Based on observation and interview, it was determined that the facility failed to ensure that the State of New Jersey inspection results were readily accessible for residents who resided in the facility. This deficient practice was identified for 4 of 4 residents (Resident #1, #6 #15, and #16) during the 4/22/25 Resident Council group meeting and evidenced by the following: On 4/21/25 at 9:00 AM, the surveyor observed that the State Survey results were located near the front entrance on the first floor. On 4/22/25 at 10:27 AM, the surveyor conducted the resident council meeting with four resident who (Resident #1, #6 #15, and #16) were alert and oriented, and selected by the facility to attend the group meeting. All four residents stated that they were not aware of the existence or location of the State Survey results. The surveyor reviewed the 2/11/25, 3/11/25, and 4/15/25 Resident Council meeting minutes. The minutes did not address the location of the State Survey results. On 4/22/25 at 10:51 AM, the surveyor interviewed the Regional Director of Recreation (RDR) and Director of Activities (DA) who confirmed the State Survey results notebook is not mentioned during the Resident Council meeting. On 4/23/25 at 12:32 PM, the surveyor informed the Director of Nursing (DON) that four of four residents from the group meeting did not know where on the first floor the State Survey results were located. The surveyor further explained that the State Survey results should be readily accessible to all residents without having to ask to read the results. On 4/24/25 at 1:54 PM, they surveyor met with the DON and Regional Licensed Nursing Home Administrator (RLNHA). There was no additional information provided. NJAC 8:39-4.1, 34

Based on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 2 (two) of 8 residents (Resident #5 and #15) This deficient practice was evidenced by the following: The MDS is a comprehensive tool, federally 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 within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. On 4/22/25 at 10:07 AM, the surveyor interviewed the Director of Nursing (DON) about the MDS Coordinator/Registered Nurse (MDSC/RN). The DON stated that the MDSC/RN worked remotely and does not go to the facility. The surveyor provided the DON with the list of 2 residents who had not completed an MDS in over 14 days. The surveyor also requested a copy of the resident's final validation report (generated after every MDS transmission) from the Centers for Medicare and Medicaid Services (CMS). On 4/22/25 at 11:59 AM, the surveyor interviewed the MDSC/RN over the phone. The MDSC/RN said she worked remotely and communicated using email with the DON. She stated that in the submission process, she would wait for the interdisciplinary team to sign their part before submitting it. On 4/23/25 at 11:00 AM, the surveyor met with the MDSC/RN who came to the facility. The surveyor and the MDSC/RN reviewed the 2 residents' MDS assessments that were not submitted within fourteen days of completion as follows: 1. Resident #5 had the following assessment, which was completed late: a. The admission MDS (A/MDS) assessment has an assessment reference date (ARD, the last day of the observation period) of 9/5/24. It was signed as completed on 9/16/24 and transmitted on 11/7/24. b. The quarterly MDS (Q/MDS) assessment with an ARD of 12/4/24 was signed as completed on 12/18/24 and was transmitted on 1/8/25. c. The Q/MDS assessment with an ARD of 3/4/25 was signed as completed on 3/18/25 and transmitted on 4/7/25. 2. Resident #15 had the following assessment, which was completed late: a. The A/MDS assessment with an ARD of 5/23/24 was signed as completed on 5/29/24 and transmitted on 7/10/24. b. The Q/MDS assessment with an ARD of 8/2/24 was signed as completed on 8/16/24 and not transmitted until 9/9/24. c. The Q/MDS assessment with an ARD of 11/1/24 was signed as completed on 11/15/24 and transmitted on 12/1/24. d. The Q/MDS assessment with an ARD of 2/1/25 was signed as completed on 2/15/25 and was not transmitted until 3/22/25. On 4/24/25 at 1:01 PM, the surveyor met with the DON regarding the above concerns and no further information was provided. NJAC 8:39-11.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines for 2 of 8 residents (Residents #4 and #15) reviewed for accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake sitting in bed with oxygen (O2) at 2 lpm (liters per minute) via nasal cannula (N/C, a medical device that provides supplemental O2 therapy, the device has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) connected to a portable oxygen concentrator (a device that supply an O2). Resident #4 stated that they also used oxygen at night and during activities at home. On 4/22/25 at 1:22 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #4, which revealed the following: A review of the admission Record (an admission summary) (AR) reflected that Resident #4 was admitted with diagnoses that included but were not limited to bronchiectasis (a condition when the walls of the bronchi, the tubes that carry air into and out of the lungs, become thickened and damaged) with acute exacerbation and obstructive and reflux uropathy (when the urine can't flow (either partially or completely) through the ureter (tube that transport urine from kidney to bladder) due to some obstruction). A review of the admission Minimum Data Set (A/MDS) of 4/4/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident had an intact cognition. Further review of the A/MDS in Section O - Special Treatments, Procedures and Programs C1 Oxygen Therapy - B While a Resident - No. A review of the Order Summary Report (OSR) with the start date of 3/28/25, oxygen at 2 lpm via nasal cannula, and check oxygen sats (saturation, amount of oxygen level in the blood) every shift. On 4/21/25 at 12:20 PM, the surveyor interviewed the Certified Nurse Assistant (CNA), who stated that she had seen Resident #4 use oxygen in the morning, when attending activities and going around the facility. On 4/21/25 at 12:30 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated that the residents were on oxygen therapy when they were admitted to the facility at night and left their rooms. On 4/23/25 at 11:37 AM, the surveyor interviewed LPN#2, who stated that she used to work at night and had seen the resident use the oxygen at night. 2. On 4/21/25 at 10:30 AM, the surveyor observed Resident #15 awake, sitting in a wheelchair on oxygen at 5 lpm via N/C connected to the concentrator, able to answer the surveyor's inquiry. On 4/22/25 at 1:00 PM, the surveyor reviewed the hybrid medical record of Resident #15, which revealed the following: A review of the AR reflected that Resident #15 was admitted with diagnoses that included but were not limited to hemiplegia (weakness on one side of the body) and hemiparesis (partial or complete loss of movement on one side of the body) following a cerebral infarction (blood flow to a part of the brain is obstructed). A review of the recent quarterly Minimum Data Set (Q/MDS) of 2/1/25 indicated that the facility assessed the residents' cognitive status using a BIMS score of 14 out of 15, which indicated that the resident had an intact cognition. Further review of the QMDS revealed in Section O - Influenza - None of the above and Pneumococcal Vaccine - Not Eligible. A review of the following Q/MDS dated [DATE] in Section O - Influenza and Pneumococcal Vaccine - Not Eligible. The QMDS dated [DATE] in Section O - Influenza - Received outside of this facility and Pneumococcal Vaccine - Not Eligible. A review of the A/MDS dated [DATE] in Section O - Influenza and Pneumococcal Vaccine - Not Eligible. A review of the admission assessment dated [DATE] in Section A - Demographics/Orientation to Facility under Immunizations, both Influenza and Pneumococcal vaccines was checked. On 4/23/25 at 12:35 PM, the surveyor interviewed the Director of Nursing (DON) regarding the above concern. The DON stated that Resident #15 must have been immunized for the influenza and pneumococcal vaccines, according to the nurse's interview with the family member on the admission assessment 5/16/24, which involved checking the resident's immunization record. The DON stated that she missed the immunization record. On 4/24/25 at 8:49 AM, the surveyor interviewed the resident's family member, who stated that they could not remember the date of the resident's vaccine and could not confirm whether it had been updated. On 4/22/25 at 11:59 AM, the surveyor interviewed the MDSC/Registered Nurse (MDSC/RN) over the phone. The MDSC/RN said she worked remotely and communicated using email with the DON and stated that she would rely on the electronic medical record since she does not come to the facility regularly. On 4/23/25 at 11:00 AM, the surveyor met with the DON and the MDSC/RN who came to the facility. The surveyor and the MDSC/RN reviewed the above concerns but did not provide further information. A review of the facility policy titled Immunization Protocol, Resident with the reviewed date on 12/20/22 under the Procedure: Upon admission, all residents will be interviewed as to their current immunization status. This information will be recorded on the resident's Immunization Record. NJAC 8:39-33.2 (c)

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included anticoagulant, antidepressant, and oxygen use. This deficient practice was identified for 3 of 8 residents (Resident #4, #5, and #15) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: 1. On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake sitting in bed on oxygen (O2) at 2 lpm (liters per minute) via nasal cannula (N/C, a medical device that provides supplemental O2 therapy, the device that has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) connected to a portable oxygen concentrator (a device that supply an O2). The resident has an indwelling urinary catheter inside the privacy bag (a tube placed inside the bladder to facilitate urine flow). On 4/22/25 at 1:22 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #4, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #4 was admitted with diagnoses that included but were not limited to bronchiectasis (a condition when the walls of the bronchi, the tubes that carry air into and out of your lungs, become thickened and damaged) with acute exacerbation and obstructive and reflux uropathy (when the urine can't flow) through the ureter (tube that transport urine from kidney to bladder) due to some obstruction). A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) of 4/4/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident had an intact cognition. Further review of the A/MDS in Section H - Appliances revealed that Resident #4 has an indwelling catheter. Section N - High-Risk Drug Classes, the resident is taking anticoagulant and antidepressant medications. A review of the Order Summary Report (OSR) includes the following orders: 1. Oxygen at 2 lpm via nasal cannula, and check oxygen sats (saturation, amount of oxygen level in the blood) every shift with an order date of 3/28/25. 2. Urinary catheter care every shift with an order date of 3/28/25. 3. Apixaban 5 mg (milligram) (anticoagulant) by mouth two times a day, with an order date of 3/29/25. 4. Venlafaxine HCl (hydrochloride) extended release 75 mg (milligram) (antidepressant) by mouth once daily, with an order date of 3/29/25. A review of the Medication Administration Record (MAR) revealed that the nurses recorded the Apixaban 5 mg by mouth two times a day, and Venlafaxine HCl extended release 75 mg by mouth once daily was given. A review of the Treatment Administration Record (TAR) revealed that the nurses recorded oxygen use and indwelling catheter care every shift. A review of Resident #4's comprehensive CP review revealed no CP for oxygen, indwelling urinary catheter, anticoagulant, or antidepressant use. 2. On 4/21/25 at 10:24 AM, the surveyor observed Resident #5 lying in bed awake. The resident has an indwelling urinary catheter inside the privacy bag hanging on the bedside frame. On 4/22/25 at 1:00 PM, the surveyor reviewed the hybrid medical record of Resident #5, which revealed the following: A review of the AR reflected that Resident #5 was admitted with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD, a condition caused by damage to the lungs) and hypertension secondary to other renal disease (high blood pressure caused by damage to the kidneys). A review of the recent quarterly Minimum Data Set (Q/MDS) of 3/4/25 indicated that the facility assessed the residents' cognitive status using a BIMS score of 15 out of 15, which indicated that the resident had intact cognition. Further review of the QMDS in Section H stated that the resident has an indwelling catheter. A review of the OSR with an order date of 2/27/25, urinary catheter care every shift. A review of Resident #5's comprehensive CP review revealed no CP for using an indwelling urinary catheter. 3. On 4/21/25 at 10:30 AM, the surveyor observed Resident #15 awake, sitting in the wheelchair on O2 at 5 lpm via nasal cannula connected to an oxygen concentrator. On 4/22/25 at 1:00 PM, the surveyor reviewed the hybrid medical record of Resident #15, which revealed the following: A review of the AR reflected that Resident #15 was admitted with diagnoses that included but were not limited to hemiplegia (weakness on one side of the body) and hemiparesis (partial or complete loss of movement on one side of the body) following cerebral infarction (blood flow to a part of the brain is obstructed). A review of the recent Q/MDS of 2/1/25 indicated that the facility assessed the residents' cognitive status using a BIMS score of 14 out of 15, which indicated that the resident had an intact cognition. Further review of the QMDS in Section N - High-Risk Drug Classes, the resident takes anticoagulant medication. A review of the Order Summary Report (OSR) with an order date of 9/24/24, apixaban 2.5 mg (milligram) by mouth twice daily. A review of the Order Summary Report (OSR) with an order date of 3/4/25, oxygen at 2 lpm via nasal cannula continuously for SOB (shortness of breath) or chest congestion. A review of Resident #15's comprehensive CP review revealed no CP for anticoagulant and oxygen use. On 4/22/25 at 12:47 PM, the surveyor interviewed the Director of Nursing (DON) regarding the CP concern. The DON stated she was the only one who initiated and revised the CP. She added that she might have missed the CP for residents who used anticoagulants, oxygen, antidepressants, and an indwelling catheter. On 4/24/25 at 1:01 PM, the surveyor met with the DON regarding the above concern, who did not provide further information. A review of the facility policy titled Comprehensive Person-Centered Care Planning given by the DON on 4/22/25 revealed that the comprehensive care plans must always reflect the current status of the resident and should be reviewed and revised on an ongoing basis. NJAC 8:39-27.1(a)

Repeat Deficiency Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) follow a physician's order, and b) place signage of oxygen (O2) therapy use according to standards of clinical practice and facility policy and procedure for 2 (two) of 2 residents, (Resident #4 and #15) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake sitting in bed on oxygen (O2 at 2 liters per minute (lpm) via nasal cannula (N/C), a medical device that provides supplemental O2 therapy, the device has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) connected to a portable oxygen concentrator (a device that supply an O2). Resident #4 stated that they used oxygen at night and during activities, and also added that they used it at home. The surveyor noted there is no signage outside the room for oxygen use. On 4/22/25 at 1:22 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #4, which revealed the following: A review of the admission Record (an admission summary) (AR) reflected that Resident #4 was admitted with diagnoses that included but were not limited to bronchiectasis (is a condition when the walls of your bronchi, the tubes that carry air into and out of your lungs, become thickened and damaged) with acute exacerbation and obstructive and reflux uropathy (when the urine can't flow through the ureter (tube that transport urine from kidney to bladder) due to some obstruction). A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) of 4/4/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident had an intact cognition. A review of the Order Summary Report (OSR) reflected physician order with the start date of 3/28/25 for oxygen at 2 lpm via nasal cannula, and to check oxygen sats (saturation, amount of oxygen level in the blood) every shift. A review of the Treatment Administration Record (TAR) revealed that the nurses recorded oxygen sat every shift. On 4/21/25 at 12:20 PM, the surveyor interviewed the Certified Nurse Assistant (CNA#1), who stated that she had seen Resident #4 using oxygen in the morning, attending activities, or going around the facility. On 4/21/25 at 12:30 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated that the residents were on oxygen therapy when they were admitted to the facility at night and left their rooms. On 4/23/25 at 11:37 AM, the surveyor interviewed LPN#2, who stated that she used to work at night and had seen the resident use the oxygen at night. 2. On 4/21/25 at 10:30 AM, the surveyor observed Resident #15 awake, sitting in a wheelchair on oxygen at 5 lpm via nasal cannula connected to an oxygen concentrator. The surveyor noted there is no signage outside the room for oxygen use. On 4/22/25 at 9:23 AM, the surveyor observed Resident #15 sitting in the wheelchair on oxygen therapy at 4 lpm via nasal cannula. On the same day at 11:00 AM, the resident was inside the activity room, and the surveyor observed Resident #15 with oxygen therapy at 5 lpm via a nasal cannula connected to the concentrator. On 4/22/25 at 1:00 PM, the surveyor reviewed the hybrid medical record for Resident #15, which revealed the following: A review of the AR reflected that Resident #15 was admitted with diagnoses that included but were not limited to hemiplegia (weakness on one side of the body) and hemiparesis (partial or complete loss of movement on one side of the body) following cerebral infarction (blood flow to a part of the brain is obstructed). A review of the recent quarterly Minimum Data Set (Q/MDS) of 2/1/25 indicated that the facility assessed the residents' cognitive status using the BIMS score of 14 out of 15, which indicated that the resident had an intact cognition. A review of the Order Summary Report (OSR) with the start date of 3/4/25, oxygen at 2 lpm via nasal cannula continuously for SOB (shortness of breath) or chest congestion every shift. A review of the TAR revealed that the nurses recorded oxygen use at 2 lpm continuously every shift. On 4/22/25 at 12:14 PM, the surveyor interviewed the CNA #1, who stated that the resident had been on oxygen therapy since last month and that she does not adjust the oxygen concentrator. On 4/22/25 at 12:16 PM, the surveyor interviewed the LPN #1 regarding the above concern, who stated that the oxygen order was 2 lpm, and she's been checking the concentrator to ensure it was correct. The LPN further stated that they could not explain why the oxygen concentrator was between 4 and 5 lpm. On 4/23/25 at 11:00 AM, the surveyor interviewed the Director of Nursing (DON) regarding the above concerns. The DON stated that the nurse should check the resident's oxygen order and could not explain why there was no oxygen signage outside the resident's room indicating oxygen therapy. On 4/24/25 at 9:45 AM, the surveyor met with the DON and Regional Licensed Nursing Home Administrator (RLNHA) and no further information was provided. A review of the facility policy titled Subject: Oxygen Administration with a reviewed date of 12/5/19 revealed under Procedure: 1. Check physician's order for liter flow and method of administration, 2. Place NO SMOKING/OXYGEN IN USE sign on resident's door, 4.f. Set the flow meter to the rate ordered by the physician. 7. Licensed staff will check the oxygen flow rate on all residents on oxygen therapy during rounds and compare it against the physician's order at the start and at the end of the shift. NJAC 8:39-25.2(c)3,6

Repeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 3 (three) of 5 (five) residents (Resident #1, Resident #10, and Resident #18) observed during the medication observation pass. 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 04/22/25 at 8:30 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN#1) in the room of Resident #18. The surveyor observed LPN#1 checking the resident's identification bracelet and informed Resident #18 that she would be administering the resident's medications. On 04/22/25 at 8:35 AM, the surveyor observed LPN #1 preparing to administer seven (7) medications to Resident #18 which included the following: Norvasc 5 mg tablets (blood pressure), Aspirin enteric coated tablet 325 mg, Fluconazole 200 mg (anti-fungal) tablet, hydrochlorothiazide 25 mg tablet (blood pressure), Losartan 100 mg tablet (blood pressure), Vitamin D3 2000-unit tablet (supplement), and Advair 250/50 inhaler. The surveyor observed LPN#1 take a bottle of Vitamin D3 2000-unit capsules and added one capsule into a medication cup with the other 5 medications. The surveyor then observed LPN#1 administer Resident #18's medications. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to displaced Trimalleolar fracture of right lower leg, hypertension (a condition in which the force of the blood against the artery walls is too high), and osteoarthritis (arthritis that occurs when flexible tissue at the ends of bones wears down). A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 3/20/25, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident's cognition was cognitively intact. A review of the April 2025 Physician's Orders (PO) revealed a Physician's Order dated 3/13/25, for Vitamin D oral tablet 50 mcg (2000 units) (Cholecalciferol) give 1 tablet by mouth one time a day for supplement. A review of the April 2025 electronic medication administration record (EMAR) revealed an order dated 03/13/25, for Vitamin D oral tablet 50 mcg (2000 units) (Cholecalciferol) give 1 tablet by mouth one time a day for supplement (plotted time at 9 AM). 2). On 04/22/25 at 8:43 AM, during the medication administration observation, the surveyor observed the LPN #1 in the room of Resident #1. The surveyor observed LPN#1 checking the resident's identification bracelet and informed Resident #1 that she would be administering the resident's medications. On 04/22/25 at 8:45 AM, the surveyor observed LPN #1 preparing to administer five (5) medications to Resident #1 which included the following: Norvasc 10 mg tablets (blood pressure), Plavix 75 mg tablet (medication used to prevent heart attacks), Hydroxychloroquine 200 mg tablet (Lupus) ,Vitamin D3 2000-unit tablet (supplement), and Lisinopril 10 mg tablet (blood pressure). The surveyor observed LPN#1 take a bottle of Vitamin D3 2000-unit capsules and added one capsule into a medication cup with the other 4 medications. The surveyor then observed LPN#1 administer Resident #1's medications. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood), hypertension (a condition in which the force of the blood against the artery walls is too high), and systemic Lupus erythematosus (chronic, illness that can affect many parts of the body). A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 4/02/25, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident's cognition was cognitively intact. A review of the April 2025 Physician's Orders (PO) revealed a Physician's Order dated 3/10/22, for Vitamin D oral tablet 50 mcg (2000 units) (Cholecalciferol) give 1 tablet by mouth one time a day for supplement. A review of the April 2025 EMAR revealed an order dated 03/13/25, for Vitamin D oral tablet 50 mcg (2000 units) (Cholecalciferol) give 1 tablet by mouth one time a day for supplement (plotted time at 9 AM). 3). On 04/22/25 at 8:59 AM, during the medication administration observation, the surveyor observed the LPN #1 administering medications. The surveyor observed LPN#1 entering the facility's activity room and checking the resident's identification bracelet and informed Resident #10 that she would be administering the resident's medications. On 04/22/25 at 9:00 AM, the surveyor observed LPN #1 preparing to administer six (6) medications to Resident #1 which included the following: Diltiazem ER 180 mg capsule (blood pressure), Plavix 75 mg tablet (atrial fibrillation), Meclizine 25 mg tablet (medication for dizziness), Miralax 17 gram (packet) (constipation), multivitamins with minerals (supplement) and Demadex 10 mg tablet (blood pressure). The surveyor observed LPN#1 removed a bottle of Miralax powder and measured approximately ¾'s of a capful and then add it to a cup with 120 ml of water and then mixed thoroughly. The surveyor then observed LPN#1 entered the activity room and administered all the medications including the Miralax to Resident #10. The surveyor observed Resident #10 drink all the contents of their Miralax solution. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood), hypertension (a condition in which the force of the blood against the artery walls is too high), and major depressive disorder (a mental disorder characterized by persistent low mood, loss of interest in activities, and other symptoms that interfere with daily life). A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 1/15/25, reflected that the resident's cognitive skills for daily decision-making score was 5 out of 15, which indicated that the resident has severe cognitive impairment. A review of the April 2025 Physician's Orders (PO) revealed a Physician's Order dated 02/15/22, for MiraLax packet 17 grams (polyethylene glycol 3350) give 17 grams by mouth one time a day for constipation mix well in at least 4 ounces of water. A review of the April 2025 EMAR revealed an order dated 02/15/22, for MiraLax packet 17 grams (polyethylene glycol 3350) give 17 grams by mouth one time a day for constipation mix well in at least 4 ounces of water (a plotted time of 9 AM). On 04/21/25 at 10:45 AM, the surveyor in the presence of LPN#1 reviewed Resident #1, Resident #10 and Resident #18's physician's orders. LPN#1 acknowledge that the Vitamin D was written for tablets for both Resident #18 and Resident #1 and that Resident #10's Miralax should have been in packets. Regarding the amount of Miralax that she measured out, she stated that she thought that she filled the appropriate amount for the resident but acknowledge that she should have double check the amount before emptying the contents into the cup. She further stated that the physician's order should match the medications that are being administered and that Vitamin D should have been changed to capsules and Miralax should have been changed to the bulk bottle. On 04/23/25 at 12:30 PM, the surveyor discussed the above concerns with the facility administration team that consisted of both the Director of Nursing and the Regional Licensed Nursing Home Administrator. There was no additional information provided. A review of the facility's policy for Medication Administration that was undated and was provided by the DON included the following: D. Medication Inspection: Confirm that medication name and dose are correct. NJAC 8:39-11.2 (b), 29.2 (d)

**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, store, and dispose of medications in one (1) of two (2) medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 11:38 AM, the surveyor inspected the high-side medication cart in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened Advair 250/50 inhaler with an opened date of [DATE] that was expired. At that time, the surveyor reviewed the manufacturer information on the inhaler in the presence of LPN#1. LPN#1 acknowledge that once opened the inhaler have an expiration date of 30-days. LPN#1 stated that the Advair inhaler was opened over 30-days ago and should have been removed from the medication cart. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Advair inhaler once opened have an expiration date of 30-days. On [DATE] at 12:30PM, the surveyor presented the above concerns to the facility administrative team which included the Regional Licensed Nursing Home Administrator (RLNHA) and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy titled Medications Administration that was undated [DATE] and provided by the DON included the following: G. Prior to Medication Administration: Check expiration date on medication label. NJAC: 8:39-29.4 (a) (h) (d)

Repeat deficiency Based on interview and record review it was determined that the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for one of three PBJ Report submissions reviewed, (Fiscal Year Quarter 1 2025, October 1 - December 31) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area that the facility failed to submit data for the third fiscal year quarter to CMS. The dates of the first quarter 2025 included October 1, 2024, through December 31, 2024. On 04/22/25 at 10:00 AM, the surveyor interviewed the Staffing Coordinator (SC) who stated she was responsible for the nursing staff scheduling as well as reporting staffing daily to the Department of Health (DOH) website. She stated that she submitted the staffing reports to CMS and that she will provide them to the surveyor. On 04/23/25 at 10:15 AM, the surveyor rreviewed the facilities CMS submission reports (PBJ submitter Final Validation Report) which showed that forms for the Fiscal Year Quarter 1 2025, contained sections that were not submitted and were not completed. On 04/23/25 at 12:30 PM, the surveyor presented the above concerns to the facility administration team which consisted of the Director of Nursing (DON) and the Regional Licensed Nursing Home Administrator. The surveyor told the administrative team that he reviewed the CMS submission reports that were provided by the facility which showed that some areas were omitted. He stated that prior to entering the facility that he ran the [NAME] reports for PBJ submission which revealed that the facility had no data returned for selected criteria for fiscal year Quarter one 2025. NJAC 8:39-41.3(a)2

Based on the interview and record review, it was determined that the facility failed to assure the Licensed Nursing Home Administrator (LNHA) attended the quarterly Quality Assurance (QA) meetings. This was identified for 5 of the 5 QA meetings reviewed. This deficient practice was evidenced by the following: On 4/24/25 at 9:16 AM, the Director of Nursing (DON) provided the surveyor with the sign-in sheets for the last five QA meetings and showed the following: on 4/10/2024, 7/17/2024, 10/9/2024, 1/20/2025, and 4/2025 the LNHA failed to attend the QA meeting. On 4/24/25 at 9:45 AM, the DON provided the surveyor with the facility Quality Assurance & Performance Improvement (QAPI) Plan. Under the section titled, Governance and Leadership - Responsibility, the QAPI Committee meets at least quarterly and is composed of the following individuals: Administrator, Director of Nursing, Medical Director, Director of Activities, Director of Social Services, Director of Administrative Manager, and Director of Rehab Services. On 4/24/25 at 11:58 AM, the surveyor interviewed the DON, who stated the LNHA has not been to the last five QA meetings. On 4/24/25 at 1:54 PM, the surveyor met with the DON and Regional Licensed Nursing Home Administrator (RLNHA) for the exit conference. No further pertinent information provided. NJAC: 8:39-33.1 (b)

Repeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to a) provide appropriate care and services of urinary catheter care to prevent urinary tract infections, b) performed hand hygiene after urinary catheter care, c) no Transmission-Based Precautions (TBP) or Enhanced Barrier Precautions (EBP) signage outside the resident's door, and d) no Personal Protective Equipment (PPE) accessible observed with 1 of 2 residents reviewed for infection control practices (Resident #4). This deficient practice was evidenced by the following: On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake and sitting in bed with an indwelling urinary catheter inside the privacy bag (a tube placed inside the bladder to facilitate urine flow) lying on top of the bed. The surveyor observed that there was no TBP sign or use of EBP outside the resident's room, and there was no available PPE. On 4/21/25 at 12:21 PM, the Director of Nursing (DON) went to the Resident #4 room after seeing the urinary catheter on top of the bed. The surveyor observed the DON donned (put on) gloves, removed the indwelling catheter on top of the resident's bed, hung it to the bedside frame, then doffed (removed) gloves, threw the used gloves in the garbage, put her hands inside her pocket, and moved the rolling walker. The DON walked out of the resident's room. The surveyor interviewed the DON regarding the above concern. She said there was no sink inside the room, and the nearest sink was outside the hallway. There is no hand sanitizer inside the resident's room; the nearest hand sanitizer is on top of the cart in the hallway. The DON stated she should do hand hygiene before and after wearing gloves, and the indwelling catheter should not be on the bed. The DON cannot state why no EBPs are implemented, the signage was not outside the room, and why there was no availability of PPE. On 4/24/25 at 1:01 PM, the surveyor met with the DON and the acting Infection Preventionist (IP) regarding the above concern and no further information was provided. A review of the facility form titled Infection Control Process Surveillance Monitoring Tool given by the DON on 4/21/25 revealed that under Process Name: Transmission Based Precautions (TBP), a. signs indicating a patient is on TBP are visible, b. PPE is stored and readily accessible outside patient's room, and c. Hand hygiene is performed upon entering/before leaving the patient's room. A review of the facility policy stated, Enhanced Barrier Protections - EBP builds upon Standard Precautions and expands the use of gowns and gloves beyond situations where exposure to blood and body fluids is anticipated. NJAC 8:39-19.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 4/21/25 at 10:00 AM, the surveyor observed Resident #3 in the facility activity room. The resident was seated in a chair with their walker next to them. The resident was dressed and groomed, and the surveyor observed no oxygen being used by the resident. On 04/21/25 at 11:00 AM, the surveyor inspected the resident's room and found no oxygen concentrator. On 4/21/25 at 11:20 AM, the reviewed the hybrid medical chart for Resident #3, which revealed the following: A review of the Resident #3's AR documented that the resident was admitted to the facility with diagnoses that included but were not limited to: anemia (low levels of healthy red blood cells), major depressive disorder (persistent depressed mood), anxiety disorder (feelings excessive fear or worry) and Alzheimer's disease (a progressive, degenerative brain disorder that causes memory loss). A review of the Annual MDS dated [DATE] revealed, under Section C, a BIMS score of 5 out of 15, which indicated severe cognitive impairment. The AMDS further revealed, under Section O, that Resident #3 was not receiving O2 therapy. A review of the April 2025 Physician Orders (PO) revealed a PO dated 9/28/2022, Oxygen at 2 liters per minute (l/min) via nasal cannula (a nasal cannula (NC) is a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory assistance) for saturation less than 92. Based on observation, interview, record review, and review of facility polices, it was determined that the facility failed to clarify an oxygen order. This deficient practice was identified for 6 of 12 residents (Resident #3, #4, #5, #6, #14, and #16) and reviewed. The deficient practices were evidenced by the following: 1. On 4/21/25 at 10:55 AM, the surveyor interviewed Resident #14 in their room. Resident #14 stated they do not and have never used Oxygen (O2) while in the facility. On 4/21/25 at 11:20 AM, the surveyor reviewed the hybrid (paper and electronic) medical chart for Resident #6, which revealed the following: A review of the Resident #14's admission Record (AR, an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: anemia (low levels of healthy red blood cells), hyperlipidemia (high cholesterol), and end stage renal disease (kidney failure). A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used for the management of care on 1/22/25, revealed, under Section C, a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. The QMDS further revealed under Section O that Resident #14 was not receiving O2 therapy. A review of the April 2025 Physician Orders (PO) revealed a PO dated 4/17/2024, Oxygen at 2 liters per minute (l/min) via nasal cannula (a nasal cannula (NC) is a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory assistance). 2. On 4/21/25 at 11:00 AM, the surveyor interviewed Resident #6 in their room, who was awake and seated upright in bed. Resident #6 was noted with aphasia (a communication disorder that makes it difficult to use words. It can affect speech, writing, and the ability to understand language). Resident #6 was able to nod to yes and no questions with accuracy. Resident #6 indicated they do not and have never used O2 while in the facility. On 4/21/25 at 11:30 AM, the surveyor reviewed the hybrid medical chart for Resident #6, which revealed the following: A review of the Resident #6's admission record documented that the resident was admitted to the facility with diagnoses that included but were not limited to: dysphagia, aphasia following cerebral infarction, and hypothyroidism. A review of the Annual Minimum Data Set (AMDS) dated [DATE] revealed, under Section C, a BIMS score of 15 out of 15, which indicated that the resident was cognitively intact. The AMDS further revealed under Section O that Resident #6 was not receiving O2 therapy. A review of the April 2025 PO revealed a PO dated 1/3/2025, Oxygen at 2 liters per minute (l/min) via nasal cannula. 3. On 4/21/25 at 11:10 AM, the surveyor interviewed Resident #16 in the room, who was awake and seated in a chair. Resident #16 stated that they do not and have never used O2 while in the facility. On 4/21/25 at 11:35 AM, the surveyor reviewed the hybrid medical chart for Resident #6, which revealed the following: A review of the Resident #16's admission record documented that the resident was admitted to the facility with diagnoses that included but were not limited to: depression, anxiety, and Alzheimer's disease. A review of the Quarterly MDS, dated [DATE], revealed under Section C a BIMS score of 8 out of 15, which indicated moderate cognitive impairment. The MDS further revealed under Section O that Resident #16 was not receiving O2 therapy. On 4/22/25 at 12:00 PM, the surveyor interviewed Licensed Practical Nurse (LPN#1), who stated Residents #6, #14, #16, #4, #5, and #3 are not on O2. The O2 order in their POs is a standard order for all residents who are admitted into the facility. The O2 order is in place if a resident becomes short of breath (SOB) or has a low oxygen saturation. LPN#1 acknowledged there were no specific directions for the oxygen. On 4/23/25 at 12:10 PM, the surveyor interviewed the Director of Nursing (DON), who stated that they put in the standard O2 for all residents admitted into the facility. The DON acknowledged that the O2 is incomplete, as the order is not specified as per resident PRN (as needed), standard (process refers to evaluation of the actual activities carried out by the caregiver), or continuous (absence of interruption). 5. On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake sitting in bed on oxygen (O2) at 2 lpm (liters per minute) via nasal cannula (N/C, a medical device that provides supplemental O2 therapy, the device has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) connected to a portable oxygen concentrator (a device that supply an O2). Resident #4 stated that they used oxygen at night and during activities. On 4/22/25 at 1:22 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #4, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #4 was admitted with diagnoses that included but were not limited to bronchiectasis (is a condition when the walls of your bronchi, the tubes that carry air into and out of your lungs, become thickened and damaged) with acute exacerbation and obstructive and reflux uropathy (when the urine can't flow) through the ureter (tube that transport urine from kidney to bladder) due to some obstruction). A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) of 4/4/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident had an intact cognition. A review of the Order Summary Report (OSR) with the start date of 3/28/25, oxygen at 2 lpm via nasal cannula, and check oxygen sats (saturation, amount of oxygen level in the blood) every shift. On 4/21/25 at 12:20 PM, the surveyor interviewed the Certified Nurse Assistant (CNA#1), who stated that she had seen Resident #4 using oxygen in the morning, attending activities, or going around the facility. On 4/21/25 at 12:30 PM, the surveyor interviewed LPN #2, who stated that the residents were on oxygen therapy when they were admitted to the facility at night and left their rooms. On 4/23/25 at 11:37 AM, the surveyor interviewed LPN#3, who stated that she used to work at night and had seen the resident use the oxygen at night. On 4/23/25 at 12:10 PM, the surveyor interviewed the DON who acknowledged that the O2 is incomplete, as the order is not specified as per resident PRN, standard, or continuous. 6. On 4/21/25 at 10:24 AM, the surveyor observed Resident #5 lying awake in bed, stating that they are not using oxygen. There is no oxygen concentrator inside the resident's room. On 4/22/25 at 1:00 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #5, which revealed the following: A review of the AR reflected that Resident #5 was admitted with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD, a condition caused by damaged to the lung) and hypertension secondary to other renal disease (high blood pressure caused by damaged to the kidneys). A review of the recent quarterly Minimum Data Set (Q/MDS) of 3/4/25 indicated that the facility assessed the residents' cognitive status using a BIMS score of 15 out of 15, which indicated that the resident had intact cognition. Further review of the Q/MDS revealed under Section O that Resident #5 was not receiving O2 therapy. A review of the Order Summary Report (OSR) with a start order of 9/3/24 oxygen at 2 lpm via nasal cannula. On 4/22/25 at 12:04 PM, the surveyor interviewed CNA #1, who stated that the resident does not receive oxygen therapy. On 4/22/25 at 12:08 PM, the surveyor interviewed LPN#2 to ask if the resident was using oxygen. The LPN revealed that the resident was not on oxygen therapy. On 4/23/25 at 12:10 PM, the surveyor interviewed the DON who stated that they put in the standard O2 for all residents admitted into the facility. On 4/24/25 at 9:45 AM, the surveyor met with the DON and RLNHA for an exit conference. No further pertinent information provided. A review of the facility policy titled Physician's Orders with a revised date of 4/4/25 revealed under Policy Interpretation and Implementation: 4. Medications, diets, therapy, or any other treatment may not be administered to the resident without the written approval from the attending physician. A review of the facility policy titled Subject: Oxygen Administration with a reviewed date of 12/5/19 revealed under Procedure: 1. Check physician's order for liter flow and method of administration, 4. Humidifier's Bottle f. Set the flow meter to the rate ordered by the physician. 7. Licensed staff will check the oxygen flow rate on all residents on oxygen therapy during rounds and compare it against the physician's order at the start and at the end of the shift. NJAC 8:39-19.4 (a) (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 4/21/25 at 10:00 AM, the surveyor observed Resident #3 in the facility activity room. The resident was seated in a chair with their walker next to them. The resident was alert and showed no signs of behaviors. The resident was participating in activities with other residents. On 4/21/25 at 11:20 AM, the surveyor reviewed the hybrid (paper and electronic) medical chart for Resident #3 which revealed the following: A review of the Resident #3's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: anemia, major depressive disorder, anxiety disorder and Alzheimer's disease. A review of the Annual MDS dated [DATE], revealed under Section C, a BIMS score of 5 out of 15 which indicated that the resident had severe cognitive impairment. A review of the resident's facility Progress Notes (PN) revealed no notes from the resident's primary physician from 11/1/24 until 04/21/25. 4. On 04/21/25 at 12:20 PM, the surveyor observed Resident #8 in the dining room in a recliner chair and was being assisted by a facility staff member. On 4/22/25 at 9:15 AM, the surveyor reviewed the hybrid (paper and electronic) medical chart for Resident #8 which revealed the following: A review of the Resident #8's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: hyperlipidemia (elevated cholestrol), hypertension (elevated blood pressure), and Alzheimer's disease (a progressive disease tht affects memory). A review of the quarterly MDS dated [DATE], revealed under Section C, a BIMS score of 0 out of 15, which indicated that the resident had severe cognitive impairment. A review of the resident's facility Progress Notes (PN) revealed no notes from the resident's primary physician from 11/1/24 until 04/21/25. Based on interview, record review, and review of facility policy it was determined that the facility failed to ensure that the responsible physician supervising (without a physician's assistant (PA) the care of residents wrote and made accessible progress notes at least once every 30 days. This deficient practice was identified for 6 of 12 residents (Resident # 3, #5, #6, #8, #15, and # 16) reviewed for physician visits and was evidenced by the following: 1. On 4/21/25 at 11:00 AM, the surveyor interviewed Resident #6 in their room, who was awake and seated in an upright position in bed. Resident #6 noted with aphasia (a communication disorder that makes it difficult to use words. It can affect your speech, writing, and ability to understand language). Resident able to nod to yes and no question with accuracy. Resident #6 indicated they have not seen their Physician (MD#1) in the past six months. On 4/21/25 at 11:30 AM, the reviewed the hybrid (paper and electronic) medical chart for Resident #6 which revealed the following: A review of Resident #6's admission record (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to: dysphagia (difficulty swallowing), aphasia (disorder that afffects communication) following cerebral infarction (blood flow to the brain is blocked), and hypothyroidism (underactive thyroid). A review of the Annual Minimum Data Set (AMDS) dated [DATE], revealed under Section C, a BIMS score of 15 out of 15 which indicated that the resident was cognitively intact. On 4/23/25 at 10:50 AM, the surveyor interviewed the Director of Nursing (DON) ) who stated MD#1 does come in weekly and will writes the monthly progress notes in his own charting system. The DON further revealed the facility staff does not have access to those notes in the charting system and MD#1 is supposed to print out the monthly progress notes and put into physical chart. The surveyor and DON reviewed the hybrid chart, and the DON confirmed Resident #6 does not have any monthly progress notes. 2. On 4/21/25 at 11:10 AM, the surveyor interviewed Resident #16 in their room, who was awake and seated in a chair. Resident #16 stated, they do not recall seeing MD#1 in the last eight months. On 4/21/25 at 11:35 AM, the reviewed the hybrid medical chart for Resident #6 which revealed the following: A review of Resident #16's admission record documented that the resident was admitted to the facility with diagnoses that included but were not limited to: depression, anxiety and Alzheimer's disease. A review of the Quarterly MDS date 3/5/25, revealed under Section C, a BIMS score of 8 out of 15 which indicated that the resident was moderate cognitive impairment. On 4/23/25 at 10:53 AM, the surveyor and DON reviewed Resident #16's hybrid chart, and the DON confirmed in Resident #16's paper chart, the last available monthly progress note was dated 9/2024. On 4/23/25 at 11:00 AM, the surveyor conducted a phone interview with MD#1, who stated he writes monthly progress notes in own charting system. MD#1 confirmed the DON and other facility staff do not have access his system. MD#1 stated he will physically bring in the monthly progress notes or will fax progress notes. MD#1 unable to state why the resident's monthly are not up to date. On 4/24/25 at 9:45 AM, the surveyor met with the DON and Regional Licensed Nursing Home Administrator (RLNHA) for exit conference. No further pertinent information provided. 5. On 4/21/25 at 10:24 AM, the surveyor observed Resident #5 lying in bed awake. The resident has an indwelling urinary catheter ( a tube placed inside the bladder to facilitate urine flow) inside the privacy bag hanging on the bedside frame. On 4/22/25 at 1:00 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #5, which revealed the following: A review of the admission Record (an admission summary) (AR) reflected that Resident #5 was admitted with diagnoses that included but were not limited to; chronic obstructive pulmonary disease (COPD, a condition caused by damaged to the lung) and hypertension secondary to other renal disease (high blood pressure caused by damaged to the kidneys). A review of the recent quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) of 3/4/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had intact cognition. A review of the resident's facility progress notes (PN) revealed no notes from the resident's primary physician from 11/1/24 until 04/21/25. 6. On 4/21/25 at 10:30 AM, the surveyor observed Resident #15 awake sitting on the wheelchair on oxygen (O2) at 5 lpm (liters per minute) via nasal cannula (N/C, a medical device that provides supplemental O2 therapy, the device has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) connected to an oxygen concentrator (a device that supply an O2) . On 4/22/25 at 1:00 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #15, which revealed the following: A review of the admission Record (an admission summary) (AR) reflected that Resident #15 was admitted with diagnoses that included but were not limited to; hemiplegia (weakness on one side of the body) and hemiparesis (partial or complete loss of movement on one side of the body) following cerebral infarction (blood flow to a part of the brain is obstructed). A review of the recent quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) of 2/1/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident had an intact cognition. A review of the resident's facility PN revealed no notes from the resident's primary physician from 11/1/24 until 04/21/25. On 4/23/25 at 10:50 AM, the surveyor interviewed Director of Nursing (DON) ) who stated MD#1 would come in weekly and would write monthly progress notes in his own charting system. The DON further revealed the facility staff does not have access to those notes in the charting system and MD#1 is supposed to print out the monthly progress notes and put into physical chart. The surveyor and DON reviewed the hybrid chart, and the DON confirmed the above residents did not have any monthly progress notes. On 4/23/25 at 11:00 AM, the surveyor conducted a phone interview with MD#1, who stated he wrote monthly progress notes in their own charting system. MD#1 confirmed the DON and other facility staff do not have access his system. MD#1 stated he would physically bring in the monthly progress notes or will fax progress notes. MD#1 unable to state why the resident's monthly are not up to date. On 4/24/25 at 9:45 AM, the surveyor met with the DON and Regional Licensed Nursing Home Administrator (RLNHA) for exit conference. No further pertinent information provided. NJAC 8:39 - 23.2 (d)

Based on interview and review of the Nurse Staffing Report it was determined that the facility failed to ensure that a required Registered Nurse (RN) was present at the facility 7 days a week for at least 8 consecutive hours a day for 5 of 14 days reviewed. This deficient practice was evidenced by the following: Per the Interpretive Guidance §483.35(b) Facilities are responsible for ensuring they have an RN providing services at least 8 consecutive hours a day, 7 days a week. However, per Facility Assessment requirements at F838, §483.70(e), facilities are expected to identify when they may require the services of an RN for more than 8 hours a day based on the acuity level of the resident population. If it is determined the services of an RN are required for more than 8 hours a day. Facilities may choose to have differing tours of duty (e.g. 8 hour- or 12-hour shifts) for their licensed nursing staff. Regardless of the approach, the facility is responsible for ensuring the 8 hours worked by the RN are consecutive within each 24-hour period. Review of the Nurse Staffing Report completed by the facility for the week of 4/6/2025 to 4/19/2025 revealed the facility had no RN coverage on any shift for five of fourteen days following days: 4/6/25, 4/7/25, 4/11/25, 4/14/25, and 4/18/25. On 4/24/25 at 11:14 AM, the surveyor interviewed the Director of Nursing (DON), who agreed that there should be a RN in the facility daily for 8 consecutive hours. The DON stated that she was previously the only RN employed by the facility. No further information was provided. NJAC 8:39-25.2(h)

Repeat Deficiency Based on observations, interview, review of facility job descriptions, it was determined that the facility failed to employ either a full time Registered Dietitian (RD) or a Dietary Manager (DM) that meets the qualifications to function as a director of food and nutrition services. This deficient practice was evidenced as follow: On 4/21/25 at 9:15 AM, the surveyor interviewed the Food Service Director (FSD #1), who is the FSD from another facility, but is covering for the facility FSD #2 today. FSD #1 revealed they work in a regional FSD capacity but does not come to the facility often. Per FSD #1, FSD #2 does not have any current dietary certifications, ServSafe, Certified Dietary Manager (CDM), and/or Certified Food Protection Professional (CFPP). FSD #1 further stated they would expect a FSD to have one or more of those certifications. On 4/22/25 at 9:39 AM, the surveyor interviewed FSD #2 who stated this was their first job as an FSD and was hired on 6/2/24, their ServSafe certification expired on 3/2024, and does not have any further certifications. FSD #2 further stated they were unaware of any certifications needed for the FSD job. On 4/23/25 at 10:54 AM, the surveyor interviewed the Registered Dietitian (RD #1), who stated they come to the facility once per week but does not perform any functions in the kitchen such as test trays or kitchen audits. RD #1 further stated they do not have any dietary certifications. On 4/23/25 at 11:05 AM, the surveyor attempted to conduct a phone interview the Regional Human Resources Director (RHRD) to review the hiring process of the FSD. The RHRD was unavailable, voicemail left. On 4/23/25 at 11:10 AM, the surveyor interviewed FSD #2 who stated, they thought they could perform the responsibilities of this job without certifications because they have twenty years of cooking experience. On 4/23/25 at 11:21 AM, FSD #1 provided the surveyor with a job description for the FSD. Under section Specific Requirements revealed, Must be licensed in accordance with current applicable standards, codes, labor laws, etc. On 4/23/25 at 11:40 AM, the surveyor interviewed the Regional Licensed Nursing Home Administrator (RLNHA) and FSD#1. Surveyor asked what qualification would be expected be for an FSD? FSD #1 described the qualifications for the FSD for the position, the ability to cook from scratch, follow standardized recipes, basic cooking skills, managing staff, and staff scheduling. In addition, the FSD #1 stated, the FSD should have a CDM qualification as well as ServSafe. RLHNA and FSD #1 acknowledged that FSD #2 does not currently have the necessary qualifications for their current position, but indicated FSD #2 will have their ServSafe certification renewed within the next week. On 4/24/25 at 9:30 AM, surveyor attempted phone interview with the RHRD but was unavailable. On 4/24/25 at 1:45 PM, the surveyor met with the RLNHA and DON for exit conference. No further pertinent information provided. NJAC 8:39-17.1(a)

Based on interview, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 4 of 4 residents (Resident # 1, # 6, #15, and #16), during the 4/22/25 Resident Council group meeting and evidenced by the following: On 4/22/25 at 10:27 AM, the surveyor conducted the resident council meeting with four resident (Resident # 1, # 6, #15, and #16), who were alert and oriented, and selected by the facility to attend the group meeting. All four residents stated that they were not offered or received snacks in the evening. On 4/22/25 at 10:51 AM, the surveyor interviewed the Regional Director of Recreation (RDR) and Director of Activities (DA) who evening snacks are provided by the Dietary Department. On 4/22/25 at 10:58 AM, the surveyor interviewed the Food Service Director (FSD) who stated the Recreation Department provides evening snacks. On 4/22/25 at 11:05 AM, the surveyor interviewed the Director of Nursing (DON) who stated the Nursing Department, specifically the Certified Nursing Assistants (CNA) are in charge of offering and passing out the evening snacks. The DON further revealed there was a tracking process in the electronic medical record (e-mar) where the CNA would enter if the resident accepted or refused the evening snack. On 4/22/25 at 11:22 AM, surveyor interviewed CNA#1, who confirmed the CNAs are responsible for the evening snack distribution and the tracking of snack acceptance or refusal are in the e-mar. The surveyor observed CNA check the evening snack history for Resident #16, #6, and #3 for 4/17/25, the e-mar revealed under the evening snack that, no history found. CNA #1 stated the no history found would indicate snacks were not offered to those residents. On 4/22/25 at 12:00 PM, the DON provided the surveyor with a facility policy titled, Snacks no created or revised date noted. Under the procedure section of the policy it states, 4. The Nursing staff or designee will distribute labeled snacks to resident and offer all other residents a snack, unless contraindicated. The nursing staff or designee will then document on the Snack Form as accepted or refused. On 4/24/24 at 1:45 PM, the surveyor met DON and Regional Licensed Nursing Home Administrator (RLNHA) for exit conference. No further pertinent information provided. NJAC 8:39-17.2 (f))(1) (i) (ii)

Repeat deficency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. On 04/21/25 at 09:15 AM, the surveyor in the presence of the Food Service Director (FSD#1), observed the following during the kitchen tour: 1. The clipboard on wall contained the weekly food temperature log, the surveyor observed that no temperatures had been taken for dinner from 4/14/25 through 4/17/25 and 4/19/25. FSD#1 acknowledged the missing temperatures and stated they should have been recorded. 2. On the bread shelf, the surveyor observed a 28 ounce (oz) whole wheat bread with an open date of 4/8/25, without a use by date. Also observed was an open bag of flour tortilla without an open or use by date. FSD #1 stated bread should be kept for three days after opening and the tortilla bag should have been labeled with an open and use by date. 3. On a shelf on the chef preparatory table the surveyor observed a 16oz can of corn starch, a 24oz can of B'gan brand beef base, 40oz bottle of honey, 80oz container of B'gan brand honey, a 7.1 oz bottle of oyster sauce, a 12 oz bottle of rice vinegar, a 32oz bottle of gravy aide, a 5oz bottle of sesame oil, a 32oz bottle of apple cider vinegar, a 32oz bottle of lemon juice, a 16oz box of baking soda, a 2 quart bottle of soy sauce, a 1 gallon bottle of Worcestershire sauce, a 6 pound (lb.) container of granulated garlic powder and a 6lb container of granulate onion powder all opened without open or use by labels. Also observed a 5 lb. container of ground cinnamon with an expiration date of 11/21/23, a clear plastic bag with beige powder-like substance labeled mashed potatoes with a use by date of 3/28/25, an 8oz container of Nestle thicken up with an expiration date of 9/2024. FSD#1 stated all bottles and containers need to be labeled with an open and a use by date when opened. FSD#1 unable to explain why the expired products had not been discarded. 4. In the standing freezer, the surveyor observed an opened package of ball park franks that had been opened but did not have an open and use by labels. The temperature log for the freezer was missing temperatures from 4/19/25 through 4/21/25. 5. In the two door standing refrigerator, the surveyor observed an 24oz ranch salad dressing and a 2lb container of ketchup, both missing open and use by labels. The temperature log for the refrigerator was missing temperatures from 4/19/25 through 4/21/25. FSD#1 stated all opened items need to be labeled. 6. The air conditioning (AC) vent was observed with a brownish dust-like debris. FSD#1 unable to state when the AC vent was last cleaned. 7. On the 3-shelf storage shelf, the surveyor observed five ½ sheet pan with wet nesting. FSD stated those sheet pans should have been fully dried before being stored. 8. On a storage shelf, the surveyor observed a 10lb container of baking powder with an open date of 6/30/23. FSD#1 stated the baking powder should have been discarded. 9. On the ground next to the oven, the surveyor observed 6 full sheet baking trays with a yellowish oil-like substance. FSD#1 stated the baking trays should not be stored on the ground and will be rewashed. 10. On the dish washing machine, the testing temperature log was missing temperatures on 4/20/25 and 4/21/25. 11. In the deep freezer, the surveyor observed one package of frozen turkey bacon, one bag of frozen mozzarella sticks, one bag of frozen meatball, one bag of frozen sausage patties, and 2 bags frozen biscuit all opened without open and use by labels. FSD#1 stated all items would be discarded immediately. 12. The two spout coffee machine was observed with a leaking valve. A grey colored bin was stored below collecting a brownish color liquid. FSD#1 stated the container would be emptied immediately. 13. In the dry storage area the surveyor observed, 2 #10 cans of sweet potatoes, 2 #10 cans of fruit cocktail and 1 #10 can of butter scotch pudding all dented and not placed in the dented can area. FSD#1 stated they would recheck all the canned goods for any dents. On 4/21/25 at 12:10 PM FSD#1 provided the surveyor with facility policy titled, Labeling and Dating with reviewed date of 5/2024, stated under the procedures section, 1. All food received in the building, dry, dairy, refrigerated or frozen must have a received date. 2. Receive date and expiration date must be visible. 3. All prepared foods are dated the date they are made and counting as day one. Must have a use by date .8. Opened bulk items, once opened, must be dated with open date and refrigerated. On 4/23/25 at 11:45 AM, the surveyor met with the Director of Nursing (DON) to review kitchen concerns. DON stated all kitchen concerns have been addressed. On 4/24/25 at 1:45 PM, the surveyor met with the DON for exit conference, no further pertinent information provided. NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that there was a Licensed Nursing Home Administrator (LNHA) who was physically present and actively involved by providing daily oversight to ensure all policies and procedures were implemented. The evidence was as follows: On 4/21/25 at 9:30 AM, during entrance conference the surveyor met with the facility administrative team that included the Director of Nursing (DON) and the Regional Licensed Nursing Home Administrator (RLNHA). The TC was informed by the facility that the facility LNHA was not at the facility because of a religious holiday. Throughout the survey that lasted from 04/21/25 through 04/24/25, the LNHA was not observed in the building. On 4/24/25 at 9:15 AM, the surveyor reviewed the facility's Quality Assurance and Performance Improvement (QAPI) book which included signed in log sheets which revealed that the LNHA was not present in 5 of 5 QAPI meetings reviewed. A review of the facility's Administrator Job Description, which was provided by the DON and was dated 02/2002 revealed the following: 1. Carries out supervisory/managerial responsibility in accordance with policies, procedures, and applicable laws including: interviewing, hiring and training staff; planning, assigning, and directing work; establishing deadlines; appraising performance; rewarding and discipling employees; and addressing complaints and resolving problems. 2. Plans, coordinates, and assign work; monitor performance; coaches, counsels, mentors, trains, and advises employees for dual goals of meeting department goals and employee career development. 4. Interprets, develops, communicates, updates, and monitors ordinances, policies, procedures, and standards; recommends improvement when necessary; and writes/revises same. 9. Serves as a liaison and /or member of various committees/teams and collaborates, persuades, presents reports to and negotiates with others outside own work area to coordinate efforts and maintain cooperative and efficient relations. 13. Directs the establishment and maintenance of essential records and files. 14. Investigates and resolves concerns of residents, families, staff, etc. On 4/24/25 at 11:15 AM, the surveyor interviewed the DON who acknowledge that the LNHA did not attend the last 5 QAPI meeting because he was not in the building. The DON further stated that the LNHA has never attended a QAPI meeting since becoming the LNHA at the facility. When asked how often the LNHA comes to the building, she stated that he comes in randomly, he was at the facility one day in March and hasn't been to the facility for the month of April. She stated that when the LNHA is not at the facility that she's in charge and that she keeps the LNHA inform with updates and that if she needed more guidance that she would reach out to the RLNHA. She stated that the RLNHA will come to the building at least once a week. The surveyor asked the DON what affect does have on the facility not having the LNHA at the facility. She acknowledges that it has a negative affect not having him at the facility, but she can always call him when she needs advice. She was unable to answer why the LNHA is not at the facility more often On 4/24/25 at 11 :30 AM, the surveyor interviewed the RLNHA who stated that the LNHA is at the facility twice weekly and that he would also comes into the facility twice weekly. The surveyor then asked the RLNHA if the facility's LNHA came to the facility twice a week and why the LNHA had not attended the QAPI meetings. The Regional LNHA was unable to provide further information. On 04/24/25 at 11:38 AM, the surveyor interviewed the Activity Director (AD), who has worked in the facility for 3 years now. The surveyor asked the AD when she last saw the administrator. She stated that she saw him last month in March. She added that she is unsure if he came monthly the previous year. 04/24/25 11:45 AM, the surveyor interviewed a Licensed Practical Nurse (LPN), who worked in the facility for 2 years, now stated that she saw the LNHA in the building last month (March) and just dropped by in the facility, then left. Sometimes he comes at least 2x/month but comes every month. On 04/24/25 at 1:30PM, the surveyor met with the DON and the RLNHA and discussed the above concerns. No further information was provided. NJAC 8:39-9.2(a)(2)

Based on interview and review of pertinent facility provided documents, it was determined that the facility failed to ensure the facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies was reviewed and updated, as necessary, and at least annually. This deficient practice was evidenced by the following: On 04/21/25 at 09:30 AM, during the entrance conference held with the facility administration, the surveyor requested a copy of the Facility Assessment (FA). On 4/24/25 at 10: 30 AM, the surveyor was reviewing the FA that was provided by Regional Licensed Nursing Home Administrator (RLNHA). The FA was not signed and had a date of 4/25/25 and they were no evidence that the FA was conducted or reviewed prior to the surveyor team entering the building. On 04/24/25 at 10:40 AM, the surveyor interviewed the RLNHA regarding the FA not being signed or dated correctly and no explanation was provided. On 4/24/25 at 10:45 AM, the surveyor requested the last FA for 2024 from the RLNHA and Director of Nursing and was not provided. The surveyor also requested the FA policy and procedure and was not provided. On 4/24/25 at 1:00 PM, the surveyor discussed the above concerns with the RLNHA and DON and no further information was provided, N.J.A.C. 8:39-5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to revise a comprehensive care plan post fall for a resident who fell and sustained a left radial fracture. This deficient practice was identified for 1 of 1 resident (Resident #7) reviewed for falls. This deficient practice was evidenced by the following: On 11/16/23 at 11:44 AM, the surveyor observed the resident in his/her room seated in a chair combing his/her hair. The resident was able to tell the surveyor that he/she had a fall sometime in September in the bathroom and broke his/her wrist. The resident stated, I slipped and fell and showed the surveyor a yellow bracelet on his/her wrist which indicated fall risk. The surveyor reviewed the medical record for Resident #7. A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included but not limited to: pneumonia, unspecified organism, unspecified fracture of the lower end of left radius, initial encounter for closed fracture, urinary tract infection, site not specified, and unspecified fall, subsequent encounter. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/6/23 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. The MDS indicated the resident was frequently incontinent of bladder and bowels. Review of section J for Health conditions in the MDS indicated the resident had one fall with major injury since admission/entry or reentry or prior assessment. A review of the electronic Progress Notes (PN) dated 9/20/23, revealed that at 1220 am CNA [certified nursing aide] came and said PT [patient] was on the floor had fallen using the rest room. PT was on [his/her] back and exclaimed [he/she] had left wrist pain and a visible skin tear on the top forearm. Vital were checked ROM [range of motion] and PROM [passive range of motion] PT had diarrhea last shift and was covid negative. Dr. [name redacted] was notified along with [his/her] family member. PT was taken to [name redacted] for evaluation. Further review of the electronic PN dated 9/20/23, revealed that the resident returned to the facility with splint to L [left] arm in place and per hospital note has a closed fracture of shaft L radius (left wrist). Review of the fall risk assessment in the electronic medical record revealed the following assessments: - Fall risk assessment dated [DATE] revealed a fall risk score of 1 which indicated low risk. - Fall risk assessment dated [DATE] revealed a fall risk score of 1 which indicated low risk. - Fall risk assessment dated [DATE] revealed a fall risk score of 2 which indicated low risk. - Fall risk assessment dated [DATE] revealed a fall risk score of 5 which indicated low risk. A review of the individualized interdisciplinary care plan (IDCP) revealed a IDCP initiated on 1/7/20 and revised 9/20/23, with a focus area for at risk for falls related to gait and balance problems and side effects of pain medications. [Resident #7] has fallen 9/16/22 and on 9/20/23 fell in BR [bathroom] and sustained closed fracture of shaft left radius. The goal of the IDCP was for the resident to be free of falls through the next review date. A review of the at risk for falls IDCP interventions revealed interventions dated 9/20/23, to monitor for pain and medicate PRN [as needed], follow up with Ortho [orthopedic], and splint to L [left] wrist/arm as ordered. There were no updated or revised IDCP interventions to address and prevent the resident from falling. On 11/17/23 at 12:20 PM, the surveyor interviewed the Director of Nursing (DON) and the Regional Administrator Consultant, a Registered Nurse (RN), who stated that the DON was responsible for developing, implementing, and updating care plans. The Regional Administrator Consultant stated that the care plan should have been updated with interventions to address and prevent the resident from falling again. At that same time, the DON stated that the care plan should have been updated either that same day or the next day. The Regional Administrator Consultant and the DON could not speak to why Resident #7's IDCP was not updated/revised with interventions to address and prevent further falls. A review of the facility Fall policy provided by the DON included the care plan is updated. A review of the facility Care Plans Comprehensive Person-Centered policy, provided by the DON, included that care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Care plan interventions address the underlying sources of the problem area(s), not just addressing only symptoms or triggers. The assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The Interdisciplinary team or respective discipline must review and update the care when there is a significant change in the residents condition, when a desired outcome is not met, when a resident has been readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required quarterly MDS assessment. NJAC 8:39-11.2(e)(1)(2)(h)(i), 27.1(a)(b)

Based on observation, interview and record review, it was determined that the facility failed to clarify a Physician's Order (PO) for oxygen administration in accordance with professional standards of practice for 1 of 1 resident reviewed for respiratory care (Resident #70). The deficient practice was evidenced by the following: On 11/15/23 at 11:41 AM, the surveyor observed Resident #70 in the facility activity room. Resident #70 was seated in a wheelchair and was participating in activities. The resident was receiving oxygen via nasal cannula. The oxygen concentrator was set at three liters per minute (LPM). On 11/16/23 at 11:10 AM, the surveyor observed Resident #70 in bed receiving oxygen via a nasal cannula. The oxygen concentrator was set at three LPM. The surveyor reviewed the medical record of Resident #70. Review of the admission Record (an admission summary) revealed that the resident was admitted to the facility in November of 2023 with diagnoses which included but was not limited to; chronic obstructive pulmonary disease (COPD, (a group of diseases that cause airflow blockage and breathing-related problems), acute and chronic respiratory failure with hypoxia (acute respiratory failure results from acute or chronic impairment of gas exchange between lungs and blood) and acute on chronic systolic (congestive) heart failure (heart does not pump blood as well as it should). Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/10/23, indicated that Resident #70 had a Brief Interview for Mental Status score of 12 out of 15, which indicated the resident's cognition was mildly impaired. Review of the November 2023 Order Summary Report (OSR) revealed a physician's order dated 11/3/23 for Oxygen at 2 LPM via nasal cannula. Review of the electronic progress notes revealed a nurses note dated 11/10/2023 at 22:03 (10:03 PM) which indicated, Patient on Oxygen at 3L/minute, no shortness of breath noted. No complaints of pain and discomfort. Requiring full assistance with ADL's. Call bell within reach. Further review of the electronic progress notes revealed a Health Status (nursing note) dated on 11/11/23 at 22:28 (10:28 PM) indicated, Resident is resting in [resident's] room watching TV when nurse came to check on [resident]. [Resident #70] verbal with needs. Confused at times but easily redirectable. No SOB noted however, [Resident] coughs once in a while with no little phlegm. [Resident's] on 3L of oxygen via nasal cannula. All medications are given with no issues. Nebulizer treatment given as ordered. On 11/16/23 at 11:15 AM, the surveyor, in the presence of a Licensed Practical Nurse (LPN), observed Resident #70 in their bed receiving oxygen via a nasal cannula. The LPN acknowledged that the resident's oxygen concentrator was set at 3 LPM. The LPN stated that the resident was receiving oxygen via nasal cannula at 3 LPM. On 11/16/23 at 11:20 AM, in the presence of the surveyor, the LPN reviewed Resident #70's electronic OSR and she acknowledged that the resident had an order for Oxygen at 2 LPM via nasal cannula. The LPN stated that the order in the electronic OSR should have been written for 3 LPM and that she would get a new order from the physician. She further stated that they were no orders to check the oxygen settings in the electronic medication administration record. On 11/21/2023 at 12:33 PM, the surveyor, in the presence of the survey team, presented the above concerns to the Regional Licensed Nursing Home Administrator, the Director of Nursing, and the facility Infection Preventionist. No further information was provided by the facility. Review of the facility's policy Oxygen Administration dated 10/2023 and provided by the DON, revealed Procedures: 1. Check physician's order for liter flow and method of administration. NJAC 8:39-11.2(a)(e)

**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 ensure that a medication was administered according to physician orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 6 (six) residents (Resident #9) observed during the medication observation pass. 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. On 11/20/23 at 8:19 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) enter Resident #9's room. The resident was seated in their wheelchair. The surveyor observed that the resident had an empty breakfast tray on the bedside table. The LPN informed Resident #9 that she would be administering the resident's medications. On 11/20/23 at 8:45 AM, the surveyor observed the LPN preparing to administer five (5) medications to Resident #9 which included Protonix 40 mg tablet (medication for Gastroesophageal reflux disease), multivitamin tablet (supplement), Metformin 1000 mg tablet (diabetes), Vitamin C 1000 mg (supplement) and Cilostazol 100 mg tablet (vasodilation). The surveyor observed the LPN administer the medications to Resident #9. The surveyor reviewed the medical record of Resident #9. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; hypertension (elevated blood pressure), type 2 diabetes (chronic condition that affects the way the body processes blood sugar), and chronic embolism and thrombosis of unspecified deep veins of the right lower extremity (blood clot and blockage). A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 10/09/23, reflected that the resident's Brief Interview for Mental Status was 14 out of 15, which indicated that the resident was cognitively intact. A review of the November 2023 order summary report (OSR) revealed a physician order (PO) dated 11/16/23 for Cilostazol oral tablet 100 mg, give 1 tablet by mouth two times a day for vasodilation before meals. A review of the November 2023 electronic Medication Administration Record (eMAR) revealed an order dated 11/16/23, for Cilostazol oral tablet 100 mg, give 1 tablet by mouth two times a day for vasodilation before meals with an administration time of 0900 and 2100 (9AM and 9PM). A review of the Manufacturer's Specifications revealed the following: Cilostazol should be administered one hour before or two hours after a meal. On 11/20/23 at 11:35 AM, the LPN in the presence of the surveyor reviewed Resident #9's electronic OSR and acknowledge that Cilostazol 100 mg oral tablet should have been administered on an empty stomach. The LPN further stated that Resident #9 was re-admitted to the facility on [DATE], and it was the responsibility of the admitting nurse to review the resident's physician orders and to assure that all medications were being administered at an appropriate time. On 11/21/23 at 1:30 PM, the surveyor presented the above observations and findings to the Regional Licensed Nursing Home Administrator, the Director of Nursing, and the facility Infection Preventionist. There was no additional information provided. A review of the facility's policy for Medication Dispensing System that was dated 2/28/23 and was provided by the DON included the following: J. Medication Administration: 3. Medications are administered in a timely fashion as specified by policy. NJAC 8:39-11.2 (b), 29.2 (d)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility staff failed to follow appropriate infection control practices for appropriately performing hand hygiene and sanitizing a blood pressure cuff between 2 of 2 residents observed during the medication pass, (Resident#5 and Resident #10). These deficient practices were evidenced by the following: On 11/17/23 at 8:35 AM, during the medication pass, the surveyor observed the Licensed Practical Nurse (LPN) obtaining Resident #10's vital signs. The LPN brought the electronic blood pressure cuff into the resident's room and took the resident's blood pressure. The LPN then returned to the medication cart which was in the hall. The surveyor observed the LPN placing the electronic blood pressure cuff on the medication cart. The surveyor did not observe the LPN sanitize the electronic blood pressure cuff or perform hand hygiene. The surveyor observed the LPN prepare medication for Resident #10 and then observed her entering the resident's room and administering the medications. After medication administration, then LPN was observed returning to the medication cart and signed off Resident #10's electronic medication administration record. The surveyor did not observed the LPN perform hand hygiene. On 11/17/23 at 8:44 AM, the surveyor observed the LPN pick up the electronic blood pressure cuff which was not sanitized and bring it into the facility's activity room to Resident #5. The surveyor observed the LPN tell Resident #5 that she will be taking the resident's vital signs and will then will administer the resident's medication. After taking Resident #5's blood pressure, the surveyor observed the LPN return to the medication cart and without performing hand hygiene start to prepare Resident #5's medications. At that time, the surveyor interviewed the LPN, who acknowledge that she should have sanitized the electronic blood pressure cuff prior to taking Resident #5's vital signs. The LPN further stated that she should have performed hand hygiene after administering Resident #10's medications. On 11/21/23 at 1:30 PM, the surveyor discussed the above findings with the Regional Licensed Nursing Home Administrator, the Director of Nursing (DON), and the Infection Preventionist. There was no additional information provided. A review of the facility's policy for Blood Pressure Equipment Cleaning that was dated 5/03/23 and was provided by the DON included the following: To ensure that blood pressure machine is sanitize and clean after use in between residents to prevent cross contamination. A review of the facility's policy for Hand Hygiene that was dated 1/31/23 and was provided by the DON included the following: Adherence to hand hygiene practices is maintained by all Center Personnel. This includes hand washing with soap and water when hands are visibly soiled and the use as alcohol-based hand rubs for routine decontamination in clinical situations. Under Process: After contact with resident's intact skin. NJAC 8:39-19.4 (a) (1) (n) (2)

Based on observations, interview, review of the facility assessment tool and facility job descriptions, it was determined that the facility failed to employ either a full time Registered Dietitian (RD) or a Dietary Manager (DM) that meets the qualifications to function as a director of food and nutrition services. This deficient practice was evidenced as follow: Refer to F812 F and E0015 F. On 11/15/2023 at 10:25 AM, the surveyor interviewed the Food Service Director (FSD) in the presence of a second surveyor. He stated that he had a Servsafe certification and started the position on 11/6/23. On 11/16/23 at 10:46 AM, the surveyor interviewed the FSD Consultant (FSDC) in the presence of the survey team. She stated that her credentials were Certified Dietary Manager (CDM), Certified Food Protection Professional (CFPP), and Servsafe certified . In addition, she stated that she was responsible to train the FSD. She acknowledged that today was the first day she was at the facility with the FSD. On 11/17/23 at 10:37 AM, the surveyor interviewed the Registered Dietitian (RD) in the presence of a second surveyor. She stated that she conducted kitchen audits occasionally and at least quarterly. In addition, the RD stated, she had not audited the FSD since he started. On 11/20/23 at 11:05 AM, the surveyor interviewed the FSDC, in the presence of a second surveyor, related to the interview process for the FSD. She stated, the FSD completed an application and submitted a resume for review. She stated that she and the Human Resource Generalist reviewed the documents and conducted interviews. THE FSDC described the qualifications for the FSD for the position, she spoke to the ability to cook from scratch, especially for soups. She included the ability to follow standardized recipes and must have good chopping techniques. She further stated, she showed the FSD where things were located in the kitchen and which size serving utensils were appropriate to use. She stated, cooking skills and customer service is key. In addition, the FSDC stated, the FSD should have a CDM qualification or needed to be enrolled in a CDM program. She stated, CMS [Centers for Medicare and Medicaid Services] required a CDM certification .because it requires continuing education to maintain the certification. The FSDC further stated, I don't believe he (the FSD) had a CDM, but I think he has Servsafe. She added, Servsafe was a food safety course [food handler (basic food safety, appropriate food temperatures, refrigerator temperatures, and cooling techniques)], or food safety manager which included managing staff, staff scheduling, and not food management. On 11/22/23 at 11:16 AM, the surveyor interviewed the FSD in the presence of a second surveyor. The FSD stated, he thought he could handle the responsibilities of this job without training except there are some little things like pureeing. He further stated that it took a while to transition from restaurant to sensitive care residents. On 11/21/23 at 1:00 PM, the surveyor conducted a phone interview with the Human Resource Generalist who stated that she participated in the hiring process. She stated that a FSD position required to a Servsafe certification and cooking experience which did not have to be in a Long-Term Care (LTC) environment. On 11/21/23 at 1:05 PM and again at 1:19 PM, the surveyor interviewed the Licensed Nursing Home Administrator Consultant (LNHAC) in the presence of the Director of Nursing (DON) and the survey team. She stated, the FSD was qualified to hold the position since he had experience as a FS manager and had a Servsafe manager certification verse a Servsafe food handler certification. She acknowledged she was unaware of the course content or if it qualified as a food management course. The LNHAC stated that Servsafe was adequate and oversite from a RD was not required. She stated, the Local Department of Health accepted his credentials but could not provide evidence. She further stated, the FSDC was qualified to oversee and audit the FSD. The LNHAC stated the FSDC audited temperatures of the food, refrigerators and dish machine. She stated, the FSDC audited quarterly and within one to two months after a new employee started. In addition, she stated the timeliness of meal deliveries and food quality could be audited by other staff including the RD. On 11/22/23 at 10:13 AM, the surveyor interviewed the LNHAC in the presence of the DON and survey team. She stated the minimum requirements that qualified the FSD to hold the position included experience in food management and stated that certification in food management was not required. On 11/22/23 at 10:21 AM, the surveyor interviewed the RD and the FSDC in presence of survey team. They stated, they think the FSD was qualified but could not speak to whether he could function independently without training. On 11/22/23 at 10:36 AM, the surveyor interviewed the LNHAC in presence of survey team. She provided the surveyor with a copy of the New Jersey State Mandatory structural organization for dietary services guidance. The LNHAC stated that she used that as a guide to ensure the FSD was qualified to hold the position. She further stated, she never referred to the federal regulatory guidelines, and could not speak to why. On 11/22/23 at 11:38 AM, the surveyor interviewed the LNHAC in the presence of the survey team. She acknowledged the FSD did not have experience in a LTC environment or the required training for kitchen operations, menus, how to interpret the menus, therapeutic diets [medically prescribed], preparation of special diets, and how things should be stored. In addition, the LNHAC stated, he could probably be able to function without training, but it would take time. She stated he required training in this type of environment. Review of the Facility Assessment Tool dated 7/17/23, indicted Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, Staff Type, should include Food and Nutrition Services; Certified Dietary Manager, support staff, registered dietitian. Review of the FSD's resume provided to the surveyor by the DON on 11/17/23 at 10:00 AM, reflected that he did not have work experience in LTC, and his education included Servsafe Food Handler, with an expiration date of 11/22/24. In addition, the facility provided the FSD's Servsafe certification for Food Protection Manager Examination, dated 10/24/23. Review of the undated facility provided job description for Food Service Director, did not include required qualifications. It included that the FSD ensures that all federal, state, departmental, and other necessary government agency requirements are met in the preparation of food, and cook foodstuffs according to menus, special dietary and nutritional restrictions, . Review of the undated facility provided job description for Registered Dietitian, did not include frequently scheduled consultations to the FSD. NJAC 8:39-17.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to a.) store foods in a sanitary manner, b.) ensure the kitchen environment and equipment was maintained in a clean and sanitary manner, and c.) handle dishware in a manner to prevent cross contamination, to limit potential bacteria growth and potential food borne illness. The deficient practice was evidenced by the following: On 11/15/2023 at 10:25 AM through 12:28 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD) in presence of a second surveyor. At 10:26 AM, the surveyor observed a dish machine temperature log which was filled out for the entire day (afternoon and dinner time). The [NAME] stated, it was a mistake, usually I check the temperatures and then log them in. At 10:27 AM, the surveyors continued the tour with FSD. The surveyor observed a single door, white reach in freezer and identified several opened foods with no opened date and were not labeled. The FSD identified the following items and stated that, items should have been labeled and dated. -Two plastic bags of cooked yellow rice on the door shelf, which had no label and no date indicating when it was cooked. -Cooked chicken cutlets in a plastic bag on the door shelf, which had no label and no date indicating when it was cooked. -An opened bag of vegetables, with no date indicating when it was opened. -A piece of salmon wrapped in clear plastic wrap, with no date. -A plastic bag of cooked white rice on the door shelf, which had no label and no date indicating when it was cooked. -An opened bag of frozen blueberries with no opened date. -Two opened plastic bags of hashed brown potatoes, with no opened date. -An opened plastic bag of French fries, with no opened date. -An opened plastic bag of chicken tenders, with no opened date. -Three opened plastic bags of fish sticks, with no opened date. -A meat like item wrapped in plastic, which had no label and no opened date. The FSD was unable to identify the item. -A ring of sweet Italian sausage wrapped in plastic, with no opened date. -An opened plastic bag of hamburger buns, with no opened date. -An opened plastic bag of French toast, with no opened date. At 10:38 AM, the surveyor observed a double door, stainless steel, reach in refrigerator which had an external digital thermometer that displayed DEF and not a numerical value. The FSD and [NAME] were unable to locate an internal thermometer to verify the refrigerator temperature. The surveyor identified the following: -An opened half golden yellow sheet cake with white icing, loosely covered in plastic, with no opened date. -An opened container of Cocktail sauce, with an opened date of 2/17/2023 (once opened and refrigerated this product is good for six months as per the USDA website FoodSafety.gov). -A 15 ounce (oz) opened glass jar of [name redacted] [NAME] Sauce, which had no opened date. -An opened bottle of Mustard, with no opened date. -An opened half gallon container of Almond milk, with no opened date. The FSD stated, it was opened this morning, and the [NAME] stated, I was late, and I did not have time to date it. -A 32 oz opened container of Coconut milk, with no opened date. -An opened plastic bag of pre-sliced [name redacted] sweet rolls, with no opened date. -An opened plastic bag of Parmesan cheese, with no opened date. -Four pieces of cake on a round white plate and wrapped with clear plastic wrap, with no prepared date. -Tortilla shells wrapped in clear plastic wrap, out of the original package, with no opened date. -An opened plastic bag of Romaine lettuce with no opened date. The FSD stated, I did not purchase it. I think it's been here from before I started the job. -An opened one-gallon container of apple juice, with no opened date. -A large amount of red meat in a deep pan, which was placed on the bottom shelf and wrapped in clear plastic. It was not labeled or dated. The FSD stated, it seemed like it had freezer burn but I put it there to thaw it. I wouldn't use it. The FSD could not speak to why he defrosted the meat if he did not intend to use it. -Cooked pork in a plastic bag, with an opened date of 11/5/23. The FSD stated that it was good for two weeks, its cooked. I won't keep it past seven days and then placed it back in the refrigerator. (Once opened and refrigerated this product is good for seven days as per the USDA website FoodSafety.gov) -Meat loaf wrapped in foil, which had no date indicating when it was cooked. -An opened 4.5 oz container of sweet and sour sauce, with no opened date. -A bowl of cooked black beans and rice covered with clear plastic and dated 11/11. -Raw seasoned chicken in a small restaurant pan, covered with clear plastic and marked with a prepared date of 11/13 (raw chicken is good for one to two days refrigerated as per the USDA website FoodSafety.gov). -A round container filled with a beige like product. The container was not labeled or dated. The [NAME] stated, the food belongs to staff, and the FSD acknowledged, it should not be stored in the kitchen refrigerator, that they (the staff) have their own refrigerator. At 11:05 AM, the surveyor observed a 10.5 oz container of collagen peptides (dietary supplement), with an expiration date of 10/2023, stored on a metal shelf next to food. The FSD stated, I think its someone's personal item and it should not be stored here next to food. The surveyor observed breadcrumbs in a plastic container (out of the original package) which was not dated. The surveyor observed silverware (forks and knives) in a plastic container that was in direct contact with the floor. The FSD stated, It shouldn't be stored on the floor. At 11:10 AM, the surveyor observed a metal rack with four shelve which contained large pans and pots. The FSD identified the shelving as a clean pot rack. In the middle of the bottom shelf, there was a large clear plastic bin which contained the following soiled items: a bread pan, a labeling gun, a black mixer, a silver tray, a soup bowl, and a saltshaker. The FSD stated, it's all garbage. The surveyor observed a metal pan cover which was soiled on the bottom shelf of the rack. The FSD removed the pan cover from the shelf, showed the surveyor and acknowledged that it was dirty and placed it in the sink. The surveyor observed a large, soiled plastic tray on the bottom shelf of the rack. The FSD acknowledged that it was dirty. The surveyor observed a 2-inch full-size stainless-steel hotel pans on the bottom shelf. The FSD stated there was, dry blueberries and breadcrumbs stuck to the bottom and acknowledge it was dirty. The FSD stated, The rack is for clean items and the garbage/soiled equipment should not be stored there. The surveyor observed a closed clear plastic container with multiple small packets wrapped in plastic, stored on a wall mounted metal shelf. The FSD opened them and identified the following: -An opened dry butterscotch pie filling/pudding mix, with no opened date. -An opened dry banana cream pie instant pudding mix, with opened date 2/6/2023. The FSD stated, It's good for 2-3 months, once its open. (Once opened this product is good for three-four months as per the USDA website FoodSafety.gov). The surveyor observed the following items stored on wall mounted metal shelves: -An opened package of bread, with no opened date. -A 30oz jar of grape jelly, with a best by date of 9/6/22. -An opened 20oz squeeze bottle of [name redacted] concord grape jelly, with no opened date. -An opened 16 oz container of peanut butter, with no opened date. -An unopened 12.75 oz glass jar of sugar free strawberry jam, with expiration date of 7/15/23. The FSD stated, they are shelf stable product, it's not going to rot. At 11:26 AM, the surveyor observed eyedrops, keys, lip balm and a cell phone on the metal shelf next to food. The FSD acknowledged these items were the cook's personal belongings. The [NAME] stated, I was late this morning, I put it up there. The FSD stated, they should not be there next to food items. The surveyor also observed an opened 16 oz box of whole grain penne pasta, with no opened date. The FSD stated, It is still good. I can tell by looking at it, and further stated, this is not something I would use. At 11:32 AM, the surveyor observed the cook remove clean items from the dishwasher with his bare hands. He touched the inside of a ladle and the inside of the small frying pan while he placed them on a hanging storage rack. The surveyor also observed the cook remove three white dinner plates from the dishwasher and place them inside the oven whereby his thumb was in direct contact with both sides of the plates. In addition, the surveyor observed the cook remove five plastic cups. The surveyor did not observe the cook perform hand hygiene prior to removing the clean dishes out of the dishwasher. The [NAME] acknowledged that he did not wash his hands and stated, we don't have to use gloves. The FSD stated, [name redacted] hands are clean, and he did not touch the glasses from inside. At 11:40 AM, the surveyor observed shelves which contained ingredients and observed the following: -An opened 16 oz bottle of Imitation Vanilla, with no opened date. -An opened 32 oz container of canola oil, with no opened date. -An opened six-pound (lbs.) container of extra light amber honey, with no opened date. -An unrefrigerated opened bottle of teriyaki sauce, with an opened date of 3/4/2023. (Once opened, this product is good for one month if refrigerated after opening as per the USDA website FoodSafety.gov). -An opened one-gallon container of molasses, with an opened date of 11/20/2019 and a best if used by date of 7/6/2023. -An opened one-gallon container of white cooking wine, with no opened date. -Two unrefrigerated, two-quart size opened containers of soy sauce with opened dates of 9/5/2022. The FSD stated it was still good, due to the salt component in this, I give it 18 months to 2 years. (Once opened this product is good for one month if refrigerated after opening as per the USDA website FoodSafety.gov) -An opened one-gallon container of beef consommé base, with an opened date of 7/25/2021. The FSD stated, I wouldn't use it. -An opened 128 oz container of Worcestershire sauce, with an opened date of 8/18/2021 and best if used by date of 5/21/2022. At 11:40 AM, the surveyor observed a three-compartment sink. The [NAME] tested the chemical strength for the sanitizer, which was 200 parts per million (ppm) but did not record the concentration on an accountability log. The cook stated, they do not record the sanitizer strength. The surveyor observed a four-slice toaster, with dried debris on top, stored near shelf stable ingredients. The FSD stated, they don't use it. But still its dirty. The surveyor also observed a two-slice toaster. The FSD stated there was boiled/dried grease on top. At 11:55 AM, the surveyor observed a flat mop stored in direct contact with the kitchen floor next to the handwashing sink. The FSD stated it should not be stored face down. It will never dry. At 12:07 PM, the surveyor observed boxes stored on the top shelves in the dry storeroom less than 18 inches from the ceiling and sprinkler heads. The FSD stated, the boxes should be six inches from the ceiling and six inches from the floor. The surveyor observed multiple five-pound tubs of peanut butter which had no received date or best by use date. At 12:11 PM, the surveyor observed three plastic bags of walnuts in the dry storage room. The FSD stated, they were approximately two pounds each with an expiration date of 6/22/23. At 12:23 PM, the surveyor observed a small refrigerator/freezer unit in the resident dining room. The FSD stated, it is the resident's refrigerator to store their personal foods. The surveyor observed a sign posted on the refrigerator which indicated, Resident food only. Food from families must have resident name and date. If not dated will be thrown out after three days. Not for employee use. The surveyor did not observe temperature logs. The FSD acknowledged there is no temperature logs and no thermometer in the refrigerator or freezer. This is the first time I opened this refrigerator. The surveyor identified several foods with no name or dates marked on them as follows: - An aluminum bread pan with a hard plastic cover which contained a baked good. There was no name or date on it. - An opened 52 oz container of lemonade with no opened date or name on it. The surveyor observed a best by use date of 10/30/2023 on the container. - A brown colored box with piece of leftover cake, with no date. At 12:27 PM, the surveyor observed an opened half gallon container of butter pecan ice-cream stuck to the freezer, with no name or opened date. The surveyor observed a brown colored sticky substance on the bottom of the freezer. The FSD stated, it looks like its melted ice cream. The FSD stated, I don't think anyone checks the temperatures but it's going to be me checking it. Review of the facility policy Food Safety and Sanitation reviewed 6/2/2023, included all local, state and federal standards and regulations will be followed in order to assure a safe and sanitary department of food and nutrition services. It also included the following: -Refrigerated food is stored at or below 41 degrees Fahrenheit (F) -Food stored in dry storage is placed on clean racks at least .18 inches from the ceiling . -All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored. -When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. -Leftovers are used within 72 hours (or discarded). -Perishable food with expiration dates is used prior to the use by date on the package. -Canned and dry food without expiration dates are used within six months of delivery or according to the manufacturers guidelines. Review of the facility policy Labeling and Dating dated 4/18/2023, included all food received in the building, dry, dairy, refrigerated or frozen, must have a received date. It also included, all prepared foods are dated the date they are made and counting as day one. Must have a use by date. Example- Egg salad made 1-15-17 use by 1-17-17. This procedure is followed for all prepared foods: egg salad, puddings, applesauce, desserts, salads, etc. All foods prepared in the kitchen must be dated with a use by date and discarded in three days. In addition, it included items once opened must be dated with open date. Review of the facility policy Staff Food Storage dated 5/20/23, included there is a refrigerator for employee food only and all food must be labeled with a name and date. All items will be discarded after 72 hours. Review of the facility policy Discarding Food Items dated 6/29/2023, included all food items that are prepared by the facility will be discarded within 72 hours (3 days). It also included all items that are packaged by the manufacturer . must be dated when opened. Review of the facility policy Cleaning Dishes/Dish Machine dated 5/18/2023, included clean hands or gloves should be used when clean dishes are removed from the dish machine. Review of the facility policy Three Compartment Sink dated 4/25/2013, included check the sanitizing compartment sink for the proper chemical dilution using the test strips. Note and initial the dilution on the monitoring form. It also included the dilution must be checked each time you re-fill the rinse compartment. Review of the facility policy Cleaning, Kitchen Floor (Mopping) reviewed 5/21/23, included return the clean bucket and mop to designated storage area. Review of the facility policy Foods Brought in from Outside Sources reviewed 5/2022, included foods items should be labeled with the resident's name, date the item(s) were purchased or prepared and the name of the item. It further included, perishable foods that require refrigeration will be discarded after 72 hours (3 days) of the food is not consumed by the resident. Review of the undated facility job description for Cook, included the following: -Discards outdated food from the refrigerators. -Check food supplies, kitchen supplies, . and ensures that cooking utensils, pans, and other equipment are kept in a clean/sanitary condition. -Employees should not have any food, drink, or any personal items (such as key, coats, bags, backpack, wallets, purses, etc.) in the kitchen. NJAC 8:38-17.2 (g)

Based on interview and record review it was determined that the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for one of three PBJ Report submissions reviewed, (Fiscal Year Quarter 3 2023, April 1 - June 30) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area that the facility failed to submit data for the third fiscal year quarter to CMS. The dates of the third quarter included April 1, 2023, through June 30, 2023. On 11/20/23 at 12:09 PM, the surveyor interviewed the Administrative Assistant (AA) in presence of a second surveyor. She stated, she was responsible for the nursing staff scheduling as well as reporting staffing daily to the Department of Health (DOH) website. On 11/21/23 at 10:25 AM, the surveyor interviewed the AA, who stated that she submitted staffing to the DOH daily and to CMS on a quarterly basis. She stated staffing must be submitted to CMS quarterly. She further stated, she submitted for the quarter 7/1/23 through 9/30/23, but not for 4/1/23 to 6/30/23. The AA stated, at that time it was someone else's responsibility. On 11/22/23 at 9:32 AM, the AA stated she could not provide a CMS validation for staffing reported for the 3rd quarter of 4/1/23 to 6/30/23. On 11/22/23 at 10:04 AM, the surveyor interviewed the AA in the presence of the survey team. She stated that she submitted staffing for the third quarter 4/1/23 to 6/30/23, on the deadline of 8/14/23. The AA further stated on 8/23/23, she resubmitted the staffing due to an emailed received which indicated something did not go through. In addition, she stated she read the manual which indicated staff submission would not be accepted after the due date. She provided the surveyor a copy of a validation report from CMS for the quarter staffing 4/1/23 to 6/30/23, which was blank. She acknowledged it was not submitted on time. NJAC 8:39-41.3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/28/21 at 9:21 AM, the surveyor observed Resident #13 sitting on the side of the bed with oxygen at 3 liters per minute via a nasal cannula. The surveyor reviewed Resident #13's Electronic Medical Record which indicated the following: According to the admission Record, the resident was admitted with diagnoses that included Heart failure and Chronic obstructive pulmonary disease. On the admission MDS dated [DATE], a Brief Interview for Mental Status was performed. The facility assessed the resident with a score of 13 out of 15 which indicated the resident was cognitively intact. The following physician orders for treatments observed on the ETAR had missing nurse's initials on the dates indicated below: - Daily weight, notify MD for weight gain of 3 pounds or more within 24 hours, every day shift, not signed 7/1/21, 7/3/21, 7/7/21, 7/8/21, 7/9/21, 7/17/21, and 7/23/21. - Check oxygen saturations every shift, not signed on day shift 7/8/21, 7/9/21, and 7/17/21, not signed on evening shift 7/3/21 and 7/23/21, and not signed on night shift on 7/21/21. On 7/29/21 at 12:22 PM, the surveyor discussed the above concern with the Administrator and DON. The DON stated that weights for this patient are discussed daily and that they could be documented elsewhere in the chart but agreed that they need to be documented on the ETAR. NJAC 8:39-11.2(b) Based on observation, interview, and record review, it has been determined that the facility failed to consistently maintain professional standards of nursing practice regarding a) obtaining a physician's order for hemodialysis (HD) for 1 of 1 resident, Resident #5, reviewed for dialysis and b) documenting on the Electronic Treatment Administration Record (ETAR) for 1 of 10 residents, Resident #13, reviewed. The deficient practice is 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 casefinding, 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. The surveyor observed and interviewed Resident #5 on 7/29/21 at 9:33 AM. The resident stated he/she received HD three times a week, leaving the facility at 5 AM and returning at 10:30 AM. A review of the resident's electronic medication record revealed the following information. The admission Record included the diagnoses of End Stage Renal Disease (ESRD). The 4/27/21 quarterly Minimum Data Set (MDS) assessment tool indicated the resident had moderate cognitive impairment and received HD for ESRD. The resident's care plan, revised 4/27/21, indicated the resident received HD three times per week. A review of the July 2021 Order Summary Report failed to reveal a physician's order for HD. The surveyor interviewed the Director of Nursing (DON) on 7/29/21 at 10:17 AM. The DON confirmed there was not a physician's order for HD. She stated there should be a physician's order. The DON provided the surveyor with the Dialysis Management policy and procedure (revised 5/12/21) on 7/29/21. Procedure #1 indicated a physician order is required.

Based on observation, interview and record review, it was determined that the facility failed to maintain the necessary respiratory care and services. This deficient practice was identified for 2 of 2 residents (Resident #13 and Resident # 18) reviewed for respiratory care and was evidenced by the following: 1. On 07/27/21 at 9:53 AM, the surveyor saw Resident #13's nasal cannula placed on the bed beside the resident. The surveyor asked if the resident needed to have the oxygen on. Resident #13 stated that he/she should wear it and put it the nasal cannula on. The oxygen was running at 3 liters per minute (lpm). The surveyor reviewed Resident #13's Electronic Medical Record which indicated the following: According to the admission Record, the resident was admitted with diagnoses that included Heart Failure and Chronic Obstructive Pulmonary Disease. According to the July 2021 Physician's Orders, Resident #13 had an oxygen order to be delivered at 3.5 lpm via nasal cannula continuously as needed for shortness of breath or oxygen saturation less than 92%. The order date was 6/3/2021. Resident #13 also had an order for oxygen at 3 lpm via nasal cannula for oxygen saturation less than 92%. The order date was 6/16/2021. Both oxygen orders remained on the Physician's Orders as active orders. The admission Minimum Data Set an assessment tool dated 6/7/21, indicated that a Brief Interview for Mental Status was performed. The facility assessed the resident with a score of 13 out of 15, which indicated the resident was cognitively intact. On 7/28/21 at 11:32 AM, the surveyor interviewed the Registered Nurse (RN). The surveyor asked how many liters per minute Resident #13 was ordered. The RN looked at the orders and said 3.5 lpm. The surveyor asked if there was another oxygen order active as well. The RN looked at the physician's orders and said 3 lpm was what the resident had been receiving. On 7/29/21 at 12:27 PM, the survey spoke with the Administrator and the DON. The DON stated that Resident #13 was now on 3 lpm of oxygen as ordered by the physician. The surveyor asked the DON why Resident #13 had two active orders for oxygen. The DON stated that oxygen order for 3.5 lpm was ordered when Resident #13 was desaturating (the percentage of oxygen in the blood was lower than it should be) and then they forgot to remove order when the new oxygen order was obtained. 2. On 7/27/21 at 9:58 AM, the surveyor observed resident #18 in bed. The resident was receiving oxygen via a nasal cannula delivered through an oxygen concentrator. The oxygen was set at 3 lpm. On 7/28/21 at 9:10 AM the surveyor observed resident #18 in bed. The resident was receiving oxygen via a nasal cannula delivered through an oxygen concentrator. The oxygen was set at 2.5 lpm. On 7/28/21 at 9:30 AM the surveyor reviewed the medical record for Resident #18 which revealed the following: The admission Record revealed the resident had diagnoses which included the following, Chronic Pulmonary Embolism and Anxiety Disorder. The July 2021 Physician's Order Sheet with a current physician's order that read: Apply Oxygen @ 2 l/min via nasal cannula for oxygen saturation <92% RA. The order date was 5/19/21. Additionally, there was an order that read Check Oxygen Sats every shift for diagnostic. The order date was 5/19/21. The Progress Notes with the following Nurses Notes regarding oxygen: 7/1/21 07:52 Sat 98% w O2 at 3L. 7/5/21 15:41 On Oxygen at 2l/min. O2 sat 95%. 7/9/21 15:39 O2 sat 94% with continuous use of O2@2l via N/C. 7/13/21 01:15 Sat w O2 at 3l. 7/13/21 13:40 O2 sat 96% on oxygen therapy at 3l/min. 7/15/21 06:39 Sat 97% on O2 at 3L. 7/15/21 13:55 O2 sat 95% on oxygen therapy at 3L/min. 7/15/21 22:07 O2 sat 95% on oxygen therapy at 3L/min. 7/20/21 07:58 Sat 96% on O2 at 3L. 7/20/21 14:11 O2 sat 94% on 3L via nasal cannula on continuous oxygen. 7/25/21 07:41 Sat 97% on O2 at 2L. 7/25/21 13:37 O2 at 96% on 3L n/c continuous O2 therapy. 7/25/21 13:43 O2 at 96% on 3L n/c continuous O2 therapy. 7/25/21 21:02 O2 at 95% on 3L n/c continuous O2 therapy. 7/27/21 15:29 O2 at 96% on 3L n/c contiuous O2 therapy. The July 2021 Electronic Treatment Administration Record (ETAR) included a physician's order that read Check Oxygen Sats every shift for diagnostic. The order date was 5/19/21. The surveyor reviewed the results of the oxygen saturation readings. There were 2 readings that were below 92%, 7/4/21 on the day shift the oxygen reading was 90%, and 7/8/21 on the evening shift the oxygen reading was 91%. All the other readings were above 92%. Under Unscheduled, other, orders it read: Apply oxygen @ 2l/min via nasal cannula for oxygen saturation 92% RA. The Significant Change Minimum Data Set assessment, dated 7/8/21, revealed the facility performed a Brief Interview for Mental Status and the resident scored a 4 out of a possible 15, which indicated that the resident had severe cognitive impairment. On 7/28/21 at 11:39 AM, the surveyor spoke with the Hospice Case Manager/Registered Nurse (HCM/RN) who was assigned to the resident. The HCM/RN said she saw the resident three times a week. She said the resident needed the oxygen continuously. She said when she saw the resident the oxygen was usually set at 2.5 lpm. The RN who was assigned to the resident said the oxygen was continuous and was set between 2 and 3 lpm. She said she checked the oxygen saturation that morning and it was at about 93%. On 7/28/21 at 1:22 PM, the surveyor spoke with the Administrator and the Director of Nursing (DON) and made them aware of the concern with Resident #18 receiving oxygen that was not in accordance with the physician's order. The Administrator and the DON said they would contact the doctor and find out what the oxygen order should have been. On 7/29/21 at 12:19 PM, the surveyor spoke with the Administrator and the DON and asked about the oxygen therapy for Resident #18. The DON stated We called the doctor yesterday. The doctor ordered the oxygen to be set at 2 lpm continuously now. He discontinued the previous order. On 7/29/21 at 12:00 PM, the surveyor reviewed the facility's policy and procedure titled Oxygen Administration. Under Procedure number 5. read Nasal Cannula/Face Mask: Connect tubing to humidifier outlet and adjust liter flow as ordered. Number 7. read: Licensed staff will check the oxygen flow rate on all residents on oxygen therapy during rounds and compare it against the physician's order at the start and at the end of each shift. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policies, it was determined that the facility failed to label and store multi dose vials in accordance with manufacturer specifications. This was found in 1 of 2 medication carts and 1 of 1 medication refrigerator. The deficient practice was evidenced by the following: On [DATE] at 10:27 AM the surveyor inspected the Long Term Care medication cart with the Licensed Practical Nurse (LPN). Inside of the medication cart there was a vial of Humalog insulin that was open and undated. There was a container that held the insulin vial. The container was dated [DATE]. The LPN confirmed the vial was not dated and that it should have been. There was also a vial of Lantus insulin that was open. The label attached to the vial read house stock. The vial had an open date written on it of [DATE]. The vial had been opened 56 days prior. According to the manufacturer, Lantus insulin should have been discarded 28 days after opening. The surveyor then inspected the medication refrigerator with the LPN. Inside of the medication refrigerator was an open Tuberculin Purified Protein Derivitive (PPD) Tuberculin testing solution. The box that held the vial was dated. The vial was not dated. The LPN confirmed that the vial was not dated and that it should have been. According to manufacturer, the PPD vial should have been discarded 30 days after opening. The surveyor reviewed the facility's policy and procedure titled Medication Storage. Under Procedure F. read: Expired, discontinued, and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. The facility also provided a form titled Storage Guidelines which included a table titled Medications with shortened expiration dates. Under Insulin Vials it listed Lantus insulin and Humalog insulin to be discarded 28 days after opening and Tuberculin Purified Protein Derivative (PPD) to discard 30 days after first use. NJAC 8:39-29.4 (h)