13 PM, during an meeting with the survey team, the [NAME] President of Growth and Transition, and ADON, the Licensed Nursing Home Administrator (LNHA) were made aware of the above findings. The LNHA stated that the expectation was that someone would go in to answer the call light. It (answering the call bell) was for everyone not just nursing. The ADON also stated that the expectation was for everyone to answer call bells, to check to see what the resident needs. A review of the facility's policy, Answering the Call Light with no revision date, revealed Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Steps in the Procedure: 1. Answer the resident call system as soon as possible. B. If the resident's request requires another staff member, notify the individual. C. If the resident's request is something you can fulfill, complete the task. 3. When answering a visual request for assistance (light above the room door), knock on the room door. When the resident responds, address the resident by his/her name (e.g How may I help you, Mr. Harris?). 2. The survey team requested the following weeks of staffing: 01/29/23, 02/05/23, 04/16/23, 04/23/23, 05/07/23, and 05/14/23. A review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report revealed the following: -02/01/32 had 4 CNAs for 38 residents on the day shift, required 5 CNAs. -02/02/23 had 4 CNAs for 38 residents on the day shift, required 5 CNAs. -02/03/23 had 4 CNAs for 46 residents on the day shift, required 6 CNAs. -02/04/23 had 4 CNAs for 45 residents on the day shift, required 6 CNAs. -02/05/23 had 4 CNAs for 42 residents on the day shift, required 5 CNAs. -02/06/23 had 4 CNAs for 42 residents on the day shift, required 5 CNAs. -02/07/23 had 4 CNAs for 42 residents on the day shift, required 5 CNAs. -02/08/23 had 4 CNAs for 42 residents on the day shift, required 5 CNAs. -02/10/23 had 4 CNAs for 45 residents on the day shift, required 6 CNAs. -02/11/23 had 4 CNAs for 45 residents on the day shift, required 6 CNAs. -04/16/23 had 4 CNAs for 53 residents on the day shift, required 7 CNAs. -04/17/23 had 6 CNAs for 53 residents on the day shift, required 7 CNAs. -04/18/23 had 5 CNAs for 53 residents on the day shift, required 7 CNAs. -04/19/23 had 5 CNAs for 53 residents on the day shift, required 7 CNAs. -04/20/23 had 5 CNAs for 53 residents on the day shift, required 7 CNAs. -04/21/23 had 5 CNAs for 53 residents on the day shift, required 7 CNAs. -04/22/23 had 4 CNAs for 53 residents on the day shift, required 7 CNAs. -04/23/23 had 4 CNAs for 55 residents on the day shift, required 7 CNAs. -04/24/23 had 6 CNAs for 55 residents on the day shift, required 7 CNAs. -04/24/23 had 4 CNAs to 10 total staff on the evening shift, required 5 CNAs. -04/25/23 had 6 CNAs for 55 residents on the day shift, required 7 CNAs. -04/26/23 had 6 CNAs for 55 residents on the day shift, required 7 CNAs. -04/27/23 had 5 CNAs for 54 residents on the day shift, required 7 CNAs. -04/28/23 had 6 CNAs for 53 residents on the day shift, required 7 CNAs. -04/29/23 had 5 CNAs for 53 residents on the day shift, required 7 CNAs. -05/12/23 had 5 CNAs for 51 residents on the day shift, required 6 CNAs. -05/13/23 had 4 CNAs for 51 residents on the day shift, required 6 CNAs. -05/14/23 had 4 CNAs for 50 residents on the day shift, required 6 CNAs. -05/16/23 had 5 CNAs for 49 residents on the day shift, required 6 CNAs. -05/17/23 had 5 CNAs for 49 residents on the day shift, required 6 CNAs. -05/18/23 had 5 CNAs for 49 residents on the day shift, required 6 CNAs. -05/18/23 had 5 CNAs to 12 total staff on the evening shift, required 6 CNAs. -05/19/23 had 5 CNAs for 53 residents on the day shift, required 7 CNAs. -05/20/23 had 3 CNAs for 53 residents on the day shift, required 7 CNAs. On 05/25/23 at 10:46 AM, during an interview with the surveyor, CNA#2 stated that she had 10 residents in her assignment today and that she can mostly get everything done but some residents need more time, and you have to go around occupation and physical therapy appointments. On 05/25/23 at 11:23 AM, during an interview with the surveyor, CNA#1 stated that she had 9 residents in her assignment for the day. On 5/25/23 at 10:45 AM, a surveyor conducted a resident council meeting with five (5) alert and oriented residents. When the surveyor asked, do you feel the facility is short staffed? five (5) of five (5) residents stated yes. On 05/31/23 at 11:24 AM, during an interview with the surveyor, the Staffing Coordinator (SC) said she was aware of the CNA ratios which she stated were 1 to 12 for the day, night, and evening shifts and yes they were trying to meet them. On 06/02/23 at 1:07 PM, during an interview with the survey team, the LNHA stated she was aware of the CNA ratios which were 1 to 8 for days, 1 to 10 for evenings, and 1 to 14 for nights. NJAC 8:39 5.1(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: a.) identify and evaluate a resident's ability to swallow medications for a resident who had episodes of chewing whole medications, b.) notify the physician of a resident who did not consistently swallow medications and c.) implement appropriate communication strategies for a resident. This deficient practice was identified for 1 of 13 residents reviewed for quality of care (Resident #118) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey 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. On 05/19/21 at 8:10 AM, the surveyor (Surveyor #1) toured the fifth floor and overheard, in a loud harsh tone, don't chew it, swallow it all!. The surveyor overheard the statement reiterated twice, while the surveyor was in the hallway and two rooms away. The surveyor then observed a nurse, Registered Nurse (RN #1) exit the room of Resident #118 and immediately proceed to a medication cart located directly outside Resident #118's room. The surveyor observed Resident #118 was lying awake in his/her bed. On 05/14/21 at 8:30 AM, Surveyor #2 interviewed Resident #118 in his/her room while he/she was consuming the breakfast meal and sitting upright in bed. Surveyor #2 observed the meal was a chopped consistency. Surveyor #1 was also present for the interview and had a clear unobstructed view of the resident while standing at the resident's doorway. Surveyor #2 interviewed the resident in a low soothing voice about the care the resident received, including when the resident was provided with medications. Resident #118 stated to Surveyor #2 I was scolded this morning. The resident who appeared visibly upset, had a quivering lip and appeared tearful. Resident #118 stated he/she was scolded because he/she chewed his/her pills. On 05/14/21 at 8:36 AM, Surveyor #1, in the presence of Surveyor #2, interviewed RN #1 about the observations that Surveyor #1 had when the surveyor overheard RN #1 speaking in a loud harsh tone and stated, don't chew it, swallow it all! while inside Resident #118's room. RN #1 confirmed she provided the medication to Resident #118 at that time, and that the resident put all the pills in his/her mouth and proceeded to chew them. RN #1 stated Resident #118 was provided with four medications and the RN #1 provided the surveyor with a copy of the May 2021 Medication Administration Record (MAR) at that time. Surveyor #1 reviewed the MAR for May 14, 2021 which revealed that Resident #118 was administered the following medications by RN #1 at 9:00 AM: Valsarten, 40 Milligrams (MG), 1 Tablet once per day by mouth; Wellbutrin XL (extended 24 hour release medication), 150 MG, 1 Tablet SR, by mouth, 24 hours; Escitalopram, 10 MG, 1 Tablet by mouth once a day; Multivitamin, Therapeutic with minerals, 1 Tablet by mouth once a day. On 05/14/21 at 12:36 PM, Surveyor #2 interviewed Resident #118 regarding his/her recall of the earlier events. The interview took place in the residents room during the lunch meal. Resident #118 stated he/she did not recall the earlier incident when RN #1 spoke to the resident in a loud harsh tone about chewing the pills instead of swallowing the pills. During the interview the resident was able to hear the surveyor without difficulty, responded appropriately, and the surveyor was wearing a face mask. The RN #1 stated that she administered four medications to Resident #118 and she provided them to the resident in a cup. She stated when she gave Resident #118 the cup of medications, the resident then put all the medications in his/her mouth. She further stated that sometimes the resident chewed on the medications instead of swallowing them and Resident #118 was not hard of hearing but sometimes we spoke loudly to the resident. She stated Resident #118 was alert and oriented X2 (alert to self and location) but sometimes the resident did not understand us. She stated her loud voice was due to the fact they don't hear us and because she wore personal protective equipment (PPE) that included a face mask and face shield. The RN #1 stated there was no specific way that Resident #118 had to take the medications and the resident did not have any swallowing problems. She stated I think it is just cognition and the resident needed a reminder to swallow the pills. The RN #1 stated that sometimes Resident #118 chewed the medication and sometimes the resident swallowed the medication. She further stated if some medications were chewed it would effect the efficacy of the medication. The RN #1 stated she told Resident #118 a couple of times that he/she needed to swallow the medication and that she had cared for the resident before and knew the resident chewed the pills. Review of the admission Record for Resident #118 revealed the resident was admitted with diagnoses which included pneumonia, unspecified organism, malignant neoplasm (cancer) of cecum (part of large intestine), unspecified severe protein-calorie malnutrition. Review of a Nursing admission Screening/History for Resident #118, dated 05/10/21, revealed the resident was confused and had a short term memory problem, had adequate hearing and was assessed as having the ability and was ready to learn and had no preferences or special learning needs. Review of a Brief Interview of Mental Status (BIMS) assessment, dated 05/16/21, revealed Resident #118 had scored 9 on the assessment. A BIMS score of 9 indicated the resident was moderately cognitively impaired. Review of the Nursing Care [NAME] for Resident #118 revealed the Dysphagia Chopped diet with thin liquids was listed under Diet and the box for hearing deficit was not checked off. Review of Resident #118's Care Plan on 05/14/21 at 10:00 AM, did not reveal a Focus area related to the resident swallowing pills or related to communicating with the resident. Review of an education file for RN #1 revealed on 03/19/20 and 03/30/21 RN #1 completed an Abuse-Post Learning Quiz. The Quiz included a question that pertained to using harsh tones, screaming or yelling at a resident and RN #1 answered correctly. A Medication Pass Observation, dated 08/22/19 and 09/14/20, was completed for RN #1 and revealed under Patient's Rights Observed that RN #1 treated patient with respect and scored excellent. A Hand in Hand Dementia training, completed by RN #1, dated 03/30/21, revealed RN #1 was trained on how to present when you cared for a person with dementia and answered be patient, treat with respect and ask resident how they like something. On 05/14/21 at 10:48 AM Surveyor #1, in the presence of the survey team, communicated the surveyor's earlier observations regarding Resident #118 and then interviewed the Director of Nursing (DON) and Chief Nursing Officer (CNO) regarding how nurses would know how to communicate with residents. The DON stated the nursing [NAME], located in the MAR, would inform the nurse if the resident was hard of hearing, and any impairments would also be listed in the Care Plan. The DON stated that if the resident was hard of hearing, and since staff wore PPE masks, the staff might have to speak a little louder to a resident. The DON and CNO were interviewed regarding the procedure if a resident did not swallow medications and instead chewed them. The DON stated that applesauce to ease a resident's ability to swallow pills could be an option. The surveyor informed the DON and CNO about the observations with RN #1 and Resident #118. Surveyor #1 inquired what should have been done when the nurse was aware the resident was not swallowing pills and instead chewed the pills. The DON stated the nurse should have intervened, conversed with the resident, assessed the resident and contacted the physician. She further stated that if a resident was on a modified diet that could have been an indicator that the pills needed to be crushed or there were also options like applesauce or ice cream to take pills with. The DON further stated that if any changes occurred with a resident that the physician would be notified. The CNO stated that the RN #1 should have notified the physician when she became aware that the resident had difficulty swallowing medications. On 05/18/21 at 10:30 AM, Surveyor #1 interviewed the Administrator (LHNA), in the presence of the survey team, regarding what should have been done if a resident chewed medications. The LHNA stated that medications, especially long acting medications, should not be crushed due to the potential of absorbing too much medication at one time instead of over a period of time. She stated the medications could have been changed to a liquid form. On 05/18/21 at 11:29 AM, Surveyor #1, in the presence of another surveyor and the DON, interviewed the primary physician (MD) for Resident #118. The MD stated the Resident was on a chopped diet for ease of consumption and the swallowing problems were related to fatigue and debilitation. The MD stated that she was able to converse with Resident #118 and it appeared as the resident understood her. She further stated she would get up close to converse with the resident and that the resident had memory issues however, the resident was able to hear her. The MD stated she was not notified that the resident had difficulty swallowing the pills and usually she would be notified if a resident had trouble swallowing. The MD stated one of the medications was a long acting medication and she should have been notified about the resident chewing the pills because they don't want the residents chewing on the long acting medications. The MD then confirmed she was not contacted by RN #1 after Resident #118 had chewed the medications on 05/14/21. She stated if the nurse had contacted her the she could have changed the medications. On 05/19/21 at 11:16 AM, Surveyor #1 interviewed the Director of Professional Services (DOPS) who stated she completed an initial activity assessment, dated 05/12/21, for Resident #118. She stated the resident understood her and answered questions appropriately. She further stated the resident was a little delayed with answers and that you needed to give him/her a little extra time. The DOPS stated the resident had adequate hearing however, sometimes staff needed to repeat the question for understanding. She continued and stated that Resident #118 was able to verbalize his/her needs and she did not feel the resident had a hearing deficit. Review of the Standards of Care-Sub-Acute/LTC Policy, Guidelines and Procedures for Administration of Medication, Policy #17.42A, Dated 04/92, revealed under guidelines: the nurse discusses any unresolved significant concerns about the medication with the patient's physician and relevant staff involved with the patient's care, treatment, etc., each patient's response to his/her medication is monitored according to the clinical needs of the patient and addresses the patient's response to the prescribed medication and actual or potential medication related problems, respect patient/resident rights and treat the patient/resident with respect. Review of the Code of Conduct Policy, Policy # 1.86, Dated 02/98 revealed all members of the health care team, including administrators, the medical staff, nursing and clinical personnel, volunteers and all hospital employees are expected to conduct themselves and their activities in a manner that supports the mission of the hospital and enables the delivery of quality, efficient patient care. Professional behaviors that promote cooperation and teamwork are a priority. Expectations include the following: 2. Staff should act in an ethical and professional manner by treating others with dignity, courtesy and respect. Behaviors to be avoided include the following: 2. Indulging in disorderly conduct or abusive language, including profanity, shouting and rudeness. NJAC 8:39- 27.1(a), 4.1(a)12