**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 notify a representative from the Office of the State of Long-Term Care Ombudsman about a resident's emergency transfer to the hospital. This deficient practice was identified for 1 of 1 resident, (Resident #16) reviewed for hospitalization as was evidenced by the following: On 07/06/23 at 10:51 AM, during the initial tour the surveyor observed Resident #16 sitting in a wheelchair in their room. At that time, the surveyor interviewed Resident #16 who stated that he/she was doing good and had no concerns. A review of the progress note dated 04/19/23 at 21:54 (9:54 PM), reflected that Resident #16 was sent to the hospital and admitted with a diagnosis of acute urinary retention (the inability to voluntarily pass urine) and acute cystitis (bladder infection). A review of the facility's Notice of Emergency Transfer signed by a nurse dated 04/26/23, revealed that the resident was sent out to the emergency room on [DATE] for abdominal pain. A further review revealed, 1. A copy of this notice must be provided to the resident/resident representative, as well as the Office of the Ombudsman. A review of the resident's medical records and pertinent facility documents reflected that there was no documentation that a representative from the Office of the New Jersey Long-Term Care Ombudsman was notified in writing regarding the hospitalization. On 07/07/23 at 12:30 PM, the surveyor inquired about the notification of the emergency transfer to the hospital for Resident #16. At that time, the Licensed Nursing Home Administrator (LNHA) stated that the notification to the Ombudsman's office was not completed for the resident. On 07/10/23 at 10:17 AM, in the presence of the LNHA, the surveyor interviewed the Social Worker (SW) who stated that she started her position at this facility last Wednesday, 07/05/23, but had worked as a SW prior. The surveyor continued to interview the SW who stated that when a resident was transferred out to the hospital, there was an assessment that should have been filled out by social services and then sent out to the family and the Ombudsman's office. She explained the assessment form was the Notice of Emergency Transfer and that the form documented the reason for the transfer. The SW stated that it was important that the form was completed and sent to the family representative to ensure the family knew of the transfer, and to the Ombudsman's office to see if there was anything that needed to be followed up on. On 07/10/23 at 10:20 AM, the surveyor continued the interview and the LNHA stated that for a while they did not have a SW and that the facility had to utilize the Assisted Living (AL) SW. The LNHA further stated that the AL/SW had covered for three (3) months from April to June of 2023. When asked who was responsible for ensuring the notification was sent out, the LNHA stated that the SW was responsible for sending out the notifications. At that time, both the SW and the LNHA acknowledged that the notice of transfer should have been completed. On 07/10/23 at 10:44 AM, the surveyor interviewed the Registered Nurse (RN) who stated that when a resident was transferred to the hospital the form called Notice of Emergency Transfer should have been completed. She explained that with their old Electronic Medical Record (EMR) it was easier to know what needed to be completed but in November of 2022 they switched over to a new EMR and they were learning the new system and honestly forgot about it because it did not remind them that it needed to be completed like the old system. The RN stated that they started the form and gave it to the SW to be completed. She further stated that if they forgot, the SW would also remind them that it needed to be started. The RN then stated that since they did not have a full time SW for a while, they simply forgot that it needed to be done and were just reminded on Friday [07/07/23] that it should be getting done. On 07/11/23 at 12:13 PM, in the presence of the Acting Director of Nursing (DON), the Infection Preventionist (IP), the Contracted Administrator and the survey team, the surveyor interviewed the LNHA who stated that the Notice of Emergency Transfer form was completed and the family was notified but it was missed a few times and that it was not sent to the Ombudsman's office. She further stated that the SW was responsible for sending the form to the Ombudsman's office and that it should have been sent out the next day or within the next few days. The LNHA stated that the AL/SW was not educated on notifying the Ombudsman's office of the emergency transfer. The LNHA acknowledged that a notification of the emergency transfer was not sent out and that it should have been sent to the NJ Ombudsman Office. A review of the facility's, Discharge and Transfers Policy, revised 07/10/23, included, Written notice will be provided by nursing/social work to the NJ [New Jersey] OOIE (Office of the Ombudsman for the Institutionalized Elderly) of all emergency leave of absence (LOA)/transfer of residents to an acute care setting on an emergency basis. A copy of this notice must be provided to the resident/resident representative, as well as to the Office of the Ombudsman Confirmation of the fax transmission to the ombudsman shall be noted in the resident's chart .A copy of the notices for Emergency Transfers to the hospital may be sent when practicable to the office of ombudsman on a monthly basis as long as list meets requirements. List of all discharges and leave of absences must be sent to the NJ Ombudsman office monthly via fax or email by the social worker/designee of each community. NJAC 8:39-4.1(a)(32)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide nail care to a resident that was dependent on the staff for activities of daily living. This deficient practice was identified for 1 of 2 residents, (Resident #3) reviewed for Activities of Daily Living (ADLs) and was evidenced by the following: On 07/06/23 at 11:02 AM, the surveyor observed Resident #3 lying in bed. The resident's nails were observed to be long with debris under them and nails on the right hand were observed to be broken, jagged, and unfiled. On 07/07/23 at 10:33 AM, the surveyor observed the resident lying in bed, dressed, clean and appeared comfortable. The surveyor observed that the residents nails on both hands were long, jagged and some were broken. The resident was pleasant and confused to specific details regarding time and place. The resident stated that his/her memory was not what it used to be. The resident showed the surveyor his/her hands and when the surveyor asked the resident the last time, he/she had their nails cut the resident stated that he/she did not know when the last time that their nails were cut but that they were a mess. The surveyor asked the resident if he/she would like his/her nails cut and cleaned and the resident stated, Sure. On 07/07/23 at 10:40 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) and asked the CNA if ADLs were performed for Resident #3, and she stated that ADLs were performed that morning and the resident was washed and dressed but did not want to get out of bed. The CNA then got called to another room and could not be further interviewed that that time. On 07/07/23 at 10:59 AM, the surveyor interviewed CNA #2 who stated that she had been employed through the agency and added that she worked at the facility frequently and was familiar with Resident #3. CNA #2 stated that when she performed ADLs, the resident was washed and dressed. She stated that Resident #3 preferred to wear pajamas and refused to get out of bed. She also added that the resident was incontinent and wore protective briefs for vanity and hygiene. She stated that all residents in the facility were provided with baths or showers twice a week. She stated that residents had the option of having a bath or a shower. She stated that baths were put on the schedule every morning. She further stated that CNAs cleaned the resident hands, but did not clip the nails. CNA #2 told the surveyor that the nurses do that. She explained that nails were done in activities where the residents nails were filed and painted. She stated that the staff did not touch the toenails. On 07/07/23 at 11:10 AM, the surveyor observed residents in the activities room and the Activities Assistant (AA) was filing and painting resident nails. The AA explained to the surveyor that resident nails were filed and painted every Friday by the AA in the activity room. She also stated that the AA were not allowed to cut the resident nails and that it was the responsibility of the nurses to cut the resident nails. She continued to explain that she made rounds in the morning to visit every resident in their room to find out if they needed anything. She stated at that time, she would inform the residents that she was filing and painting nails. She stated that if a resident was not able to leave their room and wanted their nails done, she would go to the resident's room and file and paint their nails. On 07/10/23 at 11:30 AM, the surveyor observed Resident #3 in bed. The resident showed the surveyor his/her hands and the residents nails continued to be long, some were observed jagged with debris under the nails. CNA #3 was in the hallway and the surveyor conducted an interview with her at that time. CNA #3 stated that the resident always had long nails however they should not be jagged or broken. The CNA went to the nurse and asked the Licensed Practical Nurse (LPN) if she could cut Resident #3's nails. The LPN stated that there was a change in the nail policy and that resident nails were not to be cut only filed. The LPN stated that the CNAs that had been caring for Resident #3 should have told the nurse that the resident's nails were broken or jagged so that the nurse could have filed them. On 07/11/23 at 10:12 AM, the surveyor attempted to telephone interview the Responsible Party (RP). There was no answer, so the surveyor left a message. On 07/11/23 at 10:16 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that she had been employed in the facility for approximately six years. She stated that nail care was part of showering or bathing, and nails care should be done on a needed basis. She stated that the nail care process included cleaning and filing of nails. She continued to add that residents' nails were a part of the ADLs that were performed daily. On 07/11/23 at 10:26 AM, the surveyor interviewed the Household Coordinator who identified herself as the lead CNA. The lead CNA stated that she saw Resident #3's nails and agreed that the nails needed to be filed and cleaned. She stated that she filed and cleaned the resident's nails as much as the resident would allow her to do. She stated that she educated the CNAs on proper nail care. She added that she would continue to check on Resident #3's nails and would file the resident's nails if the resident allowed her to do so. On 07/11/23 at 12:16 PM, the surveyor interviewed the Acting Director of Nursing (DON) who stated that resident nails should be observed daily to assure that they were clean and filed. The DON stated that residents were bathed two times a week and that their nails should have been cleaned and filed during bath time. The DON stated that she would provide the nail care policy to the surveyor. The surveyor reviewed the medical record for Resident #3. According to the admission Record, Resident #3 was admitted to the facility with diagnoses that included but were not limited to macular degeneration (visual impairment), scoliosis (curvature of the spine), and chronic ischemic heart disease. The quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 04/24/23, indicated that Resident #3 had cognitive impairment and required extensive assistance with activities of daily living. The surveyor reviewed Resident #3's Care Plan (CP) which indicated that the resident had a self-care performance deficit related to limited mobility and cognitive deficits. The CP was initiated on 12/08/22 and was revised on 05/22/23. The CP indicated that the resident required extensive assistance with personal hygiene. On 07/12/23 at 8:52 AM, the surveyor was provided with a copy of Resident #3's CP. A further review of the care plan included an intervention for ADLs dated 07/11/23, that indicated that the resident would have their nails cleaned and filed on bath days (Monday and Thursday on the 6:00 AM - 2:00 PM shift). On 07/14/23 at 10:30 AM, the DON did not have any additional information to provide. The facility policy, Resident Nail Care, with a last revised date of 07/11/23, indicated that residents would receive nail care when needed to maintain good grooming, hygiene, and skin integrity. The policy also indicated that the purpose for nail care was to help a prevent the spread of infection, prevent bodily injury, maintain integrity of the nail and to prevent the accumulation of dirt and microorganism underneath the nail. The policy also indicated that resident nails are to be kept short and were to be inspected on bath/shower days and file the nails often. NJAC 8:39-27.1(c),27.2 (g)

Based on observation, interviews, and review of facility documentation, it was determined that the facility failed to follow appropriate infection control practices for hand hygiene. This deficient practice was identified during a dining observation on 1 of 2 units, (2nd floor dining room) and was evidenced by the following: On 07/07/23 the surveyor observed the following: At 12:09 PM, a Certified Nursing Aide (CNA) in the second floor dining room was handed a plate of food at the door of the kitchenette. The CNA held the plate with her thumb on top of the plate and her fingers on the bottom of the plate and served it to Resident #61. The CNA then went to the small refrigerator in the dining room and touched the door handle, then returned to the door of the kitchenette and was handed another plate of food. The CNA held the plate with her thumb on top of the plate and her fingers were observed on the bottom of the plate. The CNA served the plate to Resident #39. The CNA then went back and opened the small refrigerator with the door handle, removed a small foil wrapped butter, unwrapped the butter and handed it to Resident #61. The CNA then asked Resident #8 for a beverage choice, went to the beverage dispenser area, grasped a plastic cup, went to the counter area where there was a metal bin of ice covered with plastic wrap, removed the plastic wrap, grasped the handle of the scoop that was resting on the ice, filled the cup with ice, replaced the scoop back on the ice, and then replaced the plastic wrap over the ice. The CNA then filled up the cup with juice from the beverage dispenser and handed the cup to Resident #8. Upon resident request, the CNA then returned to the small refrigerator, opened the door, removed coffee creamer, and placed them on the table in front of Resident #58. There was no hand hygiene observed at any time during the surveyors observations. On 07/07/23 at 12:13 PM, the surveyor interviewed the CNA who acknowledged she did not perform hand hygiene when she served the residents in the dining room. She stated that hand hygiene should have been performed before and after serving each resident their plated food or drink. The CNA further stated that it was important to perform hand hygiene between each resident to prevent cross contamination. On 07/07/23 at 12:27 PM, the surveyor interviewed the second floor Registered Nurse (RN) and informed her of the dining room observation. The RN stated that the CNA did not perform hand hygiene correctly during meal pass and that the CNA should have performed hand hygiene between each resident, when handling the butter, when touching the refrigerator handle, and any time touching plated food. The RN stated that it was important to perform hand hygiene when food was served to decrease transmission of any infection. On 07/07/23 at 12:37 PM, the surveyor interviewed the second floor Unit Manager (UM) who stated that in the dining room, the homemaker prepared and plated the meals and handed them to the CNA who delivered the meal to the residents. She stated that hand hygiene should have been performed before the meal service and in between each resident's meal pass. The surveyor informed the UM of the CNA dining room observation. The UM acknowledged that the CNA did not perform hand hygiene correctly and that she should have washed her hands between residents, when she touched the refrigerator, and that she should have worn gloves when she touched the butter for the resident. The UM stated that it was important to perform hand hygiene correctly for the safety and wellbeing of the residents and the staff. On 07/07/23 at 12:50 PM, the surveyor interviewed the Acting Director of Nursing (DON) who stated that in the dining room the homemaker plated the food, and the CNA served the residents. The DON stated that hand hygiene should have been performed in the dining room if the staff touched anything dirty before they touched anything clean. The surveyor informed the DON of the CNA dining room observation. The DON acknowledged that the CNA did not perform hand hygiene correctly and that she should have cleaned her hands after touching dirty areas such as the refrigerator handle. The DON stated that it was important to use proper hand hygiene when in the dining area for the prevention of sickness. On 07/11/23 at 12:01 PM, the Licensed Nursing Home Administrator was made aware of the 07/07/23 second floor CNA dining room observation. Review of facility documentation, Orientation Competency Checklist-Healthcare CNA, signed and dated by the CNA on 04/27/23, revealed Hand Washing Competency with return demonstration, was completed on 04/27/23, and the Dining and Serving Process with lecture/discussion, was completed on 04/28/23. The Staff Development Coordinator signed and dated the document on 5/18/23. Review of facility policy, Hand Hygiene, last revised 03/23/2023, revealed, Purpose: To prevent the transmission of pathogenic micro-organism from resident to resident and from inanimate surfaces to residents by the hands of all healthcare providers. Procedure: Clean hands before and after routine resident care activities, including entering and exiting the resident care areas and after hand-contaminating activities. Hand hygiene should be done (even when gloves are used): Before and after contact with each resident. After contact with an inanimate object that is potentially contaminated. Before handling food or eating. Indications for hand antisepsis with an alcohol based hand rub: After touching a patient or the patient's immediate environment. Each associate must utilize the 5 moments of hand hygiene approach recommended to clean their hands: 5. After touching resident surroundings. NJAC 8:39-19.4 (m)(n)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) On 07/06/23 at 10:55 AM, the surveyor observed Resident #44 resting in his/her recliner chair. Resident #44 stated that he/she wasn't feeling well but had informed the nurse and that the nurse was getting his/her medication. The resident stated they had a history of falls but that the staff was good at assessing and providing care to them. According to the admission Record, Resident #44 had diagnoses which included, parkinson's disease and major depressive disorder. Review of Resident #43's quarterly MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/10/23 at 10:17 AM, the surveyor interviewed the SW in the presence of the LNHA who stated that she started her position at this facility last Wednesday 07/05/23 but has worked as a SW prior. On 07/10/23 at 10:20 AM, the surveyor continued the interview and the LNHA stated that for a while they did not have a SW and that the facility had to utilize the Assisted Living SW. The LNHA further stated that the Assisted Living SW had covered for three (3) months from April to June of 2023. On 07/11/23 at 10:38 AM, the surveyor and the MDS/C reviewed the MDS for Resident #44. At that time, the MDS/C confirmed Section C and Section D of the resident's quarterly MDS dated [DATE], were not assessed. She stated that she signed off on it but that indicated it was completed but not accurate. She stated that it was important for the MDS to be accurate and complete because it showed a clear and concise record of the resident. The MDS/C acknowledged that the quarterly MDS for Resident #44 should have been completed accurately. 4.) On 07/06/23 at 11:10 AM, the surveyor observed Resident #56 resting in bed with his/her eyes closed. According to the admission Record, Resident #56 had diagnoses which included, major depressive disorder, adjustment disorder, and insomnia. Review of Resident #56's quarterly MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/11/23 at 10:40 AM, the surveyor and MDS/C reviewed the MDS for Resident #56. At that time, the MDS Coordinator confirmed Section C and Section D of the resident's quarterly MDS dated [DATE], were not assessed. She acknowledged that the quarterly MDS for Resident #56 should have been completed accurately. 5.) According to the admission Record, Resident #22 had diagnoses which included, but were not limited to, vascular dementia, anxiety, diffuse traumatic brain injury, and depressive episodes. Review of Resident #22's quarterly MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/11/23 at 10:15 AM, the surveyor interviewed the CNA who stated Resident #22 was alert and oriented, and was typically in a pleasant, happy mood. On 07/11/23 at 10:21 AM, the surveyor interviewed the Registered Nurse (RN) who stated Resident #22 was alert and oriented to self and place and was typically pleasant and cooperative. 6.) According to the admission Record, Resident #43 had diagnoses which included, but were not limited to, Alzheimer's Disease and major depressive disorder. Review of Resident #43's quarterly MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/11/23 at 10:15 AM, the surveyor interviewed the CNA who stated Resident #43 was confused and had a flat affect. On 07/11/23 at 10:21 AM, the surveyor interviewed the RN who stated Resident #43 was alert and oriented to self only and had a flat affect. 7.) According to the admission Record, Resident #65 had diagnoses which included, but were not limited to dementia and insomnia. Review of Resident #65's admission MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/11/23 at 10:15 AM, the surveyor interviewed the CNA who stated Resident #65 was confused and was typically in a pleasant mood. On 07/11/23 at 10:21 AM, the surveyor interviewed the RN who stated Resident #65 was alert and oriented to self only and was typically in a pleasant mood. On 07/11/23 at 10:32 AM, the surveyor interviewed the MDS/C who stated that the SW was responsible for completing Section C and D of the MDS, however, the facility did not have a designated SW since March 2023 and the SW from the Assisted Living facility was assisting the facility during the vacancy. The MDS/C further stated that a nurse could complete Section C and D of the MDS if the SW was unavailable, and that staff interviews could be conducted to compete the sections if the resident was not able to be interviewed. The MDS/C also explained that the importance of a complete and accurate MDS was to show a clear and concise record of the resident. The surveyor and the MDS/C reviewed the aforementioned MDS assessments for Resident #22, #43, and #65 and the MDS Coordinator verified that Sections C and D should have been completed. On 07/11/23 at 12:18 PM, in the presence of the survey team, the surveyor interviewed the Director of Nursing (DON) who stated that she expected her staff to complete MDS assessments in their entirety. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual), dated October 2018, included in Section C: Cognitive Patterns, Attempt to conduct the interview with ALL residents, and, Determine if the resident is rarely/never understood . If rarely/never understood, skip to . Staff Assessment of Mental Status. Further review of the RAI Manual included in Section D: Mood, Attempt to conduct the interview with ALL residents, and, Determine whether the resident is rarely/never understood . If rarely/never understood, skip to . Staff Assessment of Mental Status. A review of the facility's MDS Coordinator Job Description revised 03/29/22, indicated that the MDS Coordinator was responsible for, the accurate and timely completion of all Resident Assessment Instrument documents as required by regulatory agencies. Conducts concurrent MDS review to assure it accurately reflects resident status and maximize reimbursements for Medicare A residents. Monitors the overall process and tracking of RAI/MDS documentation and transmission. The Coordinator will ensure timely, accurate and complete assessment of the resident's health ad functional status during the entire assessment period. He/she will integrate nursing, dietary, social recreation, restorative, rehabilitation and physician services to ensure appropriate reimbursement for Medicare/Medicaid residents. A review of the Facility's Resident Assessment Instrument (RAI) MDS Completion Policy and Procedure last approved and dated 7/11/23, indicated, The Resident Assessment Instrument otherwise referred to as the MDS shall be completed in accordance with the Rules and Regulations set forth in Section 1819(f) (6) (A_B) for Medicare and the 1919 (f) (6) (A-B) for Medicaid in the Social Security Act, As amended by the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). The facility's Resident Assessment (RAI) MDS Completion Policy and Procedure further indicated that the MDS's purpose was an assessment tool that the facility utilized to identify resident care problems which could be addressed in the residents individualized care plan. NJAC 8:39-11.1 Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care for 7 of 17 residents, (Resident #9, #22, #43, #44, #46 #56, and #65) reviewed for accurately coding the MDS. This deficient practice was evidenced by the following: 1.) On 07/07/23 at 12:04 PM, the surveyor observed Resident #9 in the main dining room on the third floor seated next to other residents. The resident was unable to tell the surveyor how long he/she resided at the facility but told the surveyor that he/she used to live on a farm and took care of many different animals. The surveyor reviewed the medical record for Resident #9. A review of the residents admission Record (an admission Summary) indicated that the resident had resided at the facility since 2016 and had diagnoses which included but were not limited to unspecified dementia, pain, and abnormal weight loss. A review of Resident #9's quarterly MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/10/23 at 11:14 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who told the surveyor that she regularly took care of the resident, and the resident was alert and oriented to person, place with forgetfulness at times. The CNA further stated that the resident's mood was stable, and the resident was happy when she provided care to the resident. On 07/12/23 at 9:29 AM, the surveyor interviewed the residents Licensed Practical Nurse (LPN) who stated that the resident was alert and oriented to person and place with forgetfulness at times. The LPN further stated that the resident's mood was stable, and she was not involved in completing the MDS. On 07/12/23 at 9:47 AM, the surveyor interviewed the Minimum Data Set Coordinator (MDS/C) who stated that, everything fell apart in March because there was no long-term care Social Worker (SW) available to complete the MDS's at that time. The MDS/C told the surveyor that the SW from the communities Assisted Living facility was helping complete the MDS's for the residents and she had minimal experience doing so. The MDS/C further stated that Section C and Section D of the resident's MDS were not completed, and it should have been. The MDS/C told the surveyor that accurate completion of the MDS helped facilitate the management of care for the resident and it was important to fill the information out correctly because it guided in the development of the resident's care plan. 2.) On 07/07/23 at 11:27 AM, the surveyor observed Resident #46 sitting in his/her room in a lounge chair, completing a word search. The resident stated that everything was great, and he/she liked living at the facility. The surveyor reviewed the medical record for Resident #46. A review of the resident's admission Record reflected that the resident resided at the facility since October 2019 and had diagnoses which included but were not limited to seizures, hyperlipidemia (a condition where there are high levels of fat particles in the blood), nasal congestion, and major depressive disorder. A review of the May 2023, June 2023 and July 2023 Order Summary Report did not reflect a physcian's order for the use of an antipsychotic medication. A review of the resident's quarterly MDS dated [DATE], reveled in Section N0450 - Antipsychotic Medication Review that the resident had a gradual dose reduction of an antipsychotic medication when the resident had never been prescribed or administered an antipsychotic medication. On 07/12/23 at 9:33 AM, the surveyor interviewed the resident's LPN who stated the resident was alert and oriented to person, place, and time with minimal forgetfulness. The surveyor reviewed the resident's medications in the presence of the LPN who stated that the resident was receiving an antidepressant medication, not an antipsychotic medication. The LPN told the surveyor that to her knowledge, the resident had never been perscribed an antipsychotic medication. On 07/12/23 at 9:37 AM, the surveyor interviewed the MDS/C who stated that in March 2023, the facility eliminated the MDS Coordinator position, and she took on a new role with MDS at the facility which made her responsible for only competing the Medicare portion of the MDS's with the assistance from the Regional MDS Coordinator. The surveyor reviewed Resident #46's quarterly MDS dated [DATE], in the presence of the MDS/C who stated that the resident was never on an antipsychotic medication and the MDS had been coded inaccurately. On 07/14/23 at 10:58 AM, the surveyor interviewed the facility's Licensed Nursing Home Administrator (LNHA) who stated that the MDS's were missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility documentation it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain kitchen utensils in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 07/06/23 from 9:11 AM to 9:45 AM, the surveyor, accompanied by the Executive Chef (EC), observed the following in the kitchen: In the dry storage room: 1.) There was a rolling metal cart that contained 12 plastic-wrapped, circular baked items, that the EC identified as apple cakes, with no label or date. The EC stated they were made today and were good for three days. The EC further stated they should be labeled with today's date and the use-by date. In the main kitchen walk-in refrigerator: 2.) On a middle shelf, there was a plastic-wrapped metal container of strawberries with a use-by date of 07/04/23. The EC threw away the strawberries. 3.) On a cart, there was a plastic-wrapped metal container of salad mix. The label was incomplete, and the EC was unable to determine the use-by date. The EC threw away the salad mix. 4.) On a middle shelf, there was a plastic-wrapped metal container of meat, that the EC identified as Canadian ham. There was orange-tinted clear liquid pooled on top of the plastic wrap. The EC stated the liquid was possibly drippings from a metal container on the shelf above. The EC threw away the Canadian ham. 5.) On a middle shelf, there was a plastic-wrapped metal container of liquid, that the EC identified as shrimp scampi sauce with a use-by date of 07/05/23. The EC threw away the shrimp scampi sauce. 6.) On a top shelf, there was a plastic-wrapped metal container of meat, that the EC identified as sausage. There was clear liquid pooled on top of the plastic wrap. The EC stated he did not know where the liquid came from and threw away the sausage. In the outside walk-in freezer: 7.) On a middle shelf, there was plastic-wrapped open bag of frozen pierogis that was not labeled with an open or use-by date. The EC removed the bag of frozen pierogis. On 07/07/23 at 11:29 AM, the surveyor, accompanied by the Area Manager (AM), observed the following in the 3rd Floor Dining Room: In the top drawer of a cabinet: 8.) There was an open package of hamburger buns that was re-sealed with a plastic twist tie that was not labeled. The AM stated the dietary staff followed the manufacturer's date on the bread packaging. The manufacturer's use-by date was 07/05/23. The AM threw away the hamburger buns 9.) There was an open package of rye bread that was re-sealed with a plastic twist tie with a use-by date of 07/03/23. The AM threw away the rye bread. 10.) There was an open package of club wheat bread that was re-sealed with a plastic twist tie with a use-by date of 07/03/23. The AM threw away the club wheat bread. In the ice cream freezer: 11.) There was an open container of ice cream without a lid. The AM stated there should be a lid covering the ice cream. 12.) There was metal container next to the freezer with an ice cream scoop that was submerged in a white, opaque liquid. The metal container was open and exposed to air. The AM stated the ice cream scoop must have been used between meal service and should have been sent down to the kitchen to be washed before the lunch service. On 07/10/23 at 11:28 AM, the surveyor interviewed the Area General Manager (AGM) who stated that all prepared or opened food items should have been labeled with a prep and print label which included an open date, use-by date, the shelf life, and the name of the employee who printed the label. The AGM further stated that food items are checked daily for out-of-date items which are thrown away. When asked about the ice cream scoop kept in the dining room, the AGM stated that if the ice cream scoop was used outside of mealtimes, it should have been placed on the dirty cart to be brought to the kitchen for sanitization. Review of the facility's kitchen Daily Cleaning Assignments, dated 07/08/23, included, Check [NAME] for Out of Date Product Daily. Review of the facility's, Date Marking Ready to Eat TCS/PHF Foods policy, dated 04/01/22, included, Refrigerated, ready to eat, TCS/PHF food prepared and held in a food establishment must be clearly marked with a consume by/discard date, and, Food that is required to be date marked must be discarded if it: . is in a container or package that does not bear a date or day. Review of the facility's, Preventing Cross Contamination policy, dated 04/01/22, included, Packaged food may not be stored in direct contact with ice or water if the food is subject to entry of water because of the nature of its packaging, wrapping, or container, Food must be covered/protected from environmental contamination during storage and transportation, and, Utensils and equipment used for both raw and ready to eat foods must be cleaned and sanitized between uses. Review of the facility's In-Use Utensils, Between Use Storage policy, undated, included During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: . In a clean, protected location. NJAC 8:39-17.2(g)

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 5/17/2021 from 9:51 AM to 10:36 AM, the surveyor, accompanied by the Executive Chef (EC) and Food Service Director (FSD), observed the following in the kitchen: 1. The fan in the dry storage room has a substantial buildup of what appeared to be dust on the external wire frame that encloses the fan blade. The fan faces a box that contained plastic forks used for resident meals. The surveyor held their hand in front of the fan and determined that the fan was blowing in the direction of the box of plastic forks and the fan was blowing onto the cutlery boxes on the top shelf of a multi-tiered storage rack. 2. The fan in the dish room had an excessive dust buildup on the metal grill surrounding the fan blade. The fan was determined to blow air in the direction of the dry rack that contained cleaned and sanitized dishware, potentially contaminating the cleaned and sanitized dishware. On interview the FSD stated, Yeah they're dirty, we'll get them cleaned right away. 3. (2) stacks of cleaned and sanitized plates used to serve resident meals were on a middle shelf of the drying rack in the dish room. The plates were not stored in the inverted position and were exposed with the fan blowing. On interview the FSD stated, I think they were in transition between tasks and forgot to invert them. We will have them re-cleaned. 4. During observation of the milk box, the surveyor, EC and FSD were unable to find an internal thermometer to determine the internal refrigerated temperature. A review of the milk box temperature log revealed that the recorded AM temperature for the milk box on 5/17/2021 was 36 degrees Fahrenheit. The EC removed several crates of milk boxes and was unable to find an internal thermometer. The EC stated, Let me go get a new one (internal thermometer). 5. On a lower shelf of the pot drying rack, a stack of approximately 9 full baking pans were stacked on top of each other. The surveyor lifted the top pan and observed that the pan below was wet to the touch (wet nesting). This was also felt by the FSD. The FSD stated, They're wet. The FSD instructed the EC to rewash the baking pans. 6. In the Chef's prep area, a box of Plastic Food Wrap was observed on top of a prep counter. The lid had been removed from the box and the plastic wrap was exposed. A second box of Plastic food wrap was also opened and had the cardboard lid removed, exposing the plastic wrap on an additional work top next to the steamers. On interview the FSD stated, I guess they are exposed but it would only be the top of the plastic wrap and shouldn't touch the food. The surveyor reviewed a facility policy titled Washing Pots and Pans, with an updated date of 4/2006. Under the Activity 1 heading, the answer key defined the following six steps of cleaning and sanitizing pots, pans, other equipment, and utensils in a three-compartment sink. Step 1: Prepare the pot washing area. Step 2: Pre-rinse, scrape or soak. Step 3: Wash. Step 4: Rinse. Step 5: sanitize. Step 6: Air dry. In addition, under Activity 2 at #6 the following was revealed: 6. Air-dry all items; never use towels or aprons for drying. Remind employees to stand cutting boards and sheet pans upright and apart for quick drying. Never stack wet pots and pans on storage shelves. The facility did not provide a policy/procedure pertaining to a cleaning schedule for the fans in the kitchen, use of internal thermometers or protecting the plastic wrap from exposure to contamination. NJAC 8:39-17.2 (g)