**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and review of other pertinent facility documentation on 4/22/25 and 4/23/2025, it was determined that the facility staff failed to a.) consistently document in the Documentation Survey Report v2 (DSR) and b.) follow the facility's Charting and Documentation policy. This deficient practice was identified for 1 of 3 residents (Resident #4) reviewed for documentation. This deficient practice was evidenced by the following: On 4/22/25, at 11:38 A.M., the surveyor observed Resident #4 seated in a wheelchair at the bedside. During interview the resident denied having any care issues at that time. According to the admission Record, Resident #4 was admitted with the following diagnoses, that were not limited to: neoplasm of prostate (growth or tumor in the prostate gland), anxiety disorder, and acute kidney failure. The resident's quarterly MDS, dated [DATE], revealed a BIMS of 12 out of 15 which indicated the resident was moderately cognitively impaired. Review of Resident #4's care plan, revealed that the resident had an ADL Self Care Performance Deficit focus that was initiated on 6/16/24. Review of Resident #4's DSR revealed blank boxes related to the type of assistance that was provided to the resident on the following dates indicated: -4/19/25 Day shift (7 A.M. to 3 P.M) -4/20/25 Day shift (7 A.M. to 3 P.M) & Night Shift (11 P.M. to 7 A.M.) -4/21/25 Day shift (7 A.M. to 3 P.M) On 4/22/25, at 1:32 P.M., an interview was conducted with a Certified Nursing Assistant (CNA), who stated that all Assisted Daily Living (ADL) care for each resident was to be documented by CNAs in the facility's electronic system and that there should be no blanks. She further added that if a resident was assigned to her, she was responsible for providing and documenting all care. The CNA then stated, But not everyone is perfect. On 4/23/25, at 12:11 P.M., an interview was conducted with the Unit Manager (UM), who stated that CNAs were primarily responsible for providing and documenting all care in the facility's electronic system and that it was the nursing supervisor's responsibility to ensure that documentation was completed. She stated that this was important because blanks could mean that the care was not provided. On 4/23/25, at 1:40 P.M., an interview was conducted with the Administrator and the Interim Director of Nursing (DON), who stated that CNAs were primarily responsible for documenting all care provided to a resident in the facility's electronic system. They further added that nursing management was responsible for ensuring that documentation was completed and that it was their expectation that there should be no blanks in the system. The surveyor reviewed the facility's Charting and Documentation policy, reviewed March 2025, which revealed that all services provided to a resident were to be documented in the medical record. Under the Policy Interpretation and Implementation section, the policy noted that documentation was to be complete and accurate. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure guardianship documentation to support advanced directive decision making was in place for one of three residents (Resident (R) 66) reviewed for advanced directives of 26 sampled residents. R66 was not capable of making healthcare decisions and was documented as having a legal guardian. The facility did not have the guardianship documentation for R66. Findings include: Review of the undated admission Record, provided by the facility, revealed R66 was admitted on [DATE] with diagnoses including dementia, down syndrome, and aphasia (disorder resulting from damage to the brain affecting the ability to communicate). R66's family member (F) 66 was noted to be R66's responsible party and guardian. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/24 in the electronic medical record (EMR) under the MDS tab, revealed R66 was unable to complete the Brief Interview for Mental Status (BIMS) and was documented with memory problems and severely impaired decision making. Review of the EMR revealed no guardianship documentation in place. Review of the Pennsylvania Orders for Life-Sustaining Treatment (POLST) form, dated 11/30/23 in the EMR under the Miscellaneous tab, revealed R66's resuscitation status was Do Not Resuscitate (DNR). R66's guardian was noted on the document to have given verbal consent; there was no signature from the guardian (F66). Review of the Order Summary, dated 11/26/23 in the EMR under the Orders tab, revealed the Physician's order on this date for DNR and Do Not Intubate (DNI). During an interview on 05/29/24 at 9:07 AM, the Social Service Director (SSD) stated she had been employed by the facility for approximately two months and was not familiar with R66. The SSD reviewed R66's EMR and stated she did not see the guardianship papers in the record. The SSD stated the facility should have had a copy of the guardianship papers. During an interview on 05/29/24 at 1:34 PM, the Admissions Coordinator stated when new residents admitted to the facility she asked about power of attorney (POA), living will etc. The Admissions Coordinator stated these documents should have been uploaded in the EMR. The admission Coordinator stated she did not let families sign the admission agreement until the facility received the POA papers. During an interview on 05/30/24 at 10:07 AM, the Admissions Coordinator stated she called R66's guardian yesterday and was told F66 gave the guardianship papers to the previous social worker. The Admissions Coordinator stated, I looked in the medical chart and we don't have it. The Admissions Coordinator stated she had been employed by the facility for three weeks. During an interview on 05/30/24 at 4:10 PM, the Administrator stated advanced directives, including documents such as guardianship papers, should have been uploaded on admission. The Administrator verified the facility did not have a copy of R66's guardianship papers. Review of the facility's policy titled, Advance Directives, dated 09/22 and provided by the facility, revealed If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents' medical record and are readily retrievable by any facility staff. NJAC 8:39-4.1(a)(34)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 24 reviewed for abuse was free from verbal abuse by a staff member of 26 sampled residents. This had the potential to affect resident safety at the facility. Findings include: Review of R24's admission Record, dated 05/30/24 and located in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, congestive heart failure, bursitis of the left hip, anxiety, and chronic pain syndrome. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/24 and located in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. The assessment indicated the resident was receiving both scheduled and as needed pain medications and the resident experienced frequent pain that interfered with her day-to-day activities. Review of R24's Order Summary Report, dated 05/24 and found in the EMR under the Orders tab, indicated orders for the resident to receive Carisoprodol (a controlled pain medication) 350 milligrams (mg) by mouth three times a day for chronic pain (original order date 02/23/23) and oxycodone (a controlled pain medication used for severe pain) 10 mg every six hours for pain management of moderate to severe pain (original order date 09/25/23). Review of R24's Medication Administration Record (MAR), dated 05/01/24 through 05/30/24 and found in the EMR under the Orders tab, indicated the resident frequently reported pain levels between six and eight out of 10 and that she was receiving the above routine medication as ordered. Review of R24's Pain Care Plan, dated 03/21/24 and found in the EMR under the Care Plan tab, indicated the resident had the potential to experience acute and chronic pain related to her diagnoses of chronic pain syndrome, arthralgia, immobility, and multiple sclerosis. The care plan indicated staff were to respond immediately to any complaint of pain and to administer the resident's pain medications as ordered. Review of R24's Abuse Care Plan, dated 05/24/24 and found in the EMR under the Care Plan tab, indicated the resident was at risk of experiencing abuse and/or neglect. Review of R24's Incident Report, dated 05/22/24 and provided by the facility, indicated the resident informed a nurse on 05/22/24 that on 05/21/24 on the 3:00 PM to 11:00 PM shift Registered Nurse (RN) 1 used the words Drug Addict when she was administering the resident her medications. The facility's investigation into the above alleged incident, dated 05/22/24 and provided by the facility, revealed the allegation was reported timely and a thorough investigation was initiated into the allegation. According to an undated statement received by Licensed Practical Nurse (LPN) 5 during the investigation, LPN5 indicated she was present at the time of the alleged incident since RN1 was orienting her to the facility at the time and the two staff members were passing medications to the resident together. LPN5 confirmed she heard RN1 reference R24 with the term Drug Addict and stated the resident responded to RN1 by stating she wished RN1 had her sickness. LPN5 stated RN1 told R24 that she was only kidding. LPN5 indicated she later apologized to R24 for RN1's earlier statement. During an interview with the Administrator, Director of Nursing (DON) and Corporate Nurse on 05/29/24 at 10:52 AM, the Corporate Nurse indicated RN1 had been suspended immediately after the allegation and an investigation had been initiated into the alleged abuse. The Corporate Nurse indicated RN1 quit related to the incident and was no longer employed with the facility. Review of the facility's policy titled, Abuse, Neglect and Exploitation Policy, dated 07/23, read, in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures to prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; and Verbal Abuse: means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. NJAC 8:39-4.1(a)5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure a Level One PASARR (Pre-admission Screening and Resident Review) was revised for one of two residents (Resident (R) 16) reviewed for PASARR after the resident was newly diagnosed with a major mental illness (MMI) of 26 sampled residents. This failure created the potential for residents to receive inadequate mental health services. Findings include: Review of R16's admission Record, located in the electronic medical record (EMR) under the Admission tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including congestive heart failure and anxiety. A diagnosis of bipolar disorder was added to the resident's diagnoses list on 10/15/20 (approximately five months after the resident's original admission to the facility. Review of R16's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/07/24 and located in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. The assessment indicated the resident was receiving antianxiety and antidepressant medication on a routine basis. The assessment indicated the resident frequently exhibited signs of depression including feeling down, depressed, or hopeless and having trouble falling and/or staying asleep. Review of R16's Level 1 PASSAR document, dated 11/01/21 and found in the EMR under the Miscellaneous tab, revealed the Level One PASARR incorrectly indicated the resident did not suffer from any major mental illness diagnoses. During an interview with the Administrator and the Corporate Nurse on 05/29/24 at 2:23 PM, the Nurse Consultant confirmed R16's Level One PASARR assessment dated [DATE] was incorrect. The Nurse Consultant stated her expectation was Level One PASARR assessments were to be correct and were expected to be updated timely with any change in a resident's health status. Review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program Policy, dated 2023, read, in pertinent part, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate for their needs; and a. PASARR Level 1 - initial pre-screening that is completed prior to admission: i. Negative Level 1 Screen - permits admission to proceed and ends unless a possible serious mental disorder or intellectual disability arises later; and 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 2 resident review. NJAC 8:39-40.3(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure that two of 26 sampled residents (Residents (R) 9 and R100) care plans were revised to reflect the residents care needs. R9's care plan was not revised to reflect the physician ordered emergency dialysis dressing supplies to be maintained at the resident's bedside. Additionally, R100 was not allowed to participate in the scheduled care plan meetings. Findings include: 1. Review of R9's undated admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE] with diagnoses that included end stage renal disease with hemodialysis. Review of R9's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/23 and located in the resident's EMR MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score 15 out 15 which indicated the resident had intact cognition. The section for special treatments and procedures revealed the resident was assessed to receive dialysis. Review of R9's quarterly MDS with an ARD of 05/11/24 and located in the resident's EMR MDS tab revealed under special treatment and procedures the resident was to receive dialysis. Review of R9's Physicians' Orders for the month of May 2024 with a start date of 03/05/24 and located in the resident's EMR Orders tab, revealed the resident had a left chest wall perma catheter for dialysis. The orders included to ensure the following supplies were maintained at the resident' s bedside hemostats, gauze, and tape for excessive bleeding. Review of R9's Care Plan for dialysis with a revision date of 05/11/24 and located in the resident's EMR Care Plans tab, revealed the resident's care plan was not revised to reflect the physician order for the hemostats, gauze, and tape. During an interview on 05/30/24 at 12:45 PM, LPN, Unit Manager (LPN) 1 reviewed the physician's orders and stated the resident's care plan should have reflected the physician's orders. LPN1 also stated that the care plans were usually revised during the care plan meetings. However, any floor nurse could revise a resident's care plan, as necessary. During an interview on 05/30/24 at 1:08 PM, the MDS Coordinator (MSDC) stated the baseline care plan was generated by the floor nurse; then the unit manager was responsible for generating the comprehensive care plan. The MDSC stated each member of the Interdisciplinary Team (IDT) was responsible for the section for their department and then MDSC reviewed the MDS in its entirety to make sure everything had been completed. 2. Review of R100's undated admission Record, dated 05/30/24 and found in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, morbid obesity, complications of surgical and medical care, and dependence on tracheostomy (a tube in the airway to help a person breathe). Review of R100's quarterly MDS with an ARD of 03/07/24 and located in the EMR under the MDS tab, indicated a BIMS score of 15 out of 15 which indicated the resident had intact cognition. Review of R100's Comprehensive Care Plan, dated 12/28/23 and located in the EMR under the Care Plan tab. The care plan had not been updated since it was initially entered on 12/28/23. Review of R100's comprehensive EMR was reviewed and indicated nothing to show a quarterly care planning meeting, or any other care planning meeting had been held by the IDT or that R100 had been invited or was included in such a meeting since her initial care plan had been implemented. During an interview on 05/28/24 at 10:49 AM, R100 stated she did not remember participating in a care planning meeting with the IDT, and indicated she would like to participate in such a meeting since she had questions related to her medications/treatments. During an interview on 05/29/24 at 3:40 PM, the Social Services Director (SSD) confirmed IDT care planning meetings had not been happening at least quarterly like they were supposed to. She stated she was only in the building twice weekly on Mondays and Fridays, and she was trying to schedule and complete care planning meetings for residents when she was able. She confirmed R100 had not had an IDT care planning meeting since right after her admission at the end of December 2023. During an interview on 05/30/24 at 6:34 PM, the Administrator confirmed his expectation was an IDT care planning meeting was to occur for each resident in the facility at least quarterly and residents and/or their representative were expected to be invited to each meeting. Review of the facility's policy titled, Comprehensive Care Plan Policy, dated 2023, read, in pertinent part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; and 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) Assessment; and The physician, other practitioner, or professional will inform the resident and/or the resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. NJAC 8:39-11.2(e),(f),(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of one resident reviewed for activities (Resident (R) 74) was provided with a meaningful activity program of 26 sampled residents. An assessment of R74's activity preferences was lacking; the care plan was not specific to R74's interests, and R74 was not provided with sufficient activities to prevent boredom. Findings include: Review of the undated admission Record, provided by the facility, revealed R74 was admitted to the facility on [DATE]. During an interview on 05/27/24 at 11:55 AM, R74 stated he was a chess player and liked to play dominoes. R74 stated he enjoyed intellectual activities; however, there were not any people at the facility to play chess or dominoes with. R74 stated he stayed in his room with the TV on all the time and he had no activity beyond TV. R74 stated he was bored and getting weaker from doing nothing and asked, What am I supposed to do, walk up and down the hall? R74 stated he completed his own activities of daily living and was able to walk independently. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/23 in the electronic medical record (EMR) under the MDS tab, revealed R74 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R74 had intact cognition. Review of R74's activity preferences revealed it was very important to have books, newspapers, and magazines to read, very important to have music to listen to, very important to keep up with the news, and very important to go outside and get fresh air. Review of the Care Plan, dated 02/13/24 in the EMR under the Care Plan tab, revealed a problem of, I am dependent on staff for activities, cognitive stimulation, social interaction r/t [related to] cognitive deficits due to a CVA [cerebrovascular accident or stroke]. The goal was, I will maintain involvement in cognitive stimulation, and social activities as desired through review date. Interventions were: -All staff to converse with me while providing care. -Assure that the activities I am attending are compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed (such as large print, holders if I lack hand strength, task segmentation), and compatible with individual needs and abilities; and age appropriate. -Encourage ongoing family involvement. Invite my family to attend special events, activities, and meals. -Establish and record my prior level of activity involvement and interests by talking with me, caregivers, and family on admission and as necessary. -Introduce me to residents with similar backgrounds, and interests and encourage/facilitate interaction. -Invite me to schedule activities. -Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility. -Provide with activities calendar. Notify resident of any changes to the calendar of activities. -Review my activity needs with the family/representative. -Thank me for attendance at the activity function. Review of the Care Plan failed to identify R74's activity preferences and failed to establish goals related to activity participation. Review of the quarterly MDS with an ARD of 03/27/24 in the EMR under the MDS tab revealed R74 was moderately impaired in cognition with a BIMS score of ten out of 15. Review of the quarterly Recreation Assessment and Documentation, dated 03/28/24 in the EMR under the Assessment tab, revealed R74's preferences included independent pursuits and one to one visit. No specific activity preferences were documented. The heading of games was blank; a preference for chess and dominos were blank/not checked. The Summary/Comments read in full, Resident prefers to stay in his room and watch tv. Has social interactions with other residents. Review of Activity Progress Notes from 04/14/22 through current, revealed a total of two notes that read as follows: -The Activity Progress Note, dated 06/27/23 in the EMR under the Progress Notes tab, read in full, A Recreation Annual/Significant Change Assessment has been completed. -The Activity Progress Note, dated 03/28/24 in the EMR under the Progress Notes tab, read in full, A Recreation Quarterly Assessment has been completed. Observations during the survey revealed R74 remained in his room, lying on the bed with the TV on: 05/27/24 at 12:05 PM, at 1:28 PM; on 05/28/24 at 8:55 AM, at 11:13 AM, and at 4:22 PM; on 05/29/24 at 8:34 AM, at 10:01 AM, and at 3:05 PM. During an interview on 05/28/24 at 4:31 PM, the Activity Aide stated R74 did not come to activities and she did not complete one to one visits with him in his room. During an interview on 05/29/24 at 10:01 AM, Certified Nurse Assistant (CNA) 3 stated R74 stayed in his room and stayed in bed. CNA3 stated R74 was independent physically and could go to activities without assistance. During an interview on 05/30/24 at 11:39 AM, the Activity Director (AD) stated he had been employed since January 2024. The AD stated R74 did not like to come out of his room and stayed in his room and watched TV. The AD stated R74 was invited to activities; however, most of the time R74 declined to attend. The AD stated he visited with R74 about sports; however, R74 was not on a one-to-one program. The AD stated he was not aware of R74's interest in chess or dominoes. The AD verified the Recreation Assessment and Documentation, dated 03/28/24, failed to identify any activity preferences for R74. The AD also verified the Care Plan, dated 02/13/24, did not describe R74's interests. The AD stated the care plan should have included specific activity interests. Review of the facility's policy titled, Activities, dated 01/24 and provided by the facility, revealed, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility sponsored group, individual, and independent activities will be designed to meet the interests of each resident, .Each resident's interests and needs will be assessed on a routine basis. The assessment shall include .resident's interest, preferences and needed adaptions . NJAC 8:39-7.3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to change an indwelling urinary catheter every month as ordered for one of three residents (Resident (R) 26) reviewed for urinary catheter care out of 26 sampled residents. Failure to provide urinary catheter care as ordered can result in a resident developing a urinary tract infection. Findings include: Review of R26's undated Medical Diagnosis sheet, located under the Med Diag [Medical Diagnosis] tab of the electronic medical record (EMR), revealed R26 was admitted to the facility on [DATE] and had diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. Review of R26's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/24, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R26 was cognitively intact. The MDS also indicated R26 had an indwelling urinary catheter. Review of R26's current comprehensive Care Plan, located under the Care Plan tab of the EMR, revealed the following Focus, with a creation date of 10/23/19, [R26's first name] has a foley Catheter .dx [diagnosis] obstructive uropathy potential for infection. Review of the care plan interventions revealed there was not an intervention which specified when or how often R26's urinary catheter was to be changed by staff. Review of R26's Physician's Orders, located under the Orders tab in the EMR, revealed an order, dated 03/05/24, which specified, the catheter was to be changed every month and/or as needed at bedtime starting on the 24th and ending on the 24th each month for obstructive uropathy and as needed for blockage. Review of R26's monthly Treatment Administration Records (TARs), dated 02/24, 03/24, 04/24 and 05/24, provided by the facility, revealed the resident's urinary catheter was documented as being changed on 02/05/24. There was no documentation that R26's catheter was changed between 02/05/24 to 05/28/24. R26's monthly TARs for March 2024, April 2024, and May 2024 did not include the physician's order to change the resident's catheter each month. During an interview on 05/27/24 at 11:48 AM, R26 confirmed he had a urinary catheter in place. R26 stated his catheter should have been changed monthly, but it had not been changed for two months. R26 stated he needed his catheter changed because he did not want to get a urinary tract infection because they were painful. During an interview on 05/29/24 at 10:55 AM, Licensed Practical Nurse (LPN) 4 stated she changed R26's urinary catheter on 05/28/24 but was unsure when the resident's catheter was previously changed. During an interview on 05/29/24 at 11:10 AM, LPN1, who was a nurse supervisor, confirmed R26 had a physician's order for his catheter to be changed every month and as needed. LPN1 reviewed R26's medical record and stated the resident's February 2024 TAR reflected his catheter was changed on 02/05/24, but she was unable to locate documentation that showed the resident's catheter was changed between 02/05/24 to 05/28/24. During an interview on 05/29/24 at 5:55 PM, the facility's Nurse Consultant reviewed R26's medical record. The Nurse Consultant stated the staff documented on R26's February 2024 treatment record that his catheter was changed on 02/05/24. The Nurse Consultant stated when staff entered the resident's 03/05/24 catheter order they erroneously selected Order Type: Other Orders (no documentation required) so the new order to change the resident's catheter monthly on the 24th of each month did not show up on the resident's monthly TARs for March 2024, April 2024, and May 2024. The Nurse Consultant stated there was no documentation between 02/05/24 and 05/28/24 that reflected the staff had changed the R26's catheter monthly as ordered. Review of the facility's policy titled, Catheter Care, dated 11/27/23, indicated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. NJAC 8:39-19.4(a) NJAC 8:39-33.2(c)5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure that one of one resident (Resident (R) 9) reviewed for dialysis of 26 sampled residents had emergency dressing supplies at the bedside according to the physician orders. The failure has the potential to delayed response to resident bleeding excessively from the dialysis port. Findings include: Review of R9's undated admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE] with diagnoses that included end stage renal disease with hemodialysis and diabetes mellitus type II. Review of R9's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/23 located in the resident's EMR MDS tab revealed the section for special treatments and procedures identified the resident was assessed to receive dialysis. Review of R9's quarterly MDS with an ARD of 05/11/24 located in the resident's EMR MDS tab revealed special treatment and procedures identified the resident was to receive dialysis. Review of R9's Physicians' Orders for the month of May 2024 and located in the resident's EMR Orders tab, revealed the resident was receive hemodialysis on Monday, Wednesday, and Friday. The orders also directed the staff to monitor the resident's chest catheter (used for dialysis) for bleeding and signs of infections. And ensure hemostats, gauze, and tape were always kept at the resident's bedside. Observation on 05/30/24 at 11:59 AM revealed there were no dialysis dressing supplies observed at resident's bedside according to the physician's order. During an interview on 05/30/24 at 12:05 PM, R9 stated the nurse brought dressing supplies when performing dressing changes but no supplies were kept at the bedside. During an interview on 05/30/24 at 12:20 PM, Licensed Practical Nurse (LPN) 2 stated was not aware of the physician's orders for hemostats, gauze, and tape to be maintained at the resident's bedside. During an interview on 05/30/24 at 12:45 PM, Unit Manager, LPN1 stated that she was not aware of the physician's orders to maintain the emergency dressing supplies at the resident's beside in the event the resident started bleeding from the dialysis port. NJAC 8:39-2.9

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure one of six residents (Resident (R) 105) reviewed for accidents had appropriate physicians' orders, was provided informed consent, and was appropriately assessed for his use of side rails of 26 sampled residents. This failure had the potential to affect resident safety at the facility. Findings include: Review of R105's admission Record, dated 05/30/24 and located in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including bilateral primary osteoarthritis of hip, pain in left hip, muscle weakness, cognitive communication deficit, dementia, and repeated falls. Review of R105's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/24 and located in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident had moderately impaired cognition. The assessment indicated the resident required partial assistance from staff to roll left or right in his bed and to transfer in and out of his bed. The assessment indicated side rails were not in use for the resident. Review of R105's Order Summary Report, dated 05/30/24 and located in the EMR under the Orders tab, indicated no orders for the resident's use of bilateral side rails. Review of R105's undated Activities of Daily Living Care Plan, located in the EMR under the Care Plan tab, indicated the resident had an activities of daily living (ADL) self-care performance deficit related to weakness, history of falls, chronic left hip pain, and limited mobility. Interventions included the use of bilateral ¼ side rails to assist with transfers and positioning in bed. Review of R105's comprehensive EMR was reviewed and indicated nothing to show an assessment related to the resident's use of side rails had been done since his admission to the facility. R105 was observed in his room in bed with bilateral ¼ side rails in the raised position at the head of his bed on 05/27/24 at 10:40 AM, on 05/28/24 at 4:17 PM, on 05/29/24 at 8:25 AM, at 12:43 PM, and at 4:13 PM, and on 05/30/24 at 8:46 AM. During an interview on 05/30/24 at 9:08 AM, the Assistant Director of Nursing (ADON) confirmed the use of R105's rails and confirmed no information could be found in the resident's record to show physician's orders had been obtained for the use of the resident's side rails, an assessment had been completed for the use of the rails, or informed consent had been obtained for the use of the rails. She stated her expectation was all these things should have been in place for the resident prior to the use of side rails. During an interview on 05/30/24 at 9:31 AM, the Director of Nursing (DON) stated it was part of the facility's admission process to assess, receive orders, and complete the assessment for any resident's use of side rails and all of those things were expected to have been in place for R105 prior to his use of side rails. Review of the facility's policy titled, Proper Use of Bed Rails Policy, dated 2023, read, in pertinent part, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, facility ensures correct installation, use, and maintenance of the rails; and As part of the resident's comprehensive assessment, the following will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms, b. Size and weight, c. Sleep habits, d. Medications, e, Acute medical or surgical interventions, f. Underlying medical conditions, g. Existence of delirium, h. Ability to toilet self safely, i. Cognition, j. Communication, k. Mobility (in and out of bed), l. Risk of falling; 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs; 3. The resident assessment must also include the resident's risk from using bed rails. Examples of the potential risks with the use of bed rails includes: a. Accident hazards (e.g. falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails, or over the footboard), b. Barrier to residents from safely getting out of bed, c. Physical restraint (e.g. hinders residents from independently getting out of bed or performing routine activities), d. Decline in resident function, such as muscle functioning/balance, e. Skin integrity issues, f. Decline in other areas of activities of daily living such as using the bathroom, continence, eating, hydration, walking and mobility, g. Other potential negative psychosocial outcomes such as an undignified self-image, altered self-esteem, feelings of isolation, or agitation/anxiety; and Informed consent: 6. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion; and 8. Upon obtaining informed consent, the facility will obtain a physician's order for the use of the specific bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail. NJAC 27.1(a)

**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 of five residents reviewed for unnecessary medications (Resident (R58)) had a documented response to the Pharmacist's recommendations. Specifically, the Pharmacist made recommendations for dose reductions of an antidepressant medication, Lexapro, for R58 due to an irregularity. The Physician failed to document that the identified irregularity had been reviewed and what, if any, action was taken to address it, or the rationale to make no changes to the medication. Findings include: Review of the undated admission Record, provided by the facility, revealed R58 was admitted to the facility on [DATE] and had a diagnosis of depressive episodes. Review of the Order Summary, dated 02/13/24 in the electronic medical record (EMR) under the Orders tab, revealed a prescription for Lexapro [anti-depressant] Oral Tablet 20 milligrams (mg), one tablet by mouth in the morning for depression. Review of the Consultant Pharmacist's Medication Regimen Review, report from 05/01/23 through 05/29/24, the Pharmacist made recommendations to decrease R58's dose of Lexapro from 20 mg to 10 mg on 09/28/23. The report read, Resident is on Lexapro 20 mg (escitalopram) daily. The maximum recommended dose of Lexapro >[AGE] years old is 10 mg daily. The resident is [AGE] years old. Recommend reevaluating the resident and consider a lower escitalopram dose .If resident continues on this dose, please document risk vs [versus] benefit . There was no written response from the Physician and the dose of Lexapro remained the same. Review of the Consultant Pharmacist's Medication Regimen Review, report from 05/01/23 through 05/29/24, revealed the Pharmacist made the recommendation to decrease Lexapro from 20 mg to 10 mg on 11/07/23, 12/21/23, 02/13/24, and on 04/13/24. Each time the dose remained unchanged. There were notes on the reports that documented psychiatry was involved and risks outweighed benefits although specifics were not identified; however, there was no documentation by the Attending Physician either agreeing to the recommendations or disagreeing with the rationale. During an interview on 05/30/24 at 3:12 PM, the Nurse Consultant stated the notes on the Consultant Pharmacist's Medication Regimen Review, report from 05/01/23 through 05/29/24, were written by the nurses based on talking with the Physician. The Nurse Consultant verified there was no direct response documented by the Physician with the date of review or signature. During an interview on 05/30/24 at 5:05 PM, the Director of Nursing (DON) stated he had been in his position about a month and did not know where the reports with the Physician's review and signature were located. The DON stated the Physician was supposed to respond in writing to the Pharmacist's recommendations and there was a specific form on which the Physician should document whether he agreed, disagreed and the rationale if he disagreed with the recommendations. During an interview on 05/30/24 at 5:23 PM, the Physician stated he reviewed the Pharmacist's recommendations monthly and signed the form indicating he did not want to initiate a dose reduction of R58's Lexapro. The Physician stated, the resident's Psychiatrist did not want a dose reduction completed because R58 was stable on the current medication. The Physician stated this should have been documented on the forms; however, he did not know where the forms were maintained in the facility. Review of the facility's policy titled, Addressing Medication Regimen Review Irregularities, dated 04/15/24 and provided by the facility, revealed It is the policy of this facility to provide a Medication Regimen Review (MRR) for each resident in order to identify irregularities and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event . The Pharmacist must report any irregularities to the attending physician . and the reports must be acted upon .The attending physician must document in the resident medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record . NJAC 8:39-29.3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility served known food allergies and food dislikes to three of four residents (Resident (R) 102, R77, and R81) reviewed for food allergies and food choices out of 26 sampled residents. Findings include: 1. Review of R102's undated Medical Diagnosis sheet, located under the Med Diag [Medical Diagnosis] tab of the electronic medical record (EMR), revealed R102 was admitted to the facility on [DATE] and had an allergy to melon. Review of R102's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/24, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R102 was cognitively intact. Review of R102's care plan, with an initiation date of 02/28/24, located under the Care Plan tab of the EMR, contained the following Focus which specified, I have a nutritional problem or a potential nutritional problem r/t [related to] .Food Allergy. A care plan intervention specified, FOOD ALLERGY: No Melon. During an interview on 05/30/24 at 12:08 PM, R102 stated she had an allergy to melon which included watermelon and cantaloupe. R102 explained the kitchen staff were aware of this food allergy and it was noted on her meal tray slip, but she continued to receive melon on her meal trays. R102 specified since her admission to the facility (on 02/27/24) she was served melon seven times at meals, and she had discussed this allergy with the facility's Registered Dietitian (RD) on multiple occasions. R102 stated she most recently was served melon during her breakfast meal on 05/29/24. R102 stated she again informed the facility's RD on 05/29/24 that she received melon on her tray and the RD again noted this food allergy on her meal tray slip. Observation on 05/30/24 at 12:50 PM revealed R102 was served her lunch meal in her room. Review of R102's tray slip that was served with her meal tray revealed the following information, ***No melon-allergy . NO MELON! . NO MELON-ALLERGY. During an interview on 05/30/24 at 2:20 PM, the Dietary Manager (DM) confirmed R102 had a known allergy to melon and melon was listed as a food allergy on R102's meal tray slip. The DM stated when the kitchen staff prepared R102's meals, they were to review R102's tray slip for food allergies and food preferences and should not serve the resident any type of melon. During an interview on 05/30/24 at 3:35 PM, the facility's RD confirmed R102 had an allergy to melon. The RD explained she was aware R102 was served melon at multiple meals since being admitted to the facility with the most recent occurrence being on 05/29/24 when she was served watermelon on her breakfast meal tray. The RD stated R102's allergy to melon was noted on her meal tray slip multiple times and staff were instructed to carefully read the resident's meal tray slip when preparing her meal trays to prevent her from being served melon again. 2. Review of R77's undated Medical Diagnosis sheet, located under the Med Diag tab of the EMR, revealed R77 was admitted to the facility on [DATE] and had diagnoses which included gastro-esophageal reflux disease. Review of R77's quarterly MDS with an ARD of 03/23/24, located in the EMR under the MDS tab, revealed a BIMS score of 14 out of 15, which indicated R77 was cognitively intact. Review of R77's care plan, most recently reviewed on 03/28/24, located under in the EMR under the Care Plan tab, contained a Focus which specified, The resident has a nutritional problem or potential nutritional problem r/t: Therapeutic Diet Restrictions. A care plan approach specified, Honor food preferences within diet order. Review of R77's current physician's orders located in the EMR under the Orders tab, revealed the following diet order NAS (No Added Salt) diet, Regular (No Restrictions) texture, Regular Fluid consistency. During an interview on 05/27/24 at 11:05 AM, R77 stated he was not always served food that he selected on his menus. R77 specified that he did not like pancakes and this food dislike was noted on his meal tray slip, but he continued to receive pancakes at breakfast. During an interview on 05/29/24 at 12:40 PM, R77 stated he was served pancakes again during the breakfast meal on 05/28/24. The resident saved his meal tray slip served with his breakfast meal of 05/28/24 and review of the tray slip revealed it specified NO Pancakes. Observation on 05/29/24 at 1:13 PM revealed R77 was served his lunch meal in his room. Observation of the resident's meal revealed he was served mashed potatoes. Review of the resident's tray slip served with this meal revealed mashed potatoes was crossed through on the menu. During an interview on 05/29/24 at 1:13 PM, R77 stated he did not want to be served mashed potatoes on his lunch meal tray, so he crossed through them on his menu, but he received it anyway. During an interview on 05/30/24 at 2:20 PM, the DM stated R77 should not have been served pancakes at breakfast on 05/28/24 and should not have been served mashed potatoes at lunch on 05/29/24. 3. Review of R81's undated Medical Diagnosis sheet, located under the Med Diag tab of the EMR, revealed R81 was admitted to the facility on [DATE] and had diagnoses which included type two diabetes mellitus with hyperglycemia and hemiplegia. Review of R81's quarterly MDS with an ARD of 03/10/24, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated R81 was cognitively intact. Review of R81's care plan, most recently reviewed on 03/14/24, located under in the EMR under the Care Plan tab, contained a Focus which specified, The resident has a nutritional problem or potential nutritional problem r/t: Therapeutic Diet Restrictions. A care plan approach specified, Honor food preferences within diet order. Review of R81's current physician's orders located in the EMR under the Orders tab revealed the following diet order NAS (No Added Salt]/NCS [No Concentrated Sweets] diet, Regular texture, Regular [Thin] liquid consistency. During an interview on 05/27/24 at 10:50 AM, R81 stated his food preferences were not honored at meals because he was served food that he had previously informed staff that he disliked. Observations on 05/28/24 at 9:13 AM revealed R81 was eating his breakfast meal in his room. Observation of foods served on the resident's meal tray revealed he was served pancakes. Review of the meal tray slip served with R81's breakfast meal tray revealed it specified no pancakes. During an interview on 05/28/24 at 9:13 AM, R81 stated that he did not like pancakes and had informed staff a number of times that he did not want to be served pancakes, but continued to receive them at meals and he does not eat them. Observations on 05/29/24 at 9:02 AM revealed staff were serving R81's breakfast meal tray. Observations of foods served on the resident's tray, with the DM present, revealed R81 was served toast. Review of the meal tray slip served with R81's breakfast meal revealed toast was listed as a disliked food. During an interview on 05/29/24 at 9:02 AM, R81 stated he received toast on his meal tray, and he would not eat it. During an interview on 05/29/24 at 9:02 AM, the DM confirmed pancakes and toast were listed as dislikes on R81's meal tray slip, and the resident should not have been served these foods at meals. Review of the facility's policy titled, Food Preparation Guidelines, dated 03/23, indicated, Policy: It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status .5. Staff shall accommodate resident allergies, intolerances, and preferences, providing appropriate alternatives when needed .9. Resident preferences and allergies shall be obtained during the resident assessment process and added to the resident's dietary tray card. NJAC 8:39-17.4(a)(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and facility policy review, the facility failed to ensure proper infection control for one of two residents (Resident (R) 107) reviewed for respiratory services of 26 sampled residents. R107's oxygen tubing and humidification cannister were not changed weekly to ensure sanitary administration of the resident's oxygen. Findings include: Review of R107's admission Record, dated 05/30/24 and located in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including pulmonary fibrosis and acute respiratory failure with hypoxia. Review of R107's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/02/24 and located in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated the resident had severely impaired cognition. The assessment did not indicate the resident was receiving oxygen at the time of the assessment. Review of R107's Order Summary Report, dated 05/30/24 and located in the EMR under the Orders tab, indicated orders for the resident to receive oxygen via nasal cannula at three liters per minute via nasal cannula. The order indicated the resident's oxygen tubing, cannula, and humidifier were to be changed weekly on Sunday nights. Review of R107's Treatment Administration Record (TAR), dated 05/01/24 through 05/30/24 and located in the EMR under the Orders tab, indicated the resident was receiving oxygen as ordered. The record did not indicate anything to show the resident's oxygen tubing or humidification bottle had been changed since admission. Review of R107's undated Respiratory Status Care Plan, located in the EMR under the Care Plan tab, indicated the resident required oxygen related to her diagnosis of pulmonary fibrosis. During an observation, R107 was in her room in bed with her oxygen running as ordered on 05/28/24 at 8:49 AM and at 4:25 PM, on 05/29/24 at 8:29 AM, at 12:47 PM, and at 4:07 PM, and on 05/30/24 at 8:53 AM. The resident's oxygen tubing and humidification bottle was dated as most recently changed on 05/13/24. During an interview on 05/30/24 at 9:04 AM, the Assistant Director of Nursing (ADON) observed R107 with the surveyor and confirmed the resident's oxygen tubing and humidification bottle had not been changed timely. She stated her expectation was oxygen tubing and other equipment such as humidification bottles for oxygen were expected to be changed at least weekly on Sunday nights. During an interview on 05/30/24 at 9:29 AM, the Director of Nursing (DON) confirmed his expectation was nursing staff was to change out each resident's oxygen tubing and humidification bottle weekly on Sunday night. Review of the facility's policy titles, Oxygen Administration Policy, dated 2024, read, in pertinent part, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences; and 5. Staff shall perform hand hygiene and don gloves when administering oxygen when in contact with oxygen equipment. Other infection control measures include b. Change oxygen tubing and mask/cannula weekly and as needed as needed if it becomes soiled or contaminated, c. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. NJAC 8:39-19.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure seven of eight residents (Resident (R)10, R77, R9, R45, R25, R57, and R83) reviewed for dignity were treated in a dignified manner out of 26 sampled residents. The facility failed to promote a dignified dining experience which included timely meal service, eating food at the same time as tablemates, and items served in non-disposable dishes for six of six residents (Resident (R)10, R77, R9, R45, R25, and R57) reviewed for dignity in dining. Additionally, the facility failed to honor R83's right to a dignified existence and self-determination by making her wear an identification wrist band after she made staff aware that she preferred not to wear the band. Findings include: 1. Review of R10's quarterly Minimum Data Set (MDS) with an Assessment Reference Date ARD of 04/22/24, located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated R10 had moderately impaired cognition. During an observation on 05/27/24 at 12:52 PM, R10 was seated at a dining room table with R58. R10 had not been served his lunch meal tray and R58 was eating her lunch meal and R10 had not been served his lunch tray yet. Observation on 05/27/24 at 12:55 PM revealed R58 finished eating her lunch meal and R10 still had not been served his meal. Continuous observations on 05/27/24 from 12:55 PM to 1:21 PM revealed R10 remained seated at the dining room table with R58, and he was not served his lunch meal. During an interview on 05/27/24 at 1:21 PM, R10 stated I have not gotten anything to eat yet and stated that he was hungry. During an observation on 05/27/24 at 1:32 PM, staff served R10 his lunch meal and he began to eat his meal independently. A beverage observed on R10's lunch meal tray was served in a disposable plastic cup. On 05/27/24 at 1:44 PM, R10 was observed to finish his lunch meal and he ate 100 percent of the foods and beverages served on his meal tray. During an interview on 05/30/24 at 9:21 AM, R10 stated that he ate his meals in the dining room and preferred to be served and to eat his meals with his tablemates. R10 also stated that his beverages and desserts were usually served in disposable plastic cups, and he preferred for his food and beverages to be served in regular non-disposable bowls and cups. During an interview on 05/29/24 at 9:30 AM, the Dietary Manager (DM) stated the expectation was for residents who ate in the dining room to eat their meals with their tablemates. 2. Review of R77's quarterly MDS with an ARD of 03/23/24, located in the EMR under the MDS tab, revealed a BIMS score of 14 out of 15, which indicated R77 was cognitively intact. During an observation on 05/29/24 at 1:13 PM, R77 was served his lunch meal in his room. Observation of food served on R77's meal tray revealed his juice was served in a disposable plastic cup and watermelon was served in a disposable plastic cup. During an interview on 05/29/24 at 1:13 PM, R77 stated his beverages and dessert were frequently served in disposable plastic cups and he would prefer to be served his food and beverages in regular non disposable cups and dishware. 3. During the resident group interview on 05/28/24 at 10:00 AM, residents reported concerns with dignity during dining as follows: -R10 stated not all the residents sitting at the same tables were served their meals at the same time. -R9, R45, and R25 stated the staff frequently provided plastic silverware for eating and disposable small plastic cups for beverages at meals and they did not like to be served with disposable silverware or cups. All three residents also stated the cups were tiny in size; observations during lunch on 05/27/24 at 1:19 PM revealed there were small disposable plastic souffle cups that were not intended to be used as cups for drinking. 4. During an observation on 05/29/24 from 8:10 AM to 8:44 AM, dietary staff was preparing resident breakfast meals from the kitchen tray line. The dietary staff was observed placing disposable cups of juice, applesauce, and watermelon cubes on resident meal trays. During an interview on 05/29/24 at 9:30 AM, the DM stated resident beverages and foods were served in plastic disposable cups because the kitchen did not have enough regular non disposable bowls and cups available to serve to all residents at meals. 5. Review of the undated admission Record, provided by the facility, revealed R57 was admitted to the facility on [DATE]. Review of the annual MDS with an ARD of 05/02/24 in the EMR under the MDS tab, revealed R57's had a BIMS score of 13 out of 15 which indicated R57 had intact cognition. During an observation 05/27/24 at 1:16 PM, R57 was sitting at a table in the central area dining room waiting for lunch. R57 had been waiting for lunch in the dining room for over 40 minutes; the meal was late. The Activity Aide came to where R57 was sitting at the table and moved the table out from under him. R57 had a stunned look on his face and then wheeled himself in his wheelchair to the cart in the corner of the dining room where meal trays were located. R57 asked the staff for his tray, and they handed it to him. He placed the tray on top of his wheelchair arm rests and wheeled to a different table in the dining room, place the tray on the table and began eating. On 05/27/24 at 1:18 PM, the Activity Aide assisted several residents to sit where R57 had been sitting and waiting for his meal. A musician began to play his guitar and sing; a music activity began at this time. The table where R57 had been waiting for his lunch was located where residents were to sit to listen to the music activity. During an interview on 05/29/24 at 8:32 AM, R57 stated he did not like the table being pulled out from under him while he was waiting for lunch on 05/27/24. R57 stated the incident upset him and the table was removed without explanation. During an interview on 05/28/24 at 4:29 PM, the Activity Aide stated she moved the table on 05/27/24 while R57 was sitting there due to the entertainer being scheduled to play. The Activity Aide stated it looked like some of the residents had not been served lunches yet stating she did not know or ask if R57 had eaten. The Activity Aide stated she told R57 she had to move the table and then moved it. During an interview on 05/30/24 at 5:27 PM, the Director of Nursing (DON) stated it was not dignified to haul the table off if R57 was sitting there and waiting for his meal. 6. Review of the undated admission Record, provided by the facility, revealed Resident (R) 83 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/29/24 in the electronic medical record (EMR) under the MDS tab revealed R83 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident had moderately impaired cognition. During an interview on 05/29/24 at 9:23 AM, R83 pointed to her wrist and stated, They (nurses) put the band on me today. I told them I did not want it . I don't think I should have to have it. R83 stated she resented having to wear the wrist band stating she did not want to reveal her identity to the world. R83 was wearing a plastic identification wrist band that had her name and room number on it. During an interview on 05/29/24 at 10:39 AM, Certified Nurse Assistant (CNA) 3 stated R83 was alert and could express her needs. CNA stated she did not know why R83 had to wear the identification wrist band. During an interview on 05/29/24 at 11:41 AM, the Director of Nursing (DON) and Nurse Consultant stated residents were required to wear identification wrist bands because it was part of the resident identifier system so staff would not give medications to the wrong resident for example. They stated there were a lot of new and agency nursing staff who did not know the residents. The Nurse Consultant stated residents constantly removed the wrist bands and the nursing staff replaced them when they noticed the bands were missing. The Nurse Consultant stated the facility had to weigh safety versus dignity. The Nurse Consultant verified resident's photographs were included in the EMR which was also an identification system. During an interview on 05/30/24 at 9:06 AM, Licensed Practical Nurse (LPN) 3 stated R83 took her wrist band off when she was completing wound care with the resident the day before. LPN3 stated all residents were supposed to have wrist bands on; however, sometimes they came off, or residents took them off. LPN3 removed a wrist band out of her medication cart and stated this one was for a different resident whose band was missing. LPN3 stated and showed the surveyor the identification band that had the resident's name and room number on it. LPN3 verified R83 did not like her wrist band, further stating a lot of residents did not like them. R83 stated LPN1 reapplied R83's new wrist band yesterday after the resident removed it. LPN3 stated the nurses reapplied new wrist bands on residents if they noticed the wrist bands were missing. Review of the facility's policy titled, Dignity, dated February 2021 and provided by the facility, revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Review of the facility's policy entitled, Promoting/Maintaining Resident Dignity During Mealtimes, dated 11/29/23, indicated It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintain or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident .1. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. NJAC 8:39- 4.1(A)(12)

Based on observation, interview, and record review, the facility failed to ensure there was an adequate supply of linens for 10 (R9, R25, R45, R75, R33, R7, R15, R94, R74, and a resident requesting to remain anonymous) out of 26 sampled and 25 supplemental residents. Specifically, there was an insufficient supply of towels to meet residents' needs. Findings include: 1. During the Resident Council Group interview on 05/28/24 at 10:00 AM, three of five residents who attended stated there was a problem with the availability of towels: -R9 and R25 stated there were not enough towels (bath towels and wash cloths) available. R9 and R25 stated they waited for the clean linen cart to be delivered to their halls and immediately got their own towels because if they did not, there would not be any towels available. -R45 stated he used his terry cloth bathrobe as a towel because he did not have any towels in his room. 2. During an interview on 05/29/24 at 9:31 AM, a resident who requested to remain anonymous stated there were not enough towels. The resident stated there were no towels currently available. The resident stated he had missed showers due to not having any towels to dry off with. The resident stated he had been given a washcloth to dry off with after taking a shower. 3. During observation on 05/29/24 starting at 3:56 PM, the linen carts on each hall were checked for availability of towels: During an interview on 05/29/24 at 3:56 PM, Certified Nursing Assistant (CNA) 3, working on the 400-hall, stated she had passed out towels to the specific residents who would be receiving showers on the evening shift on the 400-hall. CNA3 stated the residents' rooms were not stocked with towels. She stated towels were obtained off the clean linen cart for residents as they were needed. The linen cart was observed on the 400-hall with Registered Nurse (RN) 2 on 05/29/24 at 3:35 PM. There were no hand towels or bath towels on the clean linen cart. There was a total of three wash cloths on the cart. RN2 stated the linen cart was distributed at around 3:00 PM, at the start of the afternoon shift and this was the supply of towels for the evening/night shifts. Review of the Daily Census, dated 05/26/24, revealed that there were 30 residents residing on this hall. Observation of the supply of towels on the clean linen cart for the 300-hall on 05/29/24 at 3:58 PM revealed there was a total of three bath towels on the cart. There were no hand towels or wash cloths. Review of the Daily Census, dated 05/26/24, revealed that there were 28 residents residing in this hall. Observation of the supply of towels on the clean linen cart for the 200-hall on 05/29/24 at 3:59 PM revealed there were no towels of any size on the cart. Review of the Daily Census, dated 05/26/24, revealed that there were 28 residents residing in this hall. Observation of the supply of towels on the clean linen cart for the 100-hall on 05/29/24 at 4:01 PM revealed there were seven bath towels and five wash cloths/hand towels. Review of the Daily Census, dated 05/26/24, revealed that there were 23 residents residing in this hall. 4. During an interview on 5/30/24 at 8:35 AM, the Maintenance/Housekeeping Director (MD) stated the facility had about 250 bath towels in circulation at any given time and a total of approximately 500 bath towels. The MD stated towels were delivered to each hall on the clean linen carts twice daily, in the morning and in the afternoon. The MD stated the CNAs got towels from the clean linen carts for residents' use. The MD stated residents' bathrooms were not stocked with towels; staff retrieved towels as they were needed from the clean linen carts on the halls. The MD stated the stocked clean linen carts had already gone to each hall with this morning's supply of clean towels. 5. During an observation with the MD on 05/30/24 at 8:42 AM, the total supply of clean towels was checked in the laundry room. There was a total of 17 bath towels and approximately 30 wash cloths on the shelf. There were no hand towels. The MD stated there were a lot of towels in the dirty laundry bins from the evening/night before and some were currently being washed and the rest would be washed and distributed in the afternoon. During an observation with the MD on 05/30/24 at 8:46 AM, the clean linen cart on the 400-hall was checked and there was a total of three wash cloths on the cart. There were no hand towels or bath towels on the cart. On 05/30/24 at 8:48 AM the MD and surveyor went room to room in the 400-hall making observations and asked residents who were awake and available about the supply/availability of towels. Residents' comments included: -On 05/30/24 at 8:50 AM, R75 stated, We are short of towels . I am independent. There are times I cannot get towels; I will keep and reuse a towel. -On 05/30/24 at 8:51 AM, R33 stated there were no towels in her room. -On 05/30/24 at 8:52 AM, R7 stated there were no towels in his room. -On 05/30/24 at 8:53 AM, R15 stated staff had not brought any towels into the room. -On 05/30/24 at 8:57 AM, R94 stated she thought there might be towels in the bathroom; however, observation revealed there were no towels in the bathroom. -On 05/30/24 at 8:58 AM, R74 stated he did not get towels delivered to his room today and he had been using the same towel for three days. R74 stated he had one towel in his room and kept using it because he could not get clean towels. Observation of the supply of towels on the clean linen cart for the 300-hall on 05/30/24 at 9:02 AM revealed there were no towels on the cart. The MD verified this. Observation of the supply of towels on the clean linen cart for the 200-hall on 05/30/24 at 9:05 AM revealed there was one bath towel and one wash cloth on the cart. The MD verified this. Observation of the supply of towels on the clean linen cart for the 100-hall on 05/30/24 at 9:10 AM revealed there were no towels on the cart. The MD verified this. 6. During an interview on 05/30/24 at 10:42 AM, the Director of Nursing (DON) stated he was not sure if residents could have towels in their rooms. The DON stated he had been in his position about a month. During an interview on 05/30/24 at 1:19 PM, the Administrator stated he had not been aware of a problem with the availability of towels until today. NJAC 8:39-4.1(a) NJAC 8:39-27.2(j)

Based on observation, interview, record review, facility menu review, and facility policy review, the facility failed to ensure menus were prepared in advance which included a specific vegetable that was to be served for 39 of 56 lunch and supper meals on the facility's four-week menu cycle. This had the potential to affect 114 of 116 residents who consumed food prepared in the facility's kitchen. Findings include: 1. Review of R77's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/24, located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R77 was cognitively intact. During an interview on 05/27/24 at 11:05 AM, R77 voiced a concern that the facility's menu frequently listed Vegetable of the Day instead of having a specific planned vegetable that was to be served at lunch and supper. R77 stated the same vegetables were served over and over at meals. R77 stated peas and carrots were often served at lunch and supper. During an interview on 05/29/24 at 12:40 PM, R77 stated carrots or peas were served four or more times a week at meals as the Vegetable of the Day. Observation on 05/29/24 at 1:13 PM revealed R77 was served his lunch meal in his room. Review of the resident's tray slip that was served with this meal revealed Vegetable of the Day was the only vegetable listed on his menu. Observation of the food served on R77's meal tray revealed he was served carrots as the vegetable for this meal. 2. Review of the facility planned four-week cycle menus, which were provided by the facility and signed by the facility's Registered Dietitian, revealed Vegetable of the Day was the only vegetable planned on 21 of 28 planned lunch menus and on 18 of 28 planned supper menus. Review of the planned lunch menu for 05/29/24 listed Vegetable of the Day as the planned vegetable. During an interview on 05/29/24 at 11:40 AM, Dietary Aide (DA) 1 stated she also cooked meals at the facility. DA1 stated when Vegetable of the Day was on the planned menu, the cook decided what vegetable to prepare and serve for that meal based on the vegetables available in the facility. DA1 stated Dietary [NAME] (DC) 1 prepared the lunch meal for 05/29/24. During an interview on 05/29/24 at 11:45 AM, DC1 stated she prepared the lunch meal for 05/29/24 and she decided to prepare diced carrots for this meal because she knew they were not served yesterday (05/28/24). DC1 stated she would inform the evening cook regarding the vegetable she served to residents at lunch, so residents would not be served the same vegetable at supper. DC1 also stated she would inform the cook who was scheduled to work the following day, so the same vegetable would not be served to residents on two consecutive days. DC1 stated that it was possible for the same vegetable to be served to the residents every other day. DC1 explained that the Vegetable of the Day was implemented on the menus about 15 months ago by the prior Dietary Manager (DM). During an interview on 05/29/24 at 11:50 AM, the facility's Registered Dietitian stated she was aware the Vegetable of the Day was planned on the facility's four-week cycle menus at many meals. The RD stated she signed and approved the facility's menus for nutritional adequacy. When the RD was asked how she approved the menus for nutritional adequacy when a vegetable was not planned to be served for many of the lunch and supper meals, she confirmed that she could not ensure the menus were nutritionally adequate without knowing what vegetables were going to be served at meals. The RD stated the Vegetable of the Day was put on the menu by the prior DM about a year and a half ago and the cooks decided what vegetable to prepare and serve when Vegetable of the Day was on the menu. The RD agreed residents could be served the same vegetable too often since a specific vegetable was not planned on the menu for many lunch and supper meals. Review of the facility's policy titled, Menus and Adequate Nutrition, dated 03/23, indicated, Policy: The purpose of this policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural and ethnic needs, while using established guidelines .1. The facility will ensure that menus meet the nutritional needs of residents in accordance with established nutritional guidelines. a. The facility maintains access to current national guidelines (i.e. American Diabetes Association, Academy of Nutrition and Dietetics, USDA [United States Department of Agriculture] Dietary Guidelines for Americans). b. Standard meal planning guides used for menu planning and food purchasing will be adjusted to consider individual needs .2. Menus shall be planned at least two weeks in advance for timely approval and ordering of food .7. The facility's dietitian or other clinically qualified nutrition professional will review all menus for nutritional adequacy and approve the menus. Review of the facility's policy titled, Standardized Menus, dated 03/23, indicated, The facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents based on the Recommended Daily Allowances (RDA) of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences, standardized cycle menus are prepared in advance and utilized .8. Menus will be planned to include 100% of RDA's .11. Menus will be updated periodically to mitigate the risk of menu fatigue . NJAC 8:39-17.2(b) NJAC 8:39-17.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, test tray review, record review, review of Resident Council Minutes, and facility policy review, the facility failed to serve food that was palatable and at appetizing temperature for 13 of 13 residents (Resident (R) 26, R67, R81, R10, R86, R100, R105, R83, R84, R30, R45, R25, and R9) reviewed for food palatability out of 26 sampled residents. This failure had the potential to affect all 114 of 116 residents who consumed food prepared from the facility's kitchen. Findings include: 1. Review of R26's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/24, located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview Mental Status (BIMS) score of 15 out of 15, which indicated R26 was cognitively intact. During an interview on 05/27/24 at 11:48 AM, R26 stated at times meals were barely edible. R26 specified breakfast was not good and was not always hot when served. During an interview on 05/29/24 at 11:13 AM, R26 stated his breakfast was not hot when served during the morning of 05/29/24. 2. Review of R67's annual MDS with an ARD of 03/31/24, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated R67 was cognitively intact. During an interview on 05/27/24 at 11:30 AM, R67 stated he did not always like the food served at the facility. R67 specified his food and coffee were not hot when served at meals. During an interview on 05/29/24 at 10:58 AM, R67 stated his breakfast on 05/29/24 was not hot when served. R67 specified the scrambled eggs at breakfast were only slightly warm and his coffee was very weak and only warm. R67 again stated he would like his food and coffee to be hotter when served at meals. 3. Review of R81's quarterly MDS with an ARD of 03/10/24, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated R81 was cognitively intact. During an interview on 05/27/24 at 10:50 AM, R81 stated the food he was served at meals was not hot. R81 also stated the coffee served at meals was not hot and did not taste good. During an observation and interview on 05/28/24 at 9:13 AM, R81 was in his room eating his breakfast meal. R81 stated the scrambled eggs, hot cereal, and coffee that he was served at this breakfast meal were cold. 4. Review of R10's quarterly MDS with an ARD of 04/22/24, located in the EMR under the MDS tab, revealed a BIMS score of 12 out of 15, which indicated R10 was moderately cognitively impaired. During an interview on 05/30/24 at 9:21 AM, R10 stated the food served at the facility was so/so and food served at meals was not hot especially at breakfast. R10 stated his coffee was served cold at breakfast and he preferred hot coffee. 5. Review of R86's admission Record, dated 05/30/24 and found in the EMR under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including prostate cancer and history of urinary tract infection (UTI). Review of R86's quarterly MDS assessment with an ARD Date of 03/19/24 and located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15 which indicated the resident had intact cognition. Review of R86's Nutritional Care Plan, dated 12/15/23 and found in the EMR under the Care Plan tab, indicated the resident was receiving a therapeutic diet (a cardiac diet) and indicated the resident had a history of significant weight loss due to his medical condition. Review of R86's Order Summary Report, dated 05/30/24 and found in the EMR under the Orders tab, indicated the resident was to receive a Regular Cardiac Diet with thin liquids. During an interview on 05/28/24 at 10:23 AM, R86 stated he was pretty appalled with the food in the facility. He stated the facility had been out of coffee the previous Friday, Saturday, and Sunday. The resident stated he was often not able to access fresh fruit in the facility and so his wife had to bring it in for him if he wanted it. 6. Review of R100's admission Record, dated 05/30/24 and found in the EMR under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, morbid obesity, complications of surgical and medical care, and dependence on tracheostomy (a tube in the airway to help a person breathe). Review of R100's quarterly MDS assessment with an ARD of 03/07/24 and found in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15 which indicated the resident had intact cognition. Review of R100's Nutritional Care Plan, dated 12/29/23 and found in the EMR under the Care Plan tab, indicated the resident was receiving a therapeutic diet (a regular no added salt diet with thin liquids) and indicated the resident was at risk for malnutrition due to her history of gastric sleeve surgery with major complications, including the placement of a tracheostomy tube in her airway to assist her with breathing. Review of R100's Order Summary Report, dated 05/30/24 and found in the EMR under the Orders tab, indicated the resident was to receive a Regular No Salt Added (NAS) Diet with thin liquids. During an interview on 05/28/24 at 10:50 AM, R100 stated, The food could be better. The only meal I (eat) here is breakfast and otherwise I buy my food. They (the facility) run out of things. Recently they didn't have hotdog buns, so they used sandwich bread This has happened a couple of times and so I stopped asking for hotdogs. They run out of coffee (frequently), so I got my own thingy to make coffee (in my room). During a follow-up interview on 05/29/24 at 12:36 PM, R100 stated another concern she had with the food was the facility never indicated what vegetable was being served with meals. She stated the menu always indicated Vegetable of the Day rather than indicating a specific vegetable that was to be served. She stated most frequently the vegetable served was either carrots or green beans. Meal ticket indicated Vegetable of the day and resident confirmed they never knew what vegetable they were going to get, but it was usually carrots or green beans. She stated she liked broccoli and cauliflower, but those vegetables were rarely or never served. 7. Review of R105's admission Record, dated 05/30/24 and found in the EMR under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including bilateral primary osteoarthritis of hip, pain in left hip, muscle weakness, cognitive communication deficit, dementia, and repeated falls. Review of R105's admission MDS assessment with an ARD of 04/15/24 and located in the EMR under the MDS tab, indicated a BIMS score of 12 out of 15 which indicated the resident had moderately impaired cognition. Review of R105's Nutritional Care Plan, dated 12/29/23 and found in the EMR under the Care Plan tab, indicated the resident was receiving a therapeutic diet (a regular no added salt and no concentrated sweets diet with thin liquids) and indicated the resident was at risk for malnutrition due to his history of diabetes. Review of R105's Order Summary Report, dated 05/30/24 and found in the EMR under the Orders tab, indicated orders for the resident to receive a regular no added salt and no concentrated sweets diet. During an interview on 05/28/24 at 9:39 AM, R105 stated, They (staff) tell me they are all out of things (foods and liquids) a lot. They run out of bananas. They run out of coffee. 8. During an interview on 05/27/24 at 11:38 AM, R83 stated the food was not good and she did not like it. Review of the quarterly MDS with an ARD of 02/29/24 in the EMR under the MDS tab, revealed a BIMS score of 10 out of 15 which indicated R83 was moderately impaired in cognition. 9. During an observation and interview on 05/28/24 at 8:54 AM, R84 stated the food for breakfast was so bad she asked for cereal. R84 stated she was served a pancake, toast, bacon, and eggs. R84's plate of breakfast was observed with intake of less than 25% of the meal. Review of the quarterly MDS with an ARD of 02/11/24 in the EMR under the MDS tab, revealed a BIMS score of 10 out of 15 which indicated R84 was moderately impaired in cognition. 10. During an interview on 05/29/24 at 9:31 AM, a resident who requested to remain anonymous stated the food was not served hot. Review of the annual MDS with an ARD of 03/23/24 in the EMR under the MDS tab, revealed the resident who wished to remain anonymous had a BIMS score of 13 out of 15 which indicated the resident was intact in cognition. 11. During the resident council interview on 05/28/24 at 10:00 AM, four of five residents expressed concerns about the food: -R30 stated the food was cold at times. -R45 stated the cold food was served warm. R25 agreed with R45's statement. -R45 stated yesterday at lunch his chocolate ice cream was completely melted and liquid when it was served. -R25, R9, and R45 stated they did not like the food. R25 stated The food sucks. -R25 stated the food was bland and R9 agreed. Review of Resident Council Minutes from 03/23 through 04/24 revealed concerns with palatability as follows: -Resident Council Minutes, dated 03/28/23, revealed Residents concerned over milk appearing spoiled. -Resident Council Minutes, dated 05/29/23, revealed Resident stated the coffee is sometimes cold. -Resident Council Minutes, dated 09/26/23, revealed Residents stated they wanted to see oatmeal offered more and if their food was cold, they wanted it heated up. 12. During an observation on 05/29/24, in response to resident complaints about food, a test tray was requested to be sent on the last meal delivery cart to the facility's 300 hallway for the breakfast meal. Observation revealed, before the test tray left the kitchen at 8:44 AM, temperature monitoring of food being served from the kitchen's tray line revealed the food was at acceptable levels, of greater than 135 degrees Fahrenheit (F). The meal trays were placed on an open cart with no heating element. The meal cart with the test tray was observed to arrive on the 300-hallway at 8:46 AM. Staff were observed to complete the resident meal pass at 9:15 AM when staff served and set up a resident's breakfast meal in her room on the 300-hallway. At this time, the foods and beverages on the test tray were sampled in the presence of the facility's Dietary Manager (DM) and Dietary Aide (DA) 1. The DM and DA1 verified the temperatures taken of the foods and beverages on the test tray. DA1 also tasted foods and beverages served on the requested test tray. Observation and tasting of the food on the test tray revealed the following: -The scrambled eggs served on the test tray tasted slightly warm. The temperature of the scrambled eggs was measured at 118.2 degrees F. DA1 tasted the scrambled eggs and agreed they tasted slightly warm. -The oatmeal served on the test tray tasted slightly warm. The temperature of the oatmeal was measured at 117.5 degrees F. DA1 tasted the oatmeal and agreed it tasted slightly warm. -The toast served on the test tray was barely warm and tasted spongy. The temperature of the toast was measured at 98.9 degrees F. DA1 tasted the tasted the toast and agreed it was barely warm and tasted spongy. -The bacon served on the test tray tasted slightly warm. DA1 tasted the bacon and agreed it tasted barely warm. -The coffee served on the test tray was warm and tasted weak. The temperature of the coffee was measured at 121 degrees F. DA1 tasted the coffee and agreed it was warm and tasted weak. During an interview on 05/29/24 at 9:30 AM the DM stated she was aware during prior Resident Council meetings the residents' voiced concerns regarding food not always being served hot at meals. Review of the facility's policy titled, Food Preparation Guidelines, dated 03/23, indicated, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. Definitions: 'Food attractiveness' refers to the appearance of the food when served to residents. 'Food palatability' refers to the taste and/or flavor of the food. 'Proper (safe and appetizing) temperature' means both appetizing to the resident and minimizing the risk for scalding and burns .3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include .c. Serving hot foods/drinks hot and cold foods/drinks cold. NJAC 8:39-17.4(a)2(e)

Based on observation, interview, record review, and review of the facility's meal service times the facility served meals later than scheduled to residents who resided on four of five facility hallways which included five residents (Resident (R) 10, R57, R211, R30, and R25) of 26 sampled residents. This had the potential to affect 114 of 116 residents who consumed meals that were prepared from the kitchen. Findings include: Review of the facility's undated Meal service times schedule, provided by the Dietary Manager (DM) on 05/29/24, revealed meals were scheduled to be served at the following times: -Breakfast: Wing-5 (500 Hallway): 7:40 AM to 7:55 AM; Wing-1 (100 Hallway): 7:55 AM to 8:05 AM; Wing-2 (200 Hallway): 8:05 AM to 8:15 AM; Wing-3 (300 Hallway): 8:15 AM to 8:25 AM; Wing-4 (400 Hallway): 8:25 AM to 8:35 AM. -Lunch: Wing-5 (500 Hallway): 11:55 AM to 12:05 PM; Wing-1 (100 Hallway): 12:05 PM to 12:15 PM; Wing-2 (200 Hallway): 12:15 PM to 12:25 PM; Wing-3 (300 Hallway): 12:25 PM to 12:35 PM; Wing-4 (400 Hallway): 12:35 PM to 12:45 PM. 1. Review of R10's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/22/24, located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated R10 had moderately impaired cognition. The assessment also indicated R10 resided on the facility's 400 Hallway (Wing-4). Observation on 05/27/24 at 12:52 PM revealed R10 was seated at a table in the Rotunda dining room. R10 had not been served his lunch meal tray. Continuous observations on 05/27/24 from 12:55 PM to 1:21 PM revealed R10 remained seated at the dining room table and was not served his lunch meal. During an interview on 05/27/24 at 1:21 PM, R10 stated I have not gotten anything to eat yet and stated that he was hungry. Observation on 05/27/24 at 1:32 PM revealed staff served R10 his lunch meal and he began to eat his meal independently. On 05/27/24 at 1:44 PM, R10 finished his lunch meal and was observed to eat 100 percent of the foods and beverages served on his meal tray. Observation on 05/28/24 at 9:03 AM revealed staff served R10 his breakfast meal in the Rotunda dining room. During an interview on 05/30/24 at 9:21 AM, R10 stated that he ate his meals in the Rotunda dining room and his breakfast and lunch meals were frequently served late. R10 specified his breakfast meal was not served until after 9:00 AM and his lunch meal was frequently not served until after 1:00 PM. 2. During observation of lunch on 05/27/24, residents residing on the 400-hall were served their meals up to an hour after the posted meal service time. On 05/27/24 as of 1:03 PM, no meal trays were delivered to the 400-hall. On 05/27/24 at 1:21 PM the first meal cart arrived at the 400-hall. During an interview on 05/27/24 at 1:23 PM, R57 (who resided on the 400-hall) stated he waited a long time for his lunch today in the Rotunda dining area. R57 was served at 1:16 PM when he went over to the cart in the dining room and asked for his tray. During an observation on 05/27/24 at 1:31 PM, R211 was standing at the entrance to his room on the 400-hall. R211 asked a staff member wheeling the meal cart down the hall where his lunch tray was. R211 stated, This is ridiculous, stating he had been waiting too long for lunch. On 05/27/24 at 1:44 PM, the last tray was served to residents on the 400-unit. 3. Observations during the 05/29/24 breakfast meal of meal delivery, carts leaving the kitchen or arriving on the resident hallways revealed the following resident meals were delivered later than scheduled: a. Observation on 05/29/24 at 8:15 AM revealed Wing-1's meal delivery cart, which contained prepared resident meal trays, left the kitchen. Breakfast meals for residents who resided on Wing-1 were scheduled to be served between 7:55 AM and 8:05 AM. b. Observation on 05/29/24 at 8:28 AM revealed Wing-2's meal delivery cart, which contained prepared resident meal trays, left the kitchen. Breakfast meals for residents who resided on Wing-2 were scheduled to be served between 8:05 AM and 8:15 AM. c. Observation on 05/29/24 at 8:35 AM revealed Wing-3's first meal delivery cart, which contained prepared resident meal trays, left the kitchen. Breakfast meals for residents who resided on Wing-3 were scheduled to be served between 8:15 AM and 8:25 AM. -Observation on 05/29/24 at 8:44 AM revealed Wing-3's second meal delivery cart, which contained prepared resident meal trays, left the kitchen. Breakfast meals for residents who resided on Wing-3 were scheduled to be served between 8:15 AM and 8:25 AM. Observation on 05/29/24 at 9:15 AM revealed the last resident was served a breakfast meal on the 300 Hallway which was confirmed by the DM. d. Observation on 05/29/24 at 8:54 AM revealed Wing-4's first meal delivery cart was delivered to the hallway. This cart was observed to contain 14 resident meal trays. Breakfast meals for residents who resided on Wing-4 were scheduled to be served between 8:25 AM and 8:35 AM. Observation on 05/29/24 at 8:59 AM revealed Wing-4's second meal delivery cart was delivered to the hallway. The cart was observed to contain 15 resident meal trays. Breakfast meals for residents who resided on Wing-4 were scheduled to be served between 8:25 AM and 8:35 AM. During an interview on 05/29/24 at 9:30 AM, the DM confirmed resident breakfast meals were served later than scheduled on 05/29/24. The DM stated the dietary staff started the breakfast tray line later than scheduled which resulted in meal trays being delivered to the hallways late. The DM stated staff were expected to serve resident meals on time. During an interview on 05/29/24 at 11:45 AM, Dietary [NAME] (DC) 1 stated resident breakfast meals were served later than scheduled on 05/29/24 because the kitchen's breakfast tray line started late. DC1 explained the breakfast tray line started late because the morning dietary staff had to perform some duties the evening dietary staff failed to complete on 05/28/24 which included pouring the juices for the 05/29/24 breakfast meal and making Jello. DC1 also stated resident meals were served later than scheduled at times because of staffing issues. 4. During an interview on 05/29/24 at 8:32 AM, R57 stated he waited too long for meals; the meals were served late. Review of the annual MDS with an ARD of 05/02/24 in the EMR under the MDS tab, revealed R57 had a BIMS score of 13 out of 15 which indicated he had intact cognition. 5. During an interview on 05/29/24 at 9:31 AM, a resident requesting to remain anonymous stated he was served lunch on 05/27/24 late at 1:30 PM. Review of the annual MDS with an ARD of 03/23/24 in the EMR under the MDS tab, revealed the resident who wished to remain anonymous had a BIMS score of 13 out of 15 which indicated. 6. During the Resident Group interview on 05/28/24 at 10:00 AM, three of five residents who attended the meeting (R30, R10, and R25) stated their meals were frequently served late. Review of Resident Council Minutes, dated 03/21/24 and provided by the facility, revealed Nursing not passing trays timely sometimes. During an interview on 05/29/24 at 3:38 PM, Registered Nurse (RN) 2 stated there had been a delay in receiving the evening meal from the dietary department all week, stating it was late arriving at the unit. During an interview on 05/30/24 at 5:27 PM, the Director of Nursing (DON) stated the facility had received complaints about late meals, stating food was important and residents expected things to be right. NJAC 8:39-17.2(f) NJAC 8:39-17.4(d)

Based on observation, interview, and facility policy review, the facility failed to ensure food and beverages stored in one of one kitchen were dated and did not have expired manufacturer's use by dates. This had the potential to affect 114 of 116 residents who consumed food prepared in the facility's kitchen. Findings include: 1. Observation on 05/27/24 from 9:20 AM to 10:00 AM, during the initial kitchen inspection, with the Dietary Manager (DM) present, revealed the following: a. Observation of food and beverages stored in the kitchen's walk-in refrigerator revealed an opened one-gallon container of Russian dressing with an expired manufacturer's use by date of 09/25/23, four five-pound containers of cottage cheese with expired manufacturer's use by dates of 05/15/24, one five-pound container of cottage cheese with an expired manufacturer's use by date of 05/24/24, and 10 undated and thawed four-ounce cartons of nutritional shakes. During an interview on 05/27/24 at 9:30 AM, the DM confirmed the container of Russian dressing, and five containers of cottage cheese had expired manufacturer's use by dates and the 10 cartons of thawed nutritional shakes were not dated. The DM stated the cooks and herself were responsible for checking the manufacturer's expiration and use by dates on stored food and were to discard any food with an expired expiration/use by date. During an interview on 05/29/24 at 9:30 AM, the DM stated she checked with the supplier of the thawed and undated four-ounce supplemental nutrition shakes observed in the kitchen's walk-in refrigerator on 05/27/24. The DM stated the supplier informed her the supplemental shakes should be dated when removed from freezer storage and placed in refrigeration storage to thaw and the shakes should be used within 14 days after being thawed. b. Observation of bread products stored on bread racks in the kitchen's dry storage room revealed six packages of hot dog buns had expired manufacturer's use by dates of 05/25/24, one package of hot dog buns with a handwritten date of 05/09/24 on the package, 15 undated packages of hot dog buns, 30 undated loaves of sliced bread, and one undated package of Texas Toast bread. During an interview on 05/27/24 at 9:40 AM, the DM confirmed the six packages of hot dog buns had expired manufacturer's use by dates of 05/25/24 and the undated bread products that were stored on the bread racks in the kitchen's dry storage area. The DM stated staff were expected to date bread products when received and to discard bread products with expired use by dates. Review of the facility's policy titled, Date Marking for Food Safety, dated 03/23, indicated, The facility adheres to a date marking system to ensure the safety of ready-to-eat time/temperature control for safety food .2. The food shall be clearly marked to indicate the date or the day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. 5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.) 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager (DM), or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. NJAC 8:39-17.2(g) NJAC 8:39-19.7(d)

Based on interviews, review of medical records an other facility documentation, it was determined that the facility failed to complete the Comprehensive Minimum Data Set assessment in a timely manner for 3 of 16 residents reviewed (Residents #7, #13 and #17) for system selected MDS over 120 days for late submissions. This deficient practice was evidenced by: During an interview with the surveyor on 03/04/22 at 11:50 AM, the Licensed Nursing Home Administrator (LNHA) stated that the MDS Coordinator left the facility a few months ago and he was unable to fill the position despite posting it. He stated that a Regional MDS Coordinator completed them in the interim and provided the surveyor with her contact information and an additional preferred contact. During a phone interview on 03/04/22 at 12:03 PM, the surveyor phoned the LNHA's preferred contact who identified herself as an MDS Consultant. She stated that when the previous MDS Coordinator left, it became apparent that the MDS were backed up and they had been working weekly to resolve the issue and tried to catch up. She stated that the facility was very aware of the issue and put a tremendous amount of money out to help fix the problem. She stated that employees were good at covering up what they were not doing, and they thought that they could do things tomorrow. She further stated that the staffing shortage and the pandemic was the reason why the MDS's were late. The MDS Consultant agreed to e-mail the surveyor documented rationale for each resident whose MDS was not completed within 14 days of the Assessment Reference Date (ARD, the date that signifies the end of the look back period) and transmitted within 14 days of the completion date as required. The Regional MDS Coordinator was not available for interview. On 03/07/22 at 08:09 AM, the surveyor received an e-mail correspondence from the MDS Consultant who provided the surveyor with documented evidence that the facility entered into contract with the Consultant on 12/15/21 and she provided rationale for each resident's late MDS submission: 1. Resident #7's ARD was 01/10/22 and the assessment was not completed until 02/20/22, 41 days later, and was submitted on 02/22/22. The MDS Consultant noted that staffing shortages had been and continued to be a challenge. 2. Resident #13's ARD was 01/18/22 and the assessment was not completed until 03/02/22, 43 days later. The MDS Consultant indicated that the assessment would be submitted on 03/07/22. She also noted that staffing shortages had been and continued to be a challenge. 3. Resident #17's ARD was 01/20/22 and the assessment was not completed until 03/08/22, 47 days later. The MDS Consultant indicated that the assessment would be submitted on 03/07/22. She also noted that staffing shortages had been and continued to be a challenge. She further noted that her company worked with the resources available to clean up the in-progress list and get the facility to full compliance. During an interview with the surveyor on 03/08/22 at 03:38 PM, the LNHA stated that he was informed by the MDS Consultant that they were backed up but would get to it. He stated that they hoped to get caught up as soon as possible with the resources that they had. Review of the facility policy, Electronic Transmission of the MDS (Revised 03/2021) revealed the following: All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data . Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . The surveyor reviewed the Resident Assessment Instrument (RAI) 3.0 manual (updated October 2019), Chapter 5: Submission and Correction of MDS Assessments, which indicated that the Annual MDS assessment has a completion date No Later Than the ARD +14 calendar days. NJAC 8:39 - 11.2

Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care plan for the use of oxygen for 1 of 2 residents reviewed for oxygen therapy, Resident # 57. This deficient practice was evidenced by the following: On 02/24/22 at 01:20 PM, during the initial tour of the facility, the surveyor observed Resident # 57,in bed. Oxygen was being delivered to the resident through a nasal cannula (a tube with prongs that sit in the nostrils) that was attached to an oxygen concentrator that was set at 2 lpm (liters per minute). On 03/01/22 at 12:50 PM the surveyor observed Resident #57 in bed with oxygen delivered through a nasal cannula at 2 lpm. A review of the admission Records (an admission summary) indicated Resident # 57 was admitted to the facility 02/2021 and had diagnoses, which included but were not limited to; Atherosclerotic Hearth Disease (build up in and on artery walls), Covid-19 (viral infection), and Hypertension (high blood pressure). A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate resident care, dated 12/14/2021, revealed that the resident had a Brief Interview for Mental Status score of 00, which indicated the resident had severe cognitive impairment. Further review revealed in section O special treatments indicated the resident used oxygen while a resident at the facility. A review of the resident's care plan revealed no care plan for oxygen use. During an interview with the surveyor on 03/08/2022 at 02:10 PM, the Registered Nurse Unit Manager of Long-Term Care (RN/UM/TLC) stated care plans were initiated for residents upon admission by any nurse and is based on specifics for the residents. She stated the nurses who were involved in the care of a resident can an update the care plans. She stated the unit managers and the Director of Nursing should update the care plans quarterly. She stated all residents who received oxygen should have a care plan. During a meeting with the survey team on 03/08/22 at 03:32 PM, the administrator was made aware of the surveyor's findings. A review of the Document labeled Care Planning Nursing Manual-Nursing Administration with a revision date of 11/01/2021 revealed that a licensed nurse will initiate the care plan. Further review revealed the baseline care plan to include initial goals based on admission orders, physician order, and therapy services. A review of the document labeled Oxygen Administration level III with a revised date of 12/21/2021 revealed when the staff is to prepare a resident for oxygen administration, the staff review the resident's care plan to assess for any special needs of the resident. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 03/07/22 at 10:53 AM, the surveyor observed Resident #136 seated in a wheelchair in his/her room wearing a nasal cannula connected to a portable oxygen tank delivering 4 liters of oxygen. On 03/08/22 at 1:25 PM, the surveyor observed Resident #136 seated in a wheelchair in his/her room wearing a nasal cannula connected to a portable oxygen tank delivering 4 liters of oxygen. A review of the admission Record revealed the resident was admitted to the facility with diagnoses that included, but were not limited to; pulmonary fibrosis (a disease in which the lungs become scarred causing difficulty in breathing), emphysema (a lung disease which results in shortness of breath due to destruction and dilatation of the air sacs), and congestive heart failure (the heart fails to pump blood well). A review of the Quarterly MDS, dated [DATE], revealed that the resident had a BIMs score of 6, which indicated that the resident had severe cognitive impairment. Further review revealed in section O special treatments indicated the resident used oxygen while a resident at the facility. A review of the Order Summary Report, with active orders as of 3/8/22, revealed no order for oxygen administration. A review of the Care Plan, with a revision date of 3/6/22, revealed oxygen settings: O2 via nasal prongs @ 3 LPM (liters per minute). On 03/08/22 at 2:42 PM, in the presence of the Registered Nurse/Unit Manager (RN/UM), the surveyor reviewed the electronic medical record. The RN/UM was unable to find an oxygen order and acknowledged there should be an oxygen order. During a meeting with the survey team on 03/09/22 at 02:20 PM, the administrator and DON were made aware of the surveyor's findings. During an interview with the surveyor on 03/09/22 at 2:32 PM, the DON stated that the admission nurse and the next shift nurse were responsible for checking orders and that the UM reviewed all new admission orders for accuracy and that it was important to follow correct orders. The DON acknowledged that the resident should have had an oxygen order. A review of the facility policy, Oxygen Administration, with a revision date of December 2021, revealed Policy: I. Initiation of Oxygen, A. A physician's order is required to initiate oxygen therapy . NJAC 8:39-11.2(b); 27.1(a) Based on observation, interview, record review and review of facility documents, it was determined that the facility failed to obtain physician orders to provide oxygen for 2 of 2 residents, Resident # 57 and #136, reviewed for oxygen in accordance with nursing professional standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: 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 a medical regimen 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 state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 02/24/22 at 01:20 PM, during the initial tour of the facility, the surveyor observed Resident # 57 in bed. Oxygen was being delivered to the resident through a nasal cannula (a tube with prongs that sit in the nostrils) that was attached to an oxygen concentrator that was set at 2 lpm (liters per minute). On 03/01/22 at 12:50 PM the surveyor observed Resident #57 in bed with oxygen delivered through a nasal cannula at 2 lpm. A review of the admission Records (an admission summary) indicated Resident # 57 was admitted to the faciity 02/2021 and had diagnoses, which included but were not limited to; Atherosclerotic Hearth Disease (build up in and on artery walls), Covid-19 (viral infection), and Hypertension (high blood pressure). A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate resident care, dated 12/14/2021, revealed that the resident had a Brief Interview for Mental Status score of 00, which indicated the resident had severe cognitive impairment. Further review revealed in section O special treatments indicated the resident used oxygen while a resident at the facility. A Review of the Order Summary for Active orders as of 03/02/2022, revealed no order for oxygen therapy. Further review revealed an order dated 01/04/2022, to change and date oxygen tubing and humidifier every night shift every Sunday for infection control. On 03/02/22 at 11:00 AM, in the presence of the Licensed Practical Nurse (LPN) who was assigned to the resident, the surveyor reviewed the electronic medical record. The LPN was unable to find an oxygen order. She stated that the resident went to the hospital and returned to the facility and the order was not there. During an interview with the surveyor on 03/02/2022 at 03:02 PM, the Director of Nursing (DON) stated that there was no order for the oxygen. The last oxygen order was 01/26/2021. She stated when the resident was hospitalized , the order must have been dropped off. She stated it was a slip through and the nurses should have seen that and made sure they had an order. During a meeting with the survey team on 03/08/22 at 03:32 PM, the administrator was made aware of the surveyor's findings. During a meeting with the survey team on 03/09/2021 at 02:38 PM, the DON stated orders are checked by the admitting nurse and Sunday nights the nurses check the tubing. She stated there should absolutely be a physician order for oxygen and it is important to make sure things are being followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, it was determined the facility failed to implement a physician's order for wound care to prevent the worsening of a left heel pressure ulcer and sacral pressure ulcer for 1 of 1 residents reviewed for pressure ulcers, Resident #122. This deficient practice was evidenced by the following: According the admission Record, Resident #122 was admitted to the facility in 1/2022 for rehabilitation. On 2/9/22 the resident was sent to an acute hospital and was readmitted on [DATE]. The resident had diagnoses that included, but were not limited to; hemiparesis (paralysis on one side of the body) following cerebral infarction (stroke), peripheral vascular disease (narrowing of arteries which results in reduced blood flow to head, arms, stomach and legs), and diabetes mellitus with diabetic polyneuropathy (the condition of nerve damage caused due to persistently high blood sugar level). A review of the admission Minimum Data Set (MDS), an assessment tool, dated 1/16/22, revealed resident #122 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Further review of the MDS revealed the resident required extensive assistance with activities of daily living including bed mobility, transfers, dressing, and toileting and had one Stage 3 (full thickness tissue loss) pressure ulcer which was present on admission. A review of the resident's Care Plan (CP) initiated 1/9/22, revealed the resident was at risk for skin breakdown related to immobility, incontinence, medical condition/diagnosis, and trauma. A review of the wound care consultant visit report dated 2/8/22, revealed the resident had an unhealed left heel pressure ulcer (wound #1) with wound order treatment recommendations to apply single-layer Xeroform to the wound, cover with a bordered gauze/Island dressing, change dressing daily. The resident had an unhealed sacral pressure ulcer (wound #2) with wound order treatment recommendations to apply zinc oxide barrier to the wound and surrounding skin every shift. The Plan of Care was discussed with facility staff. A review of the wound care consultant visit report dated 2/15/22, revealed that wound #1 was not healed with wound order treatment recommendations to discontinue prior treatments and to apply skin protectant wipes (skin prep) to the wound and surrounding skin daily and wound #2 was not healed with wound order treatment recommendations to apply zinc oxide barrier to the wound and surrounding skin every shift. The Plan of Care was discussed with facility staff. A review of the wound care consultant visit report dated 2/22/22, revealed that wound #1 was not healed with wound order treatment recommendations to apply skin protectant wipes (skin prep) to the wound and surrounding skin daily and wound #2 was not healed with wound order treatment recommendations to discontinue prior treatments, cleanse the wound with normal saline, do not scrub or use excessive force, pat dry, apply Calcium Alginate cut to size to the wound base, cover with a bordered gauze/Island dressing, change dressing daily and when soiled. The Plan of Care was discussed with facility staff. A review of the wound care consultant visit report dated 3/1/22, revealed that wound #1 was not healed with wound order treatment recommendations to cleanse the wound with normal saline, do not scrub or use excessive force, pat dry, apply Calcium Alginate cut to size to the wound base, cover with a bordered gauze/Island dressing, change dressing daily and when soiled and wound #2 was not healed with wound order treatment recommendations to cleanse the wound with normal saline, do not scrub or use excessive force, pat dry, apply Calcium Alginate cut to size to the wound base, cover with a bordered gauze/Island dressing, change dressing daily and when soiled. A review of the Treatment Administration Record (TAR), dated 2/1/22-2/28/22, indicated an order for the left heel was to be cleansed with NSS (normal saline solution), pat dry, apply Medi honey and cover with DSD (dry sterile dressing) daily every day shift for wound care, start date 1/18/22, d/c date 2/11/22. The TAR was signed as administered 2/1/22-2/9/22. An order for skin prep wipes apply to B/L (both) heels topically every shift for prevention for 7 days, start date 2/11/22. The TAR was signed as administered every shift from night shift 2/11/22 until evening shift 2/18/22. No sacral wound orders appeared on the TAR. A review of the Order Summary Report with active orders as of 3/8/22, revealed no wound care orders. A review of the TAR, dated 3/1/22-3/31/22, revealed no wound orders for left heel pressure ulcer wound and no wound orders for sacral pressure ulcer wound. During an interview with the surveyor on 03/03/22 at 12:06 PM, the Licensed Practical Nurse/Supervisor (LPN/S) on Unit 5 acknowledged the resident had a sacral wound and stated that the sacral wound was almost healed and that she was putting cream barrier on the wound every time personal care was performed. The LPN/S further stated that she had applied skin prep to both heels every shift. During an interview with the surveyor on 03/08/22 at 2:50 PM, the LPN/Unit Manager (LPN/UM) on Unit 5 stated that the resident was admitted to the facility with wounds on his/her left heel and his/her sacrum. The LPN/UM stated that as per the 3/8/22 wound rounds, that wound #1 was healed and the treatment was skin prep and that wound #2 was healed and the treatment was zinc. The LPN/UM stated that weekly wound rounds were done with the UM and the wound doctor consultant on all the residents on the unit, the wound doctor uploaded their reports with recommendations to the electronic medical record system, then the nurse inputted the orders for the treatments and the staff nurse would implement them on a daily basis. The LPN further stated that the orders came from the wound physician and not the house physician. The LPN/UM acknowledged complete wound orders for the left heel and the sacrum were not on the TAR and stated that if the order was not on the TAR that the treatment was not administered. During an interview with the surveyor on 03/08/22 at 3:09 PM, the Director of Nursing (DON) stated that if there were wound care orders that they would be found on the TAR. During an interview with the surveyor on 03/09/22 at 08:59 AM, the DON stated she reviewed resident #122's physician orders and that she did not observe an order for heel wound treatment and was unsure about any sacral wound orders. During an interview with the surveyor on 03/10/22 at 3:10 PM, the DON acknowledged the wound doctor consultant recommended wound treatment to the resident's left heel and sacrum. The DON stated the wound doctor consultant recommendations were put in the computer system as an order by the DON or UM and that once inputted it would show on the TAR. The DON acknowledged there was no order for wound care to the left heel and the sacrum and had no explanation as to how staff would know what wound care to perform. A review of the facility policy, Physician Orders, with a revision date of January 2022, revealed Procedure: VIII. Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order. IX. Medication/treatment orders will be transcribed onto the appropriate resident administration record. A review of the facility policy, Wound Management, with a revision date of June 2021, revealed Policy: A resident who has a wound will receive necessary treatment .Procedure: II. Wound Management, G. Per attending physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management. NJAC 8:39-27.1(e)

Based on observations, interviews, and review of other facility documentation, it was determined that the facility failed to a.) properly label and date food products stored in the walk-in refrigerator/freezer and b.) ensure that kitchen staff wore a hair restraint that fully covered their hair during food preparation in the kitchen in order to prevent foodborne illness for 1 of 1 staff member observed with improper hair restraint usage. This deficient practice was evidenced by: On 02/24/22 from 09:39 AM until 10:16 AM, the surveyor observed the following in the presence of the Director of Dining (DOD): 1. In the walk-in freezer: a. On the second shelf from the top of a four-tiered wired rack, the clear plastic outer packaging of a block of Swiss cheese was not secured and the cheese was opened and exposed to the air within the freezer. The DOD stated that he would re-wrap it correctly. b. On the second shelf from the top of a three-tiered wired rack, a previously opened package of frozen hamburger patties was wrapped in clear plastic, and was not dated. c. On the bottom shelf of a three-tiered wired rack, an unopened 2.5 lbs. bag of tater tots was not dated. The DOD stated that both the frozen hamburger patties and the tater tots should have been marked with an orange sticker that identified the received by date, the date opened and the use by date. He stated that he would discard them. 2. In the walk-in refrigerator: a. On the top shelf of a five-tiered wired rack, there was an opened jar of sauerkraut that was marked with an opened date of 02/02/22. The DOD stated that it should have been discarded within three days after it was opened. He stated that he would discard it. On 03/02/22 from 11:58 AM until 12:10 PM, during a follow-up visit to the kitchen, the surveyor observed the following in the presence of the DOD: The surveyor observed the [NAME] who was in the galley of the kitchen as she plated food for the lunch service. The surveyor noted that the Cook's hair restraint did not fully cover her hair and the hair that covered her forehead and bordered the sides of her face was left exposed bilaterally. She stated that she intentionally wore bangs and left the hair that bordered the sides of her face outside of the hair restraint as a matter of preference. She stated that she always wore it like that. She further stated that her hair could fall into the food. The DOD stated that all kitchen staff were required to wear hair restraints. He stated that if the Cook's hair were not pulled back into the hair net, it could have fallen into the food and contaminated it. The surveyor reviewed the facility policies Food Storage (Revised 12/01/11) (Policy number 03.03.003) and Employee Sanitation (Revised 12/01/11) which revealed the following: All frozen foods will be labeled and dated when received. Refrigerated foods are labeled and dated upon receipt from the vendor. Product is then stored in a manner it was received in order to preserve product integrity. Refrigerated foods are labeled and dated upon receipt from the vendor .Items will be dated upon receipt. They will then be dated upon opening of the product for use. Only a portion of the product will be divided for use. The portion not to be used will be wrapped or covered, dated and refrigerated immediately to prevent any compromise of the product. The used portion will be labeled and dated using the Labeling of Prepared Foods Policy The items will be used or discarded after five (5) days of being opened or the product use by date, whichever comes first. Employee Cleanliness Requirements: .Hair restraints, such as hats, hair coverings or nets, caps and beard/moustache restraints (snoods) or other effective hair restraints are worn to keep hair from contacting food and food-contact surfaces. NJAC 17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 02/25/22 at 11:44 AM, during the initial tour on Unit 5, the surveyor observed a plastic barrier in the hallway with posted signage which stated Observation unit (OU), Yellow Zone, PPE:N95, Faceshield/Goggles, Gowns, Gloves. DON (put on) PPE before entering the resident's room, DOFF (remove) PPE before leaving the resident's room and posted signage which stated stop, contact precautions, everyone must clean their hands including before entering and when leaving the room, all providers and staff must also put on gloves before room entry, remove gloves before room exit, put on gown before room entry, discard gown before room exit, use dedicated or disposable equipment. There was posted signage next to room [ROOM NUMBER] with instructions on donning and doffing PPE. In the hallway outside of same room the surveyor observed a three drawer plastic bin containing gloves, surgical masks, face shields, N95 masks, and disposable yellow gowns. The surveyor observed a staff member in room [ROOM NUMBER] on the OU wearing an untied yellow gown. On 02/25/22 at 11:48 AM, the staff member exited room [ROOM NUMBER] wearing a yellow gown, eyeglasses, an N95 mask with a surgical mask under it, and no gloves. The staff member placed her clipboard on the floor, her cell phone fell to the floor, and she removed the disposable gown in room [ROOM NUMBER] and placed it in the trash can in the room. The staff member then returned to the hall where the surveyor interview took place. The Business Office Manager (BOM) stated she was in room [ROOM NUMBER] obtaining information for billing purposes. The BOM acknowledged she was in the OU and that once on the unit that gowns and N95 masks were to be worn and that before leaving the hall the gown and N95 mask were to be removed. The BOM stated that the posted signage reinforced that gowns, masks and goggles were to be worn on the unit. The BOM acknowledged she wore a gown in the hallway and that she was not wearing goggles. The BOM stated that she should not have removed her gown in room [ROOM NUMBER] and that she should have taken off her gown in the resident's room before leaving and should have used hand sanitizer before entering a room and after leaving a room to prevent cross contamination. The BOM further stated she should not have placed her belongings on the floor and that she would wipe them down. During an interview with the surveyor on 03/03/22 at 12:06 PM, the Licensed Practical Nurse/Supervisor (LPN/S) on unit 5 stated that unit 5 is for quarantining persons under investigation (PUI), that the plastic barrier was for protection, and that PPE signage was posted. The LPN/S stated that when entering the plastic barrier that the required PPE in resident rooms were goggles, face shield, N95, gown and gloves. The LPN/S stated that PPE should be donned prior to entering the room and doffed before exiting the room and that once gloves were removed that handwashing should be performed in the bathroom then upon exit of the room that hand sanitizer was used. When informed of the BOM observation that took place on 2/25/22, the LPN/S stated that the BOM should not have worn her gown in the hallway and that she should have removed her PPE in the doorway and washed her hands then used hand sanitizer for everyone's protection. During an interview with the surveyor on 03/03/22 at 12:38 PM, the Director of Nursing (DON) stated that the required PPE on the OU consists of a gown, N95 mask, goggles or faceshield, and gloves and that all PPE was available on the unit. The DON stated that prior to entering a resident's room the PPE was donned and prior to exiting the room the PPE was doffed then handwashing should be performed. When informed of the BOM observation that took place on 2/25/22, the DON acknowledged the BOM did not follow proper PPE instructions and that it was important to wear proper PPE for protection. During an interview with the surveyor on 03/03/22 at 1:08 PM, the Interim Infection Preventionist (IIP) stated that the plastic barrier indicated a PUI zone and that the required PPE in that area was an N95 mask, faceshield or goggles, gown and gloves in the room and that PPE should be donned prior to entering the room and doffed prior to exiting the room. When informed of the BOM observation that took place on 2/25/22, the IIP acknowledged the BOM did not follow proper PPE instructions and that it was important to wear proper PPE for protection. During an interview with the surveyor on 03/09/22 at 10:44 AM, the BOM acknowledged that the required PPE in the PUI unit was goggles, N95 mask, gown and gloves and that she was not wearing the proper PPE during the surveyor observation on 2/25/22. The BOM demonstrated how to correctly wear an N95 mask and acknowledged there should not be a surgical mask underneath the N95 mask. The BOM stated she was inserviced on PPE and that it was important to wear PPE correctly to stay safe and to prevent cross contamination. Review of facility policy, Resident Isolation-Categories of Transmission-Based Precautions, with a revision date of 1/2022, revealed Purpose: To ensure that transmission based precautions are used when caring for residents with communicable diseases or transmittable infections. Policy: Transmission based precautions are used accordingly when caring for residents who are documented or are suspected of having communicable diseases or infections that can be transmitted to others. III. Contact precautions, C. Gloves and Handwashing, i. Gloves are worn when entering the room, iii. Gloves are removed before leaving the room and hands are washed immediately with an antimicrobial agent or a waterless antiseptic agent. D. Gown, ii. The gown is removed, and hand hygiene is performed before leaving the resident's environment. IV. Droplet precautions, C. a mask is worn when working within 3 feet of the resident. NJAC 8:39-19.4(k) Based on observations, interviews, record review, and review of facility documents, it was determined that the facility failed to maintain appropriate infection control practices for a.) maintaining the cleanliness of an oxygen concentrator and a feeding tube pump pole, for 1 of 2 residents reviewed for oxygen, Resident #57 and b.) the use of required personal protective equipment (PPE) on 1 of 5 units. This deficient practice was evidenced by the following: 1. On 02/24/22 at 01:20 PM, during the initial tour of the facility, the surveyor observed Resident # 57 in bed. Oxygen was being delivered to the resident through a nasal cannula (a tube with prongs that sit in the nostrils) that was attached to an oxygen concentrator that was set at 2 lpm (liters per minute). There was a feeding pump pole next to the oxygen concentrator. The resident was receiving nutritional formula via a tube feeding pump (Pump designed to deliver formula through a tube placed in a stomach). The pumps electronic display showed the formula was being delivered at 70 milliliters per hour (ml/hr). There was a large amount of tan/brown thick dried substance on the oxygen concentrator and on the base of the feeding pump pole. On 03/01/22 at 12:50 PM, the surveyor observed Resident #57 in bed with oxygen delivered through a nasal cannula at 2 lpm and the feeding pumping connected and delivering nutritional feeding at 70 ml per hour. There was tan/brown thick dried substance on the oxygen concentrator and on the base of the feeding pump pole. A review of the admission Records (an admission summary) dated 02/2022, which indicated Resident # 57 had diagnoses, which included but not limited to; Atherosclerotic Hearth Disease (build up in and on artery walls), Covid-19 (viral infection), and Gastrostomy. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate resident care, dated 12/14/2021, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. Further review revealed in section K that the resident had a feeding tube while at the facility. Further review revealed in section O special treatments indicated the resident used oxygen while a resident at the facility. During an interview with the surveyor on 03/01/2022 at 12:55 PM, the Licensed Practical Nurse (LPN) who was assigned to the resident, stated that she was not aware the concentrator and the feeding tube pole was dirty and was not aware of who would keep the equipment clean. During an interview with the surveyor on 03/01/2022 at 01:00 PM, the housekeeper stated she was not responsible to clean the oxygen concentrator or tube feeding pole and that maintenance is responsible to clean the equipment. During an interview with the surveyor on 03/01/2022 at 01:05 PM, the Director of Environmental Services stated normally in the evenings he had a maintenance man who made rounds and checked the equipment. This happened usually on Tuesdays and if the maintenance man felt the equipment needed to be cleaned, he would clean the equipment. He stated there are no logs for checking and cleaning the equipment. During a follow up interview with the surveyor on 03/07/2022 at 12:40 PM, the Director of Environmental Services stated he had no documentation that the equipment is being cleaned and did not have a cleaning schedule for the rooms. He stated he did not date the medical equipment as to when the equipment was cleaned. He stated that he and his staff just clean the equipment when the equipment needed to be cleaned. He further stated that the only cleaning schedule he had was for the cleaning of the wheelchairs. During a meeting with the survey team on 03/08/22 at 03:32 PM, the administrator was made aware of the surveyor's findings. A review of the policy labeled Cleaning and Disinfection of Resident Care Equipment with a revised date of 08/01/2021, revealed resident-care equipment, including reusable items and durable medical equipment is cleaned and disinfected per current CDC, recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. A review of the policy labeled Stationary Oxygen Concentrators Policy and Procedure dated 03/07/2022, Cleaning heading #2. clean the exterior of the oxygen concentrator with soapy water solution or commercial cleaner to remove any debris.

Based on observations, interviews, and review of other facility documentation, it was determined that the facility failed to ensure that mitigation measures were followed to prevent the potential spread of COVID-19, a contagious respiratory infection. This deficient practice was identified for 3 of 3 partially vaccinated staff, and 1 of 2 unvaccinated staff, and was evidenced by the following: On 03/07/22 at 11:33 AM, the surveyor observed a Licensed Practical Nurse (LPN) working on unit 2 wearing a surgical mask and goggles. During an interview at that time, the LPN stated that she believed she was scheduled to receive her second dose of the vaccine on 3/18/22. On 03/07/22 at 11:46 AM, the surveyor observed a Certified Nursing Assistant (CNA), working on unit 3 wearing a surgical mask and goggles. During an interview at that time, the CNA stated that she was scheduled to receive her second dose of the vaccine on 03/20/22. On 03/08/22 09:42 AM, the surveyor observed the receptionist, sitting behind the plastic barrier at the desk, wearing a surgical mask, no goggles/face shield. She was speaking to a resident sitting in front of the desk, who was also wearing a surgical mask. During an interview on 03/08/22 at 10:16 AM with the surveyor, the Interim Infection Preventionist (IIP) stated that you are not fully vaccinated if you only received the 1st dose of a 2-dose vaccine. You are not fully vaccinated until the second dose and booster vaccines are completed. On 03/08/22 at 10:31 AM, the surveyor observed the LPN on unit 2 wearing a surgical mask and eye goggles. She was carrying a medication cup and entered a resident's room. On 03/08/22 at 10:49 AM, the surveyor observed the CNA on unit 3 wearing a surgical mask and eye goggles. On 03/08/22 at 11:13 AM, the surveyor observed an Activity Aid (AA) in the activities room with the administrator and another staff member. The AA was wearing a surgical mask and glasses. During an interview at that time, the AA stated that he had received his second dose of the vaccine on 3/1/22. During an interview with the surveyor on 03/08/22 at 11:17 AM, the Director of Nursing (DON) stated that you are fully vaccinated once the first, second and booster vaccine was received. She stated that a first dose meant that you are only partially vaccinated. The DON stated that the LPN and CNA were to wear a N95 mask if they go off their assigned unit and/or on units 1 and 5. During an interview with the surveyor on 03/08/22 at 11:30 AM, the IIP stated that the staff that received the first dose was not considered vaccinated and that they should wear a N95 mask and shield/goggle, at all times regardless of what they are doing in the facility. During an interview with the surveyor on 03/08/22 at 11:33 AM, in the presence of the IIP, the LPN stated I should have on an N95 mask. She stated the purpose of wearing a N95 mask was to protect myself and others from COVID. The IIP stated that the N95 mask was to be worn at work at all times. During an observation by the surveyor and the IIP on 03/08/22 at 11:34 AM, the CNA was observed with a coworker at the linen cart, in the hallway of unit 3, wearing a surgical mask. The IIP stated that the CNA should have had on a N95 mask and that she should remain social distanced while on lunch. During an interview with the surveyor on 03/08/22 at 11:36 AM, in the presence of the IIP, the AA stated that he wears a surgical mask outside of the office or when around others. The IIP stated that the AA should wear a N95 mask and goggles at all times, everywhere in the building unless on break, then he must remain socially distant. The IIP confirmed that he was not fully vaccinated until 2 weeks after receiving the last dose of the vaccine. During an interview with the surveyor on 03/08/22 at 11:38 AM, in the presence of the IIP, the receptionist stated that she had not received any doses of the vaccine. She was wearing a surgical mask. The IIP confirmed that she should be wearing a N95 and a shield. During an interview with the surveyors on 03/09/22 at 02:25 PM, the Licensed Nursing Home Administrator, the [NAME] President of Operations, the DON, the IIP, and the Regional Clinical all agreed that partially vaccinated staff were unvaccinated staff and that the policy for unvaccinated staff should have been followed. A review of the facility's Employee Education Attendance Record dated 3/1/2022, Topic of In-service: Vaccine policy/Procedures; Objectives Inservice-noted wearing surgical mask; needs N95/Shield, revealed the LPN had Participated in discussion and Verbalization of content to meet objective. A review of the facility's policy, Atlas COVID-19 Policies and Procedures updated 1/28/2022, revealed Additional Precautions and Contingency Plans for Unvaccinated Staff: Adhering to universal source control and physical distancing measures even if the facility is located in a county with low-to-moderate community COVID transmission. Require use of a NIOSH-approved N95 or equivalent or higher-level respirator for sources control, regardless of whether they are providing direct care to or otherwise interacting with patients. NJAC 8:39-5.1(a)

Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS, an assessment tool), within 14 days of completing the resident's assessment. This deficient practice was identified for 13 of 16 residents reviewed (Residents #16, #20, #15, #2, #9, #12, #14, #1, #8, #4, #3, #11, #10), from system selected for MDS over 120 days for late submissions and for 2 of 28 residents reviewed (Residents #25, #24) for MDS completion and transmission. This deficient practice was evidenced by the following: During an interview with the surveyor on 03/04/22 at 11:50 AM, the Licensed Nursing Home Administrator (LNHA) stated that the MDS Coordinator left the facility a few months ago and he was unable to fill the position despite posting it. He stated that a Regional MDS Coordinator completed them in the interim and provided the surveyor with her contact information and an additional preferred contact. During a phone interview on 03/04/22 at 12:03 PM, the surveyor phoned the LNHA's preferred contact who identified herself as an MDS Consultant. She stated that when the previous MDS Coordinator left, it became apparent that the MDS were backed up and they had been working weekly to resolve the issue and tried to catch up. She stated that the facility was very aware of the issue and put a tremendous amount of money out to help fix the problem. She stated that employees were good at covering up what they were not doing, and that they thought that they could do things tomorrow. She further stated that the staffing shortage and the pandemic were the reasons why the MDS's were late. The MDS Consultant agreed to e-mail the surveyor documented rationale for each resident whose MDS was not completed within 14 days of the Assessment Reference Date (ARD, the date that signifies the end of the look back period) and transmitted within 14 days of the completion date as required. The Regional MDS Coordinator was not available for interview. On 03/07/22 at 08:09 AM, the surveyor received an e-mail correspondence from the MDS Consultant who provided the surveyor with documented evidence that the facility entered into contract with the Consultant on 12/15/21 and she provided rationale for each resident's late MDS submission: 1. Resident #16's ARD was 01/18/22 and the assessment was not completed until 02/28/22, 41 days later. The MDS Consultant documented that the MDS would be submitted on 03/07/22 and noted that staffing shortages had been and continued to be the challenge. 2. Resident #20's ARD was 01/17/22 and the assessment was not completed until 03/02/22, 44 days later. The MDS consultant documented that the MDS would be submitted on 03/07/22 and noted that staffing shortages had been and continued to be a challenge. 3. Resident #15's ARD was 01/19/22 and the assessment was not completed until 03/06/22, 46 days later. The MDS Consultant documented that the MDS would be submitted on 03/07/22 and noted that staffing shortages had been and continued to be a challenge. 4. The surveyor received a second e-mail from the MDS Consultant on 03/07/22 at 12:44 PM, which demonstrated that Resident #2's ARD was 01/04/22 and the assessment was not completed and submitted until 02/23/22, 50 days later. She noted that staffing shortages had been and continued to be a challenge. 5. Resident #9's ARD was 01/11/22 and the assessment was not completed until 02/22/22, 42 days later, and was submitted on 02/23/22. The MDS Consultant noted that staffing shortages had been and continued to be a challenge. 6. Resident #12's ARD was 01/14/22 and the assessment was not completed until 03/01/22, 46 days later. The MDS Consultant documented that the MDS would be submitted on 03/07/22 and noted that staffing shortages had been and continued to be a challenge. 7. Resident #14's ARD was 01/11/22 and the assessment was not completed until 02/21/22, 41 days later. The MDS Consultant documented that the MDS was submitted on 02/22/22 and noted that staffing shortages had been and continued to be a challenge. 8. Resident #1's ARD was 01/03 22 and the assessment was not completed and submitted until 02/23/22, 51 days later. The MDS Consultant noted that staffing shortages had been and continued to be a challenge. 9. Resident #8's ARD was 01/10/22 and the assessment was not completed until 02/20/22, 41 days later. The MDS Consultant documented that the MDS was submitted on 02/22/22 and noted that staffing shortages had been and continued to be a challenge. 10. Resident #4's ARD was 01/07/22 and the assessment was not completed until 02/17/22, 46 days later. The MDS Consultant documented that the MDS was submitted on 02/22/22 and noted that staffing shortages had been and continued to be a challenge. 11. Resident #3's ARD was 01/05/22 and the assessment was not completed and submitted until 02/23/22, 49 days later. The MDS Consultant noted that staffing shortages had been and continued to be a challenge. 12. Resident #11's ARD was 01/13/22 and the assessment was not completed and submitted until 02/28/22, 46 days later. The MDS Consultant noted that staffing shortages had been and continued to be a challenge. 13. Resident #10's ARD was 01/12/22 and the assessment was not completed until 02/22/22, 41 days later. The MDS Consultant documented that the MDS was submitted on 02/23/22 and noted that staffing shortages had been and continued to be a challenge. 14. Resident #25's ARD was 02/02/22 and the assessment was not completed until 02/24/22, 23 days later. The MDS Consultant documented that the resident's MDS was submitted over the weekend, date not specified. 15. Resident #44's ARD was 01/26/22 and remained incomplete according to the MDS Consultant who documented that she would ensure that the assessment was completed on 03/07/22. The MDS Consultant failed to specify when the MDS would be submitted. During an interview with the surveyor on 03/07/212 at 12:13 PM, the MDS Consultant stated that her company had staffing issues and had more coverage since mid-February and that was when most of the work was done. During an interview with the surveyor on 03/08/22 at 03:38 PM, the LNHA stated that he was informed by the MDS Consultant that they were backed up but would get to it. He stated that they hoped to get caught up as soon as possible with the resources that they had. Review of the facility policy, Electronic Transmission of the MDS (Revised 03/2021) revealed the following: All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data . Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . Review of the Resident Assessment Instrument (RAI) 3.0 manual (updated October 2019), Chapter 5: Submission and Correction of MDS Assessments, which indicated that the MDS assessments must be submitted within 14 days of the MDS Completion Date. NJAC 8:39-11.2

Based on observation, interview, and review of the medical record and review of other facility documentation, it was determined that the facility failed to maintain resident's equipment in a clean and sanitary condition for 1 of 27 residents observed (Resident #24). The deficient practice was evidenced by the following: On 11/15/19 at 9:24 AM, the surveyor observed Resident #24 seated in a wheelchair in the Rotunda area of the facility. The surveyor found that the wheelchair was heavily soiled with dust particles, hair, and other unknown debris. The surveyor also observed this same wheelchair in the same heavily soiled condition on the following dates: 11/18/19 at 9:02 AM and 11/19/19 at 9:33 AM. On 11/19/19 at 9:35 AM, during the surveyor interview, Resident #24 stated that he/she didn't think the facility cleaned the wheelchair and that the wheels [of the wheelchair] were so dirty. On 11/19/19 at 10:15 AM, during the surveyor interview, Housekeeper #1 stated that maintenance was responsible for cleaning the wheelchairs. Immediately following, during the surveyor interview, Housekeeper #2 stated that housekeeping will wipe the wheelchairs if visibly soiled but that there was no schedule for cleaning. Later that same day, at 1:17 PM, during the surveyor interview, the Director of Maintenance (DM) stated that the maintenance department cleans the resident's wheelchairs and that they are scheduled to be cleaned every month. On 11/20/19 at 9:08 AM, the surveyor observed Resident #24 seated in a wheelchair in the Rotunda area of the facility. The surveyor found that the wheelchair appeared to have been cleaned, but that there remained a clump of debris and hair on the lower bar of the right side of the wheelchair. On the same day at 9:51 AM, during the surveyor interview, DM said that Resident #24's wheelchair was cleaned the night before. The DM further stated that they were trying to catch up with wheelchair cleaning because the person responsible for cleaning the wheelchairs had left. The DM confirmed that the wheelchair should have been cleaned earlier. The surveyor then reviewed the wheelchair cleaning log sheets provided by the DM, which revealed a cleaning log sheet for November 2019, April 2019 and May/August 2018. Further review of the wheelchair cleaning log sheets showed that the work performed section on the sheets for Resident #24's wheelchair included: Wheelchair was washed on 11/19/19 according to the November 2019 sheet, but was left blank on the April 2019 sheet and also the May/August 2018 sheet. On 11/21/19 at 10:35 AM, during the surveyor interview, the Administrator (ADM) stated that he thought the wheelchair cleaning was to be performed monthly and as needed. The ADM said that Resident #24's wheelchair was dirty and that it should have been cleaned before it had to be brought to their attention. On the same day at 10:45 AM, the surveyor reviewed the facility policy titled, Wheelchair Cleaning Protocols, with a revised date of June 2009, which read: Under 2. Decontamination, a. All wheelchairs should be thoroughly cleaned on a monthly basis after use. N.J.A.C. 8:39-31.4(f)

**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 provide a range of motion exercises as per prescribed order. This deficient practice was identified for Resident #88, 1 of 2 residents reviewed for limited range of motion, and was evidenced by the following: On 11/14/19 at 10:59 AM, the surveyor observed Resident #88 in his/her room in a wheelchair. In the resident's room, the surveyor observed a cane leaning against the nightstand and a rolling walker in the room as well. The resident stated to the surveyor that they had been receiving physical therapy but no longer were. The resident further said he/she would like to have therapy again. On 11/18/19 at 12:08 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who was also the Unit Manager (UM). The LPN/UM stated the resident gets around by self-propelling in a wheelchair, and that the resident was not on therapy or RNP (Restorative Nursing Program). The LPN/UM did state that the resident was on functional maintenance, and the aides stretch the resident's arms and legs and help the resident roll side to side. At 12:15 PM, the surveyor reviewed the resident's record, which revealed on an admission Record that the resident was admitted to the facility on [DATE] with diagnoses which included difficulty walking, and history of an artificial hip joint. There was a physician's order dated 6/07/19 which read; D/C [discharge] from skilled OT (Occupational Therapy) services to this LTC (Long Term Care) with RNP indicated for 15 minutes/day and x 6/wk (six times a week) for AROM BUE/BLE (Active Range of Motion bilateral upper extremities and bilateral lower extremities), transfers with SUP (support) and ambulation on unit with r/w (rolling walker) SUP as tolerated. There was an additional physician's order dated 6/11/19 which read: Patient DC (discharged ) from skilled PT (Physical Therapy) services to this LTC facility, highest practical level achieved, with RNP (Restorative Nurse Program) for transfers and ambulation in the facility as tolerated using RW (rolling walker) with SUP(A) (supervision). On 11/19/19 at 10:20 AM, the surveyor interviewed the Director of Therapy who stated the resident had participated in PT and OT from 4/8/19 until 6/6/19. Upon discharge from therapy, the resident was placed on Restorative Nursing program walking 200 feet or as tolerated using a rolling walker and also practicing transfer to maintain the current level of skills. The frequency was six times a week for 15 minutes. Once the restorative program was developed, the therapists were to train the Certified Nursing Assistants (CNA's) how to carry out the program and that therapy established the program, but that it was instituted by nursing. At 10:32 AM, the surveyor reviewed the resident's Restorative Nursing Referral dated 6/8/19, which revealed the goals of the program were to maintain strength in bilateral upper extremities with a treatment plan for the active range of motion 2 x 10 repetitions each day or as tolerated. Also, to keep the current level of transfers from the wheelchair to the bed and the wheelchair to the toilet, supervised. Lastly, to maintain the resident's current level of ambulation by ambulating on the unit 200 feet or as tolerated using a rolling wheelchair with supervision. At 10:35 AM, the surveyor interviewed the resident's CNA, who stated the resident was on an RNP but had refused for a while. When asked where the refusals were documented, the CNA reported that they were in the kiosk on the wall. Together the CNA and surveyor reviewed the kiosk data, and the CNA was unable to provide documentation that the resident was refusing to follow the restorative nursing program as prescribed. The CNA did not know if the physician or therapy had been notified of the resident's refusal. At 11:01 AM, the surveyor interviewed the resident again. The resident stated that the CNA would ask them if they wanted to go for a walk but did not feel confident walking with the CNA and wanted a therapist instead. The surveyor asked the resident if the CNA had explained that they were on an RNP and following the therapist's recommendation, or that the CNA had been trained by therapy to walk the resident safely? The resident stated they did not remember the CNA explaining the RNP to them. At 11:05 AM, the surveyor reviewed the resident's most recent Minimum Data Set (an assessment tool) dated 10/9/19. The section that assessed the resident's Cognitive Patterns showed that the resident scored a 15 out of a possible 15 when the Brief Interview for Mental Status was done, indicating they were cognitively intact. Section O, Special Treatments, Procedures, and Programs revealed zero days out of the last seven days, a restorative program was performed (for at least 15 minutes a day). The surveyor then reviewed the resident's CNA task sheet (an electronic documentation sheet to indicate completion of identified tasks) for November 2019. The form reflected; ADL- walk in the corridor, every shift. Initials and times reported the task had been completed but did not show resident refusals. A review of the resident's current Care Plan last revised 11/01/19 did not address the resident's participation in an RNP. At 11:49 AM, the surveyor again interviewed the UM, who stated that after the previous days' interview with the surveyor, she had spoken with the resident's CNA. The CNA confirmed to her that the resident was not receiving RNP, because the resident had been refusing to participate. The UM further acknowledged that the CNA was not completing the task form properly and had not indicated the resident had refused RNP. On 11/21/19 at 10:20 AM, the survey team spoke with the Director of Nursing (DON), the Assistant Director of Nursing, and the facility Administrator. The surveyor reviewed the findings that the CNA was not offering the Restorative Nursing Program or documenting the resident's refusal to participate. At 12:00 PM, the DON acknowledged there was no evidence from June of 2019 until present that Resident #88 had been offered RNP or had refused RNP. The DON stated the UM was responsible for ensuring the RNP was being completed and could not provide evidence to indicate the UM was following up on the RNP either. The DON informed the survey team that she had begun extensive training with the staff regarding the RNP. At 12:10 A.M., the surveyor reviewed the facility's policy with a revised date of July 2017 and titled, Restorative Nursing Services. Under Policy Interpretation and Implementation it read: 5. Restorative goals may include, but not limited to supporting and assisting the resident in: b. Developing, maintaining or strengthening his/her physiological and psychological resources; c. Maintaining his/her dignity, independence and self-esteem; N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain a medication error rate below 5%. The surveyors observed 3 nurses administer 26 doses of medication to 4 residents, which resulted in a medication error rate of 7.69%. This deficient practice was evidenced by the following: 1. On 11/18/19 at 8:57 AM, the surveyor observed the Wing One Licensed Practical Nurse (LPN) prepare medications for Resident #268. The medications included multivitamins with minerals, a nutritional supplement, Prostat, a dietary supplement, ascorbic acid, a nutritional supplement, Carvedilol, a blood pressure medication, Eliquis, a medication used to prevent blood clots, Juven powder, nutritional supplement, and Ferrous Sulfate, a nutritional supplement. The surveyor then observed the electronic medication administration record (eMAR), which indicated Resident #268 had a physician's order for Multivitamin plain, not the multivitamin with minerals the LPN had poured to administer to the resident. At 9:10 AM, the surveyor stopped the LPN from continuing the medication pass. The surveyor and the LPN reviewed the resident eMAR together. The LPN acknowledged the order was for multivitamin plain and not the multivitamin with minerals the LPN had initially poured. The LPN stated to the surveyor she had made a mistake and chose the wrong bottle from the bulk stock. At 11:00 AM, the surveyor reviewed the resident's physician's order sheet (POS) for November 2019, which revealed the resident had an order dated 11/6/19 for multivitamins (supplement) to give one tablet by mouth one time a day for one month. 2. On 11/18/19 at 9:47 AM, the surveyor observed the Wing Two LPN (LPN #2) prepare medications for Resident #14. The following medications included; Glipizide, given to treat diabetes, Metformin, a medication to treat diabetes, cranberry capsule, a nutritional supplement, Aspirin, given to prevent heart attacks, Furosemide, a medication to treat skin tissue swelling, Gabapentin, given to treat diabetic nerve pain, methenamine, a medication to prevent urinary tract infections, Vitamin C, a nutritional supplement, Vitamin D, a nutritional supplement. The surveyor observed that LPN #2 did not add the resident's Gabapentin to the medicine cup. The surveyor stopped LPN #2 before she administered the medications. LPN #2 counted the number of medicines in the cup she had prepared and was short one medication. LPN #2 reviewed the resident's medication punch cards, as well as the resident's eMAR, and acknowledged she had not included the Gabapentin. At 11:10 AM, the surveyor reviewed Resident #14's POS for November 2019, which revealed an order initiated 9/20/18 for Gabapentin capsule 100 milligram give one capsule by mouth one time a day for diabetic neuropathy. On 11/21/19 at 9:45 AM, the survey team met with the Administrator, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) and discussed the above concerns. The DON stated the staff was nervous and acknowledged the staff should have double-checked the medications and followed the facility's process and policy for medication administration. At 12:25 PM, the surveyor reviewed of the facility's policy revised December 2012 titled, Administering Medications. The policy read under #7: The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. N.J.A.C. 8:39-29.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to secure 1 of 5 medication carts observed. This deficient practice was evidenced by the following: On 11/19/19 at 11:53 AM, the surveyor found an open drawer of an unattended and unlocked medication cart on Wing Three of the facility. The drawer contained cards that contained a variety of routine medications for the residents on Wing Three. Shortly after the initial observation, a Registered Nurse (RN) exited one of the resident rooms and observed the open drawer on the medication cart. The RN confirmed that the medication cart was open and unlocked and also that it should have been locked. The RN added that a Licensed Practical Nurse (LPN) had been assisting with blood sugar monitoring on the morning of the observation and was responsible for the medication cart. There were no residents in the vicinity of the medication cart. On the same day at 12:12 PM, the surveyor interviewed the RN, and he stated that he was not aware of any mechanical issues with the medication cart and that it was functioning properly. The surveyor and the RN verified that the medication cart locked properly. On 11/21/19 at 10:00 AM, the Assistant Director of Nursing (ADON) confirmed that it was not appropriate for a nurse to leave the medication cart open, unlocked, and unattended. The ADON added, that the LPN had been re-educated on the importance of locking the medication cart when it was out of the sight of the nurse. On 11/21/19 at 12:25 PM, the surveyor reviewed the facility policy and procedure titled, Administering Medications, with a revised date of December 2012, under Policy Interpretation and Implementation number 16 read: During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. N.J.A.C. 8:39 - 29.4(a)

Based on observation, interview, and record review conducted on 11/14/19 in the presence of facility management, it was determined that the facility failed to maintain their Packaged Terminal Air Conditioner (PTAC) units in a safe and optimal condition. This deficient practice was evidenced by the following: While touring the facility, starting at 11:10 AM, the surveyor observed that PTAC units had clogged and dirty filters in the following resident rooms: (newer PTAC units): 501, 502, 503, 504, 505, (506 broken filter frames), (older PTAC units): 201, 202, 203, 205, 208, 214, 101, 105 and 106. When interviewed at the time of the observations, the Maintenance Director agreed that the PTAC filters should not be like that in the facility. A log indicated that PTAC filters were last cleaned in May 2019. No policy and procedure on the maintenance of PTAC units were provided at that time. The Administrator was notified of the deficiency at the Life Safety Code exit conference at 12:30 PM. N.J.A.C. 8:39 - 31.2(e)