**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure one out of one resident (Resident (R) 42) reviewed for Pre-admission Screening and Resident Review (PASRR) had accurate screenings and/or were referred for a Level II review as required following a positive Level I screening. This had the potential to cause delays in receiving necessary mental health services. Total sample was 23. Findings Include: Review of the facility Preadmission Screening and Resident Review (PASARR) policy updated on 07/01/24, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include a. A resident who exhibits behavioral, psychiatric, or mood-related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment. Review of R42's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R43 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, recurrent, severe with psychotic symptoms. Review of R42's Pre-admission Screening and Resident Review (PASRR) Level I Screening, dated 06/16/23 and located under the Misc (Miscellaneous) tab of the EMR, revealed documentation R43 has a serious mental illness, did not have significant impairment in functioning related to the diagnosis of a mental illness, and had experienced one psychiatric treatment episode that was more intensive than routine follow-up care in the last two years. Review of R43's entire EMR and hard chart revealed no documentation a Level II resident review had been completed for R42. Review of Psychiatric Hospital Discharge Summary Notes, Located under the Misc tab of the EMR, dated 12/31/24, revealed multiple medical conditions and perinatal depression with major depression disorder features and Major Neurocognitive Disorder, prior psychiatric admissions one prior Suicide Attempt via Overdose on medication years ago, no h/o [history of] self-injurious behavior, currently on Zoloft 50 milligram (mg) daily and Melatonin 6 mg nightly. The resident was sent to the emergency department on 12/13/24 reportedly due to worsening depression and Suicidal ideation. The patient was admitted to the inpatient psychiatry unit for further psychiatric stabilization. R43 was in the psychiatric unit for 14 days and released on new medications. During an interview on 02/19/25 at 1:39 PM with the Social Service Director (SSD), revealed R43 had been out of the facility for fifteen days in a psychiatric facility for suicidal ideation. When asked about the PASARR in needing a PASARR II, the SSD revealed having some questions as to when to do the PASARR. When asked about another PASRR I to see if R43 needed a PASRR II, the SSD stated I never thought about the repeat of the PASRR I. During an interview on 02/20/25 at 2:57 PM with the Administrator and Regional Director of Social Services, the Administrator stated they had requested to appropriate PASARR to be completed on R43, and they will be reviewing their process. NJAC 8:39-5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of facility policies, the facility failed to ensure a respiratory assessment was completed prior to initiating a breathing treatment and failed to monitor the resident's respiratory condition, including response to therapy provided, and any changes in the respiratory condition during the breathing treatment. This involved one of 28 sampled residents (Resident (R) 29). Findings include: Review of a policy provided by the facility titled Nebulizer Therapy undated.5.Obtain baseline vital signs . 13. Observe resident during the procedure for any change in condition . Documentation record the following information in the residents medical record . 3.Resident lung sounds 4. Resident's response to treatment. Review of R29's admission Record in the electronic medical record (EMR) under the Admissions Record tab indicated R29 was admitted on [DATE] with diagnoses including Respiratory Failure. Review of R29's care plan located in the EMR under the Care Plan tab dated 08/21/24 indicated R29 was care planned for altered respiratory status/difficulty in breathing . The care plan did not address self-administration of the nebulizer. Review of Medication Administration Record (MAR), dated 08/19/24, indicated R29 had an order for nebulizer treatment Ipratropium-Albuterol solution 0.5-2.5/3 milliliters inhalation orally every six hours as needed for shortness of breath. During observation of the medication pass on 02/20/25 at 9:33AM, Licensed Practical Nurse (LPN) 1 administered R29's morning medications in his room. LPN1 started R29's nebulizer treatment and returned to the medication cart. LPN1 began to prepare the next resident's medications. LPN1 returned to R29's bedside at 10:05AM and removed R29's nebulizer mask, rinsed it out with water and laid it on a towel to air dry. R29 was asleep. LPN1 exited the room. LP1 did not complete a respiratory assessment prior to beginning the treatment. During an interview on 02/20/25 at 10:10 AM, LPN1 confirmed she started R29's nebulizer treatment before leaving the room at 9:33 AM. LPN1 confirmed she did not complete a respiratory assessment prior to beginning the treatment, and did not assess R29's lung sounds, pulse, or respirations and returned to R29's bedside to complete a respiratory assessment checking oxygen saturation and lung sounds. LPN1 stated, the respiratory assessment should be done prior to the breathing treatment and at the end of the treatment. LPN1 stated the respiratory assessment use to be on the MAR with the nebulizer order, indicating the assessment needed to be done. Review of R29's MAR on 02/20/25 at 11:31 AM, a respiratory assessment order was added by Regional Clinical Nurse (RCN) to the MAR as follows: Before treatment obtain lung sounds (LS) oxygen saturation (O2) and respirations. After treatment, obtain LS,O2, respirations and number of minutes spent completing treatment. During an interview on 02/20/25 at 10:31 AM, with Infection Preventionist (IP) and (RCN) present, stated that a resident's lung sounds and O2 saturations should always be assessed prior to a nebulizer treatment with the expectations to be assesses before and after treatment . NJAC 8:39-25.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure a catheter bag was kept off the floor for one of one resident (Resident (R) 48) reviewed for catheters in a total sample of 23 residents. The failure to keep a catheter bag off the floor increased the risk for R48 developing a urinary tract infection. Findings include: Review of the facility's policy titled, Indwelling Catheter Care, dated 02/20/25, revealed, Policy: It is the policy of this facility to ensure that residents with indwelling catheter receive catheter care and maintain their dignity and privacy when indwelling catheters are in use. Procedure . 3. Privacy bags will be changed out when soiled, with a catheter change or as needed .5. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. Drainage bag should not be touching the floor. Review of R48's undated admission Record, located in R48's electronic medical record (EMR) under the Profile tab revealed R48 was admitted to the facility on [DATE]. Review of R48's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/25 indicated R48 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact, and indicated R48 had an indwelling catheter. Observation on 02/17/25 at 3:23 PM, revealed, R48 lying supine (on his back) in bed. R48's catheter bag was observed lying on the floor next to his bed. Observation on 02/18/25 at 3:20 PM, revealed, R48 seated in a wheelchair in the hallway while working with therapy and his catheter bag resting on the floor under the wheelchair. During an observation and interview on 02/20/25 at 12:20 PM, Licensed Practical Nurse (LPN) 1 confirmed that R48 was lying in his bed supine, and his catheter bag was lying on the floor next to his bed. LPN1 stated, The catheter bag should not be touching the floor, it should never be on the floor. If it is on the floor that increases the risk of infection. NJAC 8:39-19.4

Based on observation, staff interview, and facility policy review, the facility failed to ensure kitchen staff properly air-dried pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 49 of 51 residents who resided in the facility and who received dietary services. There were two residents receiving tube feedings. The facility had a census of 51 residents. Findings include: Review of the facility's policy titled, Manual Ware washing, dated 10/2024 (sic), revealed, Policy Statement: All cookware, dishware, and service ware that is not processed through the dish machine will be manually washed and sanitized. Procedures: . 3. All service ware and cook ware will be air dried prior to storage. Review of the facility's undated policy titled, Pots and Ware washing, revealed, .9. Air-dry all items on a clean, sanitized drain board or rack. Take care not to stack items to avoid wet nesting . Wet Nesting: Wet nesting occurs when clean pans, plates, cups, bowls, etc. (et cetera, and other things), are stacked together as they are coming out of the dish machine, or 3 (sic) compartment sink without completely drying first. This action will cause water to pool and, if not dried properly or quickly, can create a breeding ground for bacteria even on clean items. To prevent wet nesting, store clean items in properly filled glass, dish or 3 (sic) compartment racks. Make sure there is no standing water in rims of trays or hotel pans. Always make sure silverware is completely dried and stored in a proper storage bin with lid. During an observation and interview on 02/17/25 at 10:30 AM, the Dietary Manager (DM) confirmed three pans, 10 inches by 12 inches by 3 inches deep; two pans, 6 inches by 12 inches, by 2 inches; four pans 6 inches by 12 inches, by 8 inches; four pans 12 inches by 24 inches by 3 inches that had been cleaned and stacked for use that were still wet and had food particles on them when they were unstacked. The pans were found to have been stacked wet and not allowed to airdry. The DM stated, They should be dry; they weren't completely dry when they were put away. When they're wet it increases the chance of contamination. They need to be rewashed. During an observation and interview on 02/17/25 at 10:35, the DM confirmed the can opener had paper and a black substance located on the blade. The DM stated, The can opener is dirty and needs to be cleaned, it shouldn't have anything on it. NJAC 8:39-17.2(g)

**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 date medication when opened and stored for continued use. This was found in 2 of 3 medication carts and 1 of 1 medication refrigerator. The deficient practice was evidenced by the following: On [DATE] at 9:35 AM, the surveyor inspected the annex medication cart with Licensed Practical Nurse #1 (LPN #1). Inside of the annex medication cart there was one vial of Humalog insulin that was open and dated [DATE] and one vial of Humalog insulin that was open and dated 9/20. LPN # 1 confirmed the dates then took them and said they were out dated and he didn't know why they were in the medication cart. According to manufacturer specifications Humalog insulin should be discarded 28 days after opening. On [DATE] at 9:55 AM, the surveyor inspected the medication refrigerator with the Unit Manager/LPN (UM/LPN). Inside of the medication refrigerator there was a vial of Influenza vaccine that was open and undated. The UM/LPN confirmed that there was no date and there should have been. According to the manufacturer specifications the vial should be discarded 28 days after opening. On [DATE] at 10:16 AM, the surveyor inspected the west hall medication cart with LPN #2. Inside of the west hall medication cart there was a Levalbuterol Inhalation Solution package of vials that was open and undated. According to manufacturer instructions once opened the vials must be used within 2 weeks. LPN #2 confirmed that the package should have been dated when it was opened. On [DATE] at 1:30 PM, the survey team spoke with the Administrator and the Director of Nursing (DON) and made them aware of the concerns with the undated or expired medication found in the medication carts and refrigerator. The DON confirmed that the vials and package should have been dated when opened and the expired vials of insulin should have been discarded. On [DATE] at 1:18 PM, the surveyor reviewed the facility's policy and procedure titled Labeling of Medication Containers. Under Policy Statement it read All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations, and reviewed the policy and procedure titled Administering Medications dated 9/2022. Under Policy it read The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. NJAC 8:39-29.4 (h)

Based on observation, interview and policy review it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development of a food borne illness. This deficient practice was evidenced by the following: On 12/19/22 at 9:15 AM, in the presence of the Food Service Manager (FSM) and the Regional Food Service Director (RFSD), the surveyor observed the following: 1. In the food preparation area, the surveyor observed grey colored material stuck on the blade of the can opener. 2. On a shelf in the Cook's refrigerator, the surveyor observed a container of cranberry sauce, which had a written date in marker of 11/16/21 and a stamped manufacturer expiration date of 7/23/22. The FSM stated he was not sure what the written date on the item or the manufacturer's date on the item was indicating, and disposed of the cranberry sauce. 3. The surveyor observed four of six stovetop burners were soiled with a black grease-like substance. FSM stated the stove was cleaned once a week. 4. Above the stove top, the surveyor observed the overhead sprinklers which were soiled with grey dust-like particles. On 12/19/22 at 10:42 AM, the surveyor informed the Licensed Nursing Home Administrator, the Director of Nursing, and the Regional Nurse of the above concerns. The surveyor reviewed the facility's policy titled, Equipment with a revised date of September 2022. The policy read All foodservice equipment will be clean, sanitary, and in proper working order. Under Procedures, it read 3. All food contact equipment will be clean and free of debris. The surveyor reviewed the facility's policy titled, Environment with a revised date of September 2022. The policy indicated that all food preparation areas, food service areas will be maintained in a clean and sanitary condition. The surveyor reviewed the facility's policy titled, Food Storage: Cold Foods with a revised date of September 2022. The policy indicated that all foods should be labeled and dated. The policy did not further address checking food item expiration dates. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to clean and disinfect three of three shower chairs observed in the shower room. This deficient practice was as evidenced by the following: On 12/22/22 at 10:40 AM, the surveyor interviewed five residents during a resident council meeting. At the end of the resident council meeting, the surveyor asked the residents if they had any other concerns and two of five residents stated that the shower chairs in the shower room were not clean and that the shower chairs had black and brown substances on them. On 12/22/22 at 12:15 PM, the surveyor went into the shower room and observed three shower chairs stored inside the room. The surveyor observed one shower chair's four metal legs were each soiled with a black colored substance and the plastic seating bench of the chair had a brown colored substance in the holes of the bench and a brown colored substance on the entire under side of the bench. The surveyor observed two of two white Polyvinyl chloride (PVC) plastic shower chairs with mesh seat backings in the shower room as well. Each of the four legs on the two PVC plastic shower chairs were soiled with a black colored substance and the mesh seat backings were both soiled with a black colored substance as well. At 12:18 PM, the surveyor asked the Director of Nursing (DON) to come to the shower room and to observe the three shower chairs. The DON stated that the three chairs were soiled and should not be like this. The DON stated that the chairs need to be cleaned. At 12:32 PM, in the presence of the DON, the surveyor interviewed the Housekeeping Director, who stated that the chairs had never been cleaned by the housekeeping department and it was never on their cleaning schedule to do so. The DON stated that the nursing staff were also not cleaning the shower chairs. The surveyor reviewed the Cleaning and Disinfecting Critical and Non-Critical Resident Equipment policy, dated 6/2022, which revealed that non-critical and reusable resident care equipment will be decontaminated and/or sterilized between residents. N.J.A.C. 8:39-19.4(a)

Based on observation, interview and record review, it was determined that the facility failed to revise a comprehensive care plan to include monitoring of injuries sustained during a fall for Resident #35, 1 of 3 residents reviewed for falls and was evidenced by the following: On 10/26/20 at 10:15 AM, the surveyor observed Resident #35 in the resident's room awake and alert, seated on top of a canvas lift pad in the geri chair. The surveyor reviewed Resident #35's medical records that revealed the following: According to the admission Record, Resident #35 had diagnoses that included Fracture of Nasal Bones and Contusion of the Scalp. The Progress Notes dated 1/15/20 at 15:26 indicated the resident had a fall in the afternoon and was sent to the Emergency Department for evaluation, and at 23:10 the documentation indicated the resident was admitted to the hospital with a diagnosis of bilateral nasal bone fractures and supra-orbital hematoma. The Event Summary Report dated 1/15/20, obtained from the Regional Clinical Quality Specialist, revealed that Resident #35 had a fall in the resident's room. There was bleeding from the nose and the resident had a bump to the right forehead. The resident stated that he/she wanted to get a nightgown from the closet. Under the Summary of Investigation: Root cause/conclusion revealed a summary of the incident and that the resident returned from the hospital with follow up for monitoring post non-displaced nasal bone fractures. In addition the summary included monitor for changes due to a hematoma over the right eyebrow. Remains on coumadin (a blood thinner medication). Resident #35 had a care plan initiated on 11/10/09 indicating [the resident] was at risk for falls and had a revised date of 4/15/18 and a target date of 11/29/20. There was no documentation on the care plan regarding the fall on 1/15/20 and injuries the resident sustained. There was one intervention that was documented in the care plan dated 1/20/20 which read when [the resident] returns via wheelchair from using Omnicycle for upper and lower body exercises, supervise [the resident] to allow [the resident] to choose [the resident] nightgown from [the resident] dresser draws . On 10/29/20 at 12:15 PM, the surveyor interviewed the Unit Manager (UM) and asked who was responsible for creating and updating residents care plans. The UM stated either she or the Director of Nursing (DON). The surveyor inquired about an update to the careplan to reflect the date of the fall, include the injuries sustained, and include interventions to monitor for changes. The UM stated she didn't know, but stated there was a care plan evaluation written in the Progress Notes. She stated that was how the care plans were updated. The UM showed the surveyor the Care Plan Evaluation note dated 1/21/20 in the Progress Notes. However, there was no documentation in that note to monitor for changes as the Summary of Investigation indicated. The DON was present at the time of the interview and agreed that there was no update on the fall care plan regarding the actual fall. A review of the facility's Person Centered Care Plan Policy with a revision date of 7/1/19 included under Practice Standards #7.2 Care plans will be: Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. NJAC 8:39-11.29 (i)