Based on observation, interview, and record review it was determined the facility failed to provide a dignified dining experience for 2 of 2 nursing unit dining rooms during the lunch meal. Evidence of the deficient practice is as follows. On 2/3/25 at 12:09 PM, the surveyor observed the lunch meal on the second floor in the day room/dining room. On each of thirteen tables, staff served the residents' meals on plastic trays. Additionally, the dome lids from the plates were placed upside down in the center of the tables and used as trash receptacles. On 2/3/25 at 12:15 PM, the surveyor observed the lunch meal on the third floor in the day room/dining room. On each of the six tables staff served the residents' meals on plastic trays. Additionally, the dome lids from the plates were placed upside down in the center of the tables and used as trash receptacles. On 2/4/25 at 11:53 AM, the surveyor observed the lunch meal on the second floor in the day room/dining room. Residents ate their meals on plastic trays, with the dome lids on the tables collecting trash. At each of five tables of two residents, one resident ate while the second resident waited for approximately ten minutes for their food to be served. On 2/5/25 at 12:02 PM, the surveyor observed the lunch meal on the second-floor day room/dining room. Residents ate their meals on plastic trays, with the dome lids on the tables collecting trash. At one table of three residents, two residents were served trays while third person waited without a tray for more than 10 minutes. At one table of two residents, one resident ate for 5 minutes while the other resident waited for their tray. On 2/7/25 at 12:54 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA stated plates are to be taken off the tray unless the resident requests it to stay and then it would be care planned. The LNHA stated the staff should not put dome lids on the table for trash. The facility policy for Meal and Dining, revised 12/13/24, indicated residents' dignity should be upheld during the dining experience, however, did not specifically address the areas of concerns which were observed. NJAC 8:39-4.1(a)12.

Complaint NJ00166888 Based on interview and record review it was determined the facility failed to notify a resident's responsible party of a change in condition and a room change for 1 (#11) of 16 residents reviewed. The deficient practice is as follows. The surveyor reviewed Resident #11's electronic progress notes during the period of 8/23/23 through 9/4/23. The nurse documented in an 8/23/23 electronic progress note that the resident had tested positive for COVID 19 and was on isolation precautions. The resident was noted to be residing on the second floor at that time. An 8/25/23 nurse progress note indicated the resident was relocated to the third floor and continued on isolation precautions. There was no documentation in the progress notes that the responsible party had been notified of the resident's COVID 19 status or of the change to another nursing unit. A 9/4/23 progress note written by the social worker indicated the resident's daughter had been notified that her mother would be transferred back to her room on the second floor nursing unit. On 2/04/25 at 11:33 AM, the surveyor interviewed the Registered Nurse Charge Nurse who stated when a resident is to be moved to another room, the responsible party is notified of the reason for the move and when the move will occur. She stated this is done by either the unit nurse or the social worker. On 2/05/25 at 9:51 AM, the surveyor interviewed the Social Worker. She stated either the social worker or the nurse notifies the responsible party of a room change. She stated it is usually done by phone prior to the change. The surveyor interviewed the Licensed Nursing Home Administrator (LNHA) on 2/10/25 at 11:32 AM. The LNHA stated she remembered the resident's daughter had come to her complaining that she was not notified of her mother's room change. The LNHA stated the resident's daughter was notified when her mother tested positive for COVID 19, however, she did not provide evidence that the responsible party received notification of the positive COVID result. NJAC 8:39-4.1(a)13.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 2 of 16 residents reviewed for the accommodation of needs (Resident # 53 and # 81) and was evidenced by the following: 1. On 2/3/25 at 12:54 PM, the surveyor observed Resident # 53 in bed. The surveyor greeted the resident and Resident # 53 did not respond to the surveyor. The surveyor observed that the resident's call bell (used to summon staff for assistance) was located behind the resident's bed, on the floor and was not within his/her reach. The surveyor reviewed the medical record for Resident # 53. A review of Resident # 53's admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; metabolic encephalopathy and was receiving hospice care services. A review of Resident # 53's quarterly Minimum Data Set (MDS), an assessment tool dated , revealed Resident # 53 had severely impaired cognition. The MDS further assessed that the resident was dependent on staff for Activities of Daily Living (ADL) care. On 2/3/25 at 1:15 PM, the surveyor interviewed the Registered Nurse, who was responsible for the resident, and she stated that the call bell should be in reach. The CNA assigned to Resident # 53 stated that the call bell should have been in reach and did not know why it was on the floor. 2. On 2/5/25 at 8:00 AM, the surveyor and the Registered Nurse/ Unit Manager (RN/UM) conducted incontinence rounds. The surveyor and the RN/UM entered Resident #81's room and observed the resident in bed with floor mats placed on each side of the Resident's bed. The surveyor and RN/UM observed that the resident's call bell (used to summon staff for assistance) was on the floor behind the headboard, not within his/her reach. The surveyor reviewed the medical record for Resident #81. A review of Resident #81's admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; Congestive Heart Failure (CHF), hypertension, and cognitive communication deficit. A review of Resident #81's quarterly Minimum Data Set (MDS), an assessment tool dated 1/30/25, revealed that Resident #81 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated severely impaired cognition. The MDS further assessed that the resident required staff assistance for Activities of Daily Living (ADL) care. A review of Resident 81's Individualized Care Plan (CP) included a problem area that the resident had cognitive loss with an alteration in thought process related to dementia; the resident has short-term memory loss as evidenced by intermittent forgetfulness with interventions that included but were not limited to; call light available and answered promptly. On 2/5/25 at 8:10 AM, the RN/UM confirmed that the resident's call bell should have been placed within the resident's reach. On 2/7/25 at 9:25 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who was assigned to Resident # 81's care on 2/4/25- 2/5/25 (11 pm-7 am shift), who confirmed that the resident was able to use their call bell and that she should have placed it within the resident's reach. On 2/7/25 at 12:45 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The LNHA confirmed that the call bells should be placed within the residents' reach. NJAC 8:39- 31.8 (c)(9)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 2 sampled residents (#11, #53), 2 unsampled residents (room [ROOM NUMBER] window, #220 window) and the area on the 2nd floor nursing unit hallway between rooms [ROOM NUMBERS]. The deficient practice is evidenced by the following. 1. During the 2/03/25 initial tour of the second floor nursing unit at 10:23 AM, the surveyor noted a strong odor of urine in the area between rooms [ROOM NUMBERS]. A full soiled laundry cart was located in the hallway between these two rooms. On the same day at 10:30 AM, the surveyor observed Resident #11's privacy curtain was stained with dark brown/black matter, the floor had several broken floor tiles, and the toilet was heavily stained with stool. On the same day at 10:40 AM, the surveyor observed room [ROOM NUMBER] window belonging to an unsampled resident. The resident's overbed table had the veneer broken off of the top of the table revealing the pressboard underneath. 2. On 2/3/25 at 12:46 PM, upon initial tour of the 2nd floor, the surveyor observed that inside of room [ROOM NUMBER] near the window, behind the unsampled resident's headboard of the bed, there was an approximately 6 inch tear along the wall and the surveyor also observed a piece of plywood secured to the wall behind the left side of the resident's headboard of the bed. At 12:54 PM, the surveyor observed that inside of Resident # 53's room [ROOM NUMBER], there was a 3 inch hole in the wall near the restroom in the resident's bathroom. NJAC 8:39-4.1(a)11. 31.4 (a), (b), (c), (f)

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 2 of 16 residents reviewed for resident assessment (Resident # 11 and # 54). This deficient practice was evidenced by: The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. The following residents were reviewed for late comprehensive MDS assessments. 1. Resident #11 - A review of the MDS schedule of submitted MDSs in the resident's electronic medical records of the previous software program and the current software program used by the facility revealed the last comprehensive MDS was done on 2/23/24. The following MDSs to date were quarterly assessment. The most recent of which was dated 1/24/25. A comprehensive MDS assessment is required to be completed at least every 12 months. 2. Resident #54 - The CMS iQIES report indicated the 8/16/24 comprehensive MDS was submitted late. The 8/16/24 comprehensive MDS was submitted on 10/16/24, over the required 14 days. On 2/11/25 at 11:35 AM, the surveyor interviewed the Director of Nursing (DON) who stated the Nurse Unit Managers have historically done the MDSs. However, since there was a turn over of Nurse Unit Managers and they had to be trained there was a delay in MDS submissions. A contracted MDS Coordinator was hired in the fall of 2023. The contracted MDS coordinator has remained on to work with the new Nurse Unit Managers. NJAC 8:39-11.2

Based on resident observation, interview and record review, it was determined that the facility failed to complete a significant change in status assessment (SCSA) for Resident #25. This deficient practice was identified for 1 of 16 residents reviewed and was evidenced by the following: This deficient practice was evidenced by the following: On 2/3/25 at 11:34 AM, during the initial tour of the facility the surveyor observed Resident #25 seated on a wheelchair, awake, and conversant. At that time, the resident stated that they went to the dialysis center three times a week. The surveyor reviewed the medical record of Resident #25. According to the admission Record face sheet, an admission summary, reflected that Resident #25 was admitted to the facility with diagnoses that included, end stage renal disease, dependence on renal dialysis. A review of the physician's progress notes dated 10/16/24, included that when the resident was readmitted to the facility from the hospital, Resident #25 had a permanent catheter to the right upper chest with a new diagnosis of End Stage Renal Disease (ESRD). A review of the Significant Change in Status Minimum Data Set (SCMDS), an assessment used to facilitate the management of care, dated 10/22/24, revealed the Assessment Reference Date (ARD) was on 10/22/2024, the MDS was signed completed, by the MDS Coordinator on 12/11/2024, 50 days past the required submission of 14 days from the ARD date. The completed MDS was transmitted to the Centers for Medicare and Medicaid Services (CMS) on 12/17/24. On 2/5/24 at 11:17 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the facility did not have an MDS Coordinator. The Unit Managers were responsible for completing the assessments and certified the accuracy of its contents. At that time, the DON stated that they had a Registered Nurse (RN) Assessment contractor. At that time, in the presence of the surveyor and the DON, the RN Assessment Coordinator stated that he was a contracted to work on the completion of the MDS and worked periodically from 2023. On 2/5/24 at 1:10 PM, in the presence of the survey team, the RN Assessment contractor stated that his signature was an attestation of completion for the same MDS and transmitted the completed MDS to CMS. The assessed areas were signed for accuracy by the staff who completed its respective sections. At that time, the MDS Assessment contractor confirmed and acknowledged that the ARD date for Resident #25 was on 10/22/24. The completion date for the same MDS was on 12/17/24, which was late, and beyond the 14 day submission requirement. The concern with the late transmission of the MDS was discussed with the RN Assessment contractor. On 2/12/25 at 12:20 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the DON, the surveyor discussed the concern regarding the late completion of the SCMDS for Resident #25 that was past the required 14 calendar day from the determination that a significant change that occurred on 10/16/24. At that time, the DON acknowledged that they had problems with staffing and electronic transmission of the MDS. The staffing issues were related to the Unit Managers who were responsible for the completion of the MDS left their position. The DON also stated that they had electronic problems that caused issues with submission. The DON stated that was the reason they had hired the RN Assessment contractor, to provide the needed services. A review of the provided facility policy, MDS - Minimum Data Set Policy, dated/revised on 11/22/24, included the following under procedure, section 4: Assessments for residents who experience significant change were completed within 14 days after the facility determined or should have determined that there had been a significant change in the resident's physical or mental condition. No further information was provided. NJAC 8:39-11.2(i)

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 3 of 16 residents reviewed for resident assessment (Resident # 11, # 26, and # 54). This deficient practice was evidenced by: The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. The following residents were reviewed for late quarterly MDS assessments. 1. Resident #11 - The Centers for Medicare and Medicaid Services (CMS) Internet Quality Improvement and Evaluation System report (iQIES) indicated the 10/24/24 quarterly MDS was submitted late. The 10/24/24 quarterly MDS was submitted on 11/15/24, over the required 14 days. 2. Resident #54 - The CMS iQIES report indicated the 11/11/24 quarterly MDS was submitted late. The 11/11/24 quarterly MDS was submitted 12/17/24, over the required 14 days. On 2/11/25 at 11:35 AM, the surveyor interviewed the Director of Nursing (DON) who stated the Nurse Unit Managers have historically done the MDSs. However, since there was a turn over of Nurse Unit Managers and they had to be trained resulting in delayed MDS submissions. A contracted MDS Coordinator was hired in the fall of 2023. The contracted MDS coordinator has remained on to work with the new Nurse Unit Managers. 3. The surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. Resident # 26 was observed to have a Quarterly MDS with an Assessment Reference Date (ARD) of 12/27/24 and was due to be transmitted no later than 1/24/25. The MDS was not transmitted until 2/3/25. On 2/5/25 at 12:00 PM, the surveyor interviewed the MDS Coordinator, who stated that Resident # 26's MDS was submitted late and could not explain why. NJAC 8:39-11.2

Based on observation, interview and record review, it was determined that the facility failed to ensure a physician order for administration was followed for a resident who was cognitively impaired (Resident #42) in accordance with professional standards of practice. The deficient practice was identified for one (1) of four (4) residents, administered by one (1) of three (3) nurses, observed during the medication administration observation, and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 2/5/25 at 8:25 AM, the surveyor observed Licensed Practical Nurse (LPN) prepare five (5) medications for Resident #42. The medications included Fish Oil Omega-3 1000 milligram softgel, give two (2) capsules orally two times a day for supplement. The order start date was on 11/24/24. At 8:31 AM, the surveyor observed the LPN removed one (1) capsule of the Fish Oil Omega-3 1000 mg from the unit dose package and placed the capsule in a medication cup with the other medications. At 8:32 AM, the LPN stated she had a total of 4 medications (tablets/ capsules) in the medication cup and was ready to administer to Resident #42. At 8:33 AM, the LPN with the medication on hand, crossed the resident's door threshold to administer the medication to Resident #42. The surveyor requested to speak with the LPN outside of the resident's room. At that time, the surveyor and the LPN reviewed the electronic Medication Administration Record (eMAR) together. The LPN acknowledged that she should have removed 2 capsules for administration. The LPN stated that she had double counted the number of medication and not the number of tablets/capsules. The surveyor reviewed the medical record for Resident #42. According to resident's admission Record, Resident #42 was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, mood disturbance and anxiety. According to the resident's quarterly Minimum Data Set, (MDS) an assessment tool dated, 2/21/24, included that the resident had a Brief Interview for Mental Status (BIMS) of 5 which indicated that the resident's cognition severely impaired. On 2/7/25 at 12:46 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyors discussed the concern regarding the failure to follow the physician's order that would have resulted to improper dosage administration to Resident #42. On 2/10/25 at 11:03 AM, during a meeting with the survey team, the DON and the LNHA acknowledged the medication pass error that occurred. A review of the provided facility policy, Administration of Medications, dated/revised 6/19/24, included the following: To provide safe and accurate medication administration to residents in accordance to State and Federal regulations. NJAC 8:39-27.1 (a) 29.2(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure respiratory nasal cannula tubing was stored in accordance with infection control measures for 1 of 1 resident reviewed for Respiratory Therapy, Resident #19. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 2/3/25 at 12:31 PM, the surveyor observed Resident #19 seated in a wheelchair with Nasal Cannula tubing undated, attached to an oxygen concentrator not in use. The surveyor observed the NC tubing on the bed and it was not contained in a bag. The surveyor reviewed the medical record for Resident #19. A review of Resident #19's admission Record indicated that the resident was admitted to the facility with diagnoses that included but were not limited to; respiratory failure with hypoxia (a medical condition that occurs when there is not enough oxygen in the body's tissues and hypercapnia (too much carbon dioxide in the blood) and dependence on hemodialysis. A review of Resident #19's most recent Minimum Data Set (MDS), an assessment tool, dated 12/24/24 included; a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident's cognition was intact. Section GG documented that Resident #19 required moderate assistance with personal hygiene and Section O documented that the resident was receiving respiratory treatment which included O2 therapy. A review of the Care Plan (CP) documented a focus area initiated on 12/18/24, which included the resident has oxygen therapy related to respiratory illness. Interventions included but were not limited to; monitor for signs and symptoms of respiratory distress and report to MD. The CP did not include proper storage of oxygen tubing. A review of the Physician's Orders revealed an active physician order (PO) with an order date of 3/29/23: O2 at 2LPM (liters per minute) as needed for shortness of breath. On 2/3/25 at 12:45 PM, the surveyor interviewed the Registered Nurse/Unit Manager on the 3rd floor Nursing Unit who confirmed that the oxygen tubing should be stored in a plastic bag when not in use. On 2/7/25 at 12:45 PM, the surveyor discussed the above observations and concerns with the LNHA and DON. On 2/7/25 at 12:45 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The DON stated the facility policy was that the O2 tubing should be stored in a bag when not in use. A review of the facility provided, Oxygen Therapy policy and procedure dated/revised 6/24/24, included the following . oxygen administration and monitoring is under the responsibility of professional nurses .regular monitoring is essential . N.J.A.C. 8:39- 19.4(a); 27.1(a)

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure a.) documentation of a removal of a controlled dangerous substance (narcotic; with high potential for drug diversion) medication from inventory, maintain accountability, accurate reconciliation of Resident #18's Oxycodone narcotic medication, that was identified during the medication storage inspection of 1 of 2 medication carts, b.) a medication was labeled with appropriate accessory and cautionary instructions for administration that was observed during the medication pass observation of 1 of 3 resident administered by 1 of 2 nurses. The deficient practice was evidenced by the following: 1.) On 2/5/25 at 9:48 AM, the surveyor and the Licensed Practical Nurse (LPN #1) began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart (narcotic box), located in the east side of the third floor. At that time, in the presence of LPN #1, the surveyor observed Resident #18's Oxycodone Immediate Release (IR) 5 milligram (mg) bingo card (a multidose card containing individually packaged medications) that was empty. A review of the Controlled Drug Administration Record (CDAR; a declining inventory log) for Resident #18's Oxycodone IR 5 mg indicated a count of one (1) tablet remained and was not signed dispensed on 2/5/25. At that time, the surveyor and LPN #1 reviewed the controlled drug and syringe count (a shift-to-shift accountability log) for February 2025. The 2/5/25 shift-to shift log revealed signatures from LPN #1 who was on duty and the previous nurse that was on duty from 11:00 PM to 7:00 AM. The LPN stated that the signatures meant that the counts were completed, and no discrepancy was found. No further annotation on the log was seen. At that time, the surveyor asked the nurse why the discrepancy was not identified during the shift-to-shift accountability check between her and the other nurse. The LPN #1 stated that she had suspected the previous nurse forgot to sign the CDAR. The surveyor reviewed the medical record for Resident #18 According to the admission Record, an admission summary Resident #18 was admitted to the facility with diagnoses which included but were not limited to; chronic pain syndrome and displaced trimalleolar fracture (a severe break in three places of the ankle joint) of the right lower leg. According to the resident's admission Minimum Data Set, (MDS) an assessment tool dated, 1/13/25, included that the resident had a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident's cognition was intact. A review of the CDAR against Resident #18's electronic Medication Administration Record (eMAR) revealed additional discrepancies: On 1/30/25 at 7:00 PM, the nurse removed one (1) tablet; was not reflected on the eMAR as administered. On 1/31/25 at 6:00 AM, the nurse removed one ((1) tablet; was not reflected on the eMAR as administered. On 1/31/25 no documented time, quantity removed was not documented; was not reflected on the eMAR as administered. On 2/1/25 at 9:00 PM, the nurse removed one (1) tablet; was not reflected on the eMAR as administered. On 2/1/25 at 6:00 AM, the nurse removed one (1) tablet; was not reflected on the eMAR as administered. On 2/5/25 at 11:53 AM, the surveyor informed the Director of Nursing (DON) regarding the discrepancies identified during the unit inspection that involved Resident #18's narcotic medication, Oxycodone. The DON stated that an internal investigation would be conducted and the surveyors would be informed of their findings. On 2./7/25 at 12:46 AM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) and the DON, the surveyor discussed the concerns with the lack of documentation for a removal of a narcotic medication, the failure to maintain accountability, accurate reconciliation of Resident #18's Oxycodone (narcotic) medication that was identified during the medication storage inspection. On 2/10/25 at 11:03 AM, during a meeting with the survey team, the LNHA and the DON provided hand-written, signed statements, from the nursing staff who had signed for the removal of Oxycodone from Resident's #18's inventory and failed to document that the Oxycodone previously removed was then administered. The signed statement reflected attestations from the associated nurses confirming that they forgot to sign the eMAR and failed to maintain accountability and reconcile Resident #18's Oxycodone from 1/30/2025 to 2/5/25, the duration, the discrepancy existed without notice. The LNHA and the DON acknowledged that the documentation, reconciliation and accountability concerns and the discrepancy was recognized after surveyor inquiry. The LNHA stated that the policy would be updated to ensure documentation of removal and administration for narcotic medications. On 2/11/25 at 11:29 AM, the surveyor observed Resident #18 seated in a wheelchair. The resident stated that they requested the Oxycodone at various times with no pattern and received the medication when needed. The resident also stated that they could not recall a time that their medication was not received when requested. A review of the provided policy, Administration of Narcotic Medications, dated/revised on 4/22/24, included the following, under Procedure, section 9: The Nurse records the Narcotic given on the Medication Administration Record, the declining sheet, the pain scale log sheet and the 24-hour report . A review of the provided policy, Medication Storage, dated/revised on 6/19/24 included the following under Medication Storage Guideline; Storage of Controlled Substance: Records must be maintained for each transaction, including receipt, administration, and disposal of controlled substances. No further information was provided 2.) On 2/5/25 at 8:49 AM, the surveyor observed LPN #2 prepare medications for Resident #50 that included Fluticasone Nasal Spray (Flonase NS) 50 micrograms (mcg)/actuation, to be administered 1 spray in nostril twice a day for seasonal allergic rhinitis. The Flonase was repackaged into a clear plastic bag with a pharmacy label, and had not cautionary, and without the manufacturer's specifications. On 2/5/25 at 9:20 AM, the surveyor observed LPN #2 administer the Flonase NS to the resident and proceeded with the medication pass. On 2/5/25 at 9:27 AM, the surveyor observed LPN #2 signed the eMAR to document that the Flonase NS was administered to Resident #50. On 2/5/25 at 9:33 AM, the surveyor asked LPN #2 to how Flonase NS should be administered. LPN #2 searched online under the United States Food and Drug Administration website for the proper administration of the medication. LPN #2 acknowledged that she should have asked Resident #50 to blow their nose as indicated on the manufacturer's specifications. On 2/5/25 at 9:40 AM, the surveyor and LPN #2 reviewed the packaging of Resident #50's Flonase NS. LPN #2 confirmed that the packaging was not in its original container, did not include the manufacturer's specifications and did not have cautionaries. On 2./7/25 at 12:46 AM, during a meeting with the survey team, the LNHA and the DON, the surveyor discussed the concerns with the Flonase that did not include the manufacturer's specifications and a cautionary label, that lead to the improper administration of the Flonase NS during the medication administration observation. On 2/10/25 at 11:03 AM, during a meeting with the survey team, and the LNHA, the DON acknowledged and confirmed the medication should have had the manufacturer's specifications included with the packaging, a cautionary label to guide the nurse during administration and the manufacturer's specification for administration should have been followed . At that time, the DON stated that she had reached out to their pharmacy provided who was at that time could not provided an answer to her why the neither was included with the packaging. A review of the provided policy, Medication Storage, dated/revised on 6/19/24 included the following, under Compliance and Regulation: All medication storage practices must comply with the New Jersey Administrative Code (NJAC 8:38-29.1) . The policy should align with the CM'S guidelines, particularly the Medicare and Medicaid Conditions of Participation. Additionally, the procedure for monitoring and auditing reflected that any discrepancies or irregularities must be reported immediately and addressed. NJAC 8:39-27.1(a), 29.4 (a)(b)3.(k), 29.7(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ# 00167595 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents for 3 of 5 residents observed during incontinence rounds (Residents #59, #65, and #81) on 1 of 2 nursing units (3rd-floor unit). This deficient practice was evidenced by the following: 1. On 2/5/25 at 8:00 AM, the surveyor performed incontinence rounds with the Registered Nurse/ Unit Manager (RN/UM) on the 3rd floor Nursing Unit and observed Resident #81 in bed. The RN/UM exposed Resident #81's incontinence brief and observed a second incontinence brief wet with urine inserted inside the adult brief. At that time, the RN/UM confirmed that the brief should have been changed every two hours and that placing two incontinence briefs on a resident was unacceptable as it could cause the resident's skin to breakdown. The surveyor reviewed the medical record of Resident #81. A review of Resident #81's admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; Congestive Heart Failure (CHF), hypertension, and cognitive communication deficit. A review of Resident #81's quarterly Minimum Data Set (MDS), an assessment tool dated 1/30/25, revealed that Resident #81 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated severely impaired cognition. The MDS further assessed that the resident required staff assistance for Activities of Daily Living (ADL) care and that the resident was incontinent of bowel and bladder. A review of Resident 81's Individualized Care Plan (CP) included a problem area dated 10/24/24 that the resident had incontinence of urine and bowel and required extensive assistance with personal hygiene. 2. On 2/5/25 at 8:15 AM, during incontinence rounds the surveyor observed Resident #59 in bed. The RN/UM exposed Resident #81's incontinence brief and observed a second incontinence brief wet with urine and inserted inside the adult brief. At that time, the RN/UM confirmed that the brief should have been changed every two hours and stated that placing two incontinence briefs on a resident was unacceptable and that it could cause the Residnet's skin to breakdown. The surveyor reviewed the medical record of Resident #59. A review of Resident #59's admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; major depressive disorder and other persistent mood disorders. A review of Resident #59's quarterly MDS, dated [DATE], revealed that Resident #81 had severely impaired cognition. The MDS further assessed that the resident was dependent on staff for personal hygiene and was incontinent of bowel and bladder. A review of Resident 59's CP included a problem area dated 4/26/24 that indicated the resident required extensive assistance with personal hygiene. 3. On 2/5/25 at 8:20 AM, during incontinence rounds, the surveyor observed Resident #65 in bed. The RN/UM exposed Resident #65's incontinence brief and observed a second incontinence brief wet with urine inserted inside the adult brief. At that time, the RN/UM confirmed that the brief should have been changed every two hours and stated that placing two incontinence briefs on a resident was unacceptable and that it could cause the resident's skin to breakdown. The surveyor reviewed the medical record of Resident #65. A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to Cerebral Vascular Accident (CVA) and aphasia (a language disorder that affects a person's ability to communicate). A review of the quarterly MDS dated [DATE] reflected the resident had a BIMS score of 15 out of 15, which indicated intact cognition. A further review reflected the resident was dependent on staff for toileting, required extensive assistance of staff for personal hygiene, and was incontinent of bowel and bladder. A review of Resident #65's CP included a problem area dated 9/25/24 that the resident required extensive assistance with all ADLs with interventions that included providing extensive assistance with all ADLs. On 2/5/25 at 8:10 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who confirmed that incontinence care should be provided every two hours and that the Residents should never have two adult incontinence briefs in place as it was against facility policy and could cause the Resident's skin to breakdown. On 2/7/25 at 9:25 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who was assigned to Resident # 81's care on 2/4/25- 2/5/25 (11 pm-7 am shift), who confirmed that incontinence care should be done every two hours and that she should not have put two incontinence briefs on the residents as it could cause their skin to breakdown. The CNA could not speak to why she had double diapered the resident. On 2/7/25 at 9:30 AM, the surveyor interviewed the DON, who confirmed that incontinence care should be provided every two hours on all shifts and that no resident should have two adult incontinence briefs in place as it could cause skin breakdown. A review of the facility's Incontinence Management Policy dated as revised 12/13/24 included .the purpose of this policy is to provide high-quality, compassionate care for incontinent residents in accordance with the best practices and regulatory requirements .the goal is to enhance dignity, comfort, prevent skin breakdown and urinary tract infections . A review of the facility's Supporting Activities of Daily Living (ADLs) policy dated as revised 12/13/24, included .residents who are unable to carry out ADLs independently will receive the care and services necessary to maintain good nutrition, grooming, personal and oral hygiene . On 2/7/25 at 12:45 PM, the surveyor discussed the above observations and concerns with the LNHA and DON. No further information was provided by the facility. NJAC 8:39-27.1(a), 27.2(h)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to consistently complete the Dialysis communication monitoring sheets for Residents on dialysis (a treatment that replicates the kidney's function and cleans the waste from the blood for individuals with kidney disease or failure). This deficient practice was identified for 2 of 2 residents (Resident #19 and #25) and was evidenced by the following: 1. On 2/3/25 at 12:31 PM, the surveyor observed Resident #19 seated in a wheelchair. The resident stated that she/he went to dialysis on Tuesdays, Thursdays, and Saturdays. The surveyor reviewed the medical record for Resident #19. A review of Resident #19's admission Record indicated that the resident was admitted to the facility with diagnoses that included but were not limited to; respiratory failure with hypoxia (a medical condition that occurs when there is not enough oxygen in the body's tissues and hypercapnia (too much carbon dioxide in the blood) and dependence on hemodialysis. A review of Resident #19's most recent Minimum Data Set (MDS), an assessment tool, dated 12/24/24, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Section GG documented that Resident #19 required moderate assistance with personal hygiene and Section O documented that the resident was receiving Dialysis. A review of Resident # 19's Care Plans (CP) revealed the Resident did not have a CP in place for dialysis. A review of the Order Summary Report (OSR) included the following active physician's orders (PO): A PO dated 12/18/24 to check the AV shunt site on the right upper chest for bleeding or infection. A PO dated 12/18/24 for Dialysis on Tuesdays, Thursdays, and Saturdays. On 2/5/25 at 9:13 AM, the surveyor reviewed Resident #19's Dialysis Communication Book, which included Dialysis Communication Monitoring Sheets (CMS) for the months of December 2024, January and February 2025, and revealed the following: On 12/28/24, the facility nurse did not complete the vital signs post-dialysis portion of the CMS. On 1/2/25, the facility nurse did not complete the vital signs post-dialysis portion of the CMS. On 1/4/25, the facility nurse did not complete the vital signs post-dialysis portion of the CMS. On 1/18/25 25, the facility nurse did not complete the vital signs post-dialysis portion of the CMS. A review of the progress notes revealed the following nurse's notes (NN): A NN, dated 12/28/24 included that the nurse assessed the dressing to the perma cath. The NN did not include vital signs. A NN dated 1/2/25 included the vital signs that had been taken at the dialysis center. No vitals were taken upon Resident #19's return to the facility. On 1/4/25 there were no NNs, no documentation of the vital signs or assessment of the access site. A NN dated 1/18/25 included the time the resident returned to the facility. The NN did not include an assessment of the access site or vital signs, On 2/5/25 at 12:45 PM, the surveyor interviewed the 3rd floor Registered Nurse/Unit Manager (RN/UM), who stated that the dialysis communication binder would be sent with the resident on dialysis days. The dialysis center nurse completed the top part of the dialysis monitoring sheet (DMS) pre-dialysis and the middle section post-dialysis. The facility nurse completed the bottom section when the patient returned to the facility, which included the time the patient returned and the vital signs. The RN/UM further stated that the facility nurse should complete the bottom section and also document the vitals and access site assessment in the NN. The RN/UM confirmed that the above dialysis dates and times did not contain vital signs upon Resident #19's return and did not have vital signs or access site assessments documented in the NNs. On 2/7/24 at 11:25 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the dialysis center nurse should complete the top and the middle sections of the DMSs, and the facility nurse should complete the bottom section when the resident returned from the dialysis center. The DON confirmed that the facility nurse should document the resident's vital signs and access site assessment in the NN. A review of the facility's Dialysis Communication policy and procedure dated as reviewed 12/13/24, included .the nurse will document in the nurses note the following: a. Complete vital signs b. Appearance of shunts/fistula c. Bruit/Thrill d. Signs/symptoms of infection e. If the dressing required changing f. Any changes in the resident's condition. On 2/10/25 at 11:02 AM, the survey team discussed the above observations and concerns with the DON and Licensed Nursing Home Administrator. No further information was provided by the facility. 2.) On 2/3/25 at 11:34 AM, during the initial tour of the facility, the surveyor observed Resident #25 seated on a wheelchair, awake, and conversant. At that time, the resident stated that they went to the dialysis center three times a week. The surveyor reviewed the medical record of Resident #25. According to the admission Record face sheet, an admission summary, reflected that Resident #25 was admitted to the facility with diagnoses that included, end stage renal disease, dependence on renal dialysis. A review of the physician's progress notes dated 10/16/24, included that when the resident was readmitted to the facility from the hospital, Resident #25 had a permanent catheter to the right upper chest with a new diagnosis of End Stage Renal Disease (ESRD). A review of Resident #25's renal dialysis (RD) communication book revealed the resident went to the RD center on Tuesday, Thursday, and Saturday at 3:45 PM. On 2/7/24 at 11:25 AM, during an interview with a surveyor, the Director of Nursing (DON), confirmed that the dialysis center nurse completed the top and the middle portions of the Dialysis Monitoring Sheet and when the resident returned to the facility a post dialysis note was to be completed by the facility nurse. The facility nurse completed the bottom portion of the Dialysis Monitoring sheet and documented the post dialysis assessment which included the vital signs, the assessment of the access site in the electronic Medical Record under the Nurses Progress Notes. A review of the January 2025, and the February 2025, communication record did not reflect consistent documentations within the Nurses Progress Notes to reflect that the resident's dialysis access site was assessed (eval; evaluation of the access site for the following: clean, dry, intact, in place, functional, signs of bleeding, signs of infections, warmth to the area, pain, bruising or redness) prior to RD (pre) and after RD (post). The communication record (CR)reflected as follows: On 1/2/25, no pre and post RD eval of access site were documented on the PN; vitals were documented on the CR. On 1/4/25, no pre and post RD eval of access site were documented on the PN; no pre-RD eval of access site were documented on the PN; vitals was documented on the CR. On 1/7/25, no post RD eval of access site was documented on the PN; vitals were documented on the CR. On 1/9/25, no pre and post RD eval of access site were documented on the PN; vitals were documented on the CR. On 1/11/25, no post RD eval of access site was documented on the PN; vitals were documented on the CR. On 1/14/25, no pre-RD eval of access site was documented on the PN; vitals were documented on the CR. On 1/16/25, no post eval of access site was documented on the PN; vitals were documented on the CR. On 1/18/25, no pre and post eval of access site were documented on the PN; vitals were documented on the CR. On 1/21/25, pre and post eval of access site were documented on the PN; vitals were documented on the CR. On 1/23/25, no pre and post eval of access site were documented on the PN; vitals were documented on the CR. On 1/28/25, no pre and post eval of access site were documented on the PN; vitals were documented on the CR. On 1/30/25, no pre-RD eval of access site were documented on the PN; vitals were documented on the CR. On 2/1/25, no pre and post eval of access site were documented on the PN; vitals were documented on the CR. On 2/4/25, no pre-RD eval of access site were documented on the PN; vitals were documented on the CR. On 2/10/23 at 11:03 AM, during a meeting with the survey team, and the LNHA, the DON clarified that the vitals were filled out on the CR and that the pre and post RD evals were documented in PN. At that time, the DON acknowledged and confirmed that the post RD documentation was inconsistent and was unable to show that the facility assessed the resident each time Resident #25 prior and when the resident returned from RD. The DON also acknowledged that the documentation pre dialysis assessment was also inconsistent. The DON stated that an in-service would be provided to staff and a new RD monitoring form would be provided to the staff to ensure the pre and post assessments were consistently completed. A review of the provided facility policy, Dialysis Communication, dated/revised 12/13/24, included the following: To maintain continuity of care and effective communication amongst [facility name redacted] staff, and staff providing off-site dialysis treatment. Additionally, under procedure section 4 reflected that the nurse would document in the nurses note the following: complete vitals signs, appearance of shunts/fistula, bruit/thrill, and signs/symptoms of infection . No further information was provided. NJAC 8:39 - 27.1 (a)

2. On 2/05/25 at 10:40 AM, the surveyor interviewed the Food Service Director (FSD) about what the kitchen does for serving food to resident's who are on Transmission Based Precautions (TBP). The FSD stated that if there is a resident who is positive for Covid, the kitchen will serve that resident's meal with all items being disposable, including disposable trays, plates, bowls, cups and utensils. The FSD stated that the nursing department was supposed to inform the kitchen about any Covid positive residents, and the kitchen was not made aware of any resident who had been positive for Covid, until 2/4/25 in the late afternoon. The FSD stated that the kitchen staff had prepared the Resident # 56 food on a regular tray, plate, and utensils from the date that the resident tested positive for Covid on 1/31/25, up until yesterday once the kitchen was made aware. Additionally, upon interview with the FSD, he stated that when used/dirty trays are brought to the kitchen after meals from the floors, there are two staff who handle dish washing. One staff is on the dirty side and only wears gloves while handling dirty trays, dishes and utensils. The staff on the clean side wear gloves to handle to clean items. The FSD stated that the facility does use disinfectant for the trucks once used trays are removed. The FSD stated that since the kitchen is not supposed to handle contaminated dishware, the staff on the dirty side would not need other personal protective equipment (PPE). At 01:01 PM, the surveyor interviewed the IP (Olayimika Adeboye, RN, FT IP), Resident # 56 tested positive for COVID 1/31/25, nursing staff at the facility tested the residents as the resident went out for doctor and appt and upon fever and runny nose observed and tested positive. No positive staff from this, IP did contact tracing done for resident and staff and no other positives,testing everyone in facility weekly- not just the exposed, when there is a positive case in the facility, the facility will start covid testing done by departments and normally the morning meetings is when staff are made aware of the positive covid case, the IP stated that since this resident tested positive Friday evening, and then the weekend happened, there was no morning rounds on the weekend done by IP to discuss the positive case. Not sure if the FSD was made aware of the positive case on 2/3 and 2/4. Review of the Isolation policy and procedure, dated 8/19/2024, it revealed that the protocol for a resident who is on isolation is that the resident must be served with disposable plated, cups, cutleries and trays. 3. On 2/5/25 at 8:20 AM, during incontinence rounds, the surveyor observed the Registered Nurse/ Unit Manager (RN/UM) on the 3rd floor perform hand hygiene. The surveyor observed the RN/UM applied soap to her hands and immediately placed them under the stream of water without first lathering. On 2/5/25 at 8:30 AM, the surveyor observed the RN/UM applied soap to her hands and immediately placed them under the stream of water without first gathering. On 2/5/25 at 8:32 AM, the surveyor interviewed the RN/UM who confirmed she should have lathered her hands outside the stream of water for 20 seconds before putting them under the stream of water. The RN/UM stated that she usually washes her hands for 20 seconds outside the stream of water but was rushing. A review of the Proper Hand Washing Technique policy and procedure, dated as reviewed 11/29/24, revealed .Wet your hands with clean, warm running water .apply soap, and lather your hands by rubbing them together with the soap .rub hands together vigorously .15-20 seconds is an acceptable range to create a lather .happy birthday song from beginning to end twice . On 2/7/25 at 1:00 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations. The DON acknowledged that the RN/UM was expected to wash her hands for 20 seconds outside of the stream of water. NJAC 8:39-19.4 (a) Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain an infection prevention and control precautions for: a.) COVID-19 positive resident during dining and meal distribution, for one (1) of one (1) resident reviewed for transmission based precaution (Resident #56), and b.) perform proper hand hygiene for one (1) of five (5) nurses observed. This deficient practice was evidence by the following: Reference: https://www.cdc.gov/clean-hands/hcp/clinical-safety/ According to the CDC Hand Hygiene in Healthcare Settings, Hand Hygiene Guidance, last reviewed on February 27, 2024, included that Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. 1.) On 2/3/25 PM at 11:18 AM, the surveyor observed Resident #56 walking from the bathroom to their bed, without assistance. The door had a posted signage that reflected contact isolation. A soft storage container with compartments was hung on the outer part of the door which contained, gowns, n-95 masks (respirators) , and gloves (personal protective equipment; PPE). The room had two beds but was only occupied by Resident #56. The surveyor reviewed the medical record for Resident #56. According to the admission Record, an admission summary, Resident #56 was admitted to the facility with diagnoses which included but were not limited to; COVID -19 and malignant neoplasm (cancerous tumor) of the bladder. According to the resident's admission Minimum Data Set, (MDS) an assessment tool dated, 1/29/25, included that the resident had a Brief Interview for Mental Status (BIMS) of 14 which indicated that the resident's cognition was intact. A review of the Nurse's Progress Notes dated 1/31/25 at 6:00 PM revealed that at 1:30 PM, of the same day, Resident #56 was rapid tested and revealed a positive test for COVID-19. At 2:00 PM, the physician was informed, and the nurse received an order to place Resident #56 on contact isolation. The staff was informed to maintain all precautions. A review of Resident #56's Order Summary Report, included a physician order for contact precautions Covid-19 every shift that was ordered and started on 1/31/25. On 2/4/25 at 12: 58 PM, the surveyor observed Resident #56 walking around in their room. At that time, the resident stated that they were feeling fine. The posted signage of contact isolation was observed, and the PPE was well stocked. From the hallway, the surveyor observed a meal tray with a plate cover over the resident's plate in the resident's room. On 2/4/25 at 1:11 PM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) stated she was assigned to the wing where the resident resided, was assigned to the resident on that day and was familiar with the resident. At that time, the LPN stated that the Certified Nursing Assistants (CNAs) passed the trays to the residents who ate in their rooms. The LPN confirmed observing the meal tray, the plate cover, and utensils in Resident #56's room. The LPN stated that for a resident on contact isolation the resident should have received their meal in a disposable tray with disposable utensils. The LPN informed the surveyor that she would remove the tray when the resident was finished and place the meal tray that contained the plate, plate cover and utensil, in a red biohazard bag. On 2/4/25 at 1:17 PM, during an interview with the surveyor, Resident #56 stated that they received all their meals on the same tray, not disposable. At that time, during an interview with the LPN/ Unit Manager (LPN/UM) confirmed that the resident did not receive their meal in a disposable container and had a regular plate with utensils. The surveyor discussed the concern with the LPN/UM regarding the failure to maintain contact isolation precautions during dining services for Resident #56. On 2/4/25 at 1:21 PM, during an interview with the surveyor, the CNA assigned to the resident's hallway stated she was not sure if she had passed (served) Resident #56's tray that day and did not recall passing meals to Resident #56 in a disposable package, with disposable utensils.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #209 was observed by the surveyor on [DATE] at 11:31 AM, in bed and conversant. The resident informed the surveyor that she/he had requested for pain medication. The surveyor asked the resident to describe his/her pain in a scale from zero to ten being the highest. Resident #209 described the pain as ten. On [DATE] at 12:20 AM, Resident #209 confirmed with the surveyor that she/he had received his/her pain medication and no longer experienced discomfort. On [DATE] at 10:46 AM, the surveyor observed Resident #209 asleep on his/her right side On [DATE] at 11:54 AM, the surveyor observed Resident #209 asleep on his/her left side. On [DATE] at 10:19 AM, the surveyor observed Resident #209 asleep on his/her right side. On [DATE] at 1:08 PM, the surveyor observed Resident #209 in his/her room in bed and conversant. The resident informed the surveyor that the medication had been working from when they first met. The resident stated the medication caused her/him to fall asleep but it's okay, I need the rest. A review of the hybrid medical record (electronic and paper) revealed the following information: The resident's Record of admission included diagnoses of malignant neoplasm of rectum, Type II diabetes mellitus, depression, anxiety disorder and other specified arthritis. The [DATE] Physician Order included the following medications: -Gabapentin 600 mg tablet, 1 tab [tablet] oral every 12 hours for Dx: [diagnosis] Neuropathic pain, ordered on [DATE]. -Acetaminophen 325 mg tablet, 2 tabs [tablets] oral as needed every six (6) hours for Dx: Pain, ordered on [DATE]. -Zanaflex 2 mg (Tizanidine Hydrochloride) 1 tab oral as needed every eight (8) hours for Dx: muscle spasm ordered on [DATE]. -Levemir Flextouch 100 U [units]/1 ml [milliliter] solution (Insulin Detemir) 5 units subcutaneous at bedtime . for Type 2 diabetes mellitus without complications ordered on [DATE]. -Humalog 100 U/1ml solution (Insulin Lispro Recombinant) 5 units with meals {breakfast, lunch, and dinner} hold for blood sugar less or equal 130 subcutaneous before meals . type 2 diabetes mellitus without complications, ordered on [DATE]. The [DATE] quarterly MDS assessment tool, Section C, indicated the resident had moderate cognitive impairment as evidenced by a BIMS score of 10. Section J, J0100 indicated the resident had not received scheduled pain or PRN [as needed medication]. Section N, N0350 was blank and did not indicate the resident received insulin. A photocopy of the Plan of Care - Current was provided to the surveyor by the Social Services Director. The care plan did not include a comprehensive care plan addressing the resident's pain and the potential for glycemic episodes with the use of insulin. The surveyor interviewed the Director of Nursing (DON) on [DATE] at 1:14 PM to discuss the care plan omissions. On [DATE] at 10:15 AM, in the presence of the survey team and the Licensed Nursing Home Administrator, the DON stated the resident should have been care planned for the as needed pain medication and the potential for glycemic episodes with the use of insulin. The DON also stated Resident #209's care plan was updated on [DATE] after surveyor inquiry. A review of the facility provided Interdisciplinary Care Plan (IDCP) policy revised [DATE] included but was not limited to the following: Purpose: Promote continuity of care communication among [redacted] staff Increase patient safety Safeguard against adverse events that are most likely to occur right after admission . Focuses on the resident as the center of control and support each resident and/ or representative in making his or her own choices by making an effort to understand: -What each resident is communicating verbally and nonverbally; identifying what is important to each resident with regard to daily routines and preferred activities; having an understanding of the resident's life before coming to reside in the nursing facility. Procedure: 4. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental or psychosocial functioning which was otherwise not identified in the baseline care plan, those changes will be incorporated into an updated summary provided to resident and his or her representative, if applicable. Comprehensive Care Plan: 3. The care plan will address all services furnished to attain, maintain highest practicable well-being; . 6. The care plan will be reviewed and revised after each quarterly, annual or significant change in status assessment; meet professional standards of quality; be provided by qualified persons; and be culturally competent and trauma informed. 9. Care plan meetings are scheduled weekly or on as needed basis and will include, in addition to the IDT [interdiciplinary team]members, participation from resident, family/representative, CNA [Certified Nursing Aide] who provides care and Dietary staff. NJAC 8:39-11.2 (d); (i); 27.1 (a) Based on observation, interview, and record review it was determined that the facility failed to initiate a comprehensive care plan for 2 of 20 residents reviewed for care planning, Residents #58 and #209. The deficient practice is evidenced by the following. 1. Resident #58 was observed by the surveyor on [DATE] at 9:39 AM awake in bed watching television. The resident was conversant with encouragement by the surveyor. A review of the hybrid medical record (electronic and paper) revealed the following information: The resident's Record of admission included admission diagnoses of major depressive disorder, paranoid schizophrenia, and vascular dementia. The [DATE] Physician Orders included an order for the antipsychotic medication, Risperdal 0.25 mg. administered twice daily for paranoid schizophrenia. The [DATE] quarterly Minimum Data Set (MDS) assessment tool, Section C, indicated the resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9. Section N indicated the resident received antipsychotic medication daily during the assessment period. The [DATE] Psychiatric Follow Up Note included documentation reflecting the resident had a history of and ongoing episodes of visual and auditory hallucinations related to deceased people. The practitioner noted the resident's condition may be improved with medication, support, redirection, and environmental factors. A photocopy of the Plan of Care - Current was provided to the surveyor by the Social Services Director. The care plan did not include a comprehensive care plan addressing the resident's psychiatric disorders or the use of psychoactive medications. The surveyor interviewed the Director of Nursing (DON) on [DATE] at 1:14 PM to discuss the care plan omission. The DON stated the resident should have been care planned for psychiatric disorders and the use of psychoactive medications

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain current equipment for the purposes of immediate response to potential life-threatening, cardiac emergencies. This deficient practice was identified in 2 of 2 Automated External Defibrillator (AED) kits reviewed during the medication labeling and storage task and was evidenced by the following: On [DATE] at 10:16 AM, the surveyor observed an AED emergency response kit, mounted on the wall of the Third-floor nurse's station, in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM). The surveyor, with the assistance of the LPN/UM, removed the AED kit from the wall mounting, opened it, and observed two defibrillator pads enclosed in a package. LPN/UM stated she had ordered replacements two weeks ago from the Central Supply Manager (CSM) and received the two incorrect defibrillator pads observed. She further explained that she had informed the CSM and had not received the correct defibrillator pads since receiving the incorrect defibrillator pads. On [DATE] at 10:25 AM, LPN/UM stated the AED device would not turn on and confirmed that the battery for the AED was not working. At that time, the LPN/UM acknowledged that the AED device should have had the correct pads on-hand and the battery to power the device should have been functional. On [DATE] at 10:33 AM, the surveyor entered the Second-floor nurse's station and observed the Director of Nursing (DON) and the Registered Nurse (RN) testing the second AED device. The surveyor asked the RN to identify the expiration date on the defibrillator pad on the AED device and the RN stated the expiration date was [DATE] and that the pad identified was expired. At that time, during an interview with the surveyor, the DON stated that the CSM ordered the defibrillator pads two weeks ago and received the incorrect pad. The DON confirmed that the AED device should have been equipped with an unexpired pad in the event of an emergency for cardiac arrest. The DON stated that at that time, the facility did not have an unexpired defibrillator pad in stock for use but the CSM was on his way to bring new defibrillator pads that day. The DON also stated she had no prior knowledge and was not informed about the expired defibrillator pads by her staff. On [DATE] at 10:45 AM, the surveyor and RN/UM reviewed the audit check list Code Cart Check/Defibrilator [Defibrillator] for the Second floor dated [DATE] and the [DATE] was not found. The RN/UM explained that the signatures on the check list meant that the AED device was checked and was ready to go with no problem. On [DATE] at 10:53 AM, the surveyor and LPN/UM reviewed the audit check list Code Cart Check/Defibrilator [Defibrillator] for the Third floor dated [DATE] and [DATE]. At that time, during a follow up interview with the surveyor, LPN/UM explained that the signatures meant it was checked and that there was not a documentation that the pads were expired. On [DATE] at 01:32 PM, during a subsequent interview with the surveyor, the DON confirmed there were only two AED device present in the building. On [DATE] at 1:05 PM, during an interview with the survey team, the DON stated that the facility did not have a policy and procedure relating to the AED device and that they followed the manufacturer's directions. The Licensed Nursing Home Administrator (LNHA) stated they had a process for ensuring the AED device was operational and the defibrillator pads were in-date however the process failed because of the lack of communication from the staff to the DON and LNHA. NJAC 8:39-23.3(a) (b)1

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to administer a medication to the manufacturer's cautionary specifications. This deficient practice was identified for 1 of 3 nurses administering medications to 1 of 5 residents (Unsampled Resident) during the medication administration observation and was evidenced by the following. A review of the manufacturer's specifications for Lokelma (sodium zirconium cyclosilicate) under section 2.3 Reconstitution and Administration. In general, other oral medications should be administered at least 2 hours before or 2 hours after LOKELMA [see Drug Interactions (7)] . On 1/6/23 at 9:20 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) preparing to administer medications to Unsampled Resident. The LPN prepared eight medications which included one packet that contained ten grams (GM) of Lokelma (a medication used to treat high levels of potassium in the blood). The surveyor observed the LPN pour the packet into a separate drinking cup, add water into the same cup and mixed its contents until dissolved. The LPN proceeded to the Unsampled Resident's room who was encouraged to a seated position on the bed. The LPN administered the medications and was immediately followed by the administration of the Lokelma mixture. Review of the Physician Order for January 2023 included the following active physician orders: Lokelma 10 GM/ 1 Packet powder for suspension (Sodium Zirconium Cyclosilicate) 1 packet (mix with 8 oz [ounce] water) oral at 9:00 for 3 days for Hyperkalemia with an order date of 1/5/23. On 1/6/23 at 10:01 AM, the surveyor with the LPN reviewed the electronic Medical Administration Record (eMAR) which reflected an order dated 1/5/23 for Lokelma 10 GM/ 1 Packet powder for suspension (Sodium Zirconium Cyclosilicate) 1 packet (mix with 8 oz [ounce] water) oral at 9:00 for 3 days for hyperkalemia. The LPN confirmed there were no additional instructions on the eMAR for the Lokelma 10GM. At that time, the surveyor with the LPN reviewed the resident's medication label for Lokelma 10 GM which had a cautionary Mix w/ [with] water. Take at least 2 hrs [hours] before or after meds [medications]. The LPN at that time, acknowledged that Lokelma 10GM should have been separated by two hours apart from the other medications. The LPN also stated she would reschedule Unsampled Resident's Lokelma 10GM two hours apart from the other medications. On 1/9/23 at 10:25 AM, during an interview with the survey team the Director of Nursing (DON) stated she was not aware of how Lokelma was to be administered. On 1/9/23 at 10:28 AM, during an interview with the survey team the Licensed Nursing Home Administrator (LNHA) stated we will check if the LPN moved the medication and inform the prescriber. A review of the facility provided Administration of Medications policy revised 11/10/22 did not include reading the resident's label for medication cautionary. NJAC 8:39-11.2(b), 29.2(d)

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) failed to sanitize and air dry steam table pans in a manner to prevent microbial growth and b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 1/4/22 at 9:55 AM, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. In the food preparation area, the surveyor observed a Food Service Worker (FSW), wearing gloves which were soiled in a red colored substance, holding a dish rag which was also soiled with a red colored substance. The FSW walked to the hand washing sink and with his gloved hands and turned on the faucet, the FSW took the soiled dish rag and put it in the sink basin and then took it out and squeezed the water off of the dish rag. The FSW took the dish rag and turned off the faucet with his gloved hands, walked to the food preparation area and began wiping multiple surfaces of the food preparation area with the same dish rag. The surveyor asked the FSD if this was how the food preparation areas should be Cleaned, if the FSW should have gloved hands which were soiled, and if the FSW should have been using the hand washing sink for cleaning the dishrag. The FSD stated that this is not how the food preparation area should be cleaned. 2. In the food preparation area, on metal dishware drying shelving unit, the surveyor observed four half sized steam table pans and seven full sized pans which were stacked with water between them. 3. The surveyor observed the 3-compartment sink and the 3rd compartment sanitizing sink was full of water. There was a greasy brown substance floating on top of the water of the 3rd compartment sanitizing sink. The FSD drained the 3rd sanitizing compartment sink and observed a grease-like substance staining the inside of the metal compartment of the 3rd compartment sanitizing sink, the FSD stated that this sink should have been cleaned properly before adding hot water and sanitizer to it as it is the last step before the dishware is air dried, request policies for the concerned areas. On 1/04/23 at 1:30 PM, the surveyor discussed the kitchen concerns with the facility Administrator and Director of Nurses. The surveyor reviewed the Dietary Services Generalized Cleaning and Sanitization p/p with a revised date of 1/4/2023, which revealed that all food contact surfaces will be cleaned with three steps: Step one all debris will be removed, step two a solution of soap and water will be used to cleanse area then area will be rinsed of soap solution, step three sanitizing solution (chemical # 8) will be used to sanitize area being cleaned, area will be allowed to dry before use and all towels used to clean will be discarded when soiled. And the surveyor received and reviewed the Dietary Services Small Equipment Sanitization with a revised date of 1/4/23, which revealed all items are to be completely air dried before they are stacked and items that are stacked wet can breed bacteria. NJAC 8:39-17.2(g)

Based on observation, interview, and record review it was determined that the facility failed to: a) provide wound care in a manner to decrease the spread of infection for 1 resident, #59, reviewed for pressure ulcer care, and b) develop a facility plan with measures to monitor for and prevent the growth of waterborne pathogens. The deficient practices are evidenced by the following. 1. The surveyor observed Resident #59 on 1/03/23 11:59 AM. The resident was awake and alert in bed with heel booties in place to right and left heels. Earlier that day, the Registered Nurse (RN) stated the resident had a hospital-acquired pressure ulcer on the right heel. The January 2023 Treatment Record contained a 12/15/22 treatment order to cleanse the right heel wound, apply medicated ointment, and cover with a dry dressing daily and as needed. On 1/6/23 at 9:20 AM the surveyor observed the Licensed Practical Nurse (LPN) perform the wound treatment to the resident's right heel. The LPN obtained the over bed table from the resident's bedside and brought it out to the treatment cart in the hallway. Without first sanitizing the table, the LPN placed the clean drape over the table. The treatment supplies were assembled on the over bed table and brought back into the resident's room and placed at the bedside. The LPN removed the soiled dressing from the wound site and discarded it in the room trash can near the resident's bed. When the LPN completed the treatment, she removed a pen from her uniform pocket and wrote the date on the tape which secured the top dressing over the resident's right foot. The LPN discarded the remainder of the items left on the supply field into the room trash can. The LPN did not remove the trash from the room before she moved to the next resident. The surveyor discussed the treatment with the LPN after it was completed. The LPN confirmed she should have sanitized the over bed table before placing the drape; should have sanitized the pen after removing it from her uniform pocket; and should have removed the trash from the resident's room when the treatment was completed. A review of the Wound Care Procedure, revised 12/21/22, revealed the over bed table should be checked for cleanliness prior to placing a drape. Additionally, the procedure indicated that all items needed for the treatment were to be placed on the treatment field using aseptic technique. Step 23 of the procedure instructed staff to leave the trash from the treatment in the room trash can. 2. The surveyor interviewed the Licensed Nursing Home Administrator (LNHA) on 1/05/23 at 11:04 AM regarding the facility water management program. The LNHA stated she did not have information on the program and would have to investigate it. She stated the previous building services person had resigned and she would look in his human resources paperwork. The surveyor spoke with the LNHA on 1/06/23 at 12:19 PM and again asked for documentation outlining the facility water management program. She replied that she was still looking. On 1/11/23 at 1:00 PM, the surveyor confirmed to the LNHA that a water management plan had not been provided to the surveyor. No further information was given to the survey team from the LNHA. NJAC 8:39-19.1; 8:39-19.4; 8:39-27.1(a);

Based on observation, interview, and record review it was determined that the facility failed to follow a physician's order for 1 of 2 residents, Resident #5, reviewed for position/mobility. The deficient practice was evidenced by the following: On 11/04/20 at 11:22 AM, the surveyor observed Resident # 5 in bed. The resident did not respond appropriately when spoken to mumbling incoherently. The resident's left arm was tight to the side and thier hand was closed on the chest. The resident was not wearing a splint and the surveyor did n ot observe a splint in the room. On 11/05/20 at 9:27 AM, the surveyor observed the resident in bed. There was a Certified Nursing Assistant (CNA) in the room. The CNA said she was finishing up with the resident's morning/hair care. The resident was not wearing a splint and there was none seen in the room. On 11/5/20 at 10:30 AM, the surveyor observed the resident in bed awake. There was no splint on the residents left hand. On 11/06/20 at 8:50 AM, the surveyor observed the resident in bed, awake and confused. No splint was on the resident's left hand. On 11/06/20 at 11:33 AM, the surveyor observed the resident fully dressed, sitting up in a wheel chair. The surveyor was unable to see if the resident was wearing the splint. There was a blanket over the resident's arm. On 11/06/20 at 12:11 PM, the resident's left arm was uncovered. The resident's left hand was resting on the resident's chest and no splint was on. The left arm was tight to the resident's side. On 11/9/20 at 11:30 AM, the surveyor reviewed the resident's record which revealed the following: The resident was admitted to the facility with diagnoses which included but mpt limited to; Other Cerebrovascular Disease, and Hemiplegia. The current Physician's Order Sheet (POS) which included a physician's order that was dated 10/5/19 read Left hand splint to be worn 8 hours after care and off before bed. On 9:00 and off 17:00. The Treatment Administration Record (TAR) which was initialed by the nurse from 11/1/20 to 11/9/20, at 0900 and 1700 to indicate that the splint had been applied for the period of time it was ordered to be worn. On 11/09/20 at 1:22 PM, the resident was in bed awake. There was no splint on the resident's left hand. On 11/09/20 at 2:16 PM, the surveyor asked the Unit Manager/Registered Nurse (UM/RN) who the CNA was that worked in the section where Resident # 5 resided. The UM/RN stated that the CNA went out to a doctor's appointment with a resident. On 11/09/20 at 3:04 PM, a CNA approached the surveyor and identified herself as the CNA who was assigned to Resident #5. The surveyor and the CNA observed resident #5 in the resident's bed. The surveyor asked the CNA why the resident was not wearing the splint. The CNA said when the facility moved resident's around due to the Covid outbreak in May and June the splint was lost. On 11/9/20 at 3:30 PM, the surveyor spoke with the Licensed Practical Nurse (LPN) and inquired about the splint. The LPN stated I know [the resident] had it on yesterday. The surveyor and the LPN went to the room and the LPN couldn't find the splint. The LPN confirmed that the resident wasn't wearing the splint. The surveyor asked the LPN why it was signed on the Treatment Administration Record (TAR) as being on today and last week but the resident wasn't wearing it. She said she made a mistake and should have checked that the CNA put it on before she signed for it. On 11/9/20 at 4:00 PM, the surveyor spoke with the UM/RN and asked about the splint. The Occupational Therapist (OT) was present and said the splint was lost a few months ago and the therapy department ordered a new one which hadn't been delivered yet. She said the resident definitely needed it. The OT further stated that the resident had been receiving therapy services in the past but was discharged and received restorative services which included splinting. The OT then went to the therapy department and retrieved a splint for the resident to borrow. In the meantime the LPN said she found a splint in the resident's bottom drawer. On 11/10/20 at 1:22 PM, the surveyor spoke with the Director of Nursing (DON) and the Administrator and made them aware of the concern for the resident not having the left hand splint on but the nurse signing the TAR to confirm that the resident had been wearing it. The DON and the Administrator nodded in agreement that the nurse should have verified that the splint was on prior to signing for it. On 11/12/20 at 10:18 AM, the UM/RN confirmed that the nurse should observe before signing the TAR that devices such as splints were applied correctly and then the nurse would sign the TAR. On 11/12/20 at 10:00 AM, the surveyor reviewed the facility's policy and procedure titled Restorative Nursing Program under Special Devices it read: During an evaluation period by the nursing/rehab department the need for splints/braces may be recommended to prevent new or decline in contractures. The following steps will be followed: The resident is referred to the rehab department for evaluation for appropriate splint/brace. A physician order is obtained and recorded in the resident's medical record. The rehab department determines and orders the appropriate device for the resident. Upon receipt of the device it is delivered to the designated nursing unit. Education on the proper application and maintenance of the device is provided by the rehab department to the nursing staff. Nursing staff apply the splint to support the body part and functional position. Device must be well padded to prevent pressure, skin abrasion and skin breakdown. Nursing staff will monitor resident for pain or edema on all shifts. Nursing staff will monitor resident for pain or edema on all shifts. Perform exercise of every immobilized area via ROM to maintain function. Splint should be applied in the morning and removed during care and before bed. NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to appropriately identify and implement measures to reduce hazards/risks for falls. This was observed for 1 of 2 residents (Resident #6) reviewed for falls and evidenced by the following. On 11/04/20 10:48 AM, the surveyor observed Resident #6 in bed with the lights off. The resident stated that he/she was stuck in the room because of the pandemic and was not very happy about it. The resident was oberved to have contractures (muscles that stiffen and prevents normal movement) of the left arm and limited mobility of the lower left leg. The surveyor observed there were no side rails on the bed. The surveyor reviewed Resident #6's medical records that revealed the following: According to the Record of Admission, Resident #6 was admitted to the facility with diagnoses that included Cerebral Vascular Accident (CVA). The Quarterly Minimum Data Set (MDS) an assessment tool dated 10/3/20 indicated that the facility performed a Brief Interview for Mental Status and the resident scored 15 out of 15 which indicated the resident was cognitively intact. Interdisciplinary Progress Notes (IPN) revealed Resident #6 had a fall on 6/11/20 at 11:05 AM. The 7-3 nurse documented that the assigned Certified Nursing Assistant (CNA#1) was providing care to the resident and the resident rolled off the bed onto the floor landing on his/her knees. The IPN revealed that the resident had a fall on 9/14/20 at 5:55 AM. The 11-7 nurse documented that CNA #2 who was assigned to Resident #6, was providing care and turned the resident to the right side. The resident started wiggling and fell to the floor. The nurse documented that the resident sustained a 2 cm x 0.2 cm skin tear to the intergluteal cleft (the groove between the buttocks). The nurse also documented that the resident stated she pushed me out of bed. On 11/10/20 at 9:45 AM, the Director of Nursing (DON) provided the surveyor with the fall investigations dated 6/11/20 and 9/14/20 which revealed the following: According to CNA #1's written statement on the Incident/Accident Statement Sheet dated 6/11/20, CNA #1 was about to tuck the pad under the resident when she saw the leg go over the side of the bed, she tried to pull the leg back but the resident ended up rolling off the bed and landing on his knees. CNA #1 stated she tried to pull the resident back and called for help but the resident already landed on the floor. There were no injuries sustained. There was no resident statement included with this investigation. According to CNA #2's written statement on the Incident/Accident Statement Sheet dated 9/14/20, CNA #2 pulled the resident over to the middle of the bed and then asked the resident to turn and the resident couldn't completely turn so she helped with the turn. CNA #2 documented that while she was doing care, the resident wiggled and moved a lot until the resident fell out of the bed. The resident sustained a skin tear. According to the resident's statement obtained after the 9/14/20 fall, Resident #6 stated that while receiving care from the CNA #2, she asked the resident to roll over to the side of the bed which the resident did. When she asked the resident to roll over further, the resident told her l'm already at the edge of the bed. The resident then stated I felt her push and then I fell out of the bed. The Fall Risk Evaluation was done quarterly to determine the fall risk score for Resident #6. The form indicated that a total score of 10 or above represents a high risk. The resident was evaluated in April 2020 and had a score of seven and in July 2020, the resident had a score of nine. The scores indicated the resident was at moderate risk for falls. The Plan of Care-Current care plans related to falls initiated on 4/23/20, revealed interventions that included my bed will be in the lowest position and locked with call light within reach, safety training and education as needed. The following interventions were added to the care plan following the fall on 6/12/20 were as follows: Ensure glasses are clean in good repair and worn appropriately, ensure resident wheel chair free from malfunctioning, follow up with Md orders, continue with safety training and education as needed, prompt to ask for assistance and attends to it on timely manner, continue to assess resident for any complaint post fall. The resident had the same type of fall from the bed on 9/14/20 at 11:15 AM. The facility reviewed and updated the fall care plan on 9/21/20 to include two new interventions, Staff will ensure that I am in the center of the bed at all times while I am in bed and Staff will ensure that my bilateral blue mats are in place while I am in bed. On 11/10/20 11:41 AM, the surveyor interviewed Resident #6 who stated that he/she only had use of the right arm and leg. The resident stated that he/she holds the head board when being turned. The resident demonstrated to the surveyor how he/she held onto the headboard. The resident stated he/she didn't feel secure. The surveyor observed the resident struggling to keep the hand on the headboard during the demonstration. The resident further stated that when he/she rolled over CNA #2 needed the resident to roll over more, then the resident stated he/she felt her push him/her and he/she rolled over the edge of the bed and landed on the floor. The resident stated he felt his bottom hit something. At 11:45 AM, the surveyor interviewed CNA #1 who worked on the 7-3 shift and was assigned to Resident #6 at the time of the 6/11/20 fall. CNA #1 stated that she had been taking care of Resident #6 for years. She stated that while the resident rolled over the leg slipped off the bed and then the resident rolled to the floor and landed on the knees. She stated it was the first time the resident rolled off the bed. At 12:40 PM, the surveyor interviewed Assistant Director of Nursing (ADON) who stated that he reviewed the 6/11/20 statements and looked at the mechanics of what happened and then he decided it was because the resident wasn't centered in the middle of the bed prior to providing care. However, he wasn't sure why the intervention of keeping the resident in the middle of the bed was not added to the care plan after the fall on 6/11/20. He stated it should have been added to the careplan. The ADON informed the surveyor that he did an in-service with the staff regarding resident safety - fall prevention on July 17, 2020. The ADON provided the sign in sheets for the education which revealed the 11-7 CNA #2 did not attend the in-service. The surveyor asked the ADON if the 11-7 staff were in-serviced, he replied yes. He stated he checks the schedule to make sure who ever was working would be in-serviced. He stated he tries to get everyone educated but he missed in-servicing CNA #2. At 2:00 PM, the surveyor discussed the above concern with the Director of Nursing (DON) regarding the care plan updates after each fall which did not address additonal safety measures to prevent the resident rolling over onto the floor. The DON had no response and provided no additional information. On 11/13/20 at 8:35 AM, the surveyor interviewed the 11-7 CNA #2 who stated she pulled Resident #6 to the middle of the bed. She stated she had to hold the resident while providing care. She stated the resident was constantly moving, when she told the resident that she was almost done, the resident rolled off the bed. She further stated that the resident doesn't stay in the middle of bed, he/she was always at the edge and he/she doesn't keep still. A review of the facility's policy titled Fall Prevention/Fall Management revised date of 11/20/19, did not include procedures regarding reviewing and revising the fall care plan to include appropriate interventions to reduce or eliminate the hazards or risk in the event a resident had a fall. NJAC 8:39-27.1(a)

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness; b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 11/04/20 09:32 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. In the food preparation area, the surveyor observed the following: - 10 stove top burners soiled with a thick black grease-like substance on the surface which was easily lifted with the tip of the FSD pen. - The food processor/mixer metal bowl was not covered with plastic and soiled with white particulates with a clear liquid pooling inside it. The FSD stated that this bowl was cleaned and ready for use but should have been covered in plastic and stated that it needed to be re-cleaned. - A food slicer was cleaned and not covered with plastic, the FSD stated that this should have been covered in plastic. 2. In the dishwashing area, the surveyor observed two cleaned frying pans, which were hung to dry and soiled with a thick black grease-like substance on the bottom of both pans. 3. In the dry storage area, the surveyor observed a random sampling of dented cans which were in rotation for use. The surveyor observed the following: - # 10 sized can of vanilla pudding with a 1/2 inch sized dent on the upper lip of the can, - # 10 sized can of potatoes with a 1 inch sized dent on the upper lip of the can, - # 10 sized can of tomato sauce with a 1 inch sized dent to the upper lip of the can, - # 10 sized can of peaches with a 2 inch dent to the body of the can, - # 10 sized can of pineapples with a 1/4 inch sized dent to the upper lip of the can, - # 10 sized can of applesauce with a 1 inch sized dent to the upper lip of the can. The surveyor reviewed the facility's policy titled, Small Equipment Sanitation dated 11/20/19. Items must be air dried only and are then stored in a clean dry storage area. The surveyor reviewed the facility's policy titled, Principles of Food Preparation and Services dated 11/5/20. Any damaged packages or cans must be discarded appropriately. Dented cans are placed on a dented can rack. The surveyor reviewed the facility's policy and procedure titled, Cleaning Schedule dated 11/20/19. The range, including the grids, burners and fry tops are cleaned daily and the mixer is cleaned daily after every use. On 11/04/20 02:09 PM, the surveyor brought the above concerns to the attention of the Administrator and Director of Nursing. NJAC 8:39-17.2(g)