COMPLAINT#: NJ00176055 Based on observation, interview, and review of pertinent facility documentation on 1/16/25, it was determined that the facility failed to: a). serve hot foods at an acceptable temperature for the residents, and b). follow its Test Tray Policy. This deficient practice was identified for a test tray that was placed on the second cart that was delivered to the second floor unit during the lunch meal service. In addition to the test tray, the cart contained meals for 9 residents. This was evidenced by the following: Resident #2 was not at the facility at the time of the survey. On 1/16/25, at 10:32 A.M., during an interview with the Food Service Director (FSD), he stated, If I received a complaint about food temperatures, I would do a test tray. The FSD stated that he could not recall when the last complaint was received, nor when he last completed a test tray. No documentation was provided to the surveyor. On 1/16/25, at 11:43 A.M., the surveyor observed the Food Service Director (FSD) calibrate his thermometer at 32 degrees Fahrenheit (F). On 1/16/25, at 12:41 P.M., the dietary aide exited the kitchen with the meal cart, which included the test tray, accompanied by the surveyor and the FSD. At this time the FSD confirmed that he brought the calibrated thermometer with him. On 1/16/25, at 12:44 P.M., the dietary aide delivered the meal cart, which included the test tray, to the hallway of the second floor. On 1/16/25, at 12:46 P.M., the resident meal pass began. On 1/16/25, at 12:53 P.M., the last resident meal tray was served. On 1/16/25, at 12:54 P.M., in the presence of the surveyor, the FSD took the following food temperatures: -Baked Ham: 117.7 degrees F -Roasted Potatoes: 123.9 degrees F -Broccoli: 121.6 degrees F At that time, the surveyor interviewed the FSD regarding what the appropriate food temperature should be when the food was served. The FSD stated that hot foods should be above 135 degrees when served. On 1/16/25, at 4:31 P.M., during an interview with the Administrator, the Director of Nursing, and the FSD, the FSD stated that the above noted foods did not meet the appropriate temperature. He further restated that test trays were only being conducted when a complaint was reported to him. The surveyor reviewed the facility's undated Food Temperatures and Holding Policy, which indicated that, Hot food should arrive to the resident above 135 degrees F. The surveyor reviewed the facility's undated Test Tray Policy, which indicated that test trays were to be completed weekly at random mealtimes. The policy further revealed that the Test Tray Forms would be kept on file for one year. NJAC 8:39-17.4 (a)

COMPLAINT #: NJ00175673 Based on interview, employee file review, and review of other pertinent documents on 7/23/24, it was determined that the facility failed to obtain and keep a record of an employee certification verification and to implement their Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This deficient practice was identified for 1 of 3 sampled agency employees (Certified Nursing Assistant #1) during the employee file review. The deficient practice was evidenced by the following: Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed on 5/2023, indicated .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to .e. staff from agencies .2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents .4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property . On 7/23/24, the surveyors reviewed 3 sampled agency employees and reviewed their pre-employment file. A review of CNA #1's employee file (EF) revealed that an orientation checklist was done on 5/7/2024 by the facility. The EF further revealed the CNAs Profile compiled on 5/23/24, obtained from the Agency Company. The Profile revealed that CNA #1's credential was created on 4/24/23, the credential indicated that her License Status was Active. The Profile further revealed that the CNAs Background Check was completed on 12/19/23. During an interview conducted by the surveyors on 7/23/24 at 12:53 p.m. with the Human Resources (HR) and the License Nursing Home Administrator (LNHA). The HR and LNHA stated that when a new agency employee comes in the building, the facility verifies the employee's certification through Online Public Registry (OPR). The HR stated that CNA #1's certification was visually check on or after 5/7/24 (unable to recall exact date). On 7/23/24 at 3:04 p.m., the surveyors contacted New Jersey Department of Health Certificate of Need and Licensing, who confirmed that CNA #1's certification was Suspended since 3/7/24 and this would have been noted if it was verified by the facility in May 2024. The facility was unable to provide documentation evidence that CNA #1's certification was verified before providing care to the residents on 5/22/24 and 6/15/24. Review of the job description Human Resource Director, dated 9/28/2022, indicated Purpose of Your Job Position .is to manage the Human Resources department in accordance with current applicable federal, state, and local standards, guidelines, and regulations. To follow all company policies and apply them uniformly to all employees as directed by your Administrator and the Director of Human Resources. To assure that qualified personnel are interviewed, trained and employed. To timely perform all administrative tasks with regards to personnel actions .Duties and Responsibilities .Administrative Functions .Check applications and references of prospective employees and arrange for interview with department managers as required or requested .Also files applications for positions, by positions or alphabetically, to include job applications, resume, reference checks, etc. of that person meeting eligibility requirements for the position to which they applied .Develop, implement and maintain an adequate personnel filing system that meets the needs of the facility and complies with current employment practices . N.J.A.C 8:39-9.3(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to report an injury of unknown origin in a timely manner for one (Resident (R) 13) out of one resident reviewed for injury of unknown origin out 21 sampled residents. The facility further failed to report an allegation of abuse between R60 and R24 in out of two residents reviewed for abuse in a timely manner out of 21 sampled residents. This failure had the potential to place residents at risk of not receiving appropriate care and protection. Findings include: 1. Review of the Census tab located in the electronic medical record (EMR) revealed R13 was readmitted to the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/29/23 revealed R13 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating the resident was severely impaired in cognition. Review of R13's nurse Progress Note dated 04/15/23 and located in the EMR under the Progress Note tab revealed R13 was found to have bruising on the top of her right hand at 8:30 AM by the Certified Nursing Assistant (CNA) and let the nurse know. Review of an Administrative Progress Note located in the EMR under the Progress Note tab dated 04/15/23 at 1:25 PM revealed the previous Administrator was informed by the nurse on duty of the bruises on the hand of R13. The note indicated R13 had pointed to her hand and told the nurse that, she beat the hell out of me. The police were called, and an investigation was initiated. Review of the Shrewsbury Police Department report provided by the facility dated 04/15/23 revealed the facility called the police at 12:29 PM and officers responded. The report revealed the call was for a welfare check and would be reported to the State Agency (SA). Review of the Reportable Event Record/Report dated 04/16/23 at 12:00 PM provided by the facility revealed the time of event of the unknown injury/bruises was at 5:00 AM on 04/15/23, however was not reported to the SA until the next day on 04/16/23. 2. Review of the admission MDS with an ARD of 06/03/23 located in the EMR revealed R60 had a BIMS) score of three out of 15 indicating severe cognitive impairment. Review of the quarterly MDS with an ARD of 02/29/24 revealed R60 had a BIMS score of two out of 15 indicating severe cognitive impairment. Review of R24's quarterly MDS with and ARD of 03/38/24 revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact. The resident had no behaviors. Review of Progress Note dated 04/07/24 revealed, [R60] wandered to [R24's] room without anybody knowing it. Then someone was yelling for help and aides went to the room and found [R60] on her right side on the floor with her left arm protecting herself. [R24] admitted that she was about to punch [R60] as she is not allowed in her room. This incident was not reported to the SA and R60 continued to wander into residents' room daily. During an interview on 05/24/24 at 7:15 PM the Director of Nursing (DON) stated the facility had questioned the resident [R24] involved with R60 during the 04/07/24 incident, however, the facility did not report the incident to the SA. Review of the Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating policy last reviewed 05/2023 revealed, all reports of resident abuse including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies as required by current regulations. Findings of all investigations are documented and reported. NJAC 8:39-9.4(f)

Based on interview, record review, and facility policy review, the facility failed to thoroughly investigate a resident to resident abuse incident between two (Residents (R) 60 and R24) out of two residents reviewed for abuse out of a sample size of 21. This failure has the potential for further resident-to-resident abuse occurring and not being investigated so interventions can be put in place. Findings include: Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/03/23 and located in the electronic medical record (EMR) revealed R60 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment. Review of the quarterly MDS with an ARD of 02/29/24 revealed R60 had a BIMS score of two out of 15 indicating severe cognitive impairment. Review of R24's quarterly MDS with an ARD of 03/38/24 revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact. The resident had no behaviors. Review of the Progress Note located in the EMR under the Progress Note tab dated 04/07/24 revealed, [R60] wandered to [R24's] room without anybody knowing it. Then someone was yelling for help and aides went to the room and found [R60] on her right side on the floor with her left arm protecting herself. [R24] admitted that she was about to punch [R60] as she is not allowed in her room. The incident was not investigated and R60 continued to wander into residents' room daily. During an interview on 05/24/24 at 7:15 PM the Director of Nursing (DON) stated the facility had questioned the resident [R24] involved with R60 during the 04/07/24 incident, however, confirmed the facility did not complete a thorough investigation. Review of the Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating policy last reviewed 05/2023 revealed, all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's transfer form, the facility failed to notify the Ombudsman program of the transfer of two of five residents (Resident (R) 17 and R38) reviewed for hospitalization out of a sample of 21 residents. This failure has the potential for residents to not be aware of their transfer rights. Findings include: 1. Review of the Progress Notes in the electronic medical record (EMR) revealed, on 04/20/24 R17 was taken to the emergency room (ER) for altered mental status and hypotension. R17 returned to the facility on [DATE]. Review of R17's EMR and hard chart located on the third floor held no documentation related to a transfer notice having been issued to the resident. 2. Review of the Progress Notes in the EMR revealed R38 had a doctor's appointment on 04/02/24 with his primary care provider; during this appointment the physician's office sent the resident to the ER due to tightness in his chest with congestion. R38 was readmitted to the facility on [DATE] with a diagnosis of shortness of breath (SOB.) Review of R38's Progress Notes tab in the EMR revealed no documentation of notification into the responsible party or the attending physician. Review of the Miscellaneous tab in the EMR revealed no documentation related to related to transfer rights. During an interview on 05/24/24 at 8:28 AM, Licensed Practical Nurse (LPN) 2 stated during a normal transfer to the hospital the nurse assigned to the resident would complete the Transfer/Bed Hold notice prior to Hospitalization or Therapeutic Leave form and provide to the resident, or their responsible party if present, or by phone prior to sending the resident out. LPN2 stated a copy would be maintained in the hard chart on the unit and the business office manager would receive a copy of the form. During an interview on 05/24/24 at 2:13 PM, the Business Office Manager (BOM) stated she was responsible for gathering the information from bed hold/transfer notices and entered them into a spreadsheet and sent a copy of the spreadsheet to the Ombudsman related to the acute care transfers. The BOM was unable to locate copies of the notice of transfer for R17 and R38. Review of the form titled Transfer/Bed Hold notice prior to Hospitalization or Therapeutic Leave dated 12/06/19 revealed the form was to be completed and given to the resident or responsible party at the time of the transfer. The form had spaces for the resident's name, resident responsible party, date of transfer, date notice was being issued, and the location to which the resident was being transferred. R17 and R38 did not have a copy of this form in their EMR or hard chart. Review of the facility policy titled, Transfer or Discharge, Emergency last revised 12/01/19 revealed . Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: . prepare a transfer form to send with the resident, notify the representative (sponsor) or other family member . NJAC 8:39-5.1(a) NJAC 8:39-5.3(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure ''Minimum Data Set (MDS)'' assessments accurately reflected residents' status for one of three residents reviewed for elopement from 21 sampled residents (Resident (R) 29). R29's ''MDS'' did not reflect R29's wandering behaviors. This had the potential for R29 to have unmet care needs. Findings include: Review of R29's ''admission Record'' located in the electronic medical record (EMR) under the ''Profile'' tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavior disturbances, repeat falls, and unsteadiness on feet. Review of R29's ''admission Elopement Assessment,'' dated 05/03/24 and located in the EMR under the ''Assessment'' tab, revealed R29 had a history of wandering behaviors in the past month. Review of R29's ''Physician's Orders'' for the month of May 2024, located in the resident's EMR under the ''Orders'' tab, revealed an order dated 05/03/24 for a Wander Guard/Wander Elopement Device due to poor safety awareness every shift check placement and functionality. Review of R29's admission ''MDS'' with an Assessment Reference Date (ARD) of 05/04/24, located in the resident's EMR under the ''MDS'' tab, revealed the resident's wandering behaviors and the physician's order for a wander-guard bracelet were not reflected. During an observation on 05/22/24 at 3:05 PM, R29 was in bed with eyes closed and a wander-guard bracelet on the right ankle. During an interview on 05/24/24 at 9:05 AM, the Unit Manager/Licensed Practical Nurse (UM/LPN) revealed R29 had a history of exhibiting wandering behaviors and had physician orders to wear a wander-guard bracelet. UM/LPN stated the wandering behaviors, and the wander guard bracelet should be documented on the ''MDS.'' During an interview on 05/24/24 at 1:30 PM, the Director of Nursing (DON) revealed that since R29's wandering behaviors were identified in the admission elopement assessment it should have been reflected on the admission ''MDS'' and it was not. Review of the RAI Manual,'' revised October 2023, indicated information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the Interdisciplinary Team completing the assessment. NJAC 8:39-33.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, interview, and observation, the facility failed to discuss and present a copy of the baseline care plan for one of 21 sampled residents (Resident (R) 84) within 48 hours of admission; and for one of 21 sampled residents (R29) the facility failed to address the resident's use of a wander-guard. This failure had the potential for care to be provided that may not be consistent with the resident's goals for care. Finding include: 1. Review of the electronic medical record (EMR) under the Census tab for R84 revealed an admission date of 05/03/24 with the diagnosis of a fractured hip. Review of the Minimum Data Set (MDS) with an Assessment Reference Date of 05/10/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. Review of the EMR Care Plan tab revealed a baseline care plan was created on 05/15/24. During an interview on 05/21/24 at 11:42 AM, R84 and his family member denied knowledge of a baseline care plan to include activities of daily living, toileting, frequency of therapies and goals of care. During an interview on 05/23/24 at 3:00 PM, Minimum Data Set Coordinator, who coordinates assessments and care plans confirmed the nurse that documented the creation of the baseline care plan failed to discuss or present the resident and/or responsible party of the care plan document. 2. Review of R29's ''admission Record,'' located in the EMR under the ''Profile'' tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavior disturbances, repeat falls, and unsteadiness on feet. Review of R29's ''admission Elopement Assessment,'' dated 05/01/24 and located in the resident's EMR under the ''Assessment'' tab, revealed the resident had a history of wandering behaviors in the past month. Review of R29's ''Physician's Orders'' dated 05/03/24 located in the resident's EMR under the ''Orders'' tab revealed order for Wander Guard/Wander Elopement Device due to poor safety awareness every shift check placement and functionality. Review of 29's admission ''MDS'' with an ARD of 05/04/24 located in the EMR under the ''MDS'' tab revealed the resident's wandering behaviors were not reflected. Review of R29's baseline ''Care Plan'' developed on 05/03/24 located in the resident's EMR tab ''Care Plan'' revealed the care plan identified the resident as an elopement risk however the interventions did not include the physicians' order for the resident to wear a wander-guard bracelet. During an observation on 05/22/24 at 3:05 PM, R29 was in bed with eyes closed and a wander-guard bracelet on the right ankle. During an interview on 05/24/24 at 1:30 PM, the Director of Nursing (DON) revealed the floor nurse developed the baseline care plan and the Interdisciplinary Team (IDT) developed the comprehensive care plan. The DON confirmed R29's care plan was not developed to reflect the use of wander-guard bracelet. Review of the facility's policy titled Care Plans, without a review date, directed staff to create a baseline care plan and discuss or present a copy of the care plan to the resident and/or responsible party within 48 hours of the resident's admission. NJAC 8:39-11.1, 11.2 NJAC 8:39-12.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to ensure that one of two residents (Resident (R) 76) reviewed for oxygen therapy from a total sample of 21 residents had nebulizer tubing changed per physician's orders and had an order for oxygen therapy. This had the potential for R76 to develop respiratory issues. Findings include: Review of R76's ''admission Record,'' located in the electronic medical record (EMR) under the ''Profile'' tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD), emphysema, and asthma. Review of R76's ''Physician's Orders,'' dated 04/23/24 and located in the resident's EMR under the ''Orders'' tab, revealed orders to change and date the nebulizer tubing every Wednesday on the 11-7 shift. There were no physician's orders for the resident to receive continuous oxygen therapy. During an observation on 05/22/24 at 10:15 AM, R76 was lying in bed wearing a nasal cannula with oxygen infusing at two liters per minute (lpm). The oxygen tubing had a change date of 05/15/24. The oxygen concentrator had a buildup dust debris around the flow meter; the concentrator machine was sticky to the touch. The concentrator filter had a heavy buildup of dust debris. The nebulizer set up with tubing located at the resident's bedside was dated 05/15/24. During an observation on 05/23/24 at 8:28AM, Licensed Practical Nurse (LPN) 3 confirmed the oxygen tubing and nebulizer tubing for R76 was still dated 05/15/24. The oxygen concentrator filter still had a heavy buildup of dust debris. The concentrator machine was sticky to the touch and had dust debris around the flow meter. LPN3 revealed the night shift was responsible for changing the oxygen tubing on the oxygen concentrator and nebulizer weekly. LPN3 stated the night staff were responsible for cleaning the oxygen concentrator and filter. During an interview on 05/24/24 at 9:05 AM, the Unit Manager/LPN (UM/LPN) revealed the 11-7 shift nurse was responsible for changing the tubing on the oxygen concentrators and nebulizers on a weekly basis. UM/LPN was unaware that R76's tubing had not been changed since 05/15/24. UM/LPN was also unaware that R76 was receiving continuous oxygen therapy without a physician's order. UM/LPN further stated that the maintenance staff was responsible for cleaning the oxygen concentrators. Review of the facility's policy titled ''Oxygen Administration'' with a revision date of 2019 revealed in part ''.Verify that there is a physician's order for oxygen therapy. Review the physicians order or facility policy for oxygen administration .'' NJAC 8:39-19.4

Based on observation, documents review, and interview, the facility failed to assess and document an assessment for the use of one-quarter bed (side) rails and care plan the use of bed rails for one resident (Resident (R) R75) reviewed for bed rails out of 21 sampled residents. This failure had the potential for residents with bed rails to be uninformed of the risk of severe injury and/or death associated with bed rail use. Findings include: Review of the electronic medical records (EMR) under the Census tab revealed R75 revealed an admission date of 04/22/24 with diagnosis including heart surgery and diabetes. Review of the admission Minimum Data Set assessment with an assessment reference date of 04/29/24 revealed R75's Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Review of the EMR Physician's Orders revealed an order dated 04/22/24 for bilateral enablers (quarter) side rails in use as needed for mobility. Review of the EMR Assessment tab and Miscellaneous tab lacked documentation of an assessment for the use of the side rails. Review of the EMR lacked evidence that risk versus benefits were discussed with the resident and informed consent was given. Review of the EMR under the Care Plan tab revealed the use at the side rails was not included in the care plan dated 04/22/24. During an observation on 05/22/24 at 9:43 AM, R75 was resting in bed with one-quarter side rails up on both sides at the head of the bed. During an observation on 05/22/24 at 1:24 PM, R75 was in bed with upper one-quarter side rails up on both sides of the bed. R75 used the right side rail to assist with movement from lying in bed to sitting on the side of the bed. During observation on 05/23/24 at 4:39 PM, R75 was in bed with the upper one-quarter side rails raised. During an interview on 05/24/24 at 6:51 PM, the Administrator confirmed there was no assessment of R75 prior to the use of bed rails and confirmed the facility lacked policies and procedures for the routine maintenance and safety checks for siderails on residents' beds. Review of the undated facility policy titled Bed Safety revealed Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails and an assessment was to be completed to determine the least restrictive means for the resident. NJAC 8:39-27.1(a)

Based on observation, interview, review of the Food Services Director (FSD) job description, and facility policy review, the facility failed to ensure one refrigerator on the second floor in the nourishment room of three refrigerators in the facility observed had all food labeled, dated and was free of dirt and sticky shelves. The facility further failed to ensure a freezer on the third floor nourishment room out of two observed was free of ice buildup. Findings include: During an observation and interview with the Food Services Director (FSD) on 05/24/24 at 7:18 AM of the refrigerator on the second floor revealed the following food items not labeled, dated, and/or expired: 1. There were three to-go containers of beans with rice, a small box containing two pieces of fried chicken, a sub sandwich, a to-go container of pasta with bread with no label or date, a clear gallon-sized bag with fried chicken and a biscuit, two 10 ounce bottles of separated liquids that appeared to be apple juice and orange juice, a container of steak, peppers, and mashed potatoes, a to-go soup container in a plastic bag, a clear bag containing four slices of pizza, a small clear container of fruit, a bag of grapes, a piece of cake wrapped in wax paper, a black bag containing a 32 ounce coffee creamer, a clear bag of chocolate, an eight ounce cup of liquid, a container of fruit, a container of cookies, a clear bag of salad, and bag of almonds all with no label or date. There was a clear container of 1.5 pounds (lbs.) of cut watermelon with an expiration date of 05/16/24, a one-third full two-liter bottle of cream soda with an expiration date of 05/20/24, a to-go wrap with an expiration date of 05/16/24, and a half of a peanut butter and jelly sandwich with an expiration date of 05/22/24. The refrigerator was observed to have dirty/sticky shelves. The FSD confirmed the above observations and confirmed the food in the refrigerators should be labeled, dated and food with expiration dates should be thrown out. 2. During an observation on 05/24/24 at 7:51 AM of the third-floor nourishment room, one of two freezers had ice build-up throughout the freezer. The FSD confirmed the findings and revealed the door to the freezer did not seal properly. Review of the undated Receiving & Storage Policy provided by the facility revealed it is the responsibility of the facility to, ensure that all foods follow the first in first out (FIFO) method and are labeled and dated. Review of the Foods Brought by Family/Visitors last reviewed 05/2023 revealed, containers will be labeled with the resident's name, the item, and the use by date. The policy further revealed the nursing staff will discard perishable foods on or before the use by date. Review of the undated Dining Services FSD job description provided by the facility revealed it is the responsibility of the FSD to direct and personally engage in food procurement and storage. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure personal protective equipment (PPE) was readily available and that staff donned (put on) the appropriate PPE for two of five residents (Resident (R) 9 and R140) on Enhanced Barrier Precautions (EBP) out of a total sample of 21 residents. This failure had the potential to increase the risk of the spread of infections. Findings include: 1. Review of R9's ''admission Record'' located in the resident's electronic medical records (EMR) ''Profile'' tab revealed R9 was admitted to the facility on [DATE] with diagnoses that included cellulitis of right lower leg. Review of R9's ''Physicians Orders'' dated 05/06/24 located in the resident EMR tab ''Orders'' revealed the resident received dressing changes to right lower leg with Medi Honey ointment (antimicrobial ointment). During an observation on 05/21/24 at 11:14 AM, R9's room had signage posted on the door frame that indicated the resident was on Enhanced Barrier Precautions. The signage directed the staff to perform hand hygiene before and after entering the room. Staff were to wear gloves and gowns when performing direct care. The isolation cart outside R9's room contained only gloves and blue face masks, but no gowns. Certified Nurse Aide (CNA) 7 performed hand hygiene and donned gloves and entered the resident's room. CNA7 assisted R9 with personal hygiene and dressing. During an interview on 05/21/24 at 2:30 PM, CNA7 acknowledged R9 was on Enhanced Barrier Precautions but there were no gowns available on the isolation cart when she provided cares to R9. CNA7 stated she was unsure who was responsible for stocking the isolation carts. 2. Review of R140's ''admission Record'' located in the resident's EMR tab ''Profile'' revealed the resident was admitted to the facility on [DATE]. Review of R140's ''Physician Orders'' dated 05/19/24 located in R140's EMR ''Orders'' tab revealed R140 was placed on Enhanced Barrier Precautions related to wounds. During an observation on 05/21/24 at 12:45 PM, R140 room's had signage on the doorframe indicating R140 was on Enhanced Barrier Precautions. There was no PPE available on the isolation cart outside the resident's room. Licensed Practical Nurse (LPN) 3 performed hand hygiene and donned gloves and entered R140's room without a gown to perform wound care on R140's feet. During an interview on 05/21/24 at 3:20 PM, LPN3 confirmed R140 was on Enhanced Barrier Precautions due to the wound on his heels that required dressing changes. LPN3 stated there were no gowns available on the isolation cart. LPN3 stated R140 was in hurry to be discharged and that was why she did not attempt to obtain an isolation gown. During an interview on 05/24/24 at 9:05 AM, Unit Manager/LPN (UM/LPN) revealed she was responsible for ensuring the isolation carts on the unit had adequate PPE supplies. UM/LPN confirmed she had not restocked the isolation carts on 05/21/24. NJAC 8:39-19.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, the facility failed to provide copies of the facility's bed hold policy to four of five residents (Resident (R) 343, R17, R38 and R27) reviewed for hospitalization out of a sample of 21 residents. This failure created the potential for residents and/or responsible parties to not have the information needed to safeguard their return to the facility. Findings include: 1. Review of R343's electronic medical record (EMR), under the Census tab revealed an admission date of 04/30/24, a discharge to the hospital date of 05/02/24, and readmission to the facility on [DATE]. The clinical record lacked evidence that the resident and/or responsible party was given a copy of the facility's bed hold policy when the resident was transferred to the hospital. During an interview on 05/24/24 at 10:14 AM, the Administrator confirmed the facility failed to provide a copy of the bed hold policy to residents and/or the responsible party upon transfer to the hospital. 2. Review of the Progress Notes in the electronic medical record (EMR) revealed, on 04/20/24, R17 was taken to the emergency room (ER) for altered mental status and hypotension. R17 returned to the facility on [DATE]. Review of R17's EMR or hard chart located on the third floor held no documentation bed hold information had been issued to the resident. During an interview on 05/24/24 at 8:28 AM, Licensed Practical Nurse (LPN) 2 stated during a normal transfer to the hospital the nurse assigned to the resident would complete the bed hold/transfer notice and provide to the resident or their responsible party if present or by phone prior to sending the resident out. LPN2 stated a copy would be maintained in the hard chart on the unit and the business office manager would receive a copy of the form. During an interview on 05/24/24 at 2:13 PM, the Business Office Manager (BOM) stated she was responsible for gathering the information from bed hold/transfer notices and entered them into a spreadsheet and sent a copy to the Ombudsman related to the acute care transfers. The BOM was unable to locate copies of the bed hold notices for R17. 3. Review of the Progress Notes in the EMR revealed R38 had a doctor's appointment on 04/02/24 with his primary care provider; during this appointment the physician's office sent the resident to the ER due to tightness in his chest with congestion. R38 was readmitted to the facility on [DATE] with a diagnosis of shortness of breath (SOB.) Review of R38's Miscellaneous tab in the EMR revealed no documentation bed hold information had been issued to the resident. During an interview on 05/24/24 at 2:13 PM, the BOM stated was unable to locate copies of the bed hold notices for R38. 4. Review of the Census tab located in the EMR revealed R27 was admitted to the facility on [DATE]. Review of Progress Notes located in the EMR revealed R27 was transferred to the hospital due to uncontrolled high blood pressure and dizziness on 10/29/23 and readmitted to the facility on [DATE]. Further review revealed R27 was transferred to the hospital due to generalized weakness in both legs on 12/26/23 and readmitted to the facility on [DATE]. Review of the EMR revealed no documentation bed hold information had been issued to the resident. During an interview on 05/24/24 at 12:15 PM, the Regional Nurse supplied a transfer notice and Ombudsman notice for R27's hospital transfers. The Regional Nurse stated R27 did not receive a bed hold notice for the two hospital transfers. Review of the form titled Transfer/Bed Hold notice prior to hospitalization or therapeutic leave dated 12/06/19 revealed the form was to be completed and given to the resident or responsible party at the time of the transfer. The form had spaces for the resident's name, resident responsible party, date of transfer, date notice was being issued, and the location to which the resident was being transferred. Review of the facility policy titled, Bed-Holds and Returns last revised 10/2019 stated, . Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: . rights and limitations of the resident regarding bed-holds; the reserve bed payment policy as indicated by the state plan (Medicaid residents); .the details of the transfer (per the Notice of Transfer) . NJAC 8:39-5.1(a) NJAC 8:39-5.3(b)

Based on record review, interview, and review of facility policy, the facility failed to ensure that seven of eight supplemental residents (R19, R51, R40, R7, R16, R49, and R58) receive adequate assistance obtaining weekly showers. During the group meeting the residents voiced concerns about not getting scheduled showers. This failure has the potential for the residents to experience a decline in their ability to perform their ADLs. Findings include: Review of the facility policy titled ''Activities of Daily Living, Supporting'' updated October 2021 documented as follows ''Residents will be provided with care, treatment and services as appropriate lo maintain or improve their ability to carry out activities of daily living (ADLs) .'' During a group meeting held on 05/23/24 at 2:30 PM, seven (R19, R51, R40, R7, R16, R49, and R58) of the eight residents attending the meeting voiced concerns about not receiving showers according to their wishes. The following comments were made during the group meeting. R19 stated he was told that a staff member must be present to assist with showers and there was not enough staff available to assist the resident with showers. R19 stated it had been several weeks since he had a shower. R51 stated all needed was for the staff setup the shower room for her and she could take the shower alone. R51 stated she was told there were not enough staff to help with her shower. R51 confirmed it had been several weeks since she had a shower. R40 stated he had been told the same thing about not enough staff to assist with showers. R7, R16, R49, and R58 agreed with what R19, R51, and R40 stated. The following residents agreed it had been several weeks since they were offered a shower according to their preference: R7, R16, R19, R40, R49, R51, and R58. 1. Review of R7 annual Minimum Data Set'' (MDS) with an Assessment Reference Date (ARD) of 02/07/24, located in R7's electronic medical records (EMR) ''MDS'' tab, revealed R7 had a Brief Interview for Mental Status (BIMS) score of 15 out 15 points which indicated the resident's cognition was intact. The resident required substantial to maximum assistance with showers. Review of R7's ''Care Plan'' with a revision date of 11/02/23, located in R7's EMR ''Care Plans'' tab, revealed R7 was scheduled for showers on the Tuesday and Fridays on the 3-11 shift with the assistance of one staff person. Review of R7s ''Bath/Shower Sheets'' for the month of May 2024 provided by the facility revealed the resident had only received one shower since 05/01/24. 2. Review of R16's Medicare MDS'' with an ARD of 05/20/24, located in R16's EMR MDS tab revealed R16 had a BIMS score of 15 out of 15 points which indicated R16's cognition was intact. R16 was assessed to require substantial to maximum assistance with showers and toileting. Review of R16's ''Care Plans'' with a revision date of 11/02/23, located in the resident's EMR ''Care Plans'' tab, revealed R16 was scheduled to receive showers on Tuesdays and Fridays on the 3-11 shift with the assistance of one staff person. Review of R16's ''Bath/Shower Sheets for the month of May 2024 provided by the facility revealed R16 had not received any showers since 05/01/24. 3. Review of R19's annual MDS'' with an ARD of 05/07/24, located in the resident's EMR ''MDS'' tab, revealed R19 had a BIMS score of 15 out of 15 points which indicated the resident's cognition was intact. R19 was assessed to require substantial to maximum assistance with showers and toileting. Review R19's ''Care Plan'' with a revision date of 11/21/23, located in the resident's EMR ''Care Plans'' tab, revealed R19 was to receive showers on Wednesday and Saturdays on 7-3 shift with the assistance of one staff member. Review of R19's ''Shower Sheets'' for the month of May 2024 provided by the facility revealed the resident has not received any showers since 05/01/24. 4. Review of R40's Medicare MDS'' with an ARD of 03/31/24, located in R40's EMR ''MDS'' tab revealed R40 had a BIMS score of 10 out of 15 points which indicated R40's cognition was moderately impaired. R40 was assessed to require substantial to maximum assistance with toileting. The resident was not observed for showers during the assessment period. Review of R40's ''Care Plan'' with a revision date of 02/14/24, located in R40's EMR ''Care Plans'' tab, revealed R40 was scheduled for showers on Wednesdays and Saturdays on the 3-11 shift with the assistance of one staff member. Review of R40's ''Shower Sheets'' for the month of May 2024 provided by the facility revealed the resident had not received any showers since 05/01/24. 5. Review of R49's annual MDS'' with an ARD of 02/17/24, located in R49's EMR ''MDS'' tab revealed R49 had a BIMS score of 15 out 15 points which indicated R49's cognition was intact. R49 did not require assistance with showers. Review of R49's ''Care Plan,'' with a revision date of 01/04/24, located in R49's EMR ''Care Plans'' tab, revealed R49 required the assistance one person for showers. The care plan did not identify the resident schedule shower days. Review of R49's ''Shower Sheets'' for the month of May 2024, provided by the facility, revealed R49 had not received any showers since 05/01/24. 6. Review of R51's quarterly MDS'' with an ARD of 02/13/24, located in R51's EMR ''MDS'' tab, revealed R51 had a BIMS score of 13 out 15 points which indicated R51's cognition was intact. R51 was assessed to not require assistance with showers. Review of R51's ''Care Plan'' with a revision date of 02/21/24, located in R51's EMR ''Care Plans'' tab, revealed R51 required the assistance of one staff person for showers. The care plan did not identify R51's scheduled shower days. Review of R51's ''Shower Sheets'' for the month of May 2024, provided by the facility, revealed R51 had not received any showers since 05/01/24. 7. Review of R58's annual MDS'' with an ARD of 02/23/24, located in R58's EMR ''MDS'' tab, revealed R58 had a BIMS score of eight of 15, which indicated R58's cognition was moderately impaired. R58 was assessed as not requiring any assistance with showers. Review of R58's ''Care Plan'' with a revision date of 04/13/23, located in R58's EMR ''Care Plans'' tab, revealed R58 was scheduled for showers on Tuesdays and Fridays on the 3-11 shift with assistance of one staff member. Review of R58's ''Shower Sheets'' for the month of May 2024 provided by the facility revealed R58 had only received two showers since 05/01/24. During an interview on 05/23/24 at 3:54 PM, Certified Nurse Aide (CNA) 1 revealed the residents use the showers in their rooms. The residents are scheduled for showers twice a week on each shift. Those scheduled showers are attached to the CNAs assignment sheets. The CNAs are responsible for assisting those residents that require assistance. An interview with the Director of Nursing (DON) on 05/24/24 at 1:30 PM revealed the residents are scheduled to take showers twice a week in their rooms. The DON reviewed the residents' showers and stated that lacked documentation of the residents receiving the scheduled showers. The DON stated it was the facility's expectation residents would receive showers as they were scheduled. An interview on 05/24/24 at 1:36 PM with the Administer revealed the issue of the residents receiving the showers was discussed with the staff. The Administrator was asked to interpret the shower sheets for the month of May. The Administrator stated that it was possible that the CNAs did give the showers but forgot to document the residents received the showers. The Administrator was reminded that this was a concern voiced by the residents. The Administrator stated this lack of documentation indicates that a performance improvement plan needs to be developed. NJAC 8:39-27.1(a) NJAC 8:39-27.2

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) implement infection control measures for the handling and storage or respiratory equipment and b.) have a physician order for the use of oxygen for 1 of 2 residents reviewed for respiratory care, (Resident #54). This deficient practice was evidenced by the following: During the initial tour of the 3rd floor on 2/28/22 at 10:44 AM, Resident #54 was observed with a nasal cannula in his/her nose connected to wall oxygen regulator at 2 liters per minute. The tubing had a piece of white tape dated 2/14/22. Resident #54 said he/she does wear oxygen sometimes. On 3/3/22 at 10:14 AM, Resident #54 was observed lying in bed without the oxygen. The oxygen tubing was observed to be draped over a back scratcher on the bedside table, uncovered and exposed. On 3/3/22 at 10:15 AM, the surveyor along with the Registered Nurse Unit Manager (RNUM #1) went to Resident #54's room. RNUM #1 said no, the tubing is not supposed to be hanging (over back scratcher exposed to air). It is supposed to be in bag. I will get a new one. A review of the Resident Face Sheet revealed Resident #54 was admitted to the facility with diagnoses including but not limited to: Acute and Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD). A review of the most recent Minimum Data Set (MDS), an assessment tool dated 1/25/22, revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating Resident #54 was cognitively intact. The MDS further showed under section O that Resident #5t4 used oxygen while a resident. A review of the current Physician's Orders did not include a physician order for oxygen use. A review of a Progress Note (PN) dated 1/22/22 at 1:36 PM, revealed as needed oxygen in use via nasal cannula. A PN dated 2/20/22 timed at 1:20 PM, indicated continuous oxygen via nasal cannula in place. A PN dated 3/1/22 timed at 11:02 AM, revealed resident was placed on 4 liters of oxygen due to low pulse oximetry (blood oxygen level). Resident Currently on 2 liters. A PN dated 3/2/22 timed at 11:19 AM, revealed O2 (oxygen) noted to be 98% via nasal cannula 2 liters. A review of a care plan revealed a Focus area of Oxygen Use with an effective date of 11/5/21. Interventions included Provide oxygen as ordered by MD (Medical Doctor). On 3/3/22 at 10:19 AM, RNUM #1 reviewed Resident #53's Physician Orders and said he/she should have a PRN (as needed) order. She went on to say there was one, but I don't see an order. She went on to say there definitely should have been a physician order. I don't know why it was discontinued on 2/14/2021. During an interview with the surveyor on 3/3/22 at 10:47 AM, the Director of Nursing (DON) said Resident #54 uses oxygen intermittently and will ask staff to take it off and put it back on. The DON said when the oxygen is taken off, we should have the cannula in a bag. She said it was nursing discretion to put oxygen on and absolutely should be contacting a physician to obtain order. A review of a facility policy titled (facility name) Oxygen Therapy, Precautions, and Adverse Reactions with a last revised date of 9/2021, revealed under the Procedure section 2. Obtain a physician's order for oxygen percentage and mode of administration. NJAC 8:39-27.1(a)

Based on interview, record review and review of other facility documentation, it was determined that the facility failed to address the recommendation identified by the Consultant Pharmacist. This deficient practice was identified for 1 of 5 Residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review (Resident #37) and was evidenced by the following: According to the Resident Face Sheet Resident #37 was admitted to the facility with diagnoses that included hypothyroidism (a problem with the thyroid gland) and renal osteodystrophy (a bone disease). A review of the Physician Order Activity Detail Report with active orders as of 2/25/2022, revealed a physician's order dated 2/25/2022, for the resident to receive calcium acetate 667 milligrams capsule 3 times per day with meals for renal osteodystrophy. There was another physician's order dated 2/25/2022, for the resident to receive levothyroxine 88 micrograms once daily for hypothyroidism. A review of the Consultant Pharmacist (CP) Evaluation dated 1/17/2022, indicated separate levothyroxine and calcium acetate by 4 hours. Upon review of the January and February 2022 Medication Administration Record (MAR) for Resident # 37, the levothyroxine was scheduled to be administered at 6:30 am and the calcium acetate was scheduled to be administered at 8:00 am, 12:00 pm, and 5:00 pm. The first calcium acetate dose is scheduled to be given 1.5 hours after the levothyroxine not 4 hours as recommended by the CP. On 03/04/22 at 10:21 AM, the surveyor and the Registered Nurse Unit Manager (RNUM #2) reviewed the MAR for Resident # 37. He stated that the levothyroxine and calcium was not separated by 4 hours as recommended. During an interview with the surveyor on 03/04/22 at 12:42 PM, the Director of Nursing (DON) stated that the Assistant Director of Nursing (ADON) spoke with the physician, and the physician did not want to follow the recommendation of the CP. She further stated that the ADON forgot to write a note saying same. During an interview with the surveyor on 03/07/22 at 10:56 AM, the corporate nurse confirmed that there is no documentation that the pharmacy recommendation was acknowledged. During an interview with the surveyor on 03/08/22 at 11:20 AM, the ADON acknowledged that there is no documentation that the physician accepted or denied the pharmacy consultant recommendations. A review of the Consultant Pharmacist Services policy with an effective date of 4/2021, the Consultant Pharmacist will provide specific activities related to medication regimen review including: 1. A documented review of the medication regimen based on applicable federal and state guidelines. NJAC 8:39 - 27.1(a)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to ensure that as-needed (PRN) psychotropic medications were administered for no more than 14 days without further evaluation with corresponding documentation. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medication use (Resident #35) and was evidenced by the following: On 2/28/2022 at 10:46 AM the surveyor observed Resident #35 lying in bed. Resident #35 was complaining of stomach pain. The certified nursing assistant alerted the assigned nurse in the presence of the surveyor of Resident #35's complaint. Resident #35 stated to the surveyor that he/she had a wound on their back that started prior to admission to facility and has been going on for weeks. According to the Resident Face Sheet, Resident #35 was admitted to the facility after hospitalization for displaced intertrochanteric fracture of right femur (right hip fracture) and generalized anxiety disorder. A review of the admission Minimum Data Set (MDS), an assessment tool, revealed that Resident #35 had a Brief Interview for Mental Status score of 15/15 indicating the resident was cognitively intact. In addition, according to section I of the MDS, Resident #35 had a current diagnosis of anxiety disorder and section N revealed Resident #35 had received antianxiety medications on 3 out of 7 days during the look back period. According to Resident #35's Care Plan Activity Report, Resident #35 had a care plan under the heading Focus: MOOD STATE: Anxiety/Psychotropic Medications, Effective: 1/9/2022. The MOOD STATE care plan revealed that Resident #35 was on anti-anxiety medication and target symptoms of anxiety will be managed with the use of minimal dose of the psychotropic medication. During a review of Resident #35's Physician Order Activity Detail Report revealed the following order dated 2/19/22, Lorazepam (Ativan) 0.5 mg (milligram) give 1 tablet (0.5 mg) by oral route every 12 hours for 14 days as needed. On 03/02/22 12:03 PM the surveyor reviewed the 1/7/2022 Consultant Pharmacist (CP) physician recommendations sheet for Resident #35. The following recommendation was documented as follows: 1. In the geriatric population, Lorazepam increases the risk of cognitive impairment, delirium, falls, and fractures. If continuing present therapy, please document the risk vs. benefit. There was no evidence that the physician accepted or did not accept the recommendation, as neither box was checked off and no comment or reason for not accepting the recommendation was documented. A physician signature was observed; however, it was undated. On 3/2/2022 at 1:43 PM, the surveyor requested documentation of the physician's rationale for the 1/7/2022 CP recommendation for Lorazepam from facility staff. During an interview with the surveyor on 3/3/2022 at 10:39 AM, the Director of Nursing (DON) stated I found additional documentation in the chart for Resident #35. The nurse practitioner documented on 1/20/2022 that resident #35 can be very anxious at times and the nurse practitioner recommended continue Ativan prn on 1/20/2022. So that would be the rationale for the use of the Ativan. The surveyor asked the DON what the ordering physician responsibility would be for continued use of PRN psychotropic medications beyond 14 days. The DON replied, We (the facility) are responsible for documenting the behaviors during the 14 days. After the 14 days are up, we speak with the physician, and he/she will decide whether to continue the prn order. The surveyor again questioned what responsibility the ordering physician would have to continue the use of a prn psychotropic medication beyond the initial 14-day period. The DON was unable to provide any further information. A review of the Medication Administration Records (MAR) for Resident #35 dated January 2022, revealed that Resident #35 had the following order and received prn Lorazepam on the following dates: Lorazepam 0.5 mg tablet give 1 tablet (0.5 mg) by oral route every 12 hours for 14 days as needed Anxiety. Start Date: 01/06/2022 (admission). Resident #35 was administered prn Ativan on the following dates: 1/8, 1/9, 1/12, 1/13, 1/14, 1/15, 1/16, 1/17, and 1/18/2022. Review of the February 2022 MAR revealed that Resident #35 had the following orders and received prn Lorazepam on the following dates: Lorazepam 0.5 mg tablet give 1 tablet (0.5 mg) by oral route every 12 hours for 14 days as needed for anxiety. Start Date: 2/5/2022. Resident #35 received prn Ativan on the following dates: 2/5, 2/6, 2/7, 2/8, 2/9, 2/15, 2/16, 2/17, and 2/18/2022. Lorazepam 0.5 mg tablet give 1 tablet (0.5 mg) by oral route every 12 hours for 14 days as needed. Start Date: 2/19/2022. Resident #35 received prn Ativan on the following dates: 2/19, 2/10, 2/21, 2/23, 2/24, 2/26, 2/27, 2/28, and 3/1/2022. A review of a Nurse Practitioner (NP) Progress Note, dated 1/20/2022 timed at 8:44 PM for Resident #35 revealed under the objective section that Resident #35 can be very anxious at times, per RN (registered nurse.) Under the assessment/plan section concerning anxiety the NP wrote, cont (continue) Ativan (Lorazepam) PRN. Resident #35 had additional orders for prn Ativan on the following dates: 2/5/2022 and 2/19/2022 without a documented rationale. On 3/7/2022 at 10:55 AM the surveyor conducted an interview in the presence of the facility DON, Administrator and Assistant Director of Nursing (ADON). The surveyor questioned if the facility had a policy and procedure on the process of responding to the CP monthly medication regimen review. The facility responded, We do not have a policy and procedure for how we respond to the CP monthly recommendations. I can tell you what we do. If it is clinically significant the CP lets us know right away and we follow up. The list of recommendations the CP sends to the facility after their monthly review is provided to staff and we give our staff a week to complete the recommendations. The DON or designee (ADON) is responsible for ensuring that all CP recommendations have been addressed at the end of the month. We do not have a policy or procedure for our end of the process. On 3/9/2022 at 9:43 AM the surveyor conducted an additional interview in the presence of the facility Administrator, DON, Corporate [NAME] President of Nursing (CVPN), and Assistant Administrator. The CVPN provided the following, It was documented on admission that the resident was anxious. The surveyor questioned the CVPN whether Resident #35 would have required a documented physician rationale for the additional 14-day PRN orders for Lorazepam on 2/5/2022 and 2/19/2022. The CVPN responded, Yes. The surveyor then questioned the CVPN if the facility was able to find any documented physician rationale for the continued use of prn Lorazepam for the ordered dates of 2/5/2022 and 2/19/2022. The CVPN/facility was unable to provide documented written rationales for prn Lorazepam ordered for Resident #35 on 2/5/2022 and 2/19/2022. A review of a facility policy titled Unnecessary Drugs - Psychotropics, Last Revised: 11/2017, reveled under the Purpose heading: Ensure that each resident's entire drug/medication is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. In addition, the following was revealed under the Policy heading: 4. PRN orders for psychotropic drugs are limited to 14 days. Except as provided in part 5, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. 5. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physicians or prescribing practitioner evaluates the resident for the appropriateness of that medication. N.J.A.C. 8:39-27.1(a)

**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 handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: 1 On 2/28/2002 at 12:01 PM the surveyor observed the Dietary Supervisor (DS) monitor food temperatures prior to the lunch meal in the main dining room. The DS performed hand hygiene with alcohol-based hand rub and then donned a clean pair of disposable gloves. The DS then removed a digital thermometer from a sealed plastic package. The DS sanitized the thermometer probe with an alcohol pad and then proceeded to insert the thermometer probe into the pan of Key [NAME] Vegetables on the steam table. The DS obtained a final temperature of 111.3 degrees Fahrenheit (F). The DS removed the thermometer and proceeded to clean the thermometer probe with an alcohol pad. The surveyor questioned the DS whether the temperature of the Key [NAME] Vegetables was safe to serve to the residents in the dining room for the lunch meal. The DS replied, Yes. The DS then inserted the thermometer probe into the meatballs and marinara sauce. The DS obtained a final temperature of 95.0 F. The surveyor questioned the DS if the temperature was appropriate to serve the meatballs and marinara sauce. The DS responded, Yes. The DS sanitized the thermometer probe and proceeded to take the temperature of the spaghetti noodles. A final temperature of 95.0 F was obtained, and when questioned if the temperature was safe to serve the DS responded, Ahh, yes. Spaghetti doesn't hold temperature for long. The DS then proceeded to clean the thermometer probe with an alcohol pad and inserted the thermometer probe into the chicken and corn soup. A final temperature of 146.0 F was obtained. The surveyor asked the DS if the soup was at a proper temperature to serve and the DS responded, Yes. After cleaning the thermometer probe the DS proceeded to take the temperature of the chicken noodle soup. A final temperature reading of 127.1 F was obtained. When questioned whether the final temperature of the soup was safe to serve the DS replied, Yes, it is ok to serve. On 2/28/2022 at 12:10 PM the surveyor observed the DS preparing to plate and serve the above referenced food to the residents in attendance in the main dining room. The surveyor proceeded to question the DS what the minimum hot holding temperature was for the hot foods on the buffet line. The DS replied, The minimum hot holding temperature is 140 F and above. The soup is ok, I'm going to take the food back to the kitchen and get hotter food. The DS further replied that the kitchen was replacing the food that was below the minimum hot holding temperature and would bring the residents' new food. The surveyor questioned the DS what the process was for reheating foods that don't meet the minimum hot holding temperature. The DS stated, All foods must be 140 F. The surveyor further questioned what time the lunch menu items had been prepared and how long the foods had been held prior to the lunch meal. The DS responded, I'm not sure I just came in to work. The Director of Food Service (DOFS) entered the main dining room on 2/28/2022 at 12:18 PM. The DOFS replaced the following foods on the steam table from the kitchen and proceeded to take temperatures of the following foods: 1. Spaghetti: The DOFS obtained a final temperature of 106.5 F. The DOFS stated, It should be at least 140 F. I will reheat. 2. Meatballs: 155 F 3. Key [NAME] Vegetables: 162 F At 12:24 PM on 2/28/2022 the surveyor questioned the DOFS what the process was for reheating hot foods that were under 135 F. The DOFS responded, The food needs to be reheated to a minimum of 165 F for 15 seconds before we can serve the food. The DS should not have served those foods because they were below the minimum hot holding temperature of 135 F. The DOFS further stated, She is a supervisor, and she should know that. A review of a facility policy titled Serving Food, Last Revised: 08/2013, revealed Under the heading Purpose section To ensure that all foods are served in a sanitary manner to prevent food-born illnesses. To ensure that all foods are presented properly. To ensure the quality of all food. In addition, the following was revealed under the Procedure heading: Step 3. Prior to services all food temperatures will be taken and documented in the Food Temperature Log. Hot foods must be 140 F or above. Cold foods must be 41 F or below. If foods are not in range corrective actions must be taken. All corrective actions must be documented. N.J.A.C. 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to conduct and document on-going re-evaluation of the need for or reduction of restraints for 1 of 1 resident reviewed for restraints (Resident #17). This deficient practice was evidenced by the following: Review of the Resident Face Sheet revealed that Resident #17 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Alzheimer's disease. Review of the resident's Quarterly Minimum Data set (MDS), an assessment tool dated 09/02/19, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) of 99 which indicated the resident was unable to complete the interview. The MDS also revealed there resident needed extensive assistance of two or more staff to transfer, did not walk in the room or corridor on their own and was totally dependent on staff for locomotion on and off the unit. The MDS also revealed the resident had a trunk restraint; no symptoms noted of being short-tempered or easily annoyed and no behaviors of physical, verbal or other noted. Review of the resident's Annual MDS, dated [DATE], revealed Resident #17 had a BIMS of 99 which indicated the resident was unable to complete the interview. The MDS also revealed that the resident needed extensive assistance of two or more staff to transfer, did not walk in the room or corridor on their own and was totally dependent on staff for locomotion on and off the unit. The MDS also revealed the resident had a trunk restraint; no symptoms of being short-tempered or easily annoyed and no behaviors of physical, verbal or other noted. The MDS also revealed a fall narrative that the resident had been free of falls this quarter; used a lap buddy (cushioned restraint that spans across the residents lap) and that there had been no ill effects related to the use of the lap buddy. The MDS also revealed a physical restraints narrative to use the resident's lap buddy when appropriate; no harm or ill effects related to the use of restraint; free from falls this quarter and resident had a tendency to stand unassisted and is restless. Review of the Physician's order, dated 01/26/17, revealed a lap buddy restraint while in the wheelchair. Release and remove the restrictive device for care and skin checks and as appropriate. Review of the Care Plan (CP) for restrictive devices/alternatives, dated effective 4/22/16, revealed re-evaluation at least monthly for need of restraint and for the restraint reduction. The surveyor reviewed Resident #17's electronic medical record (EMR), and was unable to find any monthly documented re-evaluation of the need or reduction of the lap buddy. On 11/18/19 at 10:19 AM, the surveyor observed Resident #17 in the third floor day room, in a wheelchair. Resident #17 had a pink lap buddy that was attached to the resident's wheelchair. On 11/19/19 at 10:48 AM, the surveyor observed Resident #17 in the third floor unit day room in the wheelchair with the lap buddy across the wheelchair. Resident #17 was sleeping. On 11/21/19 at 10:35 AM and 12:04 PM, the surveyor observed Resident #17 in the 3rd floor unit day room by a table. Resident #17 had a lap buddy across the wheelchair. Resident #17 was calm during the observations. On 11/22/19 at 9:33 AM, the surveyor observed Resident #17 in the 3rd floor unit day room eating breakfast with staff assistance. Resident #17's lap buddy was across the wheelchair and the resident was calm. On 11/25/19 at 8:50 AM, the surveyor observed Resident #17 in the 3rd floor unit day room with the lap buddy across the wheelchair. Resident #17 had his/her eyes closed. During an interview with the surveyor on 11/25/19 at 9:00 AM, the Certified Nursing Assistant (CNA) stated the lap buddy was usually on at all times. The CNA stated they can feed the resident without the lap buddy but the resident sometimes gets fidgety. The CNA stated the staff can take the lap buddy off for care sometimes. During an interview with the surveyor on 11/25/19 at 9:08 AM, Resident #17's direct care Registered Nurse (RN) stated the resident used the lap buddy for agitation and to prevent the resident from getting up. The RN stated the resident had not felt good for a while and therefore had been calm. The RN stated the lap buddy should be taken off every few hours. The RN stated that nursing and the Unit Manager (UM) would be responsible for re-evaluation of the use of the lap buddy and to initiate a change in the care plan if needed. During an interview with the surveyor on 11/25/19 at 9:16 AM, the RN/UM stated she had just started at the facility and didn't know anything about Resident #17. During an interview with the surveyor on 11/25/19 at 9:27 AM, the Director of Nursing (DON) stated the monthly re-evaluation was in the nursing progress notes because nursing was responsible for the re-evaluations. The DON accessed the computer in the presence of the surveyor and was unable to provide any monthly re-evaluation note. The DON stated the UM would do the re-evaluation and the staff would discuss it as a team. The DON stated that the re-evaluation should entail that the lap buddy would be removed and the resident monitored for their behaviors. The DON stated that the results of monthly evaluation should be documented in the progress notes. During an interview with the surveyor on 11/25/19 on 9:54 AM, the DON stated they only have monthly restraint notes and could not locate any re-assessments or evaluation for the need of the restraint. The DON stated that Physical Therapy (PT) department would also be involved. The DON stated the evaluations should include the behavior when the restraint was removed and that would help to determine if a resident still needed the restraint. The surveyor requested any re-evaluations for need for the last six months but the facility was unable to provide any. The DON stated she had reviewed the resident's records and there had not been a fall in over a year. During an interview with the surveyor on 11/25/19 at 10:21 AM, the PT Director stated Resident #17 had not been on therapy for a long time. The PT Director stated that they only do quarterly screens, which involved interviewing the CNA and nurses to see if there were changes with the resident. The PT Director stated they would review the residents during meetings with the nursing staff but that nursing did the removal trials for re-evaluation of the restraints. During an interview with the surveyor on 11/25/19 at 10:35 AM, the restorative CNA stated that she knew Resident #17. The restorative CNA stated the resident didn't take steps anymore but would stand and pivot with help and that the nurse would do the re-evaluation for the use of the lap buddy. During an interview with the surveyor on 11/26/19 at 10:20 AM, the DON stated that if the resident had behaviors, they should be documented in the progress notes but since the staff was so familiar with Resident #17, they hadn't documented the behaviors. The DON stated a re-evaluation and trial of removal of the lap buddy were being done now but acknowledged that none had been done prior to surveyor inquiry. Review of the Monthly Restraint Meetings, dated 01/19 through 11/19, revealed no documentation that the lap buddy was removed with behaviors noted and no documentation of any attempts to reduce the use of the lap buddy. Review of the facility's Restraint Policy, dated 03/19, revealed the policy was to use the least restrictive option for the least amount of time and document ongoing reevaluation of the need for a restraint. Additionally, the policy stated gradual reduction of the restraint will be attempted to prevent negative outcomes associated with restraint use. NJAC 8:39-27.1(a)(c)(13(i-ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. According to the Resident Face Sheet, Resident #32 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; Pneumonia, Gastric Reflux, and Methicillin Resistant Staphylococcus Aureus (MRSA) Infection (a bacteria that has become resistant to many antibiotics). Review of the resident's BIMS, dated 10/1/19, revealed that the resident had a score of 15 which indicated that the resident had an intact cognition. Review of the resident's laboratory report, dated 11/11/19 at 2:40 PM, revealed that the resident's urine was positive for three or more organisms. Review of the resident's Infectious Disease Progress Note, dated 11/11/19, reflected that the resident had MRSA of the urine. Review of the resident's Physician Order's, dated 11/15/19 at 12:11 PM, revealed that the resident was on modified contact isolation related to MRSA in the urine. Review of the resident's CP, dated 11/14/19, revealed that the resident had an infection of MRSA and a urinary tract infection. Further review of the CP reflected that on 11/15/19, the resident was on modified contact isolation due to a contagious infection that required modified contact to prevent the spread of MRSA. Review of the resident's Progress notes, written by the ICN dated 11/15/19 at 12:16 PM, revealed that the resident's urine culture was positive for MRSA and was placed on isolation with modified precautions. On 11/20/19 at 8:28 AM, the surveyor observed Resident #32 lying in bed. The room had a sign that indicated the resident was on isolation. On 11/22/19 at 9:01 AM, the surveyor observed an Environmental Services (ES) staff member enter Resident #32's room with gloves on but no gown. There was a sign that indicated the resident was on modified isolation precautions, The ES staff member went to the middle of the room and pulled the blood pressure machine closer to the door and proceeded to clean it with a wipe. During an interview with the surveyor at that time, the ES staff member stated that when a resident was on isolation, before he could enter a room, he should use hand sanitizer and put on gloves, a gown, and sometimes a mask. He also stated that was called PPE. The ES staff member then stated that a nurse told him that the isolation was discontinued and that he needed to clean the room. He could not state which nurse reported this to him. During an interview with the surveyor on 11/22/19 at 9:26 AM, the ICN stated that staff should have used PPE when cleaning an isolation room after it had been discontinued. She confirmed that Resident #32 had been discontinued from modified isolation that morning and that the ES staff member should have been wearing PPE to clean the room. During an interview with the surveyor on 11/22/19 at 12:30 PM, the Director of Environmental Services stated that when a staff member cleaned a resident's room whose isolation had been discontinued, they must wear PPE. He further stated that if a staff member entered a room to retrieve a piece of equipment to clean, they must still use PPE, and that gloves would not have been enough. During an interview with the surveyor on 11/25/19 at 12:12 PM, the ICN stated that Resident #32 was on modified isolation because the urine was able to be contained. She further stated that staff still needed to use PPE when entering the room. During an interview with the surveyor on 11/25/19 at 12:32 PM, the DON stated that during the cleaning process of a resident's room whereby isolation was discontinued, staff were required to wear PPE. During an interview with the survey team on 11/25/19 at 1:30 PM, the DON and [NAME] President of Nursing acknowledged that once a resident was discontinued from isolation, the room was still considered dirty and the ES staff would still be required to wear PPE to enter and clean the room. During an interview with survey team on 11/26/19 at 10:34 AM, the DON stated that the ES staff member should have used PPE to clean the resident's room. Review of the facility's Infection Prevention Review (which the facility used to educate staff), dated 2019, revealed Multi-drug Resistant Organisms preventing the transmission of MRSA, ESBL . Policy-the facility follows the Center of Disease (CDC) and Association of Practitioners in Infection Control (APIC) recommendations for isolation precautions. [NAME] PPE prior to entering a resident/patient room. Wear PPE at all times when entering an isolation room no matter why you are entering the room. Review of a facility policy titled, Linen Services Related to Infection Prevention, dated 02/18, included but was not limited to; Procedure-Handling Soiled Linen: All used linens shall be handled as potentially contaminated and use of standard precautions is needed: 1. Soiled linen shall not come in contact with the floor . 3. Contaminated laundry is bagged at the point of collection. (The location where it was used) . 8. Bag and store soiled linen in a designated area. Review of a facility policy Cleaning Isolation Room, approved date 05/2019, reflected that the facility should avoid cross contamination or the spread of infectious disease during the process. It further reflected that a gown, gloves and mask were required to be used according to the type of isolation the resident was on. NJAC 8:39 19.1(b), 19.4(a)(2), 21.1 (b) Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to a.) apply Personal Protective Equipment (PPE) for 2 of 2 residents (Resident #32 and #171) on isolation precautions and b.) handle linens to prevent the spread of infection for 1 of 2 residents (Resident #171) on isolation precautions. This deficient practice was evidenced by the following: 1. According to the Resident Face Sheet, Resident #171 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; Heart failure and Repeated falls. Review of the resident's Brief Interview for Mental Status (BIMS), dated 11/15/19, revealed that the resident had a score of 12 which indicated that the resident had moderately impaired cognition. Review of the resident's laboratory report, dated 11/20/19 at 10:44 AM, revealed that the resident's urine was positive for Escherichia Coli (E-Coli) and Extended Spectrum Beta-Lactamase (ESBL) (a bacterial infection). Review of the resident's Physician Orders, dated 11/20/19 at 11:14 AM, revealed that the resident was on strict isolation precautions related to ESBL of the urine. Review of the resident's Care Plan (CP), dated 11/20/19, revealed that the resident was on strict isolation related to ESBL of the urine. The CP also revealed, I have an active highly contagious infection and requires strict isolation to prevent spread of infection. Interventions included but were not limited to; Apply PPE outside upon entry to the room. Review of the resident's Progress notes written by Licensed Practical Nurse (LPN) #1, dated 11/20/19 at 12:04 PM, revealed that the resident's urine culture was positive for ESBL, was started on antibiotics, and placed on strict isolation. Review of an additional Progress note written by the infection control nurse, dated 11/20/19 at 12:17 PM, revealed that the resident had a positive urine culture of ESBL and that the resident was having difficulty with the urinal and urine was on the bed and on the resident's hands. The resident was on strict isolation and PPE was on the door for staff and visitors to put on prior to entering the room. On 11/20/19 at 11:30 AM, the surveyor observed a strict isolation sign outside of the resident's door and PPE hanging on the door. The isolation sign read, stop contact precautions and strict isolation. Gown and gloves required for all persons entering the room, limit traffic to essential staff. At that time, the surveyor observed LPN #1 inside of the resident's room, talking to the resident's roommate. LPN #1 was explaining to the resident's roommate that the resident was to be moved to another room because Resident #171 had an infection. LPN #1 did not have PPE on and stated to the resident's roommate that she technically should be wearing PPE inside the room. LPN #1 left the room. During an interview with the surveyor on 11/20/19 at 12:26 PM, a Certified Nurse Aide (CNA) #1 assigned to the resident, stated she was told that morning that the resident was on strict isolation. CNA #1 stated that when a resident was on isolation, staff cannot walk into the room without PPE. CNA #1 stated she was not sure why the resident was on isolation but that the resident required assistance with toileting and using the urinal. During an interview with the surveyor on 11/20/19 at 12:37 PM, LPN #1 stated Resident #171 was placed on strict isolation for ESBL of the urine and was placed on strict isolation because the resident drops the urinal. LPN #1 stated staff were to wear PPE which included a gown and gloves prior to entering the room. LPN #1 acknowledged that she was not wearing PPE prior to entering resident #171's room and stated she should have. On 11/21/19 at 11:13 AM, the surveyor observed a bag of linen sitting on the floor by the door way of Resident #171's room. A recreational staff member entered the room, put on PPE and stepped over the bag to speak to the resident. The staff member then stepped over the bag to remove PPE, stepped over the bag to wash her hands and stepped over the bag to leave the room. The staff member then notified CNA #2 of the bagged linen on the floor. At that time, CNA #2 walked over, put on gloves and placed the linen in the soiled linen cart. During an interview with the surveyor on 11/21/19 at 11:28 AM, CNA #2 who was assigned to Resident #171, stated when linens are removed, they are placed in a plastic bag and then in the linen cart. CNA #2 stated bagged linen cannot be on the floor due to infection control and didn't remember why she left it on the floor in the resident's room. During an interview with the surveyor on 11/21/19 at 11:47 AM, the infection control nurse (ICN) stated that the facility used strict and modified isolation guidelines. The ICN stated that when the resident is placed on isolation, isolation signs are placed outside the resident's door, PPE is provided, the CP is updated and the staff are informed. The ICN stated all staff were required to wear PPE prior to entering any type of isolation room. ICN stated Resident #171 was placed on strict isolation because of the ESBL in the urine, and that the resident had difficulty using the urinal and would get urine on the resident's hands and bed sheets. The ICN stated once linens were removed, they should be bagged and placed directly into the soiled linen cart and not on the floor. During an interview with the surveyor on 11/25/19 at 10:21 AM, the Registered Nurse Unit Manager (RN/UM) stated Resident #171 was placed on strict isolation for ESBL of the urine because the resident had difficulty using the urinal and urine would spill on the resident. The RN/UM stated that anyone who entered any type of isolation room should put on PPE prior to entering. The RN/UM stated when linen was removed it should be bagged and taken directly out of the room to the linen shoot. During an interview with the surveyor on 11/25/19 at 12:24 PM, the Director of Nursing (DON) stated when a resident was placed on isolation, the ICN places the isolation signs on the resident's door which notifies staff and visitors of what type of PPE to wear prior to entering the resident's room. The DON stated staff were to wear PPE prior to entering the isolation rooms to protect themselves and other residents. Additionally, the DON stated that linen should be bagged in the resident's room, placed directly in the linen cart and should never be on the floor.