Based on interview and record review, it was determined that the facility failed to issue the proper required Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) for 2 of 3 residents (Resident #22, and Resident #43) reviewed for Beneficiary Protection Notification. This deficient practice was evidenced by the following: On 02/14/2024, the Administrator provided the surveyor with a list of residents who were discharged from the facility within the last six months and should have received Beneficiary Notices. The surveyor reviewed two of the residents (Resident #22, and Resident #43) listed who were discharged from a Medicare Part A (helps cover skilled nursing facility care including rehabilitation services) stay at the facility and were documented as having a discontinuation of their Medicare Part A insurance payment to the facility. On 02/16/2024 at 10:34 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #22. The SNFBPNR indicated the Resident #22's last covered Medicare day was 01/16/2024 and Resident #22 remained in the facility. The SNFBPNR further revealed that both a SNFABN and a Notice of Medicare Non-Coverage (NOMNC) were provided to the resident or the resident's representative.The facility was unable to provide a signed SNFABN for the date of 01/16/2024. On 02/16/2024 at 10:34 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #43. The SNFBPNR indicated the Resident #43's last covered Medicare day was 12/14/23 and Resident #43 remained in the facility. The SNFBPNR further revealed that both a SNFABN and a Notice of Medicare Non-Coverage (NOMNC) were provided to the resident or the resident's representative. The facility was unable to provide a signed SNFABN for the date of 12/14/23. On 02/16/2024 at 10:40 AM, the surveyor interviewed the Clinical Care Coordinator who stated that she only does an initial SNFABN on long term care and that if they go out to the hospital and return to the facility, she does not get another SNFABN. She further stated that she doesn't have a policy on SNFABN's. NJAC 8:39-4.1a(8)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical records, other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 17 residents reviewed (Resident #29 and Resident #101). This deficient practice was evidenced by the following: 1. On 02/12/2024 at 11:10 AM, the surveyor observed Resident #29 out of bed in a wheelchair. The resident was first seen in the library. The nurse stated that the resident at times wanders to library. Resident was seen coming back into unit from library. Resident #29 was very pleasant and stated they were doing well. The surveyor review of Resident #29's admission record indicated that the resident was admitted with diagnoses that included, but were not limited to; a right hip fracture with surgical repair. A review of Resident #29's medical record indicated that on 11/09/2023, the resident was found on the floor by the window in the room. No injury was noted. A review of the Quarterly Minimum Data Set (MDS), an assessment tool, dated 11/12/2023, indicated a Brief Interview of Mental Status (BIMS) was 4, indicating severe cognitive impairment and Section J was coded to indicate no falls had happened since last assessment. On 02/15/2024 at 12:30 PM, the surveyor interviewed the MDS Coordinator, who confirmed that the fall was not coded on that MDS and should have been. 2. The surveyor review of Resident #101's admission record indicated that the resident was admitted with diagnoses that included, but were not limited to; urinary retention and dementia. A review of Resident #101's medical record indicated that on 05/20/2023 the resident was found on the floor near the bathroom. Resident #101 complained of right hip pain, was transferred to acute care, and found to have a right hip fracture. A review of the Discharge MDS dated [DATE], indicated both long- and short-term memory impairment and Section J was coded to indicate one fall with no injury, and one fall with injury except major and one fall with major injury. On 02/16/2024 at 11:15 AM, the surveyor interviewed the MDS Coordinator who stated that only J1900C should've been coded as one fall with major injury and the other two area should've been coded as no fall with no injury and no fall with injury except for major according to the RAI instructions. A review of the RAI User's Manual Version 1.17.1 dated October 2019 revealed . Chapter 3 MDS Items . Section J: Number of falls . Determine the number of falls that occurred since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS) and code the level of fall-related injury for each. Code each fall only once. If the resident has multiple injuries in a single fall, code the fall for the highest level of injury. A review of a facility policy titled Resident Assessment Instrument (RAI) Completion, revised 4/11/2019, includes, The person who completes each section must sign the MDS to verify accuracy of the sections completed. N.J.A.C 8:39-11.1

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical needs and failed to implement focus and interventions that are specific to the resident's skin disorder diagnosis. The deficient practice was identified for 1 of 1 (Resident #21) investigated for positioning and mobility. The deficient practice was evidenced by the following: During the initial tour of the facility on 2/12/2024 at 10:29 AM, the surveyor observed Resident #21 sleeping in his/her geri chair in the unit hallway. Resident #21 was observed wearing bilateral heel protectors. On 2/14/2024 at 12:03 PM, the surveyor observed Resident #21 in the dining area in his/her geri chair waiting for lunch. Resident #21 was observed wearing bilateral heel protectors. According to the admission Record, Resident #21 was admitted to the facility with the following but not limited to diagnoses: Disorder of the skin and subcutaneous tissue, hypertension (high blood pressure), vitamin deficiency (long term lack of a vitamin), and history of traumatic brain injury (injury that affects how the brain works). According to the 12/18/2023 Comprehensive Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, Resident #21 had short term and long-term memory problem and cognitive skills are severely impaired. Section GG of the MDS revealed Resident #21 uses a wheelchair. Section I revealed Resident #21 had an active diagnosis of disorder of the skin and subcutaneous tissue, hypertension (high blood pressure), vitamin deficiency (long term lack of a vitamin), and history of traumatic brain Injury (injury that affects how the brain works). A review of Resident #21's Care Plan date initiated 2/3/2023, revised on 11/28/2023, revealed that it did not address the bilateral heel protectors as an intervention for skin integrity. On 2/15/2024 at 9:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #2). LPN #2 stated, The aid applies the bilateral heel protectors when he/she gets out of bed to go into the geri chair. I do not apply them unless they are on the Treatment Administration Record (TAR) for me to apply them. The surveyor then asked what the purpose of the bilateral heel protectors served. LPN #2 stated, The resident uses them to off load his/her heels and it helps prevent pressure ulcers. LPN #2 also stated, There should be a physicians order for them, and it should also be listed on his/her care plan. On 2/15/2024 at 10:05 AM, the surveyor conducted an interview with the Certified Nursing Assistant (CNA #1). CNA #1 stated, The CNAs apply the resident's bilateral heel protectors. Resident #21 always wears them except when completing hygiene care. He/she needs them to prevent redness to the heels and pressure ulcers. The surveyor then asked who was responsible for ordering the heel protectors. CNA #1 said she wasn't sure who orders them. If they are ordered the nurse will relay the information to the CNA's. She also stated, It will be added to our task page that we sign off and it should be added to their care plan. On 2/16/2024 at 1:08 PM during an interview with the surveyors, the surveyor asked how you identify a resident at risk for pressure ulcers (PU) or pressure injuries (PI). The Director of Nursing (DON) stated, We complete the Braden scale on admission and quarterly. If a resident is at risk for PU/PI to the heels, we would either offload the heels with pillows or use the blue Prevalon heel boots. There would be a physicians order for the Prevalon heel boots, and the nursing department will provide them. The surveyor then asked, should the intervention in place be included on the resident's care plan. The DON stated, Yes, if they are using the Prevalon heel boots it should be included on the care plan. The surveyor reviewed the facility policy titled: Care Plan, revised 11/9/2023. The following was revealed under Procedure: 9. The care plan shall identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan shall be complete, current, realistic, time specific and appropriate to the individual needs for each resident. 32. When there are changes in the resident's condition, the Comprehensive Care Plan is updated as needed to change goals, time frames, or interventions. The surveyor reviewed the facility policy titled: Pressure Injury Prevention & Managing Skin Integrity, revised 7/14/2021. The following was revealed under Policy: Pressure ulcer/injury interventions, based on the resident's Braden assessment, will be implemented by nursing, and documented in the clinical HER. Skin care intervention when appropriated will be documented on the care plan. The surveyor reviewed the facility policy titled: Heel Protectors, revised 2023. The following was revealed under Policy: Residents will be provided with heel protectors when indicated on the Care Plan for preventative skin care, or as ordered by physician or charge nurse. N.J.A.C. 8:39-11.2 (e)2

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain professional standards of nursing practice for not obtaining a physician's order. The deficient practice was identified for 1 of 1resident (Resident #21) investigated for positioning and mobility. 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. During the initial tour of the facility on 2/12/2024 at 10:29 AM, the surveyor observed Resident #21 sleeping in his/her geri chair. Resident #21 was observed wearing bilateral heel protectors. On 2/14/2024 at 12:03 PM, the surveyor observed Resident #21 in the dining area in his/her geri chair waiting for lunch. Resident #21 observed wearing bilateral heel protectors. According to the admission Record, Resident #21 was admitted to the facility with the following but not limited to diagnoses: disorder of the skin and subcutaneous tissue, hypertension (high blood pressure), vitamin deficiency (long term lack of a vitamin), and history of traumatic brain injury (injury that affects how the brain works). According to the 12/18/2023 Comprehensive Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, Resident #21 had short term and long-term memory problem and cognitive skills were severely impaired. Section GG of the MDS revealed Resident #21 uses a wheelchair. Section I revealed Resident #21 had an active diagnosis of disorder of the skin and subcutaneous tissue, hypertension (high blood pressure), vitamin deficiency (long term lack of a vitamin), and history of traumatic brain injury (injury that affects how the brain works). A review of the Physician Order Summary Report (POS) located in the electronic medical record (EMR) revealed that Resident #21 did not have a physician's order for bilateral heel protectors. On 2/15/2024 at 9:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #2). LPN #2 stated, The aid applies the bilateral heel protectors when he/she gets out of bed to go into the geri chair. I do not apply them unless they are on the Treatment Administration Record (TAR) for me to apply them. The surveyor then asked what is the purpose of the bilateral heel protectors. LPN #2 stated, The resident uses them to off load his/her heels and it helps prevent pressure ulcers. LPN #2 also stated, There should be physicians order for them, and it should also be listed on his/her care plan. On 2/15/2024 at 10:05 AM, Surveyor conducted an interview with the Certified Nursing Assistant (CNA #1). CNA #1 stated, The CNAs apply the resident's bilateral heel protectors. Resident #21 always wears them except when completing hygiene care. He/she needs them to prevent redness to the heels and pressure ulcers. The Surveyor then asked who orders the bilateral heel protectors. CNA #1 said she wasn't sure who orders them. If they are ordered the nurse will relay the information to the CNA's. She also stated, It will be added to our task page that we sign off and it should be added to their care plan. A review of Resident #21's Task in the EMR revealed that there was no identified task for the bilateral heel protectors. On 2/16/2024 at 1:08 PM during an interview with the surveyors, the surveyor asked how you identify a resident at risk for pressure ulcers (PU) or pressure injuries (PI). The Director of Nursing (DON) stated, We complete the Braden scale on admission and quarterly. If a resident is at risk for PU/PI to the heels, we would either offload the heels with pillows or use the blue prevalon heel boots. There would be a physicians order for the prevalon heel boots, and the nursing department will provide them. The surveyor reviewed the facility policy titled: Heel Protectors, revised 2023. The following revealed under Policy: Residents will be provided with heel protectors when indicated on the Care Plan for preventative skin care, or as ordered by physician or charge nurse. NJAC 8:39-27.1(a)

Based on interview and review of other facility documentation, it was determined that the facility failed to ensure 1 of 5 Certified Nursing Assistants (CNA #3) received 12 hours of required education annually. This deficient practice was evidenced by the following: The surveyor reviewed five (5) random CNA education files for the year 2023. A review of a transcript for CNA#3 titled, SYMPIR LEARNING, revealed the following: CNA #3 completed 10.75 hours. During an interview with the Nursing Staff Educator (NSE) on 02/14/2023 at 12:16 PM, she stated that the CNA was responsible to complete the yearly mandatory 12 hours of education to include both the Abuse training and the Dementia training. The NSE stated that she could not speak to why the CNA training was not completed. During an interview with the Licensed Nursing Home Administrator (LNHA) on 02/15/2024 at 11:43 AM, she stated that they are aware that the staff are not completing their yearly mandatory education and are reviewing their processes. A review of a facility policy titled, Clinical Staff Competency (RS-52) with a revised date of 03/23/2023, revealed under Competency Content; Required in-service training, specific to nurse aides, will include at least 12 hours per year. Topics for education include all in-services required by state agency NJSHSS, CMS, and those determined by the facility assessment. NJAC 8:39-43.17 (b)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure that all medications were administered without error rate of 5% or less. During medication pass observation on 02/14/2024, the surveyor observed one nurse administer medications to five residents. There were 26 opportunities and 2 errors which calculated to a medication administration error rate of 7.69%. This deficient practice was identified for 2 of 5 residents, (Resident #105 and Resident #106) and was evidenced by the following: On 02/14/2024 at 7:18 AM, the surveyor observed Licensed Practical Nurse (LPN #1) prepare and administer Prednisone (steroid medication) 20 mg (milligrams) po (by mouth) to resident #105. The Prednisone package had a red Cautionary label on the package from the pharmacy to take with food. There was no food observed in Resident #105's room and LPN #1 did not offer the resident any food. At that time the surveyor asked Resident #105 if he/she had eaten breakfast. Resident #105 replied, No. At that time the surveyor requested LPN #1 to read the package cautionary and LPN #1 told the surveyor, Give with food. LPN #1 then explained that the facility practice is they (the nurses) give the medications and then the aides bring the breakfast. LPN #1 again stated, Our system is the resident wakes up, we give the med's (medications) and then they get breakfast. On 02/14/2024 at 08:00 AM, the surveyor observed LPN #1 prepare and administer Metoprolol ER (medication used to treat high blood pressure/extended release) 50 mg po daily with FOOD to Resident #106. A cautionary statement on the Medication Administration Record (MAR) indicated Take with meal or immediately after a meal. LPN #1 did not offer Resident #106 any food at the time of administration At that time the surveyor asked Resident #106 if he/she had eaten breakfast and Resident #106 replied, Soon. At 8:04 AM, LPN #1 said her next step would be to get Resident #106 breakfast. Resident #106's breakfast was delivered at 8:18 AM. A review of Resident #105's admission Record revealed Resident #105 was admitted with diagnoses including but not limited to: Bacterial Infection. A review of the Order Summary Report revealed a physician order for Prednisone Oral tablet 20 mg Give 1 tablet by mouth one time a day related to Bacterial Infection unspecified. A review of the admission Record revealed Resident #106 was admitted to the facility with diagnoses including but not limited to: Hypertension. During an interview with the surveyor on 02/16/2024 at 1:01 PM, the acting Director of Nursing was asked wby the surveyor what is your expectation for nurses when they are passing the medications and a medication has a cautionary statement. The acting Director of Nursing replied, I expect the nurses to follow the cautionary statements. The surveyor questioned what is not considered food and the acting DON replied Crackers, milk, and applesauce are not considered food. A review of a facility policy titled Medication Management Program Guidelines (RS-10) with a last approved date of 11/6/2023, revealed under the Procedure section: Cautionary Statements shall appear on the residents record of medication administration and the system shall include provisions for noting additional information, including but not limited to special times or routes of administration and storage conditions. N.J.A.C 8:39-29.2(d)

Based on interviews, and review of other facility documentation, it was determined that the facility failed to consistently offer nighttime snacks to all residents on a nightly basis. This deficient practice was identified for 4 of 5 residents (Residents #11, Resident #35, Resident #39, and Resident #251) during the Resident Council group meeting and was evidenced by the following: On 02/14/2024 at 10:15 AM, the surveyor conducted a group meeting with five residents who were selected by the facility. Four of the five residents stated that they were not offered evening snacks; however, they did state you can ask for anything and they will bring it to you. On 02/14/2024 at 12:33 PM, the surveyor interviewed Certified Nursing Assistant (CNA #1) who stated that usually the aide will offer snacks to the residents, or the activity aide will do it before they leave for the night. When asked what time the snacks are given, CNA #1 replied she was not sure what time snacks are given. On 02/16/2024 at 01:04 PM, surveyor interviewed the Director of Nursing (DON), who stated that the staff should be offering evening snacks to everyone, not just if the resident asks for one. On 2/20/2024 at 12:21 PM, the surveyor interviewed Licensed Practical Nurse (LPN #3), who stated that the CNAs usually hand snacks out at night and that they ask everybody. LPN #3 was not sure what time this is done. On 2/20/2024 at 12:30 PM, the surveyor interviewed the DON who stated that the CNAs hand snacks out in the evening. She also stated that sometimes the nurses do it. When asked what time snacks are handed out, she stated sometime in the evening, after dinner, before bed. Facility mealtimes as provided by the facility to team on entrance notes that breakfast is at 7:30 AM, Lunch is at 12:00 PM, Supper is at 5:30 PM, and evening snack is at 7:00 PM. A review of a facility policy titled Hydration and Snack, revised 2/14/2024, indicates: Preferred snacks will be stocked and accessible at preferred times. Snacks will always be available on a 24-hour basis in order that all preferences are accommodated. At the specified times that snacks are provided, nursing assistants will offer snacks to residents who choose to remain in their rooms and to those who retire early in the evening. N.J.A.C. 17.4 (b)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 2/12/2024 from 9:19 to 10:05 AM the surveyor, accompanied by the Executive Chef (EC), observed the following in the main kitchen: 1. On an upper shelf in the dry storage room a container of Ground Thyme was dated 1/9/2. The surveyor asked the EC if the container of thyme was dated 2022,2023, or 2024. The EC could not tell the surveyor how old the thyme was or when it was placed on the shelf. The EC removed the thyme to the trash. On a lower shelf in a previously opened card board box, a previously opened bag of pasta had no dates. The EC removed the pasta to the trash and agreed that the bag had no dates. In addition, on an upper shelf a previously opened container of Heinz tomato ketchup had dried ketchup covering the lid of the bottle. The EC agreed that it was dirty and could not identify when the bottle was opened or the use by date. Observation of the bottle of ketchup did not reveal a manufacturers use by date. 2. On a middle shelf of the walk-in refrigerator a soup tureen contained beef au jus, as identified by the EC. The plastic wrap covering the au jus was torn and the au jus was exposed. The plastic wrap had a date of 2/4 and 2/7. EC agreed that the au jus was expired and exposed. 3. A mobile 4 wheeled multi-tiered cart in the walk-in refrigerator contained a sheet pan with a vanilla cake on a middle rack. The cake was uncovered and exposed. On a separate cart a sheet pan contained sliced deli meat prepped for the dinner meal and covered with paper. The sheet pan had no dates to indicate when the product was produced or when the product was to be used by. 4. In the walk-in freezer on an upper shelf, (2) packages of individual quiches had been removed from their original container. The quiches had a prep date of 5/11 and a use by date of 5/15. The EC could not tell the surveyor what year they were prepped or how long the freezer storage period would be. The quiches were observed to be covered with frost on the inside of the packages. 5. A stand-up mixer was covered with a plastic bag and was not in current use. The EC stated that the mixer was not in use and that the mixer was cleaned and sanitized. The surveyor had the EC remove the plastic bag to inspect the mixer for cleanliness. Upon removal of the plastic bag the surveyor observed that the electric power cord was placed inside of the cleaned and sanitized mixer bowl where food ingredients are prepared and mixed. The cord was observed to be covered with unidentifiable debris. The EC then removed the contaminated mixer bowl and instructed kitchen staff to clean and re-sanitize the mixer bowl. The EC agreed on interview that the power cord should not be stored within the cleaned and sanitized mixer bowl. On 2/15/2024 from 9:38 to 10:37 AM the surveyor, accompanied by the General Manger (GM), observed the following in the main kitchen: 1. (2) containers of plastic wrap were resting on top of the loading area/prep table. The boxes were opened, and the plastic wrap was exposed. Both containers had cardboard lids attached and opened. On interview the GM stated, They should be closed when not being accessed. 2. The surveyor observed the ice machine maintenance technician in the kitchen during food production. The technician was conducting quarterly maintenance/deep cleaning of the kitchen ice machine, according to the GM. The technician was observed kneeling in front of the ice machine. The technician had no hair net/covering and their hair was exposed. The GM stated that she had previously told the technician that a hair net/covering was required to be worn while in the kitchen. The GM was observed to then tell the technician to donn a hairnet/covering. 3. The surveyor observed dust accumulation on the ceiling tiles/metal channels above the steam table, where resident food is prepped and served. In addition, dust accumulation was observed on the light shield/cover above the food production area/steamtable for the overhead lighting. The surveyor utilized a step stool to gain access to the ceiling and determined that dust accumulation was present after doing a finger swipe on the surface of the light cover. In addition, a grease-like and dust substance was determined to exist on the ceiling panel/tile in the food production area above the range/oven unit. This was determined by a finger swipe by the surveyor. A support column adjacent to the steam table was noted to have an accumulation of a dark, unidentified substance on the upper area of the column and extending down approximately 1 foot from the ceiling. On closer inspection the surveyor was able to determine that the substance was a dark dust-like substance. On interview the GM replied to the surveyor, Ok, when asked by the surveyor if the dust accumulation in the food production area could possibly contaminate food or exposed dishware/equipment in the food production area. The GMs upon further questioning did agree to the surveyor that the dust could be a potential source of contamination and also stated that the ceiling was not currently included on the kitchen cleaning schedule. 4. (3) stacks of bowls in a well on the steam table were not inverted or covered and were exposed to contamination. Active food production was not taken place at the time. On interview, the GM stated, They should be inverted or covered to prevent contamination when not in active use. 5. The surveyors observed a dust-like substance throughout the walk-in refrigerator, The dust-like substance was on the wire cage surrounding the fire sprinkler head on the ceiling, along the conduit covering the electric power supply line along the wall of the refrigerator to the left of the entry door, the ceiling of the walk-in, and dust and what appeared to be a mold- like substance was above the refrigeration unit and on the ceiling in front of the refrigeration unit entry door. The fans were actively running during the observation and the potential existed to have dust and mold contaminate the refrigerated food supply. On interview the EC and GM agreed that the walk-in was full of dust and also had mold on the ceiling. The GM stated to the surveyor that we clean the walk-in but not the walls and ceiling as part of our current cleaning schedule. The surveyor reviewed the facility policy titled Food Safety Product Labeling and Dating Guidelines, Document Code: 1.2.19, and Revision Date: 12/06/2022. The following was indicated under the heading Purpose and Scope: Assist with the labeling requirements on food products and use-by-dates. Under Receiving/Storing (Dry or Frozen) - Rotation System the following was observed: Date cartons, cases, boxes. etc., with date received. This is not needed - if products remain in master cases already dated by the manufacturer. In order to maintain traceability of food products during a potential recall it is recommended to transfer the lot number and/or the manufacture date of the product to the new container if removing contents from the original packaging for storage. The following was revealed under the heading Date Marking Time Control for Food Safety: [company name/vendor] policy using the 2017 FDA Food Code as guidance specifies ready-to-eat, time/temperature control for safety (TCS) food prepared in a food establishment and held longer than the subsequent meal period must be marked to indicate the date or day by which the food is to be consumed on the premises, sold, or discarded when held at a temperature of 5 C (Celsius) (41 F(Fahrenheit)) or less for a maximum of 7 days. In addition, the following was revealed under the heading Date Marking Non Time Control for Food Safety: The FDA Retail Food Code and [company/vendor name] policy exempts non-time control for food safety from the date marking requirements. However, Joint Commission and CMS may require dating of all opened products for stock rotation purposes. These dates are for quality purposes only and do not pose a food safety risk. Non-TCS if dated should use the manufacturer's use by date or operations can use the [company/vendor name] Product Quality Assurance Shelf Life Guidelines for guidance on dates. Once a product does have a documented use by date, the FDA Food Code and [company name/vendor] Policy requires the product to be consumed or discarded by that date. It is important to date food properly to avoid unnecessary disposal of safe food. The surveyor reviewed the facility provided policy titled Cook's Daily Cleaning Schedule, Utility Dating Cleaning Schedule, and Utility Weekly Cleaning Schedule, undated. Review of the (3) kitchen cleaning schedules revealed that per the Utility Weekly Cleaning Schedule, Walls/Columns were to be cleaned weekly. The (3) facility provided cleaning lists did not address cleaning of the kitchen ceiling and they did not address cleaning of the walk-in refrigerator ceiling or walls. The facility failed to provide a copy of their hair net/covering policy and storage of dishes/utensils when not in use as requested by the surveyor. NJAC 18:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ159493 Based on interviews, medical record review, and review of other pertinent facility documents on 5/11/2023, 5/12/2023, and 5/17/2023, it was determined that the facility failed to file a formal grievance and follow their policy titled Resident Concerns & Grievances, after receiving a family member complaint. This deficient practice was identified for 1 of 5 residents (Resident #1) reviewed for Grievances and was evidenced by the following: Review of the Medical Record was as follows: According to the Face Sheet, Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Subarachnoid hemorrhage (a brain bleed) following injury with loss of consciousness, traumatic subdural hemorrhage (a collection of blood in the brain) with loss of consciousness, laceration (deep cut) without foreign body of another part of the head, pain and benign prostate hyperplasia (an enlarged prostate). A review of a clinical note from the former Social Worker (SW) dated 11/2/22 noted that on 10/31/22, the former SW was approached by Resident #1's family member with multiple concerns regarding care over the weekend. The clinical note revealed the former SW and the Nurse Mentor / Registered Nurse (NMRN) met extensively with the resident's family members regarding the family's concerns. During this time, the SW and NMRN assured the family that their concerns would be checked into and addressed. The SW further noted that the complaints were documented via [through] a grievance form. On 5/11/2023 at 12:00 PM, the surveyor requested a list of grievances filed during October and November 2022 from the Director of Nursing (DON). Resident #1's name was missing from the list provided to the surveyor. On 5/12/2023 at 9:56 AM, the surveyor requested the former SW notes regarding Resident #1 from the DON. Further review of the SW notes indicated that she had filed a grievance form about the family member's complaints on 10/31/23. However, during the survey, the facility could not provide any grievance form about Resident #1's family members' complaints. During an interview on 5/12/23 at 11:39 AM regarding Resident #1, the former SW recalled she knew the resident and documented information about the complaint from the family. The former SW didn't remember the specific complaint by the family. She stated, If a complaint was initiated, it would be investigated. The SW did not recall or specify that a grievance form was filed during the interview. During an interview on 5/17/23 at 9:50 AM regarding the grievance form, the DON stated she spoke to the former SW, who told her that she did not file a grievance form on 10/31/22, as indicated in her progress note. The former SW told the DON that because she typed up a narrative in the progress notes with the NMRN, she felt it would be redundant to file a grievance form. According to the DON, the former SW said even though her note said she filed a grievance form; she did not actually do it. The DON stated that her expectation was if the SW said she filled out a grievance form, she should have done it. Review of the facility's policy titled Resident Concerns & Grievances, dated 1/17/23, included the following under: Purpose: To respond to resident complaints related to care, treatment, or services in a manner consistent with the procedures described below Under: Definitions: included Grievance - A grievance is any written or verbal concern by a resident, relative, or any representative related to resident care or the quality of services provided. Prompt effort to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. A complaint is considered a grievance when . The complaint is communicated verbally but cannot be resolved at the time of the complaint by staff present; it requires additional time for investigation or action, or referral to other staff for sufficient resolution. Procedure - All grievances shall, whenever possible, be responded by the designated SW or responsible department manager closest to the cause of the concern/grievance; responses to resident/responsible party shall be made as soon as possible and preferably immediately; and (1) If a concern/grievance of any kind is noted, the Concern/Grievance form is used. NJAC: 8:39-13.2(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ159493 Based on interviews, medical record review, and review of other pertinent facility documents on 5/11/2023, 5/12/2023, and 5/17/2023, it was determined that the facility failed to accurately complete an admission Assessment to reflect the resident's status and failed to follow their policy titled Healthcare admission Process, for a newly admitted resident (Resident #1). This deficient practice was identified for 1 of 5 residents (Resident #1) and was evidenced by the following: Review of the Medical Record was as follows: According to the Face Sheet (FS), Resident #1 was admitted to the facility on [DATE], with diagnoses including but were not limited to: Subarachnoid hemorrhage (a brain bleed) following injury with loss of consciousness, traumatic subdural hemorrhage (a collection of blood in the brain) with loss of consciousness, laceration (deep cut) without foreign body of other parts of head, pain and benign prostate hyperplasia (an enlarged prostate). A review of the Skilled Nursing admission Evaluation (SNAE) dated 10/25/22 at 3:38 PM, completed by the Nurse Mentor/Registered Nurse (NMRN) for Resident #1 upon entry to the facility, showed under Urinary Continence that the resident was always continent. Resident #1 was also noted to have an external urinary catheter at the time of admission. Under the section Wound Care, the resident was noted to have no wounds present at the time of admission, even though the resident had lacerations and sutures present from the fall. During an interview on 5/12/23 at 10:02 AM, the NMRN, who completed Resident #1's admission assessment. She stated Resident #1 was continent of urine. The surveyor showed the NMRN the Skilled Nursing admission Evaluation that noted Resident #1 also had an external urinary catheter at the time of admission. The NMRN stated she doesn't know why Resident #1 would have an external urinary catheter if he was continent. She further stated the resident could have had it from the hospital, but she wasn't sure. During an interview on 5/17/23 at 10:19 AM, the Director of Nursing (DON) stated the NMRN should have measured the wound and noted how many sutures were in the wound on the admission assessment form. The DON further stated the NMRN does admission assessments regularly and was aware of the procedure to complete the forms. When the surveyor asked the DON about the resident's urinary status of being continent but having an external catheter on the admission record, the DON stated, they come from the hospital that way sometimes. During an interview on 5/17/23 at 12:10 PM, regarding the Wound Care section of the admission assessment, which indicated Resident #1 had no wounds at the time of admission to the facility. The surveyor showed the NMRN Resident #1 FS which indicated lacerations from the injury sustained at home. The NMRN stated she should have documented in the Wound Care section the laceration and the number of sutures the resident had at the time of admission. She further stated that she wouldn't have measured the wound. When asked if she should have filled out the top section of the form where it noted wound, type, location, body, head, arm, and leg, the NMRN stated she didn't know if those areas should have been filled out. She continued to say she should have documented in the surgical incision section that Resident #1 had a laceration and the number of sutures where the wound was located. During a second interview on 5/17/23 at 12:40 PM, the surveyor interviewed the DON about the skilled nursing admission evaluation done by the NMRN. The DON stated the NMRN should have documented the laceration on Resident #1's head and the number of sutures present. Review of the Healthcare admission Process dated 8/12/23, revealed under (D) Nursing admission Evaluation, A head to toe assessment included the following body systems (7) genitourinary, (8) skin and (I) Wound Assessment: To be completed on the day of admission if the resident is admitted with skin changes (bruises, skin tears, pressure ulcers, etc.) and weekly until the wound is healed. NJAC 8:39-11-2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ159493 Based on interviews, medical record review, and review of other pertinent facility documents on 5/11/2023, 5/12/2023, and 5/17/2023, it was determined that the facility failed to initiate a comprehensive person center care plan for a resident with lacerations and identified urinary incontinence. The facility also failed to follow its policy titled Care Plan (RS-1), dated 01/17/2023. This deficient practice was identified for 1 of 5 residents (Resident #1) and was evidenced by the following: Review of the Medical Record was as follows: According to the Face Sheet, Resident #1 was admitted to the facility on [DATE], with diagnoses including but were not limited to: subarachnoid hemorrhage (a brain bleed) following injury with loss of consciousness, traumatic subdural hemorrhage (a collection of blood in the brain) with loss of consciousness, laceration (deep cut) without foreign body of another part of head, pain and benign prostate hyperplasia (an enlarged prostate). Review of the Skilled Nursing admission Evaluation (SNAE), dated 10/25/22 at 3:38 PM for Resident #1 completed by the Nurse Mentor/Registered Nurse (NMRN) upon the resident's entry into the facility, showed Resident #1's urinary status as continent but also noted the resident came in with an external urinary catheter (a device used to collect urine). Review of the nursing progress notes (NPNs) for Resident #1 revealed the resident was incontinent of urine on 10/26/22, 10/27/22, and 10/31/22. The Physician's admission note dated 10/26/22 also identified the resident as incontinent of urine. The surveyor reviewed a written statement from the Certified Nursing Assistant (CNA) who cared for Resident #1. The CNA's statement indicated the resident wasn't wearing incontinence briefs when he entered the facility. The CNA wrote that the next day after admission, the resident's bed was soaked. The CNA explained to the resident the need to wear incontinence briefs, and the resident was okay with that. The surveyor reviewed the Licensed Practical Nurse (LPN #1) statement dated 10/28/22 and 10/30/22, which indicated the CNA provided incontinence care due to the resident being incontinent of urine. The surveyor reviewed another statement from a second LPN (LPN #2) dated 10/30/22, which indicated LPN #2 answered the resident's call light, the resident's spouse told LPN #2 the resident needed to use the bathroom and/or be changed. Review of the Care Plan dated 10/26/22 revealed Resident #1 had no care plan in place for incontinence of urine or a laceration after it was identified by the doctor and nursing staff. During an interview on 5/17/23 at 10:19 AM, the Director of Nursing (DON) stated that urinary incontinence should be on the resident's care plan. She looked at the care plan for Resident #1 and indicated that she did not see the resident care plan for urinary incontinence. The DON explained that The resident should have been care planned after he/she was identified as incontinent of urine. She further stated that the Minimum Data Set (MDS) Coordinator would be responsible for making sure the resident was care planned for incontinence of urine. At the time of the survey, the Minimum Data Set (MDS) Coordinator was unavailable for an interview. A review of the facility policy Bladder Incontinence Management, dated 3/8/22, under Skilled Healthcare Procedure, The care plan and the resident's summary will be updated to reflect the resident's individualized toileting needs and the appropriate bladder management program. A review of the policy Care Plan under Purpose - to guide the care and treatment provided to each resident; 16. The RN MDS Coordinator is responsible to ensure that each portion of the care plan is updated; 17. The care plan process is part of a dynamic cycle: evaluation of resident care is followed up by a re-assessment of resident needs to determine whether or not the plan of care requires modification. This process is completed whenever the resident's condition changes; 18. The Care Plan is to reviewed and updated by all staff providing care or services for the resident. NJAC: 8:39-11.2(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ159493 Based on interviews, medical record review, and review of other pertinent facility documents on 5/11/2023, 5/12/2023, and 5/17/2023, it was determined that the facility failed to provide evidence that incontinence care was consistently provided to Resident #1. The facility also failed to follow its policies titled Bladder Incontinence Management and Activities of Daily Living. This practice was identified for 1 of 5 residents (Resident #1) and evidenced by the following: Review of the medical record is as follows: According to the Face Sheet (FS), Resident #1 was admitted to the facility on [DATE], with diagnoses including but were not limited to: subarachnoid hemorrhage (a brain bleed) following injury with loss of consciousness, traumatic subdural hemorrhage (a collection of blood in the brain) with loss of consciousness, laceration (deep cut) without foreign body of other part of head, pain and benign prostate hyperplasia (an enlarged prostate). A review of the Skilled Nursing admission Evaluation (SNAE) completed by the Nurse Mentor/Registered Nurse (NMRN) for Resident #1 on 10/25/22 at 3:38 p.m. indicated Resident #1's urinary status as continent, with an external urinary catheter (a device used to collect urine). According to the nursing progress notes (NPN), documented by the Registered Nurse (RN), dated 10/26/22 at 3:45 p.m., Resident #1 was incontinent of urine. Further review of the NPN revealed other incontinence episodes on 10/27/22 and 10/31/22. The physician admission note dated 10/26/22 also identified Resident #1 as incontinent of urine. A review of the Activities of Daily Living (ADLs) Verification Worksheet from 10/25/23 through 11/1/23 revealed blank spaces, which indicated the task was not documented as being completed as follows: On 10/27/22, on the day (7:00 a.m.-3:00 p.m.) and evening (3:00 p.m.-11:00 p.m.) shift was blank. On 10/28/22, on the night shift (11:00 p.m.-:7:00 a.m.)shift was blank. On 10/29 /22, on the 7:00 a.m.-3:00 p.m. and the 3:00 p.m.-11:00 p.m. shift was blank. On 10/30/22, on the 7:00 a.m.-3:00 p.m. and the 3:00 p.m.-11:00 p.m. shift was blank. On 10/31/22, 7:00 a.m.-3:00 p.m. and the 3:00 p.m.-11:00 p.m. shift was blank. On 11/1/22, on the 7:00 a.m.-3:00 p.m. shift was blank. During an interview on 5/17/23 at 11:25 a.m., the surveyor reviewed the aforementioned blank spaces with the Director of Nursing (DON). The DON acknowledged the blank spaces. She stated, We have a problem with [the] documentation of ADLs. The DON continued that if the resident refused care, there is a column the staff can document the refusal, but none were noted on the form. She further stated the Certified Nursing Assistants (CNAs) didn't document the care given to Resident #1. The CNAs should have documented every time the resident was toileted or changed. During an interview on 5/17/23 at 11:40 a.m., the CNA stated she checked the resident's incontinent briefs and would ask the residents if they needed to be changed at the start of her shift and as needed throughout the shift. The CNA stated she would change all residents, then go into the computer and document after all residents were changed, not after each resident. During a second interview on 5/17/23 at 12:40 p.m., the surveyor interviewed the DON, who presented a timeline of urinary incontinence care that was not provided for Resident #1. The DON stated, on days without documentation, I don't know if care was done. If it's not documented, it's not done. The DON said the CNAs should have provided care and then immediately documented that care was given. Reviewed of the facility's policy titled Bladder Incontinence Management (RS-11), dated 3/8/23, which noted under Purpose - to ensure that residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible; and To ensure that each resident who is incontinent of urine is identified, assessed upon admission and is provided appropriate treatment through a systematic person centered approach to assist the resident to regain urinary continence upon recovery from a significant change in functional status; Special Instructions: UMC: a 3-day voiding trial; Definitions of types of urinary incontinceChronic Urinary incontinence - overflow - leakage of small amounts of urine when the bladder has reached maximum capacity; under Skilled Healthcare Procedure: A bladder management program will be implemented based on the resident's - specific reason for incontinence, individual goals, and the schedule for toileting, as well as special concerns. Review of the facility's policy titled Activities of Daily Living, dated 7/22/20, which noted under c. other functional communication systems, A resident who is unable to carry out activities of daily living will receive necessary services to maintain grooming ., The direct care giver is responsible for documentation of the ADLs each shift, whether through paper or electronic documentation .and, The Certified Nursing Assistants (CNAs) are responsible for completing the ADL data in the kiosk or tablets each shift, however, it remains the DON/Nurse Designee and the MDS Coordinator's responsibility to check for accuracy and daily completion of ADLs. NJAC-8:39 27.1(a)

Based on observation and interview, it was determined that the facility failed to detect and remove expired medication in 1 of 1 automated pharmacy dispensing units. This deficient practice was evidenced by the following: On 10/22/21 at 12:15 PM, the surveyor checked the automated pharmacy dispensing unit (APDU, a computerized storage device in which extra medication is stored for use in residents, where such medication is otherwise not available elsewhere). The surveyor observed the following, in the presence of the Registered Nurse (RN) and the Licensed Practical Nurse (LPN): eight capsules of expired Nitrofurantoin 50 milligrams (mg) (an antibiotic), all of which expired on 10/01/21; six tablets of Levofloxacin 250 mg (an antibiotic), all of which expired on 10/01/21; six capsules of Phenytoin 100 mg (an anti-seizure medication), all of which expired on 10/01/21; one bottle of 5 milliliters (ml) of Atropine Sulfate 1% (eyedrops used to dilate the eyes or decrease pain and inflammation), which expired 09/21; ten tablets of Cefpodoxime 100 mg (an antibiotic), all of which expired 10/12/21; five tablets of Potassium Chloride Extended-Release 20 milliequivalents (mEq) (a supplement), all of which expired 09/24/21; 16 tablets of Warfarin 1 mg (a blood thinner), all of which expired 10/01/21; nine tablets of Warfarin 3 mg, all of which expired 10/12/21; and ten tablets of Warfarin 4 mg, all of which expired on 10/12/21. During an interview with the surveyor on 10/22/21 at 12:42 PM, the RN and LPN acknowledged the presence of the expired medications. The RN stated that she and the Director of Nursing (DON) are responsible for checking the medication stored in the APDU. The RN also stated she was never asked to check the storage supply and does not know who else would be responsible for checking medication in the APDU. She did not know why expired medications were present or if the pharmacy staff had any responsibility for checking the stock. The LPN stated he thought the back-up supply was checked quarterly, perhaps by a representative from the pharmacy. During an interview with the surveyor on 10/22/21 at 1:08 PM, the DON was in the process of checking the dates and removing expired medications from the APDU. She stated that she checked the expiration dates on the medications a few weeks ago and the process needs to be completed more often. She further stated that she, as the DON, was responsible for checking medication expiration dates and that it needs to be done on a weekly basis. During an interview with the surveyor on 10/22/21 at 2:20 PM, in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team, the DON confirmed that expired medication should have been removed from stock. The DON stated she was not certain if there was a policy related to expiration dates, specifically related to medications kept in storage, but that she would investigate the matter and provide any additional and relevant policies. No policy, specifically related to stored medications and expiration dates, was supplied to the team on exit. NJAC 8:39-29.1(e)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 10/21/2021 from 9:55 AM to 10:47 AM the surveyors, accompanied by Dining Director (DD) and Executive Director (ED) observed the following in the kitchen: 1. At 10:31am, the surveyor attempted to wash his hands at the designated hand washing sink. Upon turning on the water, the surveyor attempted to apply soap from the wall mounted soap dispenser. The surveyor was unable to obtain soap. The DD opened the soap dispenser, and the dispenser was empty. The DD stated, There are two other sinks available with soap. Surveyor asked if all sinks are to have soap available. The DD responded, Yes. 2. On the second shelf of the 2- Door Refrigerator an opened bag of parmesan cheese was wrapped in plastic wrap. The Parmesan cheese was dated 10/3/21 and 9/27/21. The DD was unable to determine an accurate open date. The DD threw the parmesan cheese in the trash in the presence of the surveyors. 3. The surveyor observed 2 stacks of bread-and-butter plates, 2 stacks of casserole dishes, 3 stacks of plates, 1 stack of square bowls, and one bin of dessert bowls in the wash rack area that were uncovered and not stored in the inverted position. The food contact surfaces were exposed. On interview the DD confirmed that all contents of this area are cleaned and sanitized and should be covered or inverted to prevent contamination. 4. A plastic bin contained cleaned and sanitized dessert bowls in the wash rack area. The bowls were uncovered and not stored in the inverted position with food contact surfaces exposed. On interview the DD confirmed that all contents of this area are cleaned and sanitized and should be covered or inverted when not in use. 5. On the middle shelf of the walk-in refrigerator, a half tray of cooked sausage links was covered with plastic wrap and was dated 10/17/21. The ED stated, That was left over from breakfast I don't know why they saved it. Leftovers are good for 72 hours. I'm throwing it away. In addition, on an upper back left corner shelf, an opened bag of shredded mozzarella cheese was wrapped in plastic wrap. The mozzarella cheese had no dates. The ED threw the cheese in the trash. 6. On a rear lower shelf of the walk-in refrigerator, 5 independently wrapped roast beef cuts had a sticker dated 10/10/21. On interview the surveyor questioned the DD and ED if the sticker indicated the date that the meat was pulled from the freezer to defrost. The ED stated, I think that was the received date. On further interview the ED stated, I'm sure they haven't been in here for 10 days, but I can't prove it. The ED removed the roasts from the refrigerator and threw them in the trash. 7. On the middle shelf of the walk-in freezer, an opened bag of French fries, an unopened bag of peas, and two unopened bags of carrots were removed from its original container and were not labeled or dated. A package of frozen hamburger patties was removed from its original container and the bag was torn, exposing the hamburger patties. The hamburger patties had no dates. The ED removed the patties to the trash. The surveyor reviewed facility policy titled Hand Hygiene (RS-26), last reviewed 4/17/2020. The following was revealed under the heading Procedure: Procedure: Hand hygiene procedure with soap and water: Locate appropriate equipment: liquid soap, warm running water, and paper towels. The surveyor reviewed facility policy titled Section 11: Sanitation & Infection Control Labeling & Dating, dated 1/2016. The following was revealed under the heading Procedure: Procedure: All foods are labeled, dated, and securely covered and use-by dates are monitored and followed. The surveyor reviewed facility policy Handling Service Ware and Utensils, dated 6/2003. The following was revealed under the heading WHY PROPER HANDLING IS IMPORTANT: Flatware/silverware (forks, knives, and spoons) can become easily contaminated if we touch them without bare hands or with soiled gloves, or through other possible sources of contamination. In addition, the following was revealed under the heading HOW TO PROPERLY STACK SERVICEWARE AND UTENSILS DURING AND AFTER DISHWASHING: Stack plates, bowls, cups, and glasses in clean, protected storage racks or other designated storage space. The surveyor reviewed facility policy QUICK REFERENCE LIST FOR SHELF LIFE OF PRODUCTS--PURCHASED, revised 1/2003. The following was revealed under the heading Purchased PRODUCTS WITHOUT MANUFACTURERS EXPIRATION DATE: Raw Frozen Solid Whole Muscle Meats, thawed- Use within 3 to 4 days after freezer for thawing and under refrigeration. The following was revealed under the heading PRODUCTS PREPARED IN UNIT: Hot Foods, left over after meal period- 14 to 48 hours (if acceptable for reheating once only-follow recipe.) The surveyor reviewed facility policy Utilization of Excess Prepared Foods-700.07, Shelf Life of Products, undated: PURPOSE To prevent food-borne illness. To prevent spoilage and deterioration. RESPONSIBILITY Director of Dining Services PROCEDURE 1. Excess prepared foods must be utilized within a 72-hour period from time of preparation unless properly frozen. N.J.A.C. 18:39-17.2(g)