Complaint #NJ167309 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for residents that had unwitnessed fall. This deficient practice was identified for 1 of 4 residents (Resident #278) reviewed for accidents and was evidenced by the following: The surveyor reviewed the medical record for Resident #278. A review of the admission Record (AR) revealed that Resident #278 had diagnoses which included, but were not limited to, surgical aftercare following surgery on the digestive system and retroperitoneal abscess (an infection between the abdominal wall and spine). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/17/2023, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. Review of Resident #278's electronic medical record (EMR) Progress Notes revealed the following entries: On 07/22/2023 at 11:40 AM, a nursing progress note recorded, [Approximately] 11:35am, [ .lost their] balance and fell backward. [Vital signs] taken, body assessment performed, [pt] assisted back into bed. [Neurological] checks initiated and initial assessment [within normal limits] . The surveyor requested the full fall investigation for the above identified fall. Upon review of the facility provided Accident/Incident [sic] Report Checklist, the following was identified as being submitted but was not observed by the surveyor: Registered Nurse's Statement and Neurological Assessments. During an interview with the surveyor on 10/7/2024 at 10:24 AM, Licensed Practical Nurse (LPN #1) that a Licensed Practical Nurse was responsible for obtaining vital signs of a fallen resident and the Registered Nurse (RN) would complete the full resident assessment. LPN #1 confirmed that statements are obtained from any staff member that had contact with the fallen resident including, but not limited to, the LPN, RN, Certified Nursing Assistant (CNA). and the resident. LPN #1 explained that the statement would contain a thorough description of how the resident was found any interventions that were taken. During an interview with the surveyor on 10/8/2024 at 12:42 PM, the Licensed Practical Nurse Unit Manager (LPN/UM#2) advised that neurological checks were to be initiated with any unwitnessed fall and post fall documentation is expected to continue every shift for three days. LPN/UM#2 explained that the neurological checks were completed on a paper form then submitted with the post fall incident evaluation to the Director of Nursing (DON) who would be responsible for maintaining the documents and investigation. Upon review of Resident #278 EMR, LPN/UM#2 could not identify any post fall documentation. During an interview with the surveyor on 10/9/2024 at 9:09 AM, the Director of Nursing (DON) confirmed that a thorough fall investigation was not completed since statements were not obtained (specifically from the RN that completed the fall assessment), lack of post fall documentation of the neurological checks, follow-up documentation, and signature of the title person completing the report. The DON confirmed that the importance of investigating an unwitnessed fall was to rule out abuse. A review of a facility provided policy titled Accidents and Incidents-Investigating and Reporting revealed under section Policy Interpretation and Implementation that, 2. e.) The name(s) of witnesses and their accounts of the accident or incident [ .] l.) follow-up information [ .] n.) the signature and title of the person completing the report . A review of a facility provided policy titled Charting and Documentation revealed under section Policy Interpretation and Implementation that, 2. The following information is to be documented in the resident medical record: a.) Objective observations; b.) Medications administered; c.) Treatments or services performed; d.) Changes in the resident's condition; e.) Events, incidents or accidents involving the resident; and f.) Progress toward or changes in the care plan goals and objectives [ .]. NJAC 8:39-9.4(f)

Complaint: NJ00167309 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to revise a comprehensive care plan to identify the nursing intervention required to care of a surgical wound infection. This deficient practice was identified for 1 of 26 residents (Resident #278) reviewed for care planning. The surveyor reviewed the medical record for Resident #278. A review of the admission Record (AR) revealed that Resident #278 had diagnoses which included, but were not limited to, surgical aftercare following surgery on the digestive system and retroperitoneal abscess (an infection between the abdominal wall and spine). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/17/2023, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. Under Section M (Skin Conditions) identified that Resident #278 had a surgical wound and surgical wound care. A review of Resident #278's Order Summary Report did not identify physician's orders for surgical wound care or maintenance of surgical wound upon admission. A review of Resident # 278's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not identify physician's orders for surgical wound care or maintenance of surgical wound upon admission. A review of the individualized comprehensive care plan (ICCP) included a focus area area dated 7/12/2023 for enhanced barrier precautions [related to] surgical incision. The surveyor did not observe any interventions placed regarding surgical wound care. During an interview with the surveyor on 10/7/2024 at 10:24 AM, Licensed Practical Nurse (LPN #1) described a care plan as a blueprint for the resident and is used as a guideline of what works and doesn't work with the resident. LPN#1 confirmed that care plans are to be continuously updated during the resident's stay. LPN #1 identified that a care plan should identify if a resident has a surgical wound and any nursing interventions that were put into place to maintain it. During an interview with the surveyor on 10/9/2024 at 9:09 AM, the Director of Nursing (DON) acknowledged that there was no care plan update regarding the surgical wound infection. A review of a facility provided policy titled Care Plan, Comprehensive Person-Centered revealed under section Policy Explanation and Compliance Guidelines that, 8.) a. include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well being; 13.) Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. NJAC 8:39- 11.2(e)

3.) A review of Resident # 70's admission Record indicated Resident #70 was admitted to the facility with diagnoses which include but were not limited to Heart Failure, Type 2 Diabetes Mellitus (a condition that occurs when the body doesn't respond properly to insulin, causing high blood sugar levels), and Morbid Obesity Due to Excess Calories ( a complex disease that occurs when the body stores to much fat due to an imbalance between calories consumed and calories used). A review of Resident #70's Treatment Administration Record (TAR) for March 2024 revealed a physician's order (PO) with an order date of 03/14/2024, for negative pressure therapy wound vac with Y connect to B/L [bilateral] hips, change every Mon, Wed, Fri for wound treatment. Surveyor #3 observed a blank on the TAR, there were no nurse's initials indicating the treatment was administered on 03/15/2024. Surveyor #3 observed a PO with and order date 03/07/2024 for Negative pressure therapy wound vac with Y connect to B/L hips, change every Mon, Wed, Fri for wound treatment. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/08/2024 and 03/13/2024. Surveyor #3 observed a PO with an order date of 03/07/2024 to change the wound vac canister weekly on Wednesdays. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/13/2024. Surveyor #3 observed a PO with an order date of 03/07/2024 to offload heals when in bed every shift. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/08/2024, 3/13/2024, 3/15/2024 for day shift and 3/09/2024 on night shift. Surveyor #3 observed a PO with an order date of 04/09/2024 to check the function of an air mattress every shift. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/08/2024, 3/13/2024, 3/15/2024, 03/17/2024 for day shift and 3/09/2024 on night shift. Surveyor #3 observed a PO with an order date of 04/09/2024 to apply skin prep to bilateral heels every shift. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/08/2024, 3/13/2024, 3/15/2024, 03/17/2024 for day shift and 3/09/2024 on night shift. Surveyor #3 observed a PO with an order date 04/09/2024 to complete a pain assessment every shift. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was not done on 03/08/2024, 3/13/2024, 3/15/2024, 03/17/2024 for day shift and 3/09/2024 on night shift. Surveyor #3 observed a PO with an order date of 03/07/2024 to document lung sounds. Surveyor #3 observed blanks on the TAR, there were no nurse's initials indicating the treatment was administered on 03/08/2024 for day shift and 3/09/2024 on night shift. During an interview on 10/08/2024 at 09:42 AM with Surveyor #3 the Unit Manger (UM) # 1 stated, When there are blanks on the TAR it means the treatment was not signed off. When asked if there should be any blanks on the TARs, the UM replied, No. During an interview on 10/08/2024 at 02:22 PM with Surveyor #3 the Director of Nursing (DON) stated, It could mean that the nurse failed to sign out the treatment but it comes down to not documenting when asked what does it mean when there are blanks on the TAR. When asked if there should be any blanks, the DON replied, No. A Review of a facility provided policy titled Documentation of Wound Treatments dated 9/1/2024 revealed under Policy Explanation and Compliance Guidelines: that, 3. Wound treatments are documented at the time of each treatment. If no Treatment is due, an indication on the Status of the Dressing shall be documented each shift ( i.e., clean, dry, intact). A review of a facility provided policy titled Charting and Documentation with a reviewed date of 1/2024 revealed under, Policy Interpretation and Implementation that, 2. The following information is to be documented in the resident medical record: b. Medications administered; c. Treatments or services performed; NJAC 8:39-27.1(a) Complaint # NJ167008; NJ167309; NJ100172185 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to a.) obtain admission orders for a surgical wound b.) maintain nursing documentation of a surgical wound to prevent a delay in treatment for 1 of 26 residents (Resident #278) reviewed for wounds; c.) maintain and care for a central line catheter (tube travels through one or more veins until the tip reaches the large vein that empties into your heart) and d.) maintain treatment records that were complete with staff signatures according to professional standards of clinical practice for 2 of 26 (Resident #275 and #70) residents reviewed for medication administration and evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) The surveyor reviewed the medical record for Resident #278. A review of the admission Record (AR) revealed that Resident #278 had diagnoses which included, but were not limited to, surgical aftercare following surgery on the digestive system and retroperitoneal abscess (an infection between the abdominal wall and spine). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/17/2023, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. Under Section M (Skin Conditions) identified that Resident #278 had a surgical wound and surgical wound care. A review of Resident #278's Order Summary Report did not identify physician's orders for surgical wound care or maintenance of surgical wound upon admission. A review of Resident # 278's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not identify physician's orders for surgical wound care or maintenance of surgical wound upon admission. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 7/12/2023 for enhanced barrier precautions [related to] surgical incision ns. The surveyor did not observe any interventions placed regarding surgical wound care. Review of Resident #278's electronic medical record (EMR) Progress Notes revealed the following entries: On 07/12/2023 at 4:31 AM, a Nursing Progress note recorded, abdomen soft non-tender to touch with good bowel sounds surgical incision on abdomen with steri-strips intact site clean and dry [ .]. On 7/12/2023 at 3:49 PM (time stamp was in bold found to be backdated and original creation date was identified as 7/17/2023 at 3:49 PM), a Nurse Practitioner progress note recorded, patient midline surgical incision [ .] clean dry and intact. The surveyor did not locate any surgical wound documentation for 7/13/2023. On 7/14/2023 at 6:27 AM, a Nursing Progress note recorded, patient had some sero-sanguinous drainage (thick clear or pink fluid from a wound) from the lower end of the incision [ .] area cleansed with [non sterile saline solution] and boarder gauze applied [ .] lower area around [abdomen] incision is pink [ .] boarder gauze noted to have sero-sanguinous [dressing] in AM so removed it & area cleansed with [non sterile saline solution] & a large boarder gauze applied [ .]. On 7/14/2023 at 3:58 PM (time stamp was in bold found to be backdated and original creation date was identified as 7/17/2023 at 3:58 PM), a Nurse Practitioner progress note recorded, surgical incision has distal erythema (redness and increased blood flow) and drainage- will place [them] on antibiotic and probiotic [ .] erythema to lower abdominal wound-purulent discharge (thick pus-like fluid that implies presence of infection). Upon review of the resident's MAR/TAR an antibiotic and probiotic was not submitted. On 7/15/2023 at 4:24 AM, a nursing progress note recorded, dressings to abdomen changed this shift due to dressings being soiled. The surveyor did not locate any surgical wound documentation for 7/16/2023; however, upon review of the resident's MAR/TAR, an order for cephalexin 500 milligrams (MG) was submitted for wound infection. On 7/17/2023 at 2:40 AM, a nursing progress note recorded, bandages removed from abdominal wounds, moderate amount of purulent drainage leaking from wounds, slightly thicker than water, water does have foul odor. Area cleansed and new bandages adhered to area [ .]. On the same date at 3:24 PM, a nursing progress note recorded, multiple steri-strips along medical incision line with an opening the lower end of incision with a quarter size dehiscence area which has clear drainage which was cleaned and abdominal pad placed and boarder gauze placed. MD made aware of all of the above findings and resident will be evaluated in the AM. Upon review of the resident's MAR/TAR, on 7/17/2023, the surveyor identified a physician's order to keep abdominal area clean and dry with [non sterile saline solution] and apply [conventional dry dressing] two times a day for [dehiscence] (reopening) of abdominal incision. During an interview with the surveyor on 10/7/2024 at 10:24 AM, Licensed Practical Nurse (LPN #1) confirmed that new facility residents should have their admission orders reviewed with the physician to ensure continuity of care. LPN #1 further advised that a resident with a surgical wound should have order upon admission on how to care for it. When asked regarding documentation, LPN #1 stated that if the wound was not being monitored something could get missed or lead to a decline in patient status. During an interview with the surveyor on 10/7/2024 at 10:43 AM, the Infection Preventionist (IP) revealed that admission orders for any type of a wound is important because the nurses need to know how to cleanse to prevent infection. When asked what signs are and/or symptoms of infection the IP stated, redness, swelling, tenderness, warmth, drainage, pus. The surveyor inquired about the expectations of documentation regarding wounds at which the IP responded that upon admission wounds should be thoroughly documented every shift upon it's resolution. During an interview with the surveyor on 10/7/2024 at 11:51 AM, the Licensed Practical Nurse Unit Manager (LPN/UM#1) confirmed that nursing is responsible for obtaining admission orders for a surgical wound. LPN/UM #1 further explained that nursing would assess for drainage, redness, increased pain, etc every shift and document their finding appropriately. When asked why these orders were important, LPN/UM #1 responded that nursing cannot decide on their own how to treat a surgical wound. During an interview with the surveyor on 10/9/2024 at 9:09 AM, the Director of Nursing (DON) acknowledged that there were not admission orders in place to monitor the resident's surgical site. The DON confirmed that the expectation is that every shift, or minimum every 24 hours, the surgical site should be documented on. The DON also identified that the two Nurse Practitioners Progress Notes were not entered in a timely basis. Upon review the DON confirmed that nursing's documentation should have demonstrated that they closed the gap in communication to see if any interventions needed to be in place to prevent any delay in care to the resident. A review of a facility provided policy titled Change in a Resident's Condition or Status revealed under section Policy Interpretation and Implementation that, 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): [ .] e.) need to alter the resident's medical treatment significantly [ .]. A review of a facility provided policy titled Charting and Documentation revealed under section Policy Interpretation and Implementation that, 2. The following information is to be documented in the resident medical record: a.) Objective observations; b.) Medications administered; c.) Treatments or services performed; d.) Changes in the resident's condition; e.) Events, incidents or accidents involving the resident; and f.) Progress toward or changes in the care plan goals and objectives [ .]. A review of a facility provided policy titled admission Orders revealed under section Policy Explanation and Compliance Guidelines that, The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission [ .]. 2. According to the admission Record (AR) Resident #275 was admitted to the facility with the diagnose that included but was not limited to; surgical aftercare following surgery of the digestive system and diverticulitis (Inflammation of one or more pouches in the colon wall). The surveyor reviewed the admission Assessment (AA) dated 08/24/23, which reflected that Resident #275 was alert and oriented to person, place time and situation and had a right upper arm peripherally inserted central catheter (PICC). The surveyor reviewed the physician's orders (PO) and there were no orders for the following: PICC line catheter, catheter care, dressing changes to the PICC line site or flushes to keep the PICC line patent. The surveyor reviewed the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for the month of August 2023 and there was no documentation for the following: PICC line catheter, catheter care, dressing changes to the PICC line site or flushes to keep the PICC line patent. On 10/03/24 at 11:57 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated she had been employed in the facility for 7 years. The LPN/UM explained the process for residents admitted with PICC lines. She stated that the nurse would obtain the size and measurement of PICC line from the hospital and receive orders for: measurements, dressing changes, port connector changes, flushes, and to monitor the site for s/s of infiltration or infection. The LPN/UM reviewed the residents electronic medical record (EMR) in the presence of the surveyor and confirmed that there were no physician orders for the maintenance of Resident #275 right upper extremity PICC line. The LPN stated that even if the PICC line was not being used the staff were still required to assure that the PICC line was flushed, and the dressing was changed, and the site was monitored for signs and symptoms of infection. The LPN/UM stated that dressing changes were done on admission and then weekly. She added that PICC line flushes were usually done weekly for maintenance. The LPN/UM confirmed that physician orders should have been obtained for the residents PICC line to be flushed and there also should have been dressing change orders. The surveyor reviewed the EMR and observed a Health Status Note (HSN) dated 08/25/2023 at 08:33 AM. The LPN had documented that she had flushed Resident #275's right upper extremity PICC line however there were no PO to flush the line. She also documented that the PICC line was patent, intact with no signs and symptoms of infection. On 10/03/24 at 12:26 PM, the surveyor and the LPN/UM telephone interviewed the LPN regarding the documentation in the EMR on 8/25/2023 at 08:33 AM. The LPN stated that she could not remember the details about Resident #275 and that if there were no orders to flush Resident #275's PICC line, then maybe she documented on the wrong resident. The LPN had no further details regarding her documentation or Resident #275 On 10/03/24 at 12:48 PM, the surveyor interviewed the Director of Nursing (DON) who explained that if a resident was admitted with PICC line, the nurse was responsible to find out when the PICC line was placed, confirm the PICC line's location, and length of PICC line. She stated that the nurse would be responsible to get an order from the physician for dressing changes and flushes. She stated that orders for flushes would be important to obtain to ensure that the PICC line remained patent. She also stated that it would be important to obtain orders for dressing changes to the PICC line site so that the resident was free from the potential of infection. The facility policy titled, Care and Maintenance of Central Venous Catheter implemented 09/01/2024, which indicated that the facility would adhere to accepted standards of practice regarding the care and maintenance of venous catheters. The policy indicated that compliance guidelines would include: -Document the indication for use. -Insertion date. -Type of catheter. The policy reflected that physician orders must be obtained for specific care and maintenance instructions and documentation activities should go into the nurse's notes and/or the Medication Administration Record. The facility policy titled Central Venous Access Catheter Flushing, Locking, and Removal implemented 09/01/2024, indicated that it was the policy of the facility to ensure that central venous catheters were flushed, locked, and removed consistent with current standards of practice. Compliance guidelines include obtaining physician's orders for the type of IV solution or medication, dose, rate, and length of treatment. The policy also indicated that the procedure would be documented. NJAC 8:39-27.1(a)

Complaint # NJ00177156, 00176805 Based on observation, interview, and record review, it was determined that the facility failed to ensure residents received showers as scheduled for 1 of 2 sampled residents (Resident #21), reviewed for Activities of Daily Living (ADLs). This deficient practice was evidenced by the following: On 10/03/2024 at 10:39 AM, the surveyor observed Resident #21 in the room. He/She stated they would rather be home, but had no issues with this facility. According to the admission Record Resident #21 was admitted to the facility with diagnosis that included but were not limited to intellectual disabilities and depression. The Minimum Data Set (MDS), an assessment tool, dated 08/28/2024 reflected that Resident # 21 was moderately cognitively impaired and that resident required substantial assistance with showering. A review of the September 2024 Treatment Administration Record (TAR) for Resident #21 reflected that the Resident was scheduled for showers every Sunday and Thursday on the day shift and if the resident refused a shower, staff should document in the electronic health record and the family must be notified. The same form reflected a blank for 09/5/2024. The form also reflected an n for 09/1/2024, 09/8/2024, 09/12/2024, 09/15/2024, 09/19/2024, 09/22/2024, and 09/26/2024. There was no documentation in the Progress Notes (PN), indicating the Resident refused to take showers and/or family was notified of the refusals for the month of September. On 10/04/2024 at 1:42 PM, the surveyor interviewed the Regional Clinical Director who stated that the nurses did not document in the progress notes however they did call and speak with the sister. She acknowledged that if something was not documented it was not done. On 10/07/2024 at 10:13 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who signed the September 2024 TAR. The LPN stated that most of the time Resident #21 refused the shower and she reached out to the family however it was not documented in the progress notes. She acknowledged that she should have documented it in the progress notes. A review of the facility's policy, titled, Bath, Shower/Tub reviewed on 01/2024, reflected : The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The same policy under Documentation revealed, The following information should be recorded on the resident's ADL record and/or in the resident's medical record. #5 If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. #6. The signature and the title of the person recording the data. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store, label, and remove expired drugs from the facility inventory. The deficient practice was observed in 1 of 3 medication rooms and 1 of 9 medication carts reviewed under the Medication Storage Task. On 10/04/2024 at 9:26 AM, the surveyor observed the [NAME] Wing Medication Storage room in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM) #1. At that time, the surveyor observed the following concerns: Three cultures that expired on 09/23/2024. Three cultures that expired on 08/08/2024. Two urine vacutainers that expired on 06/30/2024. One 1000 milliliter (mL) bag of Dextrose solution that expired in July of 2024. Two bottles of Pantoprazole 2 milligram(mg)/mL with a use-by date of 08/30/2024. One bottle of Pantoprazole 2mg/mL with a use-by date of 09/27/2024. At that time, during an interview with the surveyor, the LPN/UM # 1 stated that all medication should have an opening date. Further, she stated that she did not know when the medication Pantoprazole expired but that it should be discarded after use. Lastly, she confirmed that the cultures and urine vacutainers were expired and needed to discard them. On the same date at 9:41 AM, the surveyor observed the [NAME] Wing odd-side medication cart in the presence of LPN # 1. At that time, the surveyor observed the bubble-package for the medication lorazepam 0.6 mg (medication used to treat symptoms of Anxiety). At that time, the surveyor observed that the paper on the back of the package was opened and torn for two tablets of lorazepam. At that time, LPN # 1 confirmed she did not look at the back of the package when she counted the medication in the morning. The LPN concluded by stating that she would notify the supervisor and discard the tablets. On the same date at 10:15 AM during an interview with the surveyor, LPN/UM # 1 said she did not know that when nurses were counting medications that they should be looking at the back of the package to ensure that the integrity of the paper that holds the medication was intact, worn, or torn. On the same date at 10:49 AM during an interview with the surveyor, the acting-Assistant Director of Nursing confirmed that when nurses count the medications, they should be looking at the front of the package and back of the package to ensure that nothing is worn, torn, or taped. Further, she said that if it is worn or torn, the medication could be lost, and the inventory could be wrong. She said that if the package is taped, then the nurse would not know if that were the correct medication. Lastly, if the issue is observed then the medication should be discarded, and the nurse should notify the supervisors and Director of Nursing before signing that the inventory was correct. On the same date at 1:03 PM during an interview with the surveyor, the Director of Nursing (DON) said that in-service education would be conducted for all nurses individually that tape is not to be used if the package is damaged, worn, or torn. A review of the facility provided policy titled, Storage of Medications updated on 1/2024 revealed under, Policy and Interpretation that, 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. § 8:39-29.4 (a)

B.) On 10/04/2024 at 8:30 AM, Surveyor #2 from the hallway observed Registered Nurse (RN) #1 inside Resident # 425's room. At that time, Surveyor # 2 observed a sign on the room door that revealed Resident # 425 was on Contact Precautions. The sign had instructions that revealed a gown must be worn while inside the room. RN # 1 was not wearing a disposable gown while in the room. A review of Resident # 425's physician's orders located in the Electronic Medical Record revealed he/she had an order to maintain contact isolation precautions related to Group B Streptococcus (a highly contagious bacteria) and Methicillin Resistant Staphylococcus Aureus (a multi-drug resistant pathogen) in a wound located on the Resident's knee. The order revealed that, nurse to ensure proper isolation equipment is present: stop sign on door, supplies (gown, gloves, mask) are in the bin outside room . During an interview with Surveyor # 2 on 10/04/2024 at 8:35 AM, RN # 1 said she was not wearing a gown. RN # 1 then said she should be wearing a gown to protect herself and the resident from infection. During an interview with surveyor on 10/04/2024 9:03 AM, the Director of Nursing (DON) said if someone is on contact barrier precautions the nurses should be wearing personal protective equipment (PPE) while completing wound care. During an interview with surveyor on 10/04/2024 1:43 PM, Licensed Practical Nurse/Unit Manger (LPN/UM#1) said nurses should wear PPE when completing wound care for residents on contact or enhanced precautions to protect themselves. A review of a facility policy dated 09/01/2024 titled, Transmission-Based (Isolation) Precautions, revealed under contact precautions letter c, Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. N.J.A.C. § 8:39-19.4(a) Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to A.) perform hand hygiene before applying gloves and between changing gloves and B.) failed to follow transmission-based precautions, specifically by not using a gown within a resident's room who was on transmission-based precautions. The deficient practice was observed for 1 of 2 nurses observed for Medication Administration task and 1 of 1 Resident (Resident # 425) reviewed for Transmission Based Precautions. This deficient practice was evidenced by the following: A.) On 10/03/2024 at 08:18 AM during the Medication Administration task, surveyor #1 observed Licensed Practical Nurse (LPN) # 1 putting on personal protective equipment (PPE) prior to administering medications to Resident #100. LPN# 1 did not perform hand hygiene prior to putting on gloves. On 10/03/2024 at 08:33 AM surveyor #1 observed LPN # 1 put on a pair of gloves without performing hand hygiene to place a medication patch on Resident # 32. LPN #1 then realized her pen was in her pocket to date the patch. LPN # 1 then took off the gloves and signed the patch before putting on a new pair of gloves. LPN # 1 did not perform hand hygiene between the glove change. On 10/03/2024 at 08:39 AM during an interview with Surveyor #1, LPN #1 replied Yes when asked if hand hygiene should be performed prior to putting on gloves. When asked if she had done that, LPN#1 replied, No. On 10/08/2024 at 12:31 PM during an interview with Surveyor # 1 the Infection Preventionist (IP) stated, Hand hygiene should be performed before and after using gloves, after using the bathroom, before and after eating, and any time visibly soiled. On 10/08/2024 at 02:22 PM during an interview with Surveyor # 1, the Director of Nursing (DON) replied Yes when asked if hand hygiene is required prior to putting on gloves and during glove changes. A review of a facility provided policy titled Administering Medications with a revised date of 1/2024 revealed under Policy Interpretation and Implementation that, 12. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for administering medications, as applicable. A review of a facility provided policy titled Handwashing/Hand Hygiene with a revised date of 1/2024 revealed under Policy Interpretation and Implementation that, 2. All personal shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personal, residents, and visitors; 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as best practice for preventing healthcare-associated infections.

Based on interview and record review it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 3 of 5 residents reviewed for medication management (Resident #70, Resident #92, and Resident #50). The deficient practice was evidenced by the following: On 10/03/2024 at 08:48 AM the surveyor requested from the Director of Nursing (DON) the CP's recommendations for Resident #70, Resident#92, and Resident # 50, from the last 6 months. 1. A review of the admission Record for Resident#70 revealed the resident was admitted to the facility with the diagnoses which included but were not limited to Heart Failure, and Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). On 10/03/2024 at 01:17 PM, the DON provided the surveyor with Resident #70's CP recommendation reports for April 2024 through September 2024. The CP recommendation dated 09/12/2024, indicated that the medication Carvedilol (medication used to treat blood pressure and heart failure) should be administered with food or meals. This recommendation was not completed or acted upon by the facility until 10/03/2024. The CP recommendation dated 08/16/2024, indicated there was a duplicate order for Tylenol (medication used to treat pain and/or reduce fever). This recommendation was not completed or acted upon by the facility until 10/03/2024. The CP recommendation dated 08/16/2024, indicated to correct the MiraLAX (medication used to treat constipation) dosage. This recommendation was not completed or acted upon by the facility until 10/03/2024. 2. A review of the admission Record for Resident#92 revealed the resident was admitted to the facility with the diagnoses which included but were not limited to Palliative Care, (specialized medical care for people living with a serious illness) Rhabdomyolysis (a condition caused by muscle injury or breakdown) and Hypertension (high blood pressure). On 10/03/2024 at 01:17 PM, the DON provided the surveyor with Resident #92's CP recommendation reports for April 2024 through September 2024. The CP recommendation dated 09/17/2024 indicated that a previous recommendation made on 08/15/2024 for Morphine sulfate to write separate orders for each indication was not addresses. This recommendation was not completed or acted upon by the facility until 10/03/2024. The CP recommendation dated 08/15/2024 indicated to sequence the indication for Tylenol as needed. This recommendation was not completed or acted upon by the facility until 10/03/2024. The CP recommendation dated 08/15/2024 indicated verify orders for Morphine Sulfate liquid dosage. This recommendation was not completed or acted upon until 10/03/2024. 3.According to the admission Record (AR), Resident #50 was admitted to the facility with the diagnoses which included but was not limited to hypertension and depression. The admission Minimum Data Set (MDS), an assessment tool dated 09/02/2024, reflected that the resident had no cognitive deficits. On 10/04/2024 at 08:48 AM, the surveyor reviewed the Pharmacist Consultant (CP) comments report for Resident #50. The CP recommendation dated 09/16/2024, indicated the Ammonium Lactate (used to treat skin conditions) should be placed on the treatment administration record instead of the medication administrative record. This recommendation was not completed by the facility. The CP recommendation dated 08/27/2024, indicated that the medication Omeprazole (used to treat heartburn) should be administered on an empty stomach, at least 30 minutes before eating. This recommendation was not completed or acted upon by the facility until 10/03/2024. The CP recommendation dated 08/27/2024, indicated not to crush Guaifenesin ER (used to treat congestion) and Potassium Chloride ER. This recommendation was not completed or acted upon by facility until 10/03/2024. The CP recommendation dated 08/27/2024, indicated to identify the duration of therapy for Guaifenesin ER. This recommendation was not completed or acted upon by facility until 10/04/2024. The CP recommendation dated 08/27/24, indicated the facility should clarify the diagnosis for Atenolol (used to treat blood pressure), Furosemide (used to treat water retention), and Umeclidinium (used to treat shortness of breath, wheezing). This recommendation was not completed or acted upon by facility until 10/03/2024. The CP recommendation dated 08/27/24, indicated that acetylcysteine (used to treat congestion) should be administered separately in the nebulizer. This recommendation was not completed or acted upon by the facility until 10/03/2024. On 10/07/2024 at 11:37 AM, the surveyor interviewed the North Unit Manager who stated that each nurse manager is responsible for completing the CP's recommendations. The Director of Nursing (DON) receives the report from the CP then the DON distributes the report to the Unit Managers. The North Unit Manager stated she normally completes the CP recommendations within two days, goes through them, and contacts the physician to review the recommendations. She stated that she was running behind for Resident #50's CP recommendations. She acknowledged that the CP recommendations for Residents #70, #92, and #50 should have been completed sooner. On 10/09/2024 at 10:19 AM, the surveyor interviewed the DON who stated the unit managers should complete the CP recommendations within five days. The surveyor reviewed the facility provided policy titled, Medication Regimen Review, implemented 09/1/2024. The policy reflected f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. NJAC 8:39-29.3 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) properly label and date food products stored in a refrigerator, spice rack, and meat freezer; b) properly discard food products on or before the expiration date; and c) properly store food products in a manner without covers. The deficient practice was evidenced by the following: On 10/02/2024 from 9:47 AM to 10:48 AM, the surveyor, accompanied by the Dietary Director (DD) and later at 10:47 AM joined by the Regional Dietary Director (RDD), observed the following: 1.) Next to the preparation table near the sink, the surveyor observed breadcrumbs inside a clear container labeled flour and not labeled with an open and use by date. The surveyor then observed a refrigerator referred to as the everything refrigerator. Within the refrigerator, the surveyor observed the following: 2.) A stick of butter opened to air and not labeled with an open and use by date. 3.) Two tomatoes in plastic wrap labeled with a use by date of 09/24/2024. 4.) One quarter pan of cooked puree pork labeled with a use by date of 10/01/2024. 5.) Two souffle cups filled with salad dressing that were not labeled with a use by date. 6.) A 1-gallon container of thousand island salad dressing labeled with an open date of 04/07/2024 and use by date 05/06/2024. 7.) An opened, 48-ounce container of cottage cheese not labeled with an open and use by date. 8.) An opened, 32-ounce plastic bottle of lemon juice not labeled with an open and use by date. 9.) An opened, 8-pound container of feta cheese not labeled with an open date. 10.) An opened, 1-quart glass jar of minced garlic not labeled with an open and use by date. The surveyor then observed the spice rack located above the stove. The surveyor observed the following: 11.) A 16-ounce container of granulated garlic powder that was opened to the air. A 16-ounce container of ground ginger without a visible open and use by date label. A 16-ounce container of chili powder and 11-ounce container of parsley flakes, neither was labeled with an open date or use by date. An 11-ounce container of dry spice that was labeled with an open date of 05/05/2023 and a use by date of 05/05/2024. An opened, 1-gallon container of soy sauce. A 1-gallon container of white vinegar, and a one quart container of gravy aid not labeled with an open and use by date. Also located on the rack above the stove, the surveyor observed: 12.) A 28-ounce bag of cream of wheat opened to air. An opened 28-ounce bag of cream of rice in plastic wrap, and two bags of 5-pound dry pancake waffle mixes opened to air and not labeled with an open and use by date. 14.) In a lower shelf under the preparation countertop, there was a 45-pound box of instant beef soup base in a plastic bag opened to air and not labeled with an open and use by date. The surveyor then observed the freezer referred to as the meat freezer. The surveyor observed the following within the freezer. 15.) Three pie crusts opened to air and not labeled with an open and use by date. 16.) One bag of opened, chicken nuggets in plastic wrap and not labeled with an open and use by date. 17.) One box of bacon opened to air and not labeled with an open and use by date. 18.) One quarter pan of vanilla pudding labeled with a use by date 10/01/2024. 19.) One bin filled with assorted juices with no individual expiration dates. During the observation with the DD and RDD, the DD stated that food items should be labeled with an opened and use-by date to ensure freshness. Further they said items exposed to air can become contaminated with bacteria and pose a risk for illness. Lastly, the DD said she will dispose of all the items. During an interview with the surveyor on 10/02/2024 at 10:50 AM, the DD said every item is labeled once opened with an opened and use by date. A review of the undated facility policy titled, Dating and Labeling Policy, under Procedure revealed, 1.) Upon receiving and storing, all items must be labeled with the name of food and received date. Once opened, the label must be updated with the current date and a use by date of 3 days (including date opened) unless indicted on Labeling and Dating Protocol. The policy also revealed the following, 2.) Prepared Ready-to-eat foods are to be wrapped and labeled with the name of food and 3 days use by date (including date prepared) prior to being placed in refrigerator. 3.) All items with an expired use by date must be discarded immediately. A review of the undated facility policy titled, Dry Food Policy, revealed under, Procedure that, 1.) Upon delivery, all dry food items will be checked to ensure all packaging is intact and marked off against the packing slip. No torn or broken boxes, wet stains, missing labels. The policy also revealed that, 2.) Immediately after delivery, date products for proper rotation using first in and first out method, (FIFO). 3.) Keep products in original packaging or in tightly covered, clearly labeled containers. A review of the undated facility policy titled, Opened Foods and Storage Policy, revealed that 1.) All opened foods should be wrapped tightly with plastic wrap or stored in an airtight container to avoid exposure to air and contaminants. 2.) After proper wrapping, all opened items must have an opened on/made on and use by date. 3.) All opened foods must be discarded by end of day on use by date. N.J.A.C 8:39-17.2 (g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00160150 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that proper incontinence care was provided to dependent residents. This deficient practice was identified for 2 of 3 residents (Resident #13, and #14) observed for incontinence care and was evidenced by the following: On 12/29/23 at 7:52 AM, the surveyor accompanied by Certified Nursing Assistants (CNA) completed an incontinence tour on the South Wing Nursing Unit. Three random residents who were identified by the CNAs as being dependent on staff for care, were observed for incontinence care. Surveyor #1, Surveyor #2, and CNA #3 entered Resident #13's room. Resident #13 was in bed wearing a hospital style gown. At that time, the resident granted permission for the surveyors to observe his/her incontinence brief. Surveyor #1 observed an incontinence brief applied to the resident. The CNA opened that brief exposing an additional brief underneath. The addition brief was damp. At this time CNA #3 informed the surveyors that residents should not be double briefed. He stated the reason this resident may have had two briefs put on is due to being a heavy wetter. On 12/29/23 at 8:05 AM, Surveyor # 1 and Surveyor #2 in the presence of CNA #4 observed Resident #14 in bed. Resident #14's sheets were dry, and no odor was discovered. At that time, the resident granted permission for surveyors to observe his/her incontinence brief. Surveyor #1 observed an incontinence brief applied to resident. CNA #4 opened the resident's brief exposing an additional brief underneath. The additional brief was damp. At that time, CNA #4 stated that residents should never be double briefed with two incontinence briefs. The resident then asked the CNA to be helped to the toilet so that they could use the commode. On 12/29/23 at 8:10 AM, the surveyor interviewed the Licensed Practical Nurse #3 (LPN #3), who stated that the majority of residents on this nursing unit have incontinence and require staff to check them every two hours. LPN #3 stated incontinence briefs should never be doubled up when applied to residents as it could cause skin disorders. On 12/29 at 8:25 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM #1), who stated residents should not be double diapered. She further stated, applying double briefs on residents could cause skin breakdown, and stated, I'm appalled, I don't know what happened. The RN/UM stated that short staffing could be a cause as to why this occurred, and that the CNA's receive education and know better. On 12/29/23 at 8:40 AM, the surveyor interviewed the Director of Nursing (DON), who stated incontinent residents should be checked every two hours, and if they were a heavy wetter then they should be checked more frequently. The DON stated residents should never be double diapered, stating we don't practice that, it can cause skin breakdown. The DON stated that old school CNA's might double diaper, and it is not acceptable. According to the admission Record, Resident #13 had diagnoses that included, but were not limited to: dementia and cerebral infarction (stroke). Review of Resident #13's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/4/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident had severe cognitive impairment. The MDS further revealed that Resident #13 was incontinent. According to the admission Record, Resident #14 had diagnoses that included, but were not limited to: dementia and failure to thrive. Review of Resident #14's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 6 out of 15, which indicated that the resident had severe cognitive impairment. The MDS further revealed that Resident #14 was incontinent. Review of the facility's Activities of Daily Living (ADLs) policy (Updated 1/2023) indicated the following: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (meals and snacks); and e. communication (speech, language, and any functional communication systems). NJAC 8:39-27.1 (a), 27.2 (h)

Compliant Number: NJ00159616 Based on observation, interview, and record review, it was determined that the facility failed to provide indwelling urinary catheter (a tube that is placed inside the bladder to facilitate the flow of urine) care in a manner to prevent urinary tract infections (UTI). This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for catheter care and urinary tract infection and was evidenced by the following: According to the admission Record, Resident #6 was admitted to the facility with diagnoses which included but not limited to: neuromuscular dysfunction of bladder (person who lacks bladder control due to brain, spinal cord, or nerve problems), chronic kidney disease (gradual loss of kidney function over time), and Type 2 diabetes mellitus (a disease of inadequate control of blood levels of glucose). According to the admission Minimum Data Set (MDS), an assessment tool, dated 9/20/2022, revealed that Resident #6's cognitive skills were severely impaired, and had an indwelling catheter. Additional review revealed active diagnosis of Renal Insufficiency, Neurogenic Bladder, and Diabetes Mellitus. A review of the Physician Order Summary Report, dated 9/17/2022, revealed the following physician orders for Resident #6: Patient has indwelling Foley Catheter, size 16Fr (French) balloon size 10 cc (cubic centimeters), every shift for diagnosis of urinary retention. Check placement and patency every shift. A review of Resident #6's comprehensive care plan revealed a care plan focus: Resident #6 has Foley Catheter: Neurogenic bladder. Date Initiated: 09/27/2022. Care planned interventions included: The resident will be/remain free from catheter related trauma through review date. Date Initiated: 09/27/2022. The resident will show no s/sx (signs/symptoms) of Urinary infection through review date. Date Initiated: 09/27/2022. Monitor/document for pain/discomfort due to catheter. Date Initiated: 09/27/2022. Monitor/record/report to MD (medical doctor) for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date Initiated: 09/27/2022. A review of October 2022 Medication Administration Record (MAR) revealed the following physician orders: Order start date of 9/27/2022 for Document Foley drainage every shift. Include color, clarity, consistency, amount, presence of sediment. every 12 hours related to neuromuscular dysfunction of bladder, unspecified. Document Foley drainage every shift. Include color, clarity, consistency, amount, presence of sediment. Order start date of 10/23/2022 for Bactrim DS Tablet 800-160 MG (milligrams) (Sulfamethoxazole-Trimethoprim) (an antibiotic) Give 1 tablet by mouth every 12 hours for UTI for 10 Days. Order was discontinued on 10/27/2022. Order Date of 10/27/2022 for Diflucan Tablet 100 MG (Fluconazole) (an antifungal medication) Give 1 tablet via PEG-Tube one time a day for R/T (related to) infection for 3 Days. A review of the Progress Notes dated 12/29/2023 at 11:20 AM, revealed that on 10/23/2022 Resident #6 had a fever and was started on Bactrim (an antibiotic used to treat urinary tract infections) for 10 days for UTI. On 10/27/2022 there were new orders for Resident #6 to discontinue the Bactrim and start Diflucan for 3 days for UTI. On 10/28/2022 Resident #6 was noted to have a possible penile infection. Resident #6 was sent to the emergency room (ER) and admitted to the hospital for diagnosis of UTI. A review of October 2022 Treatment Administration Record (TAR) revealed that Resident #6 did not have a physician order for Foley Catheter care. On 12/28/2023 at 1:40 PM, the surveyor interviewed the Licensed Practical Nurse #2 (LPN #2). LPN #2 stated that there should be a physician's order for foley catheter care in the electronic Medication Administration Record (eMAR). When asked what does foley catheter care include? LPN#2 stated It includes cleaning around the foley catheter insertion site. If we notice any signs or symptoms of infection, we will notify the physician. LPN #2 went into the computer to show the surveyor an order for a resident with an indwelling catheter. The order read Render foley care q (every) shift and PRN (as needed) During an interview with the Registered Nurse Unit Manager #2 (RN/UM #2) on 12/28/2023 at 1:50 PM, RN/UM #2 stated the nurses and aides will clean the foley catheter area during peri-care (care of the private areas). When asked if there should be a physician's order for Foley catheter care, RN/UM #2 stated, I don't believe we need an order for foley catheter care. On 12/29/2023 at 9:05 AM, the surveyor conducted an interview with the Director of Nursing (DON). The DON stated, there should be a physician's order for Foley catheter care. The order will show up on the TAR. When asked what does foley catheter care include? The DON said it includes managing the foley catheter, monitoring it for kinks in the tubing, observing the urine for color, cleaning the meatus (site of entrance of the catheter into the body) and area around the foley catheter. The DON then stated If foley catheter care is not completed the resident is at risk for Urinary Tract Infection (UTI) and/or trauma. The Surveyor reviewed the facility provided policy and procedure: Catheter Care, Urinary last revised date: August 2022 which included, Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. The following was revealed under the steps in the Procedure. Routine Perineal Care Hygiene: 14. For a male resident: a. Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse around the meatus. 15. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from insertion site to approximately four inches outward. The following was revealed under Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 5. Any problems noted at the center-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. NJAC 8:39-19.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00160024, NJ00160394, NJ00160202 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain the resident nurse call system to operate as designed for 3 of 5 call bells observed. This deficient practice was evidenced by the following: On 12/29/23 at 8:00 AM, the surveyor observed North Wing Unit, no resident rooms had a call bell light illuminated above room doors. On 12/29/23 at 8:12 AM, the surveyor entered the Star Spa Bathroom (shower room) on North Wing and observed three call systems. The call bell located next to the toilet was activated by the surveyor at 8:12 am. The surveyor waited three minutes and exited the Star Spa Bathroom and notice no light was illuminated above the door. On 12/29/23 at 8:15 AM, the surveyor interviewed the Unit Clerk (UC). She indicated that if a call system is activated that the phone at the nurses station will sound and indicate what room it was triggered in, additionally the lights above the room will illuminate. She also stated that if it is a light to a resident room, it will illuminate a white flashing light and the bathroom will illuminate a red flashing light. The surveyor observed no flashing light outside the door of Star Spa Bathroom and no ringing of the call bell system at the nurses station. On 12/29/23 at 8:23 AM, the surveyor activated the call bell system of the visitor's bathroom near the entrance of the facility by the dining hall. Upon exit of the bathroom a white light was illuminated above the door. The surveyor proceeded to the East Wing call bell location indicator panel. The surveyor observed the call system was alarming but it did not indicate the location of the alarm. On 12/29/23 at 8:32 AM, the surveyor interviewed the Unit Manager Licensed Practical Nurse (UM/LPN). The surveyor requested the UM/LPN to pick a random unoccupied room to activate the call system. The UM/LPN activated the call system of room [ROOM NUMBER]. The surveyor and UM/LPN observed a white call light illuminate above the entrance door of room [ROOM NUMBER], indicating the call bell alarm was activated in that room. At this time, the surveyor and UM/LPN proceeded to the nurses station where the Maintenance Director was present. The UM/LPN and the Maintenance Director confirmed the call bell indicator at the nurses station did not indicate room [ROOM NUMBER]'s call bell had been activated. On 12/29/23 at 8:42 AM, on the East Wing, the surveyor interviewed the facility Maintenance Director. He confirmed the call bell system was alarming but could not identify the location of the alarm. At this time, the surveyor also interviewed Certified Nurses Assistants #1 (CNA #1) and CNA #2, both CNAs confirmed that the call system was triggered, and they checked every room but could not identify the location of the call alarm. At this time, the Maintenance Director accompanied by the surveyor proceeded to the visitor's bathroom near the entrance of the facility by the dining hall and turned the unanswered call system off. On 12/29/23 at 8:53 AM, the surveyor along with the Maintenance Director, proceeded to the Star Spa Bathroom, where the call bell was initially activated at 8:12 AM. The Maintenance Director confirmed that the call light next to the toilet is activated. The surveyor and the Maintenance Director exited the bathroom, and no flashing red light was illuminated above the door or alarming at the nurses station. The Maintenance Director confirmed that the call systems were not working properly and stated, it is not working. On 12/29/23 at 10:20 AM, in the presence of the survey team, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the last time a call bell audit was completed was 10/31/23. The LNHA confirmed that all the call bell systems should be working, and it is not acceptable for any call alarm to not function properly. A review of the facility provided policy on call lights last updated on 1/2022 included but was not limited to, check lights when providing care to ensure that cord length is appropriate, and that light is in working order. Report defective call lights promptly to maintenance for immediate repair and arranges for alternate call system or change patients room and frequent checks on resident. Review of the facility call bell checklist included, check call bells in facility once per quarter. Confirm bells, outdoor lights, and nurses stations are functioning for all beds. NJAC 8:39-31.2 (e), 31.8 (c)9

Complaint #: NJ00160150, NJ00169450, NJ00159215 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to, a.) provide sufficient staffing numbers to meet minimum staffing requirements and b.) provide nursing and related services to assure the residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment. This deficient practice was identified for 2 of 3 residents (Resident #13, and #14) observed for incontinence care and was evidenced by the following: Refer F677(D) a.) Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, 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 02/01/2021: One (1) Certified Nurse Aide (CNA) to every eight (8) residents for the day shift. One (1) 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 (1) 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. As per the Nurse Staffing Report completed by the facility for the weeks listed, the staffing-to-resident ratio did not meet the minimum requirements and is documented below: For the week of Complaint staffing from 10/23/2022 to 10/29/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in total staff for residents on 7 of 7 overnight shifts as follows: -10/23/22 had 12 CNAs for 133 residents on the day shift, required at least 17 CNAs. -10/23/22 had 3 total staff for 144 residents on the overnight shift, required at least 9 total staff. -10/24/22 had 13 CNAs for 132 residents on the day shift, required at least 16 CNAs. -10/24/22 had 3 total staff for 132 residents on the overnight shift, required at least 9 total staff. -10/25/22 had 14 CNAs for 132 residents on the day shift, required at least 16 CNAs. -10/25/22 had 3 total staff for 132 residents on the overnight shift, required at least 9 total staff. -10/26/22 had 13 CNAs for 132 residents on the day shift, required at least 16 CNAs. -10/26/22 had 3 total staff for 132 residents on the overnight shift, required at least 9 total staff. -10/27/22 had 12 CNAs for 132 residents on the day shift, required at least 16 CNAs. -10/27/22 had 3 total staff for 132 residents on the overnight shift, required at least 9 total staff. -10/28/22 had 13 CNAs for 139 residents on the day shift, required at least 17 CNAs. -10/28/22 had 3 total staff for 139 residents on the overnight shift, required at least 10 total staff. -10/29/22 had 9 CNAs for 138 residents on the day shift, required at least 17 CNAs. -10/29/22 had 7 total staff for 138 residents on the overnight shift, required at least 10 total staff. For the week of Complaint staffing from 12/11/2022 to 12/17/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts, deficient in CNAs to total staff on 1 of 7 evening shifts, and deficient in total staff for residents on 7 of 7 overnight shifts as follows: -12/11/22 had 14 CNAs for 130 residents on the day shift, required at least 16 CNAs. -12/11/22 had 3 total staff for 130 residents on the overnight shift, required at least 9 total staff. -12/12/22 had 12 CNAs for 129 residents on the day shift, required at least 16 CNAs. -12/12/22 had 3 total staff for 129 residents on the overnight shift, required at least 9 total staff. -12/13/22 had 13 CNAs for 129 residents on the day shift, required at least 16 CNAs. -12/13/22 had 9 CNAs to 20 total staff on the evening shift, required at least 10 CNAs. -12/13/22 had 4 total staff for 129 residents on the overnight shift, required at least 9 total staff. -12/14/22 had 12 CNAs for 129 residents on the day shift, required at least 16 CNAs. -12/14/22 had 4 total staff for 129 residents on the overnight shift, required at least 9 total staff. -12/15/22 had 13 CNAs for 129 residents on the day shift, required at least 16 CNAs. -12/15/22 had 4 total staff for 129 residents on the overnight shift, required at least 9 total staff. -12/16/22 had 13 CNAs for 137 residents on the day shift, required at least 17 CNAs. -12/16/22 had 3 total staff for 137 residents on the overnight shift, required at least 10 total staff. -12/17/22 had 13 CNAs for 137 residents on the day shift, required at least 17 CNAs. -12/17/22 had 3 total staff for 137 residents on the overnight shift, required at least 10 total staff. For the 3 weeks of Complaint staffing from 12/03/2023 to 12/23/2023, the facility was deficient in CNA staffing for residents on 21 of 21 day shifts, deficient in total staff for residents on 1 of 21 evening shifts, and deficient in total staff for residents on 21 of 21 overnight shifts as follows: -12/03/23 had 12 CNAs for 138 residents on the day shift, required at least 17 CNAs. -12/03/23 had 3 total staff for 138 residents on the overnight shift, required at least 10 total staff. -12/04/23 had 13 CNAs for 138 residents on the day shift, required at least 17 CNAs. -12/04/23 had 3 total staff for 138 residents on the overnight shift, required at least 10 total staff. -12/05/23 had 13 CNAs for 138 residents on the day shift, required at least 17 CNAs. -12/05/23 had 4 total staff for 138 residents on the overnight shift, required at least 10 total staff. -12/06/23 had 14 CNAs for 138 residents on the day shift, required at least 17 CNAs. -12/06/23 had 3 total staff for 138 residents on the overnight shift, required at least 10 total staff. -12/07/23 had 13 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/07/23 had 3 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/08/23 had 14 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/08/23 had 3 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/09/23 had 12 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/09/23 had 3 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/10/23 had 12 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/10/23 had 3 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/11/23 had 13 CNAs for 144 residents on the day shift, required at least 18 CNAs. -12/11/23 had 4 total staff for 144 residents on the overnight shift, required at least 10 total staff. -12/12/23 had 13 CNAs for 144 residents on the day shift, required at least 18 CNAs. -12/12/23 had 3 total staff for 144 residents on the overnight shift, required at least 10 total staff. -12/13/23 had 13 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/13/23 had 3 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/14/23 had 14 CNAs for 143 residents on the day shift, required at least 18 CNAs. -12/14/23 had 4 total staff for 143 residents on the overnight shift, required at least 10 total staff. -12/15/23 had 13 CNAs for 141 residents on the day shift, required at least 18 CNAs. -12/15/23 had 3 total staff for 141 residents on the overnight shift, required at least 10 total staff. -12/16/23 had 13 CNAs for 139 residents on the day shift, required at least 17 CNAs. -12/16/23 had 3 total staff for 139 residents on the overnight shift, required at least 10 total staff. -12/17/23 had 13 CNAs for 135 residents on the day shift, required at least 17 CNAs. -12/17/23 had 3 total staff for 135 residents on the overnight shift, required at least 10 total staff. -12/18/23 had 9 CNAs for 135 residents on the day shift, required at least 17 CNAs. -12/18/23 had 3 total staff for 135 residents on the overnight shift, required at least 10 total staff. -12/19/23 had 14 CNAs for 135 residents on the day shift, required at least 17 CNAs. -12/19/23 had 3 total staff for 135 residents on the overnight shift, required at least 10 total staff. -12/20/23 had 12 CNAs for 135 residents on the day shift, required at least 17 CNAs. -12/20/23 had 3 total staff for 135 residents on the overnight shift, required at least 10 total staff. -12/21/23 had 14 CNAs for 141 residents on the day shift, required at least 18 CNAs. -12/21/23 had 3 total staff for 141 residents on the overnight shift, required at least 10 total staff. -12/22/23 had 11 CNAs for 139 residents on the day shift, required at least 17 CNAs. -12/22/23 had 3 total staff for 139 residents on the overnight shift, required at least 10 total staff. -12/23/23 had 14 CNAs for 135 residents on the day shift, required at least 17 CNAs. -12/23/23 had 10 CNAs to 23 total staff on the evening shift, required at least 11 CNAs. -12/23/23 had 3 total staff for 135 residents on the overnight shift, required at least 10 total staff. On 12/29/23 at 7:39 AM, the surveyor interviewed CNA #3 who stated CNAs are usually assigned to 11 to 14 residents because of being short staffed often. The CNA further stated they will have only 9 resident assignment if lucky. On 12/29 at 8:25 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM #1), who stated short staffing could be a potential cause of resident incontinence care being affected. On 12/29/23 at 8:40 AM, the surveyor interviewed the Director of Nursing (DON) regarding staffing. The DON confirmed the required staffing ratio and stated she believed it was being met. On 12/29/23 at 9:52 AM, the surveyor interviewed the staffing coordinator. She stated the CNA staffing ratios for the 7 AM to 3 PM shift was 8 residents per CNA, for the 3 PM to 11 PM shift 10 residents per CNA, for the 11 PM to 7 AM shift 14 residents per CNA. She stated the facility meets these ratio requirements when there are no call outs but stated we have a lot of those (meaning call outs). She further stated since the facility runs on 12-hour nursing shifts, it's tricky. b.) On 12/29/23 at 7:52 AM, the surveyor accompanied by Certified Nursing Assistants (CNA) completed an incontinence tour on the South Wing Nursing Unit. Three random residents who were identified by the CNAs as being dependent on staff for care, were observed for incontinence care. Surveyor #1, Surveyor #2 and CNA #3 entered Resident #13's room. Resident #13 was in bed wearing a hospital style gown. Resident #13's sheets were dry, and no odors were discovered. At that time, the resident granted permission for the surveyors to observe their incontinence brief. Surveyor #1 observed an incontinence brief applied to the resident. The CNA opened that brief exposing an additional brief underneath. The addition brief was damp. At this time the CNA informed the surveyors that residents should not be double briefed. He stated the reason the resident may have had two briefs put on was due to being a heavy wetter. On 12/29/23 at 8:05 AM, Survey# 1 and Surveyor #2 in the presence of CNA #4 observed Resident #14 in bed. Resident #14's sheets were dry, and no odor was discovered. At that time, the resident granted permission for surveyors to observe their incontinence brief. Surveyor #1 observed an incontinence brief applied to resident. The CNA opened the brief exposing an additional brief underneath. The additional brief was damp. At that time, CNA #4 stated that residents should never be double briefed with two incontinence briefs. The resident then asked the CNA to be helped to the toilet so that they could use the commode. Review of the facility's provided staffing policy titled Nursing Services dated 2/1/2022 included but was not limited to, .the facility will have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment . providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident needs . Review of the facility's Activities of Daily Living (ADLs) policy (Updated 1/2023) indicated the following: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (meals and snacks); and e. communication (speech, language, and any functional communication systems). NJAC 8:39-5.1(a), 27.1 (a), 27.2 (h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide privacy to one of 43 residents (Resident (R)101) on the South unit during care. The failure created the potential for R101 to be exposed to other residents, staff, and visitors. Findings include: Record review of the Medical Diagnoses, located in the electronic medical record (EMR), revealed R101 was admitted to the facility on [DATE] with diagnoses including dementia, gastrostomy, and colostomy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/23, located in the ''MDS'' tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severely impaired cognition. R101 was assessed to require extensive assistance of two persons for activities of daily living (ADL's). R101 was observed on 05/16/23 at 3:47 PM lying in bed in his room. The door to the room was open as well as the privacy curtain which permitted the resident to be seen, without obstruction, from the doorway and hall. R101 was observed with his gown up, exposing his stomach and incontinent brief. A Licensed Practical Nurse (LPN1) was providing care for R101's percutaneous endoscopic gastrostomy (peg-tube, feeding tube which is placed directly into the stomach). In the hall at the time of the observation were two surveyors, the Maintenance Director (MD), Administrator (ADM), Corporate Maintenance Director, a housekeeper, and other residents. LPN1 was interviewed at 03:50 PM and asked how the resident's privacy is maintained during care? LPN1 said I usually pull the curtain but didn't because (state) was in the hall and she thought we wanted to watch. Observation of the care of R101's peg-tube was not requested by the surveyors. Review of the facility's policy and procedure titled Quality of Life - Dignity, dated 01/20/23, revealed Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. During an interview on 05/19/23 at 10:00 AM, the Director of Nursing (DON) stated she would add the exposure to LPN1's disciplinary action, she should not have done that. NJAC 8:39-4.1(a)16

Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 43 facility residents on one of four wings (South). For seven of 43 residents (Resident (R) 76, R17, R60, R122, R35, R30, R82) the environment was not maintained. Throughout the South unit the temperature was not controlled in a comfortable range creating a warm environment for residents, staff, and visitors. Findings include: ENVIRONMENT Observations of the South wing, a secured unit with 43 residents, on 05/16/23 10:44 AM, revealed the following: Resident (R)76's room: Part of a floor tile, approximately five by eight inches, near the head of bed B was heavily damaged with tile missing. There was an unsightly glue-like substance underneath the length of the windowsill that appeared to have run down and dried on the wall. The paint on the bathroom door was heavily marred and scarred. R17's room: There was a broken stationary chair, missing the right arm which exposed an approximate seven-inch spindle where the armrest should have been. The armrest was on top of the dresser. R60's room: There was a missing chair rail at the head of bed A exposing unpatched and unpainted wall. There was a screw, approximately 1/2 inch out from the wall where the chair rail should have been. R122's room: There was a broken chair rail at the head of bed A. The wooden bedframe was heavily marred and scarred. The chair rail at the head of bed B was heavily marred and scarred. The wooden headboard and footboard were heavily marred and scarred. R35's room: There was an approximate three by three-inch area of bubbled paint above the head of the B bed. The bathroom door and door frame were heavily marred and scarred. R30's room: There was a broken chair rail, separated from the wall, at the head of bed A. The separation, greater than 1/2 inch, could fit a person's fingers underneath where nails were exposed. There was an approximate two by four inch corner of the headboard missing, which revealed a hole through the missing particle board. The footboard had a large chunk of particle board missing, approximately seven by nine inches, exposing the metal bedframe underneath the bed. The wall by the window was patched but not painted. R82's room: The chair rail, at the head of bed A was heavily marred and missing pieces. An over the bed table, used in the assisted dining room, was heavily marred, had missing and cracked edges and peeling veneer. Approximately five feet of baseboard was missing from a half wall in the assisted dining room. The wall was heavily marred with holes in the drywall where the baseboard should have been. One end of the half wall was missing approximately three inches of baseboard which exposed damaged drywall. This was located directly under a resident dining table. The carpet in the two hallways was dingy and stained. On 05/16/23 at 1:17 PM, the kitchenette, located in the solarium, was observed. Underneath the sink were two cabinet doors with handles. A hole had been drilled above each handle in the corner of each cabinet door. In each hole was a screw, approximately two inches in length, that was not screwed in and could be easily removed from the hole. The kitchenette had a half door on each end of the area with locks, however the locks were not engaged allowing access to residents. The Maintenance Director (MD), Corporate Maintenance (CM) person, Corporate Administrator (Corp Admin), and the Administrator in Training (AIT) were shown the conditions on 05/16/23 at 2:24 PM and on 05/19/23 at 10:05 AM. The MD confirmed all areas pointed out during the two environmental tours. The MD stated rounds of the South wing were conducted monthly. The MD was asked to provide documentation of the monthly rounds or a plan to fix the identified areas. No additional documentation was provided. TEMPERATURE LEVELS On 05/16/23 at 10:44 AM, the South wing, a secured unit, was observed to be stuffy and hot. At 2:38 PM on 5/16/23, the MD was asked to take air temperatures of the South wing. Using an electronic temperature gun, the MD registered a hallway temperature of 83.5 degrees, an assisted dining room temperature of 85.5 degrees, and a temperature of 84.0 degrees across the assisted dining room nearest the split air conditioning unit. The MD pointed the temperature gun at the right side of the split air conditioning unit which read 84.0 degrees. When asked how the temperature felt to the MD, he stated this is what it's reading the temperatures noted on the gun. The Corp Admin stated, on 05/16/23 at 3:03 PM, that the air conditioning units were just turned back on earlier today. The Corp Admin said I had to shut all the windows, it's a warm day today. In an interview on 05/16/23 at 12:07 PM, Certified Nursing Assistant (CNA) 3 said it's hot in here. In an interview on 05/16/23 at 3:43 PM, CNA2 said it gets a little warm, more people out, it was very warm today, I'm sweating. In an interview on 05/16/23 at 4:42 PM, CNA4 said it's hot, it's hot, that's why we have a fan in nurses' station. The CADM, stated on 05/16/23 at 4:35 PM, it's the warmest day for past two weeks. Review of the weather report showed outside high temperatures as: 05/14/23 79.0 degrees, 05/15/23 80.0 degrees; and 05/16/23 79.0 degrees. When asked how long the air conditioning had been off, the Adminsitrator said, on 05/16/23 at 04:03 PM, that he did not know. On 05/16/23 at 04:15 PM, the MD said today was the first day [this year] it was turned on. The CM said they need to keep it comfortable 75-80, no more than 81 or less than 71. In an interview on 05/16/23 at 4:20 PM, the CM said he expects daily rounds to check temps but doesn't expect them to write it down, just to keep an eye. On 05/16/23 at 4:35 PM, the Corp Admin said all other units were turned on today, but not the secured unit. The Corp Admin did not state why the secured unit air conditioners were not turned on. In an interview on 05/16/23 at 6:34 PM, a family member (F)1 said the staff kept the windows open for air circulation, that's what I'm told. On 05/16/23 at 4:35 PM, the split air conditioning unit was observed. The left side of the unit was blowing warm air while the right side was not blowing cool or warm air. At 4:45 PM on 05/16/23, the MD was observed to remove an air filter from the split air conditioners on the South wing. The filter was noted to be very dirty with a heavy build- up of dirt and dust. On 05/17/23 at 8:45 AM, the MD said he had not changed the filter since last year. Two maintenance manuals were reviewed, on 05/18/23 at 4:55 PM. 1.Mitsubishi Electric split type air conditioners indoor unit MSZ=GL18NA Cleaning Air filter (nano platinum filter) clean every two weeks. Air cleaning filter (anti-allergy enzyme filter) back side of air filter every 3 mon. [months] Important, Clean the filters regularly for best performance and to reduce power consumptions. Dirty filters cause condensation in the air conditioner which will contribute to the growth of fungi such as mold. Is therefore recommended to clean air filters every 2 weeks. 2.Bryant Single Package Rooftop Cooling only, nominal 3-10 tons with Puron (R-410A) refrigerant. This unit is designed for use with Puron refrigerant. Do not use any other refrigerant in this system. On 05/17/23 at 12:15 PM, the MD was asked for documentation to show that the air conditioning units were checked and serviced on a routine basis including filter changes. No documentation was provided prior to exit from the facility. NJAC 8:39-4.1(a)11 NJAC 8:39-31.4(a) NJAC 8:39-31.8(e)

Based on observation, interviews, and facility policy review, the facility failed to ensure one of two medication carts on the secured unit was locked while unattended. This had the potential to affect 10 (Resident (R) 80, R93, R30, R57, R240, R115, R13, R95, R17 and R10) of 43 residents who were at risk for wandering on the secured unit. Findings Include: Review of R80's quarterly Minimum Data Set (MDS), located under the MDS tab of the electronic medical record (EMR) and with an Assessment Reference Date (ARD) of 03/10/23, revealed R80 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R80 was severely cognitively impaired. The MDS recorded R80 had diagnoses which included dementia, anxiety, and major depressive disorder, and self-propelled per wheelchair. Review of R93's significant change MDS, located under the MDS tab of the EMR and with an ARD of 02/23/23, revealed R93 had a BIMS score of 0 out of 15, which indicated R93 was severely cognitively impaired and had diagnoses including dementia with agitation, major depressive disorder, and mood disorder. During the days of the survey, R93 was observed ambulating throughout the secured unit. Review of R30's annual MDS, located under the MDS tab of the EMR and with an ARD of 03/16/23, revealed R30 had a BIMS score of eight out of 10, which indicated R30 was moderately cognitively impaired; had diagnoses including dementia, major depressive disorder, and generalized anxiety disorder; and ambulated with supervision. Review of R57's quarterly MDS, located under the MDS tab of the EMR and with an ARD of 03/23/23, revealed R57 had a BIMS score of 11 out of 15, which indicated R57 was moderately cognitively impaired; had diagnoses which included dementia, major depressive disorder, and generalized anxiety disorder; and ambulated independently. Review of R240's quarterly MDS, located under the MDS tab of the EMR and with an ARD of 02/26/23, revealed R240 had a BIMS score of one out of 15, which indicated R240 was severely cognitively impaired; had diagnoses which included dementia, mood disorder, and generalized anxiety disorder; and ambulated with supervision. Review of R115's significant change MDS, with an ARD of 03/15/23 and located under the MDS tab of the EMR, revealed R115 had a BIMS score of three out of 15, which indicated R115 was severely cognitively impaired; had diagnoses which included dementia, major depressive disorder, and altered mental status; and self-propelled in a wheelchair. Review of R13's quarterly MDS, with an ARD of 04/21/23 and located under the MDS tab of the EMR, revealed R13 had a BIMS score of six out of 15, which indicated R13 was severely cognitively impaired; had diagnoses which included dementia, major depressive disorder, and generalized anxiety disorder; and ambulated with supervision. Review of R95's significant change MDS, with an ARD of 04/23/23 and located under the MDS tab of the EMR, revealed R95 had a BIMS score of zero out of 15, which indicated R95 was severely cognitively impaired; had diagnoses which included dementia, major depressive disorder, mood disorder and anxiety disorder; and ambulated with limited assistance. Review of R17's significant change MDS, with an ARD of 02/13/23 and located under the MDS tab of the EMR, revealed R17 had a BIMS score of zero out of 15, which indicated R17 was severely cognitively impaired; had diagnoses which included Alzheimer's disease, dementia, major depressive disorder, and generalized anxiety; and required limited assistance with ambulation. Review of R10's significant change MDS, with an ARD of 02/13/23 and located under the MDS tab of the EMR, revealed R10 had a BIMS score of zero out of 15, which indicated R10 was severely cognitively impaired; had diagnoses which included dementia, major depressive disorder, and generalized anxiety; and self-propelled in a wheelchair. On 05/16/23 at 3:37 PM, one medication cart on the secured unit was observed to be unattended and unlocked. Licensed Practical Nurse (LPN) 1, to whom the cart was assigned for the shift, was observed in a resident's room providing gastrostomy care. The medication cart was not in LPN1's line of sight. Staff members were observed at the nurses' station engaged in their work and did not have the medication cart in their line of sight. Residents were observed wandering about the unit in close proximity to the medication cart. The Administrator approached the surveyor, confirmed the medication cart was unlocked and unattended, asked staff who was assigned to the cart, and then locked the cart. During an interview on 05/16/23 at 3:45 PM, LPN 1 confirmed the medication cart was her assigned cart for the current shift and confirmed she had left it unlocked and unattended. During an interview on 05/18/23 at 6:12 PM, the Director of Nursing (DON) stated her expectations were for the nurses to keep medication carts always locked and secure. Review of the facility's policy titled Storage of Medications, updated 01/2023, revealed, . Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . 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(h)

Based on observation, resident, staff, and Ombudsman interviews, the facility failed to provide access to the resident identified telephone, for three of four units (West, East, and North), where calls can be made without being overheard. This failure created the potential for residents to be without private telephone communication. Findings include: On 05/17/23 at 1:00 PM, a Resident Council Meeting was conducted with seven residents (R31, R36, R39, R72, R84, R89, and R91) including the Resident Council President and the Resident Council [NAME] President. The residents present regularly attend the facility's monthly Resident Council meetings. R91 said the Resident Telephone, located at the end of the [NAME] Wing just before entering the secured South wing, is always blocked by wheelchairs and the lift. R91 further stated residents who do not have a private phone or a cell phone cannot access the phone. The other six residents, in attendance, confirmed R91's statement. R91 stated the concern had been raised numerous times with the Ombudsman (resident advocate) without any changes being made. The specified Resident Telephone was located at the end of the [NAME] wing, in an area off the hallway. A sign was posted next to the telephone identifying it as the Resident's Telephone. Three stationary chairs were placed along the wall, under the windows, next to the telephone which was mounted on the wall. A privacy curtain was hung along the outside of the area to be able to pull around the telephone which gave visual privacy, but no privacy from being overheard during a telephone call. The following observations were made of the identified Resident Telephone: On 05/16/23 at 5:00 PM, the resident telephone, a black phone on the wall, was blocked by multiple wheelchairs. The telephone was not accessible for use. On 05/17/23 at 9:40 AM, the resident telephone was blocked by a wheelchair and a mechanical lift. The telephone was not accessible for use. On 05/17/23 at 4:41 PM, the resident telephone was blocked by two wheelchairs, a reclining Geri chair, and a mechanical lift. The telephone was not accessible for use. On 05/17/23 at 9:45 PM, the resident telephone was observed to have three wheelchairs blocking the telephone. The telephone was not accessible for use. On 05/18/23 at 9:44 AM, the resident telephone was observed to be blocked by a wheelchair, a mechanical lift behind the wheelchair, and another wheelchair on the side of the mechanical lift. The telephone was not accessible for use. The same observation was made at 10:10 AM. The telephone was not accessible for use. On 05/18/23 at 11:50 AM, the resident telephone was blocked by a wheelchair. The telephone was not accessible for use. On 05/18/23 at 12:29 PM, the resident telephone was blocked by a wheelchair. The telephone was not accessible for use. On 05/18/23 at 5:37 PM, the resident telephone was blocked by two wheelchairs and a mechanical lift. The telephone was not accessible for use. In an interview on 05/19/23 at 10:05 AM, the Maintenance Director stated the resident phone was not his department. In an interview on 05/19/23 at 1:05 PM, the Ombudsman stated the resident telephone has been blocked for years. The Ombudsman said the resident telephone used to be in the front of the building and was private, but some wheelchairs couldn't fit so it was moved to the [NAME] wing. In an interview on 05/19/23 at 5:30 PM, the Director of Nursing (DON) stated she was made aware of the resident telephone being blocked. The DON confirmed that the wheelchairs and mechanical lift were placed in front of the telephone blocking access. The DON stated It's a struggle with the age and size of the building to make sure there is enough space especially for the large wheelchairs. The telephone used to be in the front, but the wheelchairs could not fit and the residents wanted the phone closer to their unit so it was moved to the [NAME] wing. NJAC 8:39-4.1(a)20

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident, staff, and Ombudsman interviews, the facility failed to provide a functioning ice/water machine on one (West) of four wings. This deficient practice had the potential to affect the proper hydration status of 38 residents who resided on the [NAME] unit. Findings include: 1. Review of R96's electronic face sheet, located on the Profile tab of the electronic medical record (EMR) revealed R96 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, hypertension, hyperlipidemia, anxiety disorder and anemia. Review of R96's Physician Orders, located under the Orders tab of the EMR, revealed no orders for a fluid restriction for R96. Review of R96's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/24/23 and located under the MDS tab of the EMR, revealed R96 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R96 was cognitively intact. The assessment recorded R96 was independent in locomotion, both on and off the unit, and did not require set-up help from staff. During an interview on 05/16/23 at 12:42 PM, R96 stated the ice machine on the west unit had been out of order and he had been told that he could not go and get his own water and ice. R96 stated he did not receive any ice or water from staff during the previous night or on this day. R96 stated the ice machine had been out for months. 2. Review of the monthly Resident Council Meeting minutes, dated 04/25/23, revealed water/ice machine on [NAME] unit broken. The staff response was noted still working on a part for the ice machine. Residents are allowed to use the ice/water machine in North wing. 3. On 05/17/23 at 1:00 PM, a Resident Council Meeting was conducted with seven residents (Resident (R) 31, R36, R39, R72, R84, R89, and R91) including the Resident Council President and the Resident Council [NAME] President. The residents present regularly attended the facility's monthly Resident Council meetings. R31 stated the ice/water machine on the [NAME] wing had been broken for six months. The residents in attendance confirmed R31's statement. R91 stated, They keep telling us they're waiting for a part, how long does it take to get a part? R31 stated the staff told the [NAME] wing residents they could go get ice on the North wing, however not all in attendance wanted to go off the [NAME] wing for ice/water. R91 stated not all the residents could get themselves up the ramp to get into the North wing to get ice/water by themselves. R91 stated, The ones in electric wheelchairs can go on their own, but I can't. The residents in the meeting stated they wanted to be able to access ice/water on their own and when they desired. The statement was confirmed by the seven residents. Observations were made of the [NAME] wing ice/water machine throughout the survey, from 05/16/23 through 05/19/23, by four surveyors. The ice/water machine was located at the end of the [NAME] wing, across from the Nurses Station, with easy access for residents and staff. A sign posted on the ice/water machine read, Out of Service. In an interview on 05/19/23 at 10:05 AM, the Maintenance Director (MD) stated, It's been broken for a while, probably more than two months. The Corporate Maintenance (CM) person stated he did not know how long it had been broken, however he knew they were waiting for a part. No documentation or dates were provided, when requested on 05/19/23, to show when the part was ordered. The entrance to the North unit, from the [NAME] unit, was observed on 05/19/23 at 10:15 AM and revealed an incline in the hall just after the Activity room door leading up to the closed North unit entrance. During an interview on 05/19/23 at 1:32 PM, the Ombudsman confirmed the ice machine on the west unit had been out for months. She stated there was an ice machine on the rehabilitation hall, but the residents would have to go up a ramp. The Ombudsman stated if a resident was in a wheelchair, it would be hard for the resident to move up or down the ramp. She stated the facility had reported the part was on order, but the ice machine still was not fixed. During an interview on 05/19/23 at 2:13 PM, the Administrator, Corporate Maintenance and Maintenance Director confirmed the ice machine on the west unit had been out of order for a few months. The Maintenance Director stated there was another ice/water machine ordered and a contractor was coming to fix the current machine. On 05/19/23 at 2:28 PM, the MD was asked to provide documentation of when the ice/water machine part was ordered. The MD stated, The Administrator had the paperwork and was fiddling with it. On 05/19/23 at 4:40 PM, the Administrator and MD provided a purchase order, dated 05/19/23, which revealed a new ice machine was ordered on 05/19/23. No other documentation was provided to show when the ice/water machine part was ordered. NJAC 8:39-27.2(k)

Based on observation, interview, record review, review of Resident Council meeting minutes, and facility policy review, the facility failed to have sufficient dietary staff to assure resident meals were served as scheduled. The failure had the potential to affect 115 residents who consumed meals prepared from the facility's kitchen. Findings include: 1. Review of the Resident Council meeting minutes, dated 04/25/23 and provided by the facility, revealed the following concern, . lunch and dinner has been served late . The staff response was . lunch trucks delivered at 11:30 AM and 4:30 PM . dietary must notify staff on the unit floor when trucks arrived . 2. A group interview was conducted on 05/17/23 at 1:00 PM with seven residents whom the facility identified as reliable historians. During the meeting, seven of the seven residents (Residents (R) 31, R36, R39, R72, R84, R89, and R91) voiced complaints about meals being served later than scheduled. R84 stated The food is always cold, tastes terrible, and it's late being delivered. R91 stated Meal trays are brought out on a cart, but they sit there waiting for staff to deliver them and then the food is cold by the time it gets to us in our rooms. The other six residents in attendance at the meeting confirmed R91's statement. The residents explained when their evening meal trays were delivered later than scheduled, they ran the risk of missing their scheduled evening activities (which were scheduled Monday to Friday, beginning at 6:00 PM) which they really enjoyed and did not want to miss. 3. Review of R34's electronic medical record (EMR) revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/23 located under the MDS tab. The assessment revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15 for R34, which indicated the resident was cognitively intact. During an interview on 5/17/23 at 5:25 PM, R34, who resided on the facility's [NAME] hallway, stated she was upset because her evening meal had not been served and her evening meal the day before was not served until 5:56 PM. R34 stated her evening meal better come soon because she had a scheduled activity to attend at 6:00 PM. R34 explained her meals were previously served on time, but with the current kitchen staff she could never tell how late her meals would be served. On 05/17/23 at 5:36 PM, the last [NAME] hallway meal cart was delivered to the hallway. This was 21 minutes later than the scheduled time of 5:15 PM noted on the facility's meal delivery schedule. On 05/17/23 at 5:39 PM, R34 was observed receiving her evening meal. 4. In response to resident complaints about meals being served later than scheduled, a test tray was requested to be sent to the facility's [NAME] hallway, the last scheduled resident hallway meal cart to be delivered, during the breakfast meal on 05/19/23. Observation revealed the meal cart, which contained the test tray, left the kitchen at 8:47 AM. The cart was delivered to the [NAME] hallway by the Dietary Manager (DM) at 8:48 AM, which was 23 minutes later than the scheduled delivery time of 8:25 AM noted on the facility's meal delivery schedule. 5. During an interview on 05/17/23 at 6:50 PM, the DM confirmed the resident evening meal on 05/17/23 was served later than scheduled. The DM stated the facility's current meal schedule was developed when the facility had a census of 80 to 90 residents. The DM explained that the current facility census was 134 residents, so it took the kitchen staff longer to prepare and serve meals which caused resident meals to be served later than scheduled. Review of the facility's undated policy titled, Food Truck Delivery Schedule, revealed, the resident meals were scheduled to be delivered to facility units at the following times: Ventilator Unit: Breakfast 7:45 AM, Lunch 11:40 AM, Dinner 4:40 PM South Unit: Breakfast 8:20 AM, Lunch 11:45 AM, Dinner 4:45 PM Low North Unit: Breakfast 8:10 AM, Lunch 11:50 PM, Dinner 4:50 PM West Unit: Breakfast 8:05 AM, Lunch 11:55 AM, Dinner 4:55 PM Mid North Unit: Breakfast 8:10 AM, Lunch 12:15 PM, Dinner 5:00 PM South Unit: Breakfast 8:20 AM, Lunch 12:15 PM, Dinner 5:05 PM High North Unit: Breakfast 7:45 AM, Lunch 12:10 PM, Dinner 5:10 PM West Unit: Breakfast 8:25 AM, Lunch 12:15 PM, Dinner 5:15 PM NJAC 8:39-17.3(b)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, tasting of foods on a requested test tray, record review, review of Resident Council meeting minutes, and facility policy review, the facility failed to serve food that was palatable and hot to eleven of eleven residents (Resident (R) 33, R34, R67, R111, R31, R36, R39, R72, R84, R89, and R91) reviewed for food palatability. This failure had the potential to affect 115 residents who consumed food prepared from the facility's kitchen. Findings include: 1. Review of R33's electronic medical record (EMR) revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 located under the MDS tab. The assessment recorded a Brief Interview for Mental Status (BIMS) score of 15 of 15 for R33, which indicated the resident was cognitively intact. During an interview on 05/16/23 at 10:40 AM, R33 stated the food served at meals was not hot. R33 specified the food served at the breakfast meal was cold more often than the other meals. 2. Review of the electronic face sheet for R34, located under the Profile tab of the EMR, revealed R34 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disorder (COPD) and atrial fibrillation. Review of R34's Care Plan, located under the Care Plan tab of the EMR revealed R34 had a diagnosis of depression and was at risk for variations in intake/appetite and at risk for blood sugar fluctuations. During an interview on 05/16/23 at 12:21 PM, R34 stated that she had complained about the food and spoken with the Ombudsman, but the food had gotten worse. R34 stated the food was bland and cold. R34 stated the facility had previously used closed metal carts to deliver the food trays, but now they used small, open carts that were not capable of holding all the trays brought to the hall at one time. She stated the food was often late and, on most day, because activities began at 6:00 PM, she had to cut her dinner short in order to go to activities. During an observation on 05/16/23 at 12:26 PM through 12:57 PM, the lunch cart was observed arriving late and without a covering to help maintain food temperatures. 3. Review of R67's EMR revealed a quarterly MDS with an ARD of 04/18/23 located under the MDS tab. The assessment recorded a BIMS score of 15 of 15 for R67, which indicated the resident was cognitively intact. During an interview on 05/16/23 at 12:25 PM, R67 stated the food served at meals was often cold when she received meals in her room. R67 specified she was often served cold pancakes at breakfast. 4. Review of R111's EMR revealed a significant change MDS with an ARD of 02/20/23 located under the MDS tab. The assessment recorded a BIMS score of 15 of 15 for R111, which indicated the resident was cognitively intact. Review of R111's current physician's orders, located under the Orders tab of the EMR, revealed an order for a cardiac, no added salt, carbohydrate-controlled diet. During an interview on 05/16/23 at 2:17 PM, R111 stated the food served at meals was too salty and when she was served a muffin and cottage cheese on the same plate, her muffin was soggy. 5. In response to resident complaints about food, a test tray was requested to be sent to the facility's [NAME] hallway during the breakfast meal on 05/19/23. Observation revealed before the meal tray cart, which contained the test tray, left the kitchen at 8:47 AM, the food temperatures were at acceptable levels of 140 degrees Fahrenheit and above. The meal trays were placed on an open tray cart with no heating element and were delivered to the [NAME] hallway. The last resident breakfast tray was served on the [NAME] hallway on 05/19/23 at 8:55 AM. At this time, the food on the test tray was sampled in the presence of the facility's Dietary Manager (DM). Tasting of the food revealed the following: a. The scrambled eggs served on the test tray were warm when tasted. The DM also tasted the scrambled eggs and confirmed the eggs were not hot. b. The waffles served on the test tray were warm when tasted. The DM also tasted the waffles and confirmed the waffles were not hot. During an interview on 05/19/23 at 9:00 AM, the DM stated residents should be served hot food at meals. 6. On 05/17/23 at 1:00 PM, a Resident Council Meeting was conducted with seven residents (R31, R36, R39, R72, R84, R89, and R91) including the Resident Council President and the Resident Council [NAME] President. The residents present regularly attend the facility's monthly Resident Council meetings. The residents were asked about their dining experiences at the facility. The following concerns were expressed: R84 said, The food is always cold, tastes terrible, and it's late being delivered. R72 said she asked for an orange for three days, was told the kitchen would get me an orange but never did. R72 said the kitchen always runs out of everything. R36 said she has requested more varieties in the food, specifically actual ham versus processed lunchmeat that has too much salt. That's not good for us, so much salt. R39 asked for butter not margarine. R36 said they have been told the dietary budget was cut which is why they cannot always accommodate all their requests. R91 said the meal trays are brought out on a cart, but they sit there waiting for staff to deliver them and then the food is cold by the time it gets to us in our rooms. All seven residents confirmed the cold food statement made by R91. The residents were asked if they utilized the main dining room for meals. The group said they used to go to the dining room until COVID. Since then, they have been eating in their rooms. The residents said when the trays are late to be delivered to them, they run the risk of missing their evening activities which they really like and do not want to miss. During an interview on 05/19/23 at 1:05 PM, the Ombudsman said Cold food has been an issue. The Ombudsman said the residents used to eat in the main dining room which is much closer to the kitchen which would keep the food hotter than carting it to each wing. The Ombudsman said the facility used to have insulated carts to deliver the meal trays, but she does not know why they changed to the open carts, I'm sure the food is cold. 7. Review of Resident Council Minutes, provided by the facility, revealed the following: On 01/26/23, a concern was noted as need more food choices. The staff response was will add more choices. On 02/23/23, a concern was noted as food is cold when delivered to rooms. The staff response was all food leaves the kitchen at correct temperatures. On 04/25/23 a concern was noted as lunch and dinner has been served late. The staff response was lunch trucks delivered at 11:30 AM and 4:30 PM . dietary must notify staff on the unit floor when trucks arrived. Review of the facility's policy titled, Food Preparation, dated 02/07/22, revealed, . The chef or cook and dining services director are responsible for tasting all prepared food in order to judge the quality of the finished product . NJAC 8:39-17.4(a)2 NJAC 8:39-17.4(e)

Based on observation, interview, and review of the facility's meal schedule, the facility failed to have no more than 14 hours between the resident evening meal and breakfast meal the following day. This failure had the potential to affect 115 residents who received meals from the facility's kitchen. Findings include: Review of the facility's undated policy titled, Food Truck Delivery Schedule, revealed the following scheduled resident evening and breakfast meal delivery times for each unit and the total time scheduled between these two meals that exceeded the 14-hour time frame requirement: Ventilator Unit: Dinner 4:40 PM and Breakfast 7:45 AM- A total of 15 hours and 5 minutes scheduled between the resident evening meal and following breakfast meal. South Unit cart 1: Dinner 4:45 PM and Breakfast 8:20 AM- A total of 15 hours and 35 minutes scheduled between the resident evening meal and following breakfast meal. Low North Unit: Dinner 4:50 PM and Breakfast 8:10 AM- A total of 15 hours and 20 minutes scheduled between the resident evening meal and following breakfast meal. West Unit cart 1: Dinner 4:55 PM and Breakfast 8:05 AM- A total of 15 hours and 10 minutes scheduled between the resident evening meal and following breakfast meal. Mid North Unit: Dinner 5:00 PM and Breakfast 8:10 AM- A total of 15 hours and 10 minutes scheduled between the resident evening meal and following breakfast meal. South Unit cart 2: Dinner 5:05 PM and Breakfast 8:20 AM- A total of 15 hours and 15 minutes scheduled between the resident evening meal and following breakfast meal. High North Unit: Dinner 5:10 PM and Breakfast 7:45 AM- A total of 14 hours and 35 minutes scheduled between the resident evening meal and following breakfast meal. West Unit cart 2: Dinner 5:15 PM and Breakfast 8:25 AM- A total of 15 hours and 10 minutes was scheduled between the resident evening meal and following breakfast meal. During an interview on 05/17/23 at 6:50 PM, the Dietary Manager (DM) confirmed the resident meal schedule exceeded 14 hours between the resident evening meal and breakfast meal the following day. The DM stated she was not aware there could be no more than 14 hours between the resident evening meal and breakfast meal. The DM stated the facility offered bedtime snacks but did not have resident agreement to exceed the 14-hour time frame between serving the resident evening meal and the resident breakfast meal the following day. Observation of the evening meal on 05/18/23 revealed the [NAME] unit's second meal cart was delivered to the hallway at 5:15 PM. Observation of the breakfast meal on 05/19/23 revealed the [NAME] unit's second meal cart was delivered to the hallway at 8:48 AM. A total of 15 hours and 33 minutes elapsed between the 05/18/23 resident evening meal being delivered to the [NAME] hallway and the 05/19/23 resident breakfast meal being delivered to the hallway. NJAC 8:39-17.2(f)1 NJAC 8:39-17.4(b)

Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's milk refrigerator, electric slicer, three kitchen drawers, and canned food storage racks clean and sanitized and failed to date opened bread products and discard creamed soup and hot dog buns with expired use by dates. This failure had the potential to affect 115 residents who consumed food prepared from the facility's kitchen. Findings include: 1. Observation during the initial kitchen inspection on 05/16/23 from 9:45 AM to 10:30 AM, with the Dietary Manager (DM) present, revealed the following unclean food preparation and storage equipment: a. The interior of the kitchen's milk refrigerator had a very strong odor of soured milk. Observation under the crates of milk stored inside this refrigerator revealed a brownish and white colored liquid pooled in the bottom of refrigerator that smelled like soured milk. b. The kitchen's electric slicer, covered and ready for use, was unclean with a greasy residue and food debris on its blade and base. c. Three kitchen drawers, with food preparation equipment that included scoops, spatulas, serving spoons, and tongs stored in them, were unclean with greasy residues and food debris. When the interior of each drawer was wiped with a wet paper towel a black residue was observed on the towel. d. The kitchen's two large metal can storage racks, with cans stored on them, were unclean. Accumulated dirt, dust and food debris were on the rack's metal tracks where cans were stored. During an interview on 05/16/23 at 10:30 AM, the DM confirmed the kitchen's milk refrigerator, electric slicer, three drawers housing food preparation equipment and two large can storage racks were not clean. The DM stated the kitchen equipment should be kept cleaned by staff. The DM explained that she was not sure when the kitchen's two large can storage racks were last cleaned because they were not on the kitchen's current cleaning schedule. 2. Observation during the initial kitchen inspection on 05/16/23 from 9:45 AM to 10:30 AM, with the DM present, revealed the following concerns with food storage: a. Observation of the kitchen's bread storage shelves revealed an opened and undated package of rye bread, an opened and undated package of cinnamon raisin bread and two packages of hot dog buns with expired use by dates of 05/11/23. b. Observation of the kitchen's walk-in refrigerator revealed a large plastic container with a commercial label that indicated it contained hard boiled eggs. The exterior of the container also had a label with a use by date of 05/11/23. Observation of the container's contents revealed a congealed food with approximately a half inch of water on top of it. The DM initially identified the congealed food as leftover gravy and later identified it as leftover creamed soup. The DM stated the container should have been correctly labeled with the food stored inside and the leftover creamed soup should have been discarded by staff on 05/11/23. During an interview on 05/16/23 at 10:30 AM, the DM stated staff should discard any food that was not labeled and dated or had an expired use by date. Review of the facility's policy titled, Cleaning Schedules, dated 02/07/22, revealed, Policy: The food service staff will maintain the cleanliness and sanitation of the food service areas through compliance with a written, comprehensive, cleaning schedule developed by the Food Service Director (FSD). Procedure: 1. The FSD will determine all cleaning and sanitation tasks needed for the department . Review of the facility's policy titled, Food Storage, dated 02/07/22, revealed, . All leftover food for storage in refrigeration is put in a storage container and completely covered with plastic or foil wrap, marked with the same name of item, dated and given a use by date to be use within 72 hours . Review of the facility's undated policy titled, Dry Food Policy, revealed, . Immediately after delivery all products will be dated for proper rotation . Keep product clearly labeled and in its original packaging . NJAC 8:39-17.2(g) NJAC 8:39-19.7(d)

Based on interview and facility job description review, the facility failed to employ either a full time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition service since March 2023. This failure had the potential to affect 115 residents who received food from the kitchen. Findings include: During an interview on 05/16/23 at 9:35 AM, the DM stated she had been employed as the facility's DM since March 2023. The DM confirmed that she recently completed the Serv Safe course but was not a Certified Dietary Manager (CDM). The DM stated the facility's Registered Dietitian (RD) was employed on a consultant basis and usually visited the facility once or twice per week. During an interview on 05/19/23 at 2:39 PM, the DM stated she worked as the facility's assistant dietary manager for a year prior to becoming the DM two and a half months ago. The DM confirmed she did not have prior experience working as a director of food and nutrition services in a nursing facility, was not a CDM and was not currently enrolled in a CDM course. The DM stated a full-time RD was not employed at the facility since she started working as the DM in March 2023. During an interview on 05/19/23 at 2:50 PM, the Regional Dietary Manager confirmed the facility's DM was not currently certified but thought a waiver was still in effect that allowed a non-certified DM additional time to become a CDM in the State of New Jersey. During an interview on 05/19/23 at 3:20 PM, the facility's Registered Dietitian (RD) confirmed she was not a full-time employee and worked at the facility as a consultant. The consultant RD stated she visited the facility once or twice a week and provided clinical coverage for the resident population. Review of the facility's undated job description entitled Food Services Director, revealed, . Education & Qualifications . Must provide documentation of registry/certificate upon application for position . NJAC 8:39-17.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the initial tour of the North Wing on 3/19/2021 at 12:22 PM the surveyor observed Resident #258 lying on their bed with their head at the foot of the bed and receiving oxygen via a nasal cannula. The surveyor also observed a red magnetic sign on the door frame that read Oxygen in Use. On 3/24/2021 at 9:37 AM Resident #258 was observed in their room receiving oxygen via a nasal cannula at the rate of 2 liters per minute. According to the admission Record, Resident #258 was admitted to the facility with the following diagnoses: Acute respiratory failure with hypoxia (a condition in which the body or region of the body is deprived of oxygen) and COPD. According to the MDS dated [DATE], Resident #258 had a BIMS score of 15/15, indicating intact cognition. The MDS also noted that the resident did not receive oxygen therapy. A review of the Medication Review Report dated 2/1/2021 -3/31/2021 included the following physician order dated 3/23/2021: Apply oxygen per nasal cannula/mask at 2 liters/minute. A review of the Weights and Vitals summary with Vital of O2 Sats (saturation) indicated that on 3/16/2021, 3/17/2021, 3/18/2021, 3/19/2021, 3/20/2021, and 3/22/2021 the resident received oxygen via nasal cannula. A review of the Progress Notes dated 3/17/2021 indicated the resident had received oxygen via nasal cannula at 2 liters per minute. A review of the March 2021 Treatment Administration Record (TAR) revealed that on 3/23//2021 Resident #258 had an order to Apply oxygen per nasal cannula/mask at 2 liters/minute. There was no order for oxygen on 3/16/2021 which was Resident #258's readmit date until 3/23/2021, a period of 8 days. A review of Resident #258's care plan revealed that a care plan intervention for [resident name] has oxygen therapy related to ineffective gas exchange, dated 3/23/2021. On 3/25/2021 at 11:36 AM the surveyor interviewed Resident #258 who stated, I have been using the oxygen at 2 liters per minute pretty much since I was readmitted from the hospital. During an interview on 3/25/2021 LPN #2, who was responsible for Resident #258's care, stated, He/she returned from the hospital on the 16th. He/she was on oxygen at 2 liters per minute continuously. I thought there was an ancillary order for the oxygen. During an interview on 3/25/2021 at 1:57 PM the LPNUM stated, He/she did not have an order for oxygen between the 16th of March and the 22nd of March. He/she should have had an order to use the oxygen for that time period. A review of a facility policy titled Oxygen Administration with an updated date of 10/2019, revealed under the Preparation section, 1. Verify that there is a physician's order for this procedure. NJAC 8:39-27.1(a) Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to obtain a physician order for the use of oxygen for 2 of 2 residents reviewed for oxygen, (Resident #64 and Resident #258). This deficient practice was evidenced by the following: 1. During the initial tour of the North Wing on 03/19/21 at 11:29 AM the surveyor observed Resident #64's room which had an oxygen concentrator in the room turned on to 2 liters with a nasal cannula (a device used to deliver supplemental oxygen) connected to the concentrator. Resident #64 was observed ambulating with rollator in hallway without the oxygen. The surveyor interviewed the resident who said that they needed oxygen at home and uses it on and off while in the facility. On 03/22/21 at 10:05 AM Resident #64 was observed lying in bed asleep with the nasal cannula in place and receiving oxygen at the rate of 2 liters per minute. According to the admission Record, Resident #64 was admitted to the facility with diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The surveyor reviewed the Minimum Data Set (MDS) assessment tool, dated 11/10/2020 and 2/5/2021. Resident #64 was noted to have a Brief Interview for Mental Status (BIMS) score of 8/15 indicating impaired cognition. Both MDS's also revealed that Resident #64 used oxygen (O2) while at the facility. The surveyor reviewed the Order Summary Reports dated 05/01/2020-06/30/2020 and 01/01/2021-03/26/2021 and noted there was no physician order for oxygen. A review of the Weights and Vitals summary with Vital of O2 Sats (saturation) indicated that on 12/12/20, 2/10/21 and 3/9/21 the resident had received oxygen via nasal cannula. A review of the Progress notes dated 10/19/20, 1/21/21 and 3/13/21 indicated the Resident #64 had nasal oxygen in use. A review of the June 2020 Medication Administration Record (MAR) indicated a physician order for Oxygen at 2 liters per minute to maintain SPO2 above 92% with an order date of 07/16/2018 and a discontinue date of 6/2/2020. A review of Resident #64's care plan did not include the resident's need for oxygen use. The surveyor interviewed the resident's assigned Licensed Practical Nurse (LPN#1)on 03/25/21 at 01:12 PM. She stated Resident #64 has COPD and uses oxygen as needed. LPN #1 did also state that a physician's order is needed for use of oxygen. LPN #1 and the surveyor reviewed the physician orders for Resident #64. LPN #1 agreed there was no order for oxygen and that there should be. The surveyor interviewed the LPNUM on 03/25/21 at 01:56 PM who told the surveyor the LPNUM said she did not know why the oxygen was discontinued in June (2020). She went on to say Resident #64 has COPD and had no physician order for oxygen. She also said the policy is a physician order for oxygen is required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On 3/19/2021 from 10:04 AM to 10:29 AM the surveyor, accompanied by the Director of Dining Services (DDS), observed the following in the kitchen: 1. On an upper shelf of the pot/pan dry storage rack, a stack of 6 metal bowls were not stored in the inverted position and leaving the working surface exposed. On interview the DDS stated, They should be stored inverted. They are not wet though. The DDS removed the bowls to be rewashed and sanitized. 2. In the dry storage room on an upper shelf an opened cardboard box contained plastic forks. The forks were removed from the plastic bag and were exposed. On interview the DDS stated, They (the forks) should be in a plastic bag that is closed. I'm going to throw them in the trash. The DDS threw the box of plastic forks in the trash. 3. The surveyor reviewed the Complete Care at [NAME] Area Refrigerator/Freezer Temperatures for Ice Cream 1 and Ice Cream 2 freezers. The logs were both completed for the dates 3/1/2021 to 3/18/2021. The logs had no temperatures recorded for the AM or PM for the date 3/19/2021. The surveyor and the DDS were unable to find an internal thermometer in Freezer 1 and Freezer 2. On interview the DDS stated, Neither freezer has a functioning internal thermometer, I think my staff is just writing them in (temperatures). 4. On the top shelf inside the Cook's box the surveyor noted a clear, hard plastic container holding sliced deli cheese. The container had no open or use by dates. On interview the DDS stated, I'm throwing it out, it's not labeled. On 3/29/21 from 9:49 AM to 10:29 AM the surveyor, accompanied by the DDS observed the following in the kitchen: 1. Observation of the top of the high temperature dish machine revealed unidentified brown debris, a kitchen knife, a pen, and a garden type hose sprayer/nozzle. On interview the DSD stated, The machine should be cleaned after each service or use. We are coming off the weekend. I guess it didn't get cleaned. The dietary aides are responsible for the cleaning of the dish machine. I do daily walk throughs. It's Monday that may have been from the weekend. 2. In the microwave/prep area 4 stacks of bread and butter and dessert dishes were stacked on a counter and not inverted or covered, exposing the eating surface. On interview the DDS stated, they should be covered when not in use. Were going to run them through the machine and reclean them. The surveyor reviewed an undated facility policy titled Food Storage. The policy revealed the following under the heading Cold Storage: 4. All foods will be stored either wrapped or in closed storage containers and be clearly dated and labeled. The surveyor reviewed an undated facility policy titled Complete Care Management Warewashing. Under the Procedures section the policy revealed the following: 4. All dishware will be air dried and properly stored. The surveyor reviewed an undated facility policy titled Completecare Management Proper Dishroom and Sanitizing Procedures. The policy revealed the following under the Procedures section: 2. Always start with clean dishwasher and area. Make sure heating element is on and tanks of dishwasher are full. Always check detergent and rinse additive for product. Product is automatically dispensed. 6. When finished clean dishwasher screens, wash arms and nozzles. Scrub all surfaces with detergent. Weekly descale machine with descaler. NJAC 8:39-17.2 (g)