**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 the comprehensive care plan was reviewed and revised by an interdisciplinary team to address the implementation of fall interventions for 2 of 5 fall incidents, in 1 of 6 residents, (Resident #118), reviewed for accidents. This deficient practice was identified by the following: On 3/25/25 at 11:20 AM, the surveyor observed Resident # 118 seated in a wheelchair (w/c) inside the activity room with other residents. The surveyor reviewed Resident #118's medical records and revealed: A review of the Resident Face Sheet (an admission summary) reflected that Resident #118 was admitted to the facility with medical diagnoses which included but not limited to; type 2 diabetes mellitus without complications, vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), unspecified severity, with agitation, mood disorder due to known physiological condition, unspecified, major depressive disorder, recurrent, unspecified, and insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or experiencing poor sleep quality, often leading to daytime fatigue and impaired function) unspecified. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 1/30/25, included a brief interview for mental status (BIMS) score of 3 out of 15, reflected that the resident's cognition was severely impaired. A review of the current Resident #118's personalized care plan (CP) reflected that the resident had multiple falls due to unsteady gait and balance and poor safety awareness secondary to dementia with an original date of 11/8/23, effective date of 2/5/25, and was revised on: -5/2/24 Actual fall -5/16/24 Lowered self to the floor -6/29/24 Actual fall -9/17/24 Actual fall -12/20/24 Actual fall Further review of the CP revealed interventions that included but were not limited to: Effective date of 6/20/24, one person assists with ADLs (activities of daily living) such as dressing, toileting needs and hygiene; one person assists with transfers. Effective date of 11/1/24: -W/c use for locomotion when out of bed (OOB). -Engage with diversional activities such as listening to music, religious gatherings, live entertainment in the dayroom . -Ensure that staff hold the resident's hand securely until the resident comfortably seated on a regular chair in the dayroom. -Assist the resident OOB and bring the resident to the dayroom when noted awake in the morning during rounds. -RNP (Restorative Nursing Program) ambulation program 3-5 x/week (3 to 5 times per week) as tolerated. Effective 1/13/25, magic cushion high back w/c when OOB. A review of the provided fall investigations by the Chief Executive Officer Secretary (CEOS) revealed that the two of five fall investigations new interventions and recommendations were not transcribed in the CP. The comprehensive CP was not reviewed and revised to reflect the new interventions and recommendations for the following fall investigations: -The 5/2/24 fall was investigated with a conclusion that the resident had an unwitnessed fall in the dayroom with no injury, which the resident stated that they were picking up something on the floor and the resident fell. The resident at that time was noticed with a piece of tissue paper near them and tried to pick it up. The recommendation: Staff will ensure dayroom floor is free of trash. The recommendation due date was 5/2/24, and date implemented 5/16/24. -The 6/29/24 fall was investigated with a conclusion that the resident during rounding, nurse noticed the resident walking in the room unsafely, and the nurse walked the resident to the dayroom with handheld assist. During the process to make the resident sit in the chair, the resident turned around suddenly and tripped on a chair and fell on their right side. There was no injury noted. CP was updated. Staff was instructed to use w/c to transport resident from room to dayroom for safety. The recommendation: Staff to provide w/c for locomotion. The recommendation due date was 6/29/24, and date implemented 7/5/24. A review of the Daily Note Summary of the Physical Therapist on 7/1/24 revealed that the resident had a fall, ambulating in the unit without any assistive device, thus, reiterated importance of safety. Resident's level of function fluctuating at this time due to observed episodes of lethargy. A review of the Physical Therapy (PT) Discharge summary dated [DATE], revealed that the resident ambulated 150 feet with rolling walker and contact guard assist with close w/c follow for safety. Further review of the medical records revealed that there was no documented evidence why the 5/2/24 and 6/29/24 recommendations for new interventions status post (s/p) falls were not documented in the resident's CP. On 3/27/25 at 12:25 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) in the Serenity nursing station, who informed the surveyor that it was the responsibility of the MDS person, Unit Manager, and Charge Nurse to initiate, update, and revise CP. She further stated that when the resident had fall incident, all new interventions and recommendations should be immediately put in the CP. On that same date and time, the surveyor asked the RN/UM to print the resident's fall CP. The surveyor also notified the RN/UM of the above concern regarding two fall investigations that the recommendations were not in the CP. The RN/UM stated that she had to call the MDS person to talk to the surveyor. On 3/27/25 at 12:30 PM, the surveyor interviewed the MDS Facilitator (MDSF) in the presence of the RN/UM. The MDSF informed the surveyor that they (RN/UM and MDSF) both could initiate, update and revise CP. The surveyor notified them of the above concern that the 5/2/24 and 6/29/24 fall investigations recommendations were not in the resident's CP. The MDSF stated that she would get back to the surveyor and check the records. On 3/27/25 at 12:38 PM, the MDSF confirmed to the surveyor that she did not find the CP interventions for new recommendations as part of investigations for the two fall incidents on 5/2/24 and 6/29/24. The MDSF acknowledged that the CP should have been updated of the new interventions for the two falls according to the recommendations. On 3/31/25 at 12:22 PM, the survey team met with the CEO (Chief Executive Officer, also known as the Licensed Nursing Home Administrator) and the Director of Nursing (DON). The surveyor notified the CEO and the DON of the above concerns and findings regarding the resident's CP. On 4/1/25 at 1:08 PM, the survey team met with the CEO, DON, Assistant Chief Executive Director-Clinical (ACED-C), and ACED-Clinical Support (ACED-CS). The ACED-C stated that the 5/2/24 fall intervention was initially put in the CP and in November 2024, there was a significant change and decline noted with the resident, and the 5/2/24 intervention was resolved that was why it was not active. The ACED-C further stated that the 6/29/24 intervention for w/c was given by therapy after evaluation on 7/1/24. On that same date and time, the surveyor asked the facility, was the 5/2/24 CP intervention that was resolved was the same intervention, and the DON acknowledged that the interventions in the CP for 5/2/24 that was resolved was not the same interventions on 5/2/24 fall investigation. The surveyor also asked where the CP was that on 7/1/24 to reflect that the w/c as part of intervention for the 6/29/24 fall, and both the DON and the ACED-C stated that they would get back to the surveyor. At that same time, the surveyor asked the DON, ACED-C and the ACED-CS should the interventions and recommendations for each fall reflected in the CP to prevent further fall, and the DON stated yes. A review of the facility's Care Planning Policy, with a revision date of 9/22, that was provided by the CEOS, revealed: Purpose: To ensure that interdisciplinary plans of care are developed, implemented, and evaluated to meet the individual needs of Resident. Practice: 7. CP are reviewed and updated quarterly and as needed. Decisions are recorded on the IDCP (interdisciplinary care plan) notes as to the progress towards goals and effectiveness of interventions . 9. When a goal is met, it is documented in the IDCP CP Notes and the CP is updated/revised . 12. At the case conference, the CP revision sheet will be generated by the Nurse Facilitator to indicate any changes in the Resident's plan of care from prior review .Nurse Facilitator will review goal revision sheet with the charge nurse weekly and when indicated. A review of the facility's Resident Fall Prevention and Management Policy, with a revision date of 12/24, that was provided by the CEOS, revealed: Purpose: 1. To identify Resident at risk for falls and develop an individualized CP . Procedure: 3. If Resident is re-admitted from the hospital, admitting nurse/MDSF needs to complete the fall risk assessment and initiate a CP. If Resident is high risk for falls any new intervention must be added to the CP and the CP revision sheet. 4. When a Resident experience a fall, a RN will conduct full body assessment prior to moving the resident, including range of motion, vital signs, neuro-check, accucheck, and urine dipstick if appropriate. The nurse/MDSF will add new appropriate interventions to the CP and the CP revision sheet . On 4/2/25 at 11:42 AM, the survey team met with the CEO, DON, ACED-C, ACED-CS, Central Office Director, and ACEO Non-Clinical for an exit conference, and there was no additional information provided by the facility. NJAC 8:39-11.2(e) 2; 27.1(a)

Based on observation, interview, and record review, it was determined the facility failed to: a.) follow a physician's order for 1 of 37 residents, (Resident #162), and b.) provide pharmaceutical services in accordance with professional standards to ensure accurate documentation of the receipt of a controlled substance for 6 packages Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on 1 Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) reviewed. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. 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. On 3/25/25 at 10:35 AM, the surveyor observed Resident #162 was not in their room. The Registered Nurse/Unit Manager (RN/UM) stated the resident was out to dialysis. The surveyor reviewed the medical records of Resident #162. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate management of care, with an assessment reference date (ARD) of 2/14/25, indicated a Brief Interview Mental Status (BIMS) score of 13 out of 15, which reflected that the resident's cognition was intact. Resident #162 was documented with diagnoses that included, but were not limited to, End stage renal [kidney] disease, and hypertension (HTN; high blood pressure). A review of the physician's order (PO) dated 10/4/23, read: Metoprolol tartrate 25 milligram (mg) 1 tablet by mouth daily at 8 AM on Monday, Wednesday, Friday, and Sunday for HTN; Hold for systolic blood pressure (SBP) < [less than] 120 or heart rate (HR) < 70. A review of the Medication Administration Record (MAR) entries dated 1/9/25 to 2/5/25, revealed the nurses signed for the metoprolol tartrate medication (med) as administered 14 of 16 times when the med should have been held as per the parameters of the PO as follows: -On 1/10/25, the resident's documented HR was 62. -On 1/12/25, the resident's documented blood pressure (BP) was 118/61 and HR was 61. -On 1/13/25, the resident's documented HR was 65. -On 1/15/25, the resident's documented HR was 61. -On 1/17/25, the resident's documented BP was 112/56 and HR was 62. -On 1/19/25, the resident's documented HR was 61. -On 1/20/25, the resident's documented HR was 64. -On 1/22/25, the resident's documented BP was 116/61 and HR was 67. -On 1/24/25, the resident's documented HR was 63. -On 1/26/25, the resident's documented HR was 64. -On 1/31/25, the resident's documented HR was 66. -On 2/2/25, the resident's documented BP was 117/66 and HR was 64. -On 2/3/25, the resident's documented BP was 119/73 and HR was 63. -On 2/5/25, the resident's documented HR was 62. There was no documentation on the MAR that indicated the identified entries were held and not administered. A review of the MAR entries dated 2/6/25 to 3/5/25, revealed the nurses signed for metoprolol tartrate med as administered 9 of 16 times when the med should have been held as per the parameters of the PO as follows: -On 2/7/25, the resident's documented HR was 65. -On 2/9/25, the resident's documented HR was 62. -On 2/10/25, the resident's documented HR was 67. -On 2/17/25, the resident's documented HR was 64. -On 2/19/25, the resident's documented HR was 68. -On 2/23/25, the resident's documented HR was 63. -On 2/24/25, the resident's documented HR was 63. -On 2/26/25, the resident's documented HR was 64. -On 3/2/25, the resident's documented HR was 66. There was no documentation on the MAR that indicated the identified entries were held and not administered. Additionally, the following entries had a documented BP, and no documented HR as follows: -On 2/12/25 the written entry for indicated 123/66. The entry was signed as administered by the nurse. - On 2/16/25 the written entry indicated 122/67. The entry was signed as administered by the nurse. - On 2/21/25 the written entry indicated 139/80. The entry was signed as administered by the nurse. A review of the MAR entries dated 3/6/25 to 4/5/25, revealed the nurses signed for metoprolol tartrate med as administered 4 of 15 times when the med should have been held as per the parameters of the PO as follows: -On 3/7/25, the resident's documented HR was 61. -On 3/10/25, the resident's documented HR was 60. -On 3/24/25, the resident's documented BP was 114/88 and HR was 61. -On 3/30/25, the resident's documented BP was 109/65 and HR was 67. There was no documentation on the MAR that indicated the identified entries were held and not administered. On 4/1/25 at 11:17 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) about medications (meds) with parameters. The LPN stated that it was expected for nurses to follow hold parameters as per the PO. The surveyor reviewed with the LPN the metoprolol tartrate entries for Resident #162. The LPN confirmed there were entries in which the med should have been held as per the PO. The LPN stated if the BP or HR results were outside the parameters of the med order, the med should be held and not administered to the resident. The LPN explained if a med was not administered to the resident the nurses' circled their initials on the entry and on the back of the MAR documented why the med was not given to the resident. On 4/1/25 at 11:21 AM, the surveyor interviewed the RN/UM about meds with parameters. The RN/UM stated it was expected for nurses to follow the PO for meds with parameters. The surveyor reviewed with the RN/UM the MARs of Resident #162. The RN/UM acknowledged there were entries where the med should have been held and not administered to the resident as per the PO. On 4/1/25 at 11:37 AM, the surveyor interviewed the Director of Nursing (DON) about med orders with hold parameters, and the DON stated meds with parameters should be held as per the PO. The DON further explained that standards of practice were for the nurses to document the reason a med was held or not, and a prescribed order to be clarified with the physician as needed if the nurses had any concerns. At that same time, the surveyor notified the DON of the concern regarding the metoprolol tartrate med parameters not being followed per the PO for Resident #162. The DON acknowledged it was expected for the nurses to follow parameters for meds as ordered, and to document when a med was held. On 4/1/25 at 1:20 PM, the surveyor notified the Chief Executive Officer (CEO, also known as the Licensed Nursing Home Administrator), the DON, and the Assistant Chief Executive Director-Clinical (ACED-C) about the concern that the PO for Resident #162's metoprolol tartrate med with parameters was not being followed. On 4/2/25 at 11:20 AM, the CEO, the DON, and the ACED-C met with the survey team. The DON stated the Medical Director was informed of the identified concern, that it was determined there was no harm that occurred to the resident, the resident's meds were reviewed, and the metoprolol tartrate med was discontinued by the physician. The DON further stated that she was in the process of following up with the nurses from the identified entries and that the staff had previously received in-service education regarding meds with parameters. There was no additional information provided to the surveyor. A review of the facility's Administering Medications Policy, with a last revised date of 7/31/24, which indicated Medications shall be administered in a safe and timely manner, as prescribed. Under Policy Interpretation and Implementation of the policy revealed: 4. Meds are administered in accordance with prescriber orders, including any required time frame . 11. The following information is checked/verified for each resident prior to administering meds .b. Vital signs, if necessary . 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the med shall initial and circle the MAR space provided for that drug and dose . 2. On 3/31/25, the surveyor reviewed a binder provided by the facility Chief Executive Officer's Secretary (CEOS), containing, but not limited to, facility DEA 222 Forms, copies of medical director state and federal controlled substance registration certificates, and packing slips associated with the DEA 222 Forms for controlled substance deliveries. A review of the facility DEA 222 Forms that were filled out and used to order controlled substances (CDS) revealed the following: DEA 222 Form with order form # 240136292 dated 8/30/24 for six packages of morphine 10 mg/0.5 ml (0.5 milliliters) syringes (a schedule II-CDS used for pain) with the section Part 5: to be filled in by purchaser, number received, date received, not filled in. A supplier packing slip for the items was not present. On 3/31/25 at 12:23 PM, the survey team met with CEO and DON to notify them of concerns with the DEA 222 forms. The surveyor showed the DON the DEA 222 form in question and asked if it should be filled in. The DON stated, yes, it should be filled out per the regulations, and she would correct it and obtain a packing slip. On 4/1/25 at 1:08 PM, the survey team met with the CEO and DON for concerns and responses to prior concerns. The DON provided the surveyor with a copy of the DEA 222 form in question with the blanks filled in and a copy of the associated packing slip obtained from the pharmacy, after surveyor inquiry. The facility offered no further pertinent information. The surveyor reviewed the instructions for completing the DEA 222 Forms located in the Code of Federal Regulations at 21 CFR1305.13. The CFR 1305.13 revealed at section (e) The purchaser must record on its copy of the DEA Form 222 the number of commercial or bulk containers furnished on each item and the dates on which the containers are received by the purchaser. A review of the facility's Medication Dispensing Controlled Substances Policy, Effective date January 2015. The policy reflected: I. Controlled dangerous substances are handled by the facility in a manner that promotes proper storage, security and compliance with applicable state and federal regulations. III. The DON is designated by the facility to be responsible for the control of such drugs. NJAC 8:39-11.2(b); 29.2(d); 29.7(c) 21 CFR 1305.13(e)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication for 1 of 5 medication carts inspected according to facility's policy and standard of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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 3/27/25 at 11:28 AM, the surveyor began to inspect selected medication (med) storage areas in the facility. The surveyor observed the following: The surveyor in the presence of the Licensed Practical Nurse (LPN), the surveyor inspected the med cart identified as the L Wing cart. The surveyor observed, in the 3rd drawer of the med cart a quantity of loose tablets and capsules on the bottom of the drawer. The surveyor counted the loose medications (meds) which amounted to seven items. The surveyor asked the LPN if they could positively identify any of the meds. The LPN stated they could not positively identify all of them, but what some could be. The surveyor asked the LPN if meds should be stored that way. The LPN stated no, they should be in the packaging they came in. At that same time, the surveyor observed the LPN disposed of the loose meds in the drug disposal device located in the bottom of the med cart. The surveyor also interviewed the Director of Nursing (DON) who happened to enter the nursing unit at that time. They surveyor asked the DON if meds should be loose in the med cart, The DON stated no, med should be kept in the packaging and the cart should be kept clean. On 3/31/25 at 12:23 PM, the survey team met with the Chief Executive Officer (CEO, also known as the Licensed Nursing Home Administrator) and DON to notify them of concerns with med storage. The DON affirmed that she was on the unit at the time of discovery and agreed that meds should be stored in proper packaging. On 4/1/25 at 1:08 PM the survey team met with the CEO and DON for responses to concerns. The DON provided education in-service attendance sheets that included but were not limited to checking med carts for loose meds. The DON also stated that the facility will be instituting new checks for the med carts every shift for loose or dropped meds and any compromised packaging. The facility did not provide any further pertinent information. A review of the facility's Medication Use, Medication Storage Policy, Effective date January 2015, revealed, meds will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with the NJ Department of Health guidelines. The policy also reflected under PROCEDURE: 3. Meds will be stored in an orderly, organized manner in a clean area . 5. Meds will be stored in the original, labeled containers received from the pharmacy . NJAC 8:39-29.4(h)

Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate storage of disinfecting wipes and b.) disinfect the treatment area after use and follow appropriate infection control practices during the treatment pass observation of 1 of 2 nursing staff (Registered Nurse) to 1 of 2 residents, (Resident #68), reviewed for pressure ulcers, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following: According to the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities Guideline for Disinfection and Sterilization in Healthcare Facilities (2008), Disinfection and Sterilization Guideline, dated 12/7/23, included: 5. Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities: 5.a. Clean housekeeping surfaces (e.g., floors, tabletops) on a regular basis, when spills occur, and when these surfaces are visibly soiled . 5.c. Follow manufacturers' instructions for proper use of disinfecting (or detergent) products - such as recommended use-dilution, material compatibility, storage, shelf-life, and safe use and disposal . 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 well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. On 3/25/25 at 11:00 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who informed the surveyor that Resident # 68 had a facility acquired wound, stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) to buttocks. On 3/25/25 at 11:16 AM, the surveyor observed Resident # 68's room with an enhanced barrier precaution (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes, primarily through targeted gown and glove use during high-contact resident care activities) posted sign outside the resident's door and the resident was not inside the room. On 3/25/25 at 11:27 AM, the surveyor observed Resident # 68 seated in recliner wheelchair with padded arm rests and leg rest with chair cushion while attending activity with other residents. The surveyor reviewed the medical records of Resident #68 and revealed: A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; dementia in other diseases classified elsewhere, unspecified severity, with agitation, muscle weakness, and age-related osteoporosis (a bone disease characterized by a decrease in bone density and mass, making bones weaker and more prone to fractures) without current pathological fracture. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 1/2/25, included a brief interview for mental status (BIMS) score of 3 out of 15, which reflected that the resident's cognitive status was severely impaired. A review of the physician's order dated 3/19/25, to cleanse stage 2 pressure ulcer to sacrum with normal saline (NS), apply zinc oxide 20% daily and cover with bordered gauze, remove zinc oxide with mineral oil prior to treatment changes x 14 days. A review of the provided wound timeline by the Director of Nursing (DON) revealed that Resident #68's sacral stage 2 pressure ulcer was a facility acquired wound that was discovered on 3/4/25. On 3/31/25 at 8:40 AM, the surveyor observed the Registered Nurse (RN) was assisted by the RN/UM for wound treatment of Resident # 68. The RN informed the surveyor while reading the orders in the Treatment Administration Record (TAR) that resident had an order for EBP, order for wound consultation, pain management, and that the resident was administered with Tramadol (a narcotic, can treat moderate to severe pain) prior to wound treatment. The RN also confirmed an order for stage 2 sacral ulcer with zinc oxide 20%, cleanse with mineral oil and NS covered with border gauze. Inside the room, the RN assessed the resident for pain and checked resident's identification. The RN performed handwashing inside the resident's room, donned (put on) gloves and gown, used the disinfecting wipes (purple top with 2 minutes contact time) for disinfecting the table, doffed (removed) off gloves, performed handwashing, donned gloves, placed a liner on top of dry table, and prepared supplies: 4 x 4 gauze (seven packets), NS container, two scissors, mineral oil poured over 4 x 4 gauze. At 9:00 AM, the surveyor observed the RN left the disinfecting wipes container open on top of the treatment cart in front of the room. The RN informed the surveyor that the contact time for the disinfecting wipes was two minutes. In the room, the surveyor observed the RN performed handwashing and donned gloves. The RN/UM entered room performed handwashing and put gloves and gown, drawn the privacy curtain and closed the door. The RN completed the wound treatment, disposed the garbage, left the room, signed the TAR, and informed the surveyor that she was done with wound treatment. The RN and the RN/UM left the resident's room without disinfecting the table that was used during wound treatment. The disinfecting wipes was left open. On 3/31/25 at 9:30 AM, the RN then pushed her treatment cart in the hallway, the surveyor stopped the RN for an interview. The surveyor asked the RN about the disinfecting wipes container that was left open from 9:00 AM up to this time, for total of 30 minutes, and the RN had no answer. The surveyor then asked the RN what the importance was of keeping the disinfectant wipes closed when not in use, and the RN responded that it should have been closed because it dries up and it contaminate. The surveyor asked the RN should she disinfect the table she used for treatment, and she responded yes it should be cleaned and disinfected after use. The surveyor asked why she did not disinfect the table after the wound care treatment, and the RN did not respond. On 3/31/25 at 10:20 AM, the surveyor asked the Chief Executive Officer Secretary (CEOS) of facility's policy and procedure for wound treatment, and she stated that she would get back to the surveyor. On 3/31/25 at 12:22 PM, the survey team met with the CEO (also known as the Licensed Nursing Home Administrator) and the DON. The surveyor discussed the concern with Resident #68's wound observation regarding storage of disinfecting wipes and not disinfecting the table after use. A review of the provided Infection Control Program, Non -Sterile Dressing Change Policy, that was provided by the CEOS, with a revised date of 3/13/24, revealed that there were no steps included to disinfect the table after treatment or after use of the table for wound treatment. A review of the Cleaning and Disinfection of Environmental Surfaces, with a revised date of 3/13/24, revealed that the environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration, a United States government agency within the Department of Labor, whose mission is to ensure safe and healthy working conditions for workers by setting and enforcing standards, and providing training, outreach, education, and assistance) Bloodborne Pathogens Standard . On 4/1/25 at 1:08 PM, the survey team met with the CEO, DON, Assistant Chief Executive Director-Clinical (ACED-C), and ACED-Clinical Support (ACED-CS). The DON stated that the RN was provided education with regard to the surveyor's concerns and will be monitored. On 4/2/25 at 11:42 AM, the survey team met with the CEO, DON, ACED-C, ACED-CS, Central Office Director, and ACEO Non-Clinical for an exit conference, and there was no additional information provided by the facility. NJAC 8:39-19.4(a)(l)

Based on observation, staff interviews, record review, and facility policy review, it was determined the facility failed to maintain an error rate of less than 5%. There were two medication errors out of 30 opportunities which resulted in a 6% medication error rate. Medications given by Licensed Practical Nurse (LPN) #1 exceeded the time frame for medication administration. LPN #1 also failed to follow medication instructions by not giving medication with food as prescribed. Findings included: 1. A medication administration pass was observed on 10/18/2021 at 9:20 AM, with LPN #1. LPN #1 administered medication to Resident #56 which included carbidopa/levodopa 25/100 milligram (mg) tablet and potassium chloride 10 milliequivalents (MEQ) tablet. No food was administered at that time. Following the medication pass, a medication reconciliation (a review of physician orders compared to what medications were given) was conducted. The physician orders, dated 10/2021, indicated 1) carbidopa/levodopa 25/100mg tablet to be given three times daily for Parkinson's disease at 7:30 AM, 11:30 AM, and 4:30 PM. 2) potassium chloride 10 MEQ tablet to be given once daily with breakfast for supplement at 7:30 AM. On 10/18/2021 at 10:51 AM, an interview was conducted with LPN #1. The LPN stated he knew those two medications were given late, and the only reason was because of the number of residents the LPN had to pass medications to. The LPN stated the breakfast trays came to the floor at 7:30 AM. LPN #1 stated he did not know how much or what the resident had eaten for breakfast. On 10/18/2021 at 3:24 PM, an interview was conducted with Nursing Supervisor (NS) #1. The NS stated the breakfast trays came up to the floor at 7:30 AM, but if the medication was given later, then the resident should have been given something to eat with it. NS #1 stated she expected the LPN to call the physician if the medications were given late. On 10/19/2021 at 3:43 PM, an interview was conducted with the Director of Nursing (DON). The DON stated medications were to be given within a one-hour window of the ordered time. The DON stated she expected the nurse to give crackers or milk, which are on the medication cart, when a medication was ordered to be taken with food and the breakfast hour had passed. A review of the facility procedure, titled, Medication Pass Safety and Infection Control Reminders, undated, indicated, 14: Administer all medications within time frame (one hour before-to-one-hour after). New Jersey Administrative Code § 8:39-29.2(d)