**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 1 of 28 residents reviewed (Resident # 132). The deficient practice was evidenced by the following: The surveyor reviewed Resident # 132's records. The resident was discharged from the facility and according to the Discharge Return Not Anticipated MDS, an assessment tool used to facilitate the management of care, dated 5/3/24, the resident was assessed as being discharged to the hospital. A review of Resident # 132's progress notes dated 5/3/24 revealed the resident was discharged home with family. On 8/8/24 at 12:50 PM, the surveyor interviewed the MDS Coordinator, who stated that the MDS dated [DATE] should have indicated discharge to home or lesser care and that it was an error that it indicated discharge to the hospital. During an interview on 8/8/24 at 1:30 PM, the surveyor brought the above concerns to the attention of the Director of Nursing and Administrator. NJAC 8:39-11.2(e)1

Deficiency Text Not Available

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: On 08/01/24 at 10:29 AM in the presence of the Food Service Director (FSD) and the Regional FSD (RFSD) the surveyor observed the following: 1. Inspection of the Microwave unit revealed the interior to have multi-colored splattered food debris stuck to the interior upper wall. 2. During inspection of the oven the surveyor observed 3 cast iron grill plates that were visibly used, dirty with solidified grease in the oven. The FSD stated they had been used the night before. On 08/05/24 at 10:15 AM, the surveyor interviewed the FSD. who stated that the cooking equipment should have been removed from the oven and cleaned after use. It needs to be cleaned and maintained in a sanitary way to prevent food borne illness and contamination. The microwave should be thoroughly cleaned daily in the evening. The FSD acknowledged that the above items should have been cleaned. On 08/05/24 10:30 AM, the surveyor interviewed the RFSD. who stated that the cooking equipment should have been cleaned and maintained in a sanitary way to prevent food borne illness and contamination according to regulations. It did not meet supervisory expectations, facility policy or regulations. A review of the facilities General Kitchen Cleaning Policy, dated revision February 2024, revealed . Policy: The staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. A review of the facilities Food Borne Illness Policy, dated revision 1/2024, revealed . Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Definitions: Contamination means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. Policy Explanation and Compliance Guidelines: 1) Food safety practices shall be followed throughout the facility's entire food handling process. Elements of the process include the following: c.) Preparation of food, including thawing, cooking, cooling, holding, and reheating. 6) All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. a) Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ172653 Based on interviews, medical record review, and review of other pertinent facility documents on 04/08/2024 and 04/09/2024, it was determined that the facility failed to develop and implement a NPO (Nothing by Mouth) Care Plan (CP) for a resident (Resident #2) with a Peg Tube (a tube inserted through the wall of the abdomen directly into the stomach, it can be used to give drugs and enteral nutrition to a patient) and failed to follow its policy titled Care Plans, Comprehensive Person-Centered. This deficient practice was identified for 1 of 3 residents reviewed for CP and was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to Dysphagia, Pneumonia, Acute Chronic Kidney Failure and Obstructive Reflux Uropathy. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 02/08/2024, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 3/15, which indicated the resident was severely cognitively impaired. The MDS also indicated the resident was admitted with a Feeding tube. A review of Resident #2's CP initiated on 02/03/2024 did not reveal evidence of a NPO CP being placed. During an interview on 04/09/2024 at 12:38 p.m. the Surveyor asked if Resident #2 should have had a NPO CP in place, The Licensed Practical Nurse (LPN) stated, Yes, there should have been a CP initiated upon admission for Resident #2's NPO status. She further stated the importance of the CP is to show how a resident care is to be provided and how the interventions should be followed. A review of Resident #2's Progress Notes (PNs) dated 02/03/2024 through 02/08/2024 revealed documentation of the resident's NPO status been maintained. During an interview on 04/08/2024 at 1:23 p.m., the Certified Nursing Aide (CNA) assigned to Resident #2 stated she was aware of Resident #2's NPO status from the shift-to-shift report given by Resident #2's Nurses. She further revealed Resident #2 had a blue dot [a system the facility used to indicate NPO status for residents] on his/her room door, name identification bracelet and at the head of their bed which was an indication of their NPO status. During an interview on 04/09/2024 at 12:51 p.m., the Assistant Director of Nursing (ADON) stated, The purpose of the CP is to ensure continuity of care for the residents and that the proper care is provided to the residents. She stated that the NPO CP should have been initiated upon admission. When presented with Resident #2's CP, the ADON stated, I don't see a CP for NPO. A review of the facility's Care Plans, Comprehensive, Person-Centered revised 10/2022 under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs developed and implemented for each resident. N.[NAME].C.: 8:39-11.2(d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to provide full visual privacy and maintain confidentiality when discussing the resident's pain during medication administration and a physical assessment, for 1 of 24 residents reviewed, Resident #116. The deficient practice was evidenced by the following: On 3/3/22 at 8:40 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare to administer medication to Resident #116. The surveyor observed the LPN speaking to the resident from outside the doorway of the resident's room. The LPN entered the room of Resident #116 to administer medication and examine the resident's abdomen. The door to the room was open and the resident could be seen from the hallway lying in the bed. During the physical exam, the resident's abdomen was exposed, the resident's gown raised, and blankets were below the resident's waist. The LPN returned to the medication cart outside of the resident's doorway to prepare pain medication for the resident. The LPN spoke to Resident #116 from outside the doorway of the resident's room and asked about the resident's level of pain. The LPN repeated back the resident's answers from the doorway in a loud voice. On 3/3/22 at 8:50 AM, the surveyor spoke with the LPN about the observations of speaking to Resident #116 from outside doorway of the resident's room, examining the resident with the door open and the resident being visible from the hallway. The LPN acknowledged she should have closed the door when examining the resident and should have not asked questions from outside the room's doorway for resident privacy. The surveyor reviewed the medical record of Resident #116 which revealed the following: The Minimum Data Set assessment dated [DATE], revealed the resident scored 15 out of a possible 15 when the Brief Interview for Mental Status was done which indicated the resident was cognitively intact. On 3/3/22 at 12:53 PM, the surveyor spoke with the Administrator, the Director of Nursing (DON), the Regional Clinical Specialist and Regional Administrator about the above concerns. The DON provided the surveyor with policies as requested. On 3/4/22 at 9:50 AM, the surveyor reviewed the facility's policy and procedure dated 10/2021, titled Quality of Life-Dignity. Under Policy Interpretation and Implementation it read, 9. Staff shall maintain an environment in which confidential clinical information is protected .10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The surveyor also reviewed the facility's policy and procedure, dated 10/2021, titled Administering Medications, but it did not address the need to provide privacy. NJAC 8:39-4.1(a)12,16

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to notify resident families or resdient representatives (RR), and the Ombudsman's office in writing for a facility-initiated transfer to the hospital for 6 of 6 residents (Resident #81, #15, #18, #167, #105, and #106) reviewed for hospitalization. The deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) that revealed facility-initiated hospital transfers had occurred without written notification to the families and Ombudsman's office for the following residents: 1. According to the Discharge Minimum Data Set (MDS) an assessment tool dated 11/16/21, Resident #81 was transferred to the hospital with anticipated return to the facility. There was no documentation that the facility had notified the resident's family or RR in writing regarding the reason for transfer and bed hold policy. In addition, the Ombudsman's office was not notified. 2. According to the Discharge MDSs dated 9/29/21, 11/5/21 and 1/25/22, Resident #15 was transferred to the hospital with anticipated return to the facility. There was no documentation that the facility had notified the resident's family or RR in writing regarding the reason for transfer and bed hold policy. In addition, the Ombudsman's office was not notified. 3. According to the Discharge MDSs dated 11/16/21 and 1/18/22, Resident #18 was transferred to the hospital with anticipated return to the facility. There was no documentation that the facility had notified the resident's family or RR in writing regarding the reason for transfer and bed hold policy. In addition, the Ombudsman's office was not notified.4. The 2/2/22 MDS indicated the Resident #167 was discharged from the facility on 2/2/22 and anticipated to return to the facility. The Census tab indicated the resident was discharged to the hospital on 2/2/22 and readmitted to the facility on [DATE]. The surveyor interviewed Resident #167's resident representative (RR) on 3/2/22 at 11:30 AM. The RR stated the facility provided notification of the transfer by phone. The reason for emergency transfer and a review of the facility bed hold policy was not provided to the RR in writing. 5. The 1/18/22 MDS indicated the Resident #105 was discharged from the facility on 1/18/22 and anticipated to return to the facility. The Census tab indicated the resident was transferred to the hospital on 1/18/22 and returned to the facility on 1/29/22. There was no documentation that the family or RR, and Ombudsman's office were notified in writing for the reason of the transfer. 6. The 1/19/22 MDS indicated the Resident #106 was discharged from the facility on 1/19/22 and anticipated to return to the facility. The Census tab indicated the resident was transferred to the hospital on 1/19/22 and readmitted to the facility on [DATE]. There was no documentation that the family or RR, and Ombudsman's office were notified in writing for the reason of the transfer. On 3/1/22 at 1:13 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated families or RRs had not been provided with written notification of emergency transfer or provided with the facility's bed hold policy at the time of transfer. Additionally, the facility had not provided notification of resident emergency transfers to the New Jersey Long-Term Care Ombudsman (LTCO) office. On 3/3/22 the DON provided the surveyor with the facility policy titled Transfers-Bed Hold, revised 5/2021. The policy indicated before transfer the resident or RR is to be provided with written information of the bed hold policy. The policy did not address written notification of the reason for emergency transfer to the resident or RR or written notification to the LTCO office. NJAC 8:39-5.3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow physician's orders and failed to handle medication appropriately. This was found with 2 of 24 residents reviewed, Resident # 115 and Resident # 81. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 2/24/22 at 11:19 AM, the surveyor observed Resident #81 seated in the wheelchair in the activity room. During an interview with the resident, the resident informed the surveyor that he/she doesn't always get their medications and many times not on time. The surveyor asked the resident if they had received their medications today. The resident replied no. After completing the interview with the resident, the surveyor interviewed Licensed Practice Nurse #1 (LPN #1) who was assigned to the resident. The surveyor asked the nurse if she had given the resident the 9 AM medications. LPN #1 replied yes. Resident #81 had come up behind the surveyor and quickly stated no you didn't. LPN #1 stated she would check. LPN #1 opened the medication cart and went into the locked narcotic box and took out an unlabeled medicine up with pills inside and stated that these were the medications for the resident. LPN #1 stated she had poured the medications and realized the resident wasn't in the resident's room. She stated she put the medicine cup with the resident's prescribed medication in the narcotic box. LPN #1 agreed it was not best practice to store the medications in the narcotic box. The surveyor asked what time the medications are scheduled to be administered and LPN #1 stated 9 AM. She agreed that the medications should be administered at the time they are scheduled. The surveyor reviewed Resident #81's the electronic medical records (EMR) that revealed the following: According to the admission Record, Resident #81 was admitted to the facility with diagnoses that included Cardiac Arrhythmia, Hyperlipidemia, Gastroesophageal Reflux Disease, and Congestive Heart Failure. The Quarterly Minimum Data Set (MDS) an assessment tool dated 1/23/22, the facility performed a Brief Interview for Mental Status that revealed a score of 15 out of 15 indicating the resident was cognitively intact. The February 2022 Electronic Medication Administration Record (EMAR) revealed the following medications were scheduled to be administered at 9 AM: Amiodarone 200 mg, Cholecalciferol 1000 units, Ferrous Sulfate 325 mg, Furosemide 20 mg, Loratadine 10 mg, multi-vitamin one tablet, Oxybutynin ER 10 mg, Potassium Chloride ER 10 mEq, Protonix 40 mg, Apixaban 5 mg, Colace 100 mg, Fluticasone 50 mcg/act nasal spray, Refresh eye drops, and Tylenol 325 mg two tablets. The EMAR Resident Details form showed an administration history for all the medications listed above that were due at 9 AM were given between 11:47 AM and 11:55 AM. On 2/24/22 at 12:54 PM, the surveyor discussed the above concern with the Administrator, Director of Nursing (DON), Regional Clinical Specialist and Regional Administrator. The DON provided the surveyor with the Administering Medication policy. The surveyor reviewed the policy titled Administering Medication with an update dated 10/2021. Under Policy Interpretation and Implementation #3 and #4 revealed the following, Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Surveyor: [NAME], [NAME] A. 2. On 2/24/22 at 11:45 AM, the surveyor observed Resident #115 in bed. The resident was on their back asleep. On 2/28/22 at 11:35 AM, the surveyor observed Resident #115 on their back in bed asleep. On 3/1/22 at 9:41 AM, the surveyor observed Resident #115 asleep in bed on their back. On 3/1/22 at 12:34 PM, the surveyor observed Resident #115 asleep in bed on their back. On 3/2/22 at 1:21 PM, the surveyor observed Resident #115 asleep in bed on their back. The surveyor reviewed the Resident #115's medical record which revealed the following: According to the admission Record, Resident #115 was admitted to the facility with diagnoses which included Dementia without behavioral disturbance, difficulty walking, and abnormal posture. A Treatment Administration Record (TAR) with a physician's order that read Ensure resident is turned and reposition side to side q 2 hrs (every 2 hours). Resident should only be on [the] back during meals. The order date was 1/4/22. The order was initialed by a nurse every day to indicate that the order was being followed. A quarterly MDS dated [DATE] that indicated the resident had severely impaired cognition and was rarely/never understood. On 3/7/22 at 11:28 AM, the surveyor asked the LPN #2 about the resident being observed multiple times on the back when there was a physician's order for the resident to only be on the back during meal time. LPN #2 said the resident stayed on their back for about 15 minutes after eating. The surveyor informed LPN #2 that there were multiple observations of the resident on their back long after meal time. LPN #2 stated she was not aware. On 3/7/22 at 11:41 AM, the surveyor asked LPN #2 who was responsible for repositioning the resident. LPN #2 said the Certified Nursing Assistant (CNA) but that she signed for it. LPN #2 said the order should have read, turn and reposition every two hours and not that the resident should only be on their back during meals. She said she would call the doctor and have it changed. The Unit Manager/LPN was present and stated yeah, it's a funky order. She agreed that if the nurse was signing for it she was signing for the order as it was written. On 3/7/22 at 12:41 PM, the surveyor discussed the above concern with the Administrator, DON, the Regional Clinical Specialist, and Regional Administrator. The DON agreed that the nurse should have clarified the physician's order and not signed for it if it was not an accurate order. she would get NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for 1 of 1 resident (Resident #15) reviewed for respiratory services. The deficient practice was evidenced by the following: On 2/25/22 at 8:22 AM, the surveyor observed Resident #15 in bed awake and alert receiving oxygen (O2) via a nasal cannula at 4 l/m (liters per minute) and a CPAP (continuous positive airway pressure to prevent the collapse of airway) mask on the nightstand not secured in a plastic bag. During the interview with resident, the resident stated that the nurses do not clean the mask. On 3/4/22 at 10:38 AM, the surveyor observed the resident in bed awake and alert with O2 via nasal cannula at 4 l/m O2 and the CPAP mask was in a plastic bag. The surveyor asked the resident if the tubing gets changed and she replied yes, they change it weekly, but they still haven't cleaned my mask. On 3/4/22 at 12:12 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPNUM) who stated that the night shift nurse takes off the CPAP mask and they should wash it with soap and water. The surveyor reviewed Resident #15's hybrid medical records (paper and electronic) that revealed the following: According to the admission Record, Resident #15 was admitted to the facility with diagnoses that included, Acute and Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Obesity. The Annual Minimum Data Set an assessment tool dated 2/14/22, indicated that the facility performed a Brief Interview for Mental Status which the resident scored a 14 out of 15. The score of 14 indicated that the resident was cognitively intact. The March 2022 Physician's Order Summary Sheet revealed the following order BIPAP Pressure: CPAP or IPAP and EPAP Back-Up Rate: 15/5 Oxygen Liter Flow (for bleed in): 4 LPM Apply at HS and remove in AM. Interface type: Nasal Pillows/Mask/ Full face mask Humidification (if appropriate) Heated or Cool Fill humidifier with sterile or distilled water. every evening and night shift. This order was initiated on 2/3/22. The March 2022 Electronic Treatment Administration Record (ETAR) reveal the above order was initiated on 2/3/22 and the nurses signed the ETAR 12 AM - 8 AM and 4 PM - 12 AM daily. The care plan titled [the resident] has oxygen therapy r/t (related to) CHF, ineffective gas exchange, respiratory illness. The interventions do not include how to care for the CPAP equipment. According to the manufacturer's specifications the CPAP mask should be cleaned every day. The mask can be cleaned with mild soap where it touches face or nose to clean the facial oils from the seal. Then rinse the mask with warm water and sit the mask on a paper towel or hang to let air dry. On 3/7/22 at 11:22 AM, the surveyor observed the resident in bed awake and alert, and the CPAP mask lying on the nightstand not secured in a plastic bag. The surveyor asked the resident if the CPAP mask was being cleaned in the morning when removed. The resident stated, they still don't clean the mask. The surveyor asked the LPNUM to come to the resident's room. The LPNUM looked at the nightstand and stated, the mask should be in a plastic bag. The LPNUM restated to the surveyor that the nurse who removes the CPAP mask should wash it with soap and water. The surveyor and LPNUM reviewed the physician's orders. There was no physician's order for the care of the CPAP equipment. There was no documentation in the Electronic Medication Administration Record and no documentation in the ETAR that the nurses were cleaning the CPAP equipment. On 3/7/22 at 12:13 PM, the surveyor returned to the resident's room and observed the CPAP mask was still on the nightstand not secured in a plastic bag. On 3/7/22 at 1:00 PM, the surveyor discussed with the Administrator, Director of Nursing, Regional Clinical Specialist and Regional Administrator the above concern and that the mask was still on the nightstand not secured in a plastic bag even after the LPNUM had observed it. The surveyor reviewed the facility's policy titled BiPAP CPAP dated 5/2021, under Procedure #8 The machine, tubing and masks must all be cleaned according to manufacturer's instructions and facility policy. A review of the facility's policy titled B-PAP/C-PAP Cleaning Policy indicated the following Mask and filter should be cleaned weekly in warm soapy water and rinsed in warm water. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to properly label and date medications in 1 of 8 medication carts and 1 of 3 medication storage rooms inspected. The deficient practice was evidenced by the following: 1. On 2/28/22 at 12:26 PM, the surveyor inspected the medication cart on the [NAME] unit in the presence of the Licensed Practical Nurse (LPN) who was assigned to the cart. There was a Lispro insulin vial box with a resident's last name written with a marker on the box. The lispro insulin vial removed from inside the box, had written in marker a different resident's last name. There was a second lispro insulin vial box with a pharmacy label. The lispro insulin vial removed from inside the box, had written in marker, the resident's last name which was smeared and only partially visible. There was no pharmacy label on the vial. An Ozempic insulin pen (A device used to inject insulin. It contains a cartridge, a dial to measure dosage, and a disposable needle), had a resident's first name written in marker on it and there was no pharmacy label. At that time, the surveyor asked the LPN about the insulin vials and pens with resident's name written in marker, she stated the pharmacy labels come off. On 2/28/22 at 12:40 PM, the surveyor inspected the medication room refrigerator on the [NAME] unit with the LPN. Inside the refrigerator was a Glargine insulin pen. There was a pharmacy label with the date of 2/19/22. The plastic bag containing the insulin pen read Refrigerate until opened. The LPN acknowledged unopened insulin pens should have been stored in the refrigerator and said she didn't know if the pen was unused as she was not the nurse who wrote the date on the medication. On 3/1/22 at 1:40 PM, the surveyor spoke with the Administrator, the DON, the Regional Clinical Specialist and Regional Administrator of the above concerns. On 3/2/22 at 9:55 AM, the surveyor reviewed the facility's policy and procedure titled, Storage of Medications, with the revised date of November 2021. Under Policy Interpretation and Implementation it read, 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing and 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. The surveyor reviewed the facility's policy and procedure, titled Administering Medications, updated on 10/2021. Under Policy Interpretation and Implementation it read, 14. Insulin pens will be clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse will verify that the correct pen is used for that resident. NJAC 8:39-29.4(a)

Based on observation, interview, and record review it was determined that the facility failed to consistently provide coordination between facility staff and hospice agency staff to meet the resident's nursing needs. The deficient practice was identified for 1 of 2 residents (Resident #366) reviewed for hospice/end of life care and was evidenced by the following. On 2/24/22 at 11:18 AM, the surveyor observed Resident #366 in bed. The resident's family member was at the resident's bedside. The resident's family member said the resident was on hospice. The resident appeared weak, looked at the surveyor and mouthed words but did not speak. The resident's family member said the resident could no longer hear or see very well. The resident's family member said the hospice aide went to the facility to see the resident every day at 7 AM. On 3/1/22 at 10:12 AM, the surveyor reviewed the resident's hybrid medical record which revealed the following: According to the admission Record, Resident #366 was admitted with diagnoses which included, Epilepsy, Unspecified Asthma, and Myelodysplastic Disease. A 1/26/22 Significant Change Minimum Data Set assessment tool, indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 and was enrolled in a hospice program. The 1/25/22 facility hospice care plan included interventions to provide personal care, pureed diet with pleasure foods, emotional and spiritual support, and notify hospice of any changes in condition or medication changes. Inside of the front cover of the resident's paper chart contained a sheet that read This patient is under the care of [Name of Hospice Provider] as of 1/21/22. The first page in the resident's chart was a sheet of paper that read Nursing Home-Nursing Visit. The top line had the resident's name and it read On 1/27/22 a nursing visit was made by the [hospice providers name] nurse .Computer generated nursing notes to be put in patient chart at next planned visit. If this nursing note should be required before next visit, please feel free to call us. That visit sheet was signed by the nurse. There was no other paper work from the hospice provider in the chart. On 3/1/22 at 10:12 AM, the surveyor asked the Unit Clerk for the hospice documentation that wasn't in the paper chart. She looked in the chart and agreed that there was no hospice documentation. She said she would find out where it was. On 3/1/22 at 1:10 PM, the Director of Nursing (DON) provided documentation that she stated was just sent over from the Hospice provider. The DON said she didn't know why the hospice provider was not leaving any documentation on the chart but she would call the hospice provider and ask. On 3/1/22 at 1:45 PM, the surveyor spoke with the DON, Administrator, the Regional Clinical Specialist and Regional Administrator and mentioned the concern with there being no documentation in the resident's record by the hospice provider. They agreed that the hospice provider should have documented each time they saw the resident and it should be part of the record. On the last day of the survey the surveyor asked the DON if she was able to find out from the hospice provider why there was no documentation left in the facility. The DON said she had not heard from the hospice provider about it. On 3/7/22 at 11:44 AM, the surveyor called the hospice provider and spoke with a Registered Nurse Supervisor (RNS). The surveyor asked the RNS what paperwork was required to be left in the resident's chart at the facility. The RNS stated the plan of care and any orders we recommend, we have an IDT (Interdisciplinary Team) note, that is the note by the hospice nurse, and when we have our meetings every two weeks those notes are sent over after being reviewed by the team. Non skilled care notes by the hospice aide should be kept in the chart after every visit. The Hospice Nurse sees the resident 1-2 times per week minimum, depending on the need. The notes are available for the facility to request at any time between the IDT meetings. On 3/7/22 at 12:00 PM, the surveyor reviewed the facility's policy and procedure titled Hospice Program with a review date of 3/2021. Under Policy Interpretation and Implementation 10 d. read Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. Number 12 read Our facility has elected the Director of Nursing or Designee to coordinate care provided to the resident by our facility staff and the hospice staff .He or she is responsible for the following: d. Obtaining the following information from the hospice: 1) The most recent hospice plan of care specific to each resident 2) Hospice election form 3) Physician certification and recertification of the terminal illness specific to each resident 4) Names and contact information for hospice personnel involved in hospice care of each resident 5) Instructions of how to access the hospice's 24 hour on-call system 6)Hospice medication information specific to each resident; and 7) Hospice physician and attending physician (if any) orders specific to each resident. NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control procedures in a manner that would decrease the possibility of spreading infection. This was found with: 1 of 2 certified nursing assistants (CNA) during urinary drainage bag changes, 1 of 5 nurses during medication administration and 1 of 3 nurses during wound care observation. The deficient practice was evidenced by the following: 1. On 3/1/22 at 10:12 AM, the surveyor observed the CNA who was assigned to Resident #83 change their large urinary drainage bag to a urinary leg bag. The resident had a urinary catheter (A flexible tube used to empty the bladder and collect urine in a drainage bag). The CNA, with gloved hands, pulled a garbage can towards her, removed her gloves, and put on a new pair of gloves. The CNA did not perform hand hygiene and continued the task of changing the urinary drainage bags. The CNA disconnected the large drainage bag from the catheter and laid the urinary catheter tubing on the inside of the resident's soiled incontinent brief. The CNA then cleansed the leg bag connection tip with an alcohol swab and connected the tube to the catheter. The CNA placed the large drainage bag on the foot of the resident's bed while she retrieved a clear plastic bag for storage. The tube attached to the large drainage bag was not capped and was touching the bed. The CNA placed the large drainage bag with uncapped tubing in a clear plastic bag and placed it in the resident's bed side table. The CNA went to the resident's bathroom, removed her gloves, and washed her hands. The CNA lathered her hands outside of running water for 9 seconds. On 3/2/22 at 1:05 PM, the surveyor interviewed the CNA, about the techniques used and observations during the change of the drainage bags for Resident #83. T he CNA stated, I should have connected the new bag immediately. The surveyor asked the CNA about the storing of the drainage bag and if there was a cap for the drainage bag. The CNA acknowledged there should have been a cap for the drainage bag and said, they go missing and there are times a new drainage bag is used or bags are stored without a cap. The CNA acknowledged the drainage bag should be stored with a cap on and said she had not reported to nurse or unit manager when a cap was missing. The surveyor asked the CNA about the facility's hand hygiene policy. The CNA stated hand hygiene should be performed at least 30 seconds or you can sing the happy birthday song. The surveyor reviewed the Resident #83's hybrid medical records (paper and electronic) which revealed the following: According to the admission Record, Resident #83 was admitted to the facility with diagnoses that included Chronic Kidney Disease, Begnin Prostatic Hyperplasia, Urinary Retention and history of Urinary Tract Infection (UTI). A physician order which read Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth two times a day for UTI for 14 days with a start date of 2/24/22. A Quarterly Minimum Data Set assessment tool, dated 1/25/22, indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15. On 3/2/22 at 1:37 PM, the surveyor informed the Administrator, the Director of Nursing (DON), Regional Clinical Specialist and Regional Administrator of the concerns during the urinary drainage bag change observation. On 3/3/22 at 10:50 AM, the DON provided the policies and procedures for hand hygiene and changing of urinary bags. The surveyor reviewed the facility's policy and procedure revised on 12/21, titled, Policy and Procedure for Changing of Urinary Bags. Under Policy, it read It is the policy of the facility to decrease the incidences of nosocomial infections by utilizing clean techniques when a drainage bag or leg bag is disconnected. Under Procedure, it read 8. Carefully remove sterile cap over the connection tip on leg bag or bedside drainage bag being switched to. 10. Carefully apply sterile cap to drainage system being switched from. The surveyor reviewed the facility's policy and procedure updated on 3/2021, titled, Handwashing/Hand Hygiene. Under Policy Interpretation and Implementation, it read: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .m. After removing gloves . and 9. The use of gloves does not replace handwashing/hand hygiene. Under Washing Hands, it read 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds. 2. On 3/3/22 at 8:40 AM, the surveyor observed the Licensed Practical Nurse #1 (LPN #1) administer medication to Resident #116. LPN #1 administered an eye drop medication to each eye to Resident #116. The surveyor observed LPN #1 use the same tissue for each eye when giving eye drops. On 3/3/22 at 8:50 AM, the surveyor spoke with LPN #1 about observation of using same tissue for both eyes. LPN #1 said she used different corners of tissue for each eye. On 3/3/22 at 12:53 PM, the surveyor informed the Administrator, the DON, and two regional directors of the above concerns. On 3/4/22 at 9:50 AM, the DON provided policy and procedure for eye drop administration. The surveyor reviewed the facility's policy and procedure reviewed on 11/21, titled Eye-Drop Administration. Under Procedure, it read 8. Gently dry the eyelid with a tissue if dripping occurs. (Note: Use only one tissue per eye.). 3. On 3/4/22 at 10:32 AM, the surveyor observed LPN #2 perform a wound treatment to the sacrum of Resident #115. After washing her hands LPN #2 removed a wet paper towel that had fallen in the sink. The LPN then donned gloves without performing any hand hygeine after removing the wet paper towel from inside of the sink. LPN #2 prepared supplies on the overbed table after sanitizing it and establishing a clean field, removed the old dressing from the resident's sacrum, and sprayed the wound on the sacrum with saline wound wash. LPN #2 then squeezed Santyl (a debriding ointment) onto a tongue blade and wiped it into the wound, while LPN #2 was wiping the Santyl into the wound, the can of saline wound wash fell on the floor. LPN #2 picked up the can of saline wound wash with her gloved hand and placed it back onto the overbed table. Without changing gloves or performing any hand hygeine, LPN #2 picked up the calcium alginate (an absorbent dressing) and placed it into the wound, she then pressed it into the wound with a cotton swab. LPN #2 covered the wound with foam gauze and returned the can of saline wound wash to an opened zip lock bag and placed it into the treatment cart. She did not sanitize the over bed table when she was done. On 3/4/22 at 12:02 PM, the surveyor spoke to LPN #2 and asked her about the observation of her removing the wet paper towel from the sink and not performing any hand hygeine. LPN #2 said she recognized that she dropped the paper towel in the wet sink but she used another paper towel to remove it. The surveyor then asked her about the can of saline wound wash that she picked up from the floor. LPN #2 said that she should not have picked up the can of saline wound wash from the floor and continued with the treatment without any hand hygiene. The surveyor then asked about spraying the wound with the saline wound wash and then returning the can back to the treatment cart in an open ziplock bag. LPN #2 agreed with the risk of splash back onto the spray can. LPN #2 showed the surveyor the can in the treatment cart that was in an open zip lock bag. LPN #2 showed the surveyor that the zip lock bag could be closed with the can inside and that it was labeled for and dedicated to resident # 115. She said she could have used a disinfectant wipe before putting the can of saline wound wash back in the treatment cart. On 3/4/22 at 1:00 PM, the surveyor discussed the wound treatment concerns with the Director of Nursing, (DON), the Administrator, Regional Clinical Specialist and Regional Administrator. They were in agreement that the concerns were infection control issues. On 3/7/22 at 11 AM, the surveyor reviewed the facility's policy and procedure titled Dressings, Dry/Clean and updated 10/2021. Under Preparation number 4 read Wipe nozzles of wound [cleanser] with alcohol pledget or facility disinfectant wipe. (Note: this may be performed at the treatment cart). Number 22 read Clean the bedside stand. NJAC 8:39-19.4 (a)

15. The hybrid medical records of Resident #83 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022, and February 2022. On 3/3/22 at 12:22 PM, the surveyor interviewed LPN #2 about where the physicians sign the orders for residents. LPN #2 stated the physicians sign in the resident's electronic chart. 16. Resident #19's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022 and February 2022. On 3/4/22 at 1:05 PM, the surveyors discussed the above concern with the Administrator, Director of Nursing (DON), Regional Clinical Specialist and Regional Administrator. On 3/8/22 at 12 PM, the DON provided the surveyor with the facility's policy titled Physician Orders. Under Process #5 indicated the following: All orders must be signed by an authorized, credentialed physician or other authorized practitioner in accordance with state regulations regarding prescriptive privileges. NJAC 8:39-23.2 Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 16 of 24 residents (Resident #81, #15, #74, #18, #70, #167, #68, #12 #57, #106, #366, #98, #7, #115, #83, and #19) reviewed and occurred over several months. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above that revealed the resident's primary physician had not hand signed the Order Summary Reports (monthly physician's orders) located in the residents' chart. In addition, there were no electronic signatures under the physician's orders for the following residents 1. Resident #81's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2021, January 2022 and February 2022. December 2021's physician's orders was not on the chart. 2. Resident #15's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2021, January 2022 and February 2022. The physician's orders for December 2021 were not in the chart. 3. Resident #74's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January 2022 and February 2022. 4. Resident #18's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022 and February 2022. 5. Resident #70's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2021, December 2021, January 2022 and February 2022. On 3/03/22 at 12:17 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated it was her understanding that the physicians come monthly. The LPNUM stated she was not aware of the process of who checks to make sure the physicians are signing their orders. 11. Resident #366's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022, or February 2022. 12. Resident #98's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022, or February 2022. 13. Resident #7's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022, and February 2022. 14. Resident #115's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022, and February 2022. On 3/4/22 at 11:30 AM, the surveyor asked LPN #2, where the physician's signed their orders. LPN #3 said they sign the medical record electronically. 6. Resident #167's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022, and February 2022. 7. Resident #68's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022, and February 2022. 8. Resident #12's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022, and February 2022. 9. Resident #57's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022, and February 2022. 10. Resident #106's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021, January 2022, and February 2022. On 3/03/22 at 12:12 PM the surveyor interviewed LPN #1 regarding the process for doctors signing their resident's monthly orders. LPN #1 stated the physicians sign orders electronically, however, LPN #1 was unable to show the surveyor that physicians had signed orders in the electronic record.

Based on interview and record review, it was determined that the facility failed to follow acceptable standards of clinical practice for accurately following a physician's orders to administer medication to treat varying pain levels. This deficient practice was observed for 1 of 3 facility residents reviewed for pain management, Resident #46, as evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 11/14/19 at 11:30 AM, during the initial tour, the resident was observed to be in bed in the room watching TV. The resident was alert and oriented. The surveyor interviewed Resident #46, who stated that he/she frequently experiences pain and requests pain medication from the nurse. On 1/18/19 at 11:25 AM, the surveyor reviewed the resident's Physician's orders on the Electronic Medical Record (EMAR) which revealed an order for Acetaminophen 325 milligrams (mg) Tablet give 2 tablets (650 mg) by oral route every 4 hours as needed for mild pain that was ordered on 9/4/19. Review of the September and November 2019 EMAR, revealed that Resident #46 received numerous doses of Acetaminophen 325 mg 2 tablets (650 mg) for documented pain scale rates between 3 to 7. Review of the facility Pain Severity Scale Crosswalk (pain evaluation form) designated level 3 as moderate pain and level 7 as severe pain. On 11/19/19 at 12:25 PM, the surveyor interviewed Resident #46's nurse, who stated that before administering pain medication, she assesses the level of pain of the resident. The nurse added that she considers mild pain to be rated from 1-3, moderate pain as 4-6, and severe pain as 7-10. On 11/19/19 at 1:00 PM, the surveyor interviewed Resident #46, who stated that the Tylenol ordered by the Physician was effective for the pain experienced. A review of the facility's form titled. Pain Severity Scale Crosswalk under the section titled Numeric Rate Scale revealed that mild pain is from 1-2, moderate pain is 3-4, severe pain 5-6, very severe is 7-8, and worst possible is 9-10. On 11/19/19 at 2:25 PM, the surveyor informed the Administrator and the Director of Nursing, who both agreed that the medication was not being administered according to the physician's order for treating mild pain. NJAC 8:39- 29.2 (d)

Based on observation, interview, record, and policy review, it was determined that the facility failed to a.) prepare potentially hazardous foods in a manner to prevent foodborne illness b.) failed to sanitize and air dry dishware, steam table pans, and silverware in a manner to prevent microbial growth, and c.) failed to store potentially hazardous foods in a manner to prevent foodborne illness. This deficient practice was evidenced by the following: On 06/14/18 at 09:47 AM, in the presence of the Food Service Director, the surveyor observed the following: 1. In the food preparation area, the surveyor observed a Food Service Worker (FSW) using a knife to cut lettuce on a yellow cutting board. The surveyor found a bag containing bread, two bags containing lettuce, and a roll of labeling tape sitting on top of the cutting board while the FSW was using it to cut the lettuce. 2. In the food preparation area on a shelf holding clean dishware, the surveyor observed three steam table pans with brown colored and crusted debris on each one. On the same shelving area in a container holding clean silverware, the surveyor also observed four spoons with white-colored debris on them. 3. In a dishwashing area on a rack holding clean dishware, the surveyor observed two knives soiled with white debris and a ladle with white-colored debris on it. On the same shelf, the surveyor also found five bowls, two plates, and three sheet pans stacked and wet nested with water between them. 4. On a shelf in the standing milk refrigerator located outside, the surveyor observed two cases of 8oz milk cartons with a stamped manufacturer expiration date of November 11, 2019. 5. In the food preparation area, the surveyor observed containers filled with bread crumbs, powdered food thickener, and flour. There were scoops stored inside of each of the containers. 6. In the dry storage room on a shelf, the surveyor observed two 1/2 full bags of dried and uncooked pasta, which were unwrapped and opened to the air. On 11/14/19 at 10:05 AM, the surveyor brought the above concerns to the attention of the Administrator. The surveyor reviewed the facility's policy titled, Dry Storage/Food Storage with a review date of 11/1/19. The policy showed that dry bulk items should be stored in seamless metal or plastic containers with tight-fitting covers or lids, and the scoops should be stored covered and outside of the bin. The policy also reflected that open packages are stored closed containers, tightly secured with ties or in food quality storage bags. The surveyor reviewed the facility's policy titled, Dry Storage/Supply Storage with a review date of 11/1/19. This policy reflected that extra dishes, glassware, silverware, and service ware are to be stored clean, off the floor, and safely to avoid accidents. NJAC 8:39-17.2(g)