Based on observation, interviews, record reviews and reviews of facility provided documents, it was determined that the facility failed to obtain a physician order for supplemental oxygen. This deficient practice occurred for 1 of 1 resident (Resident #110) reviewed for respiratory care. The deficient practice was evidenced by the following: On 06/27/2025 at 09:12 AM Resident #110 was observed to be seated in a chair next to the bed. Resident #110 was observed to actively receive oxygen via nasal cannula (a medical device used to deliver medical-grade supplemental oxygen to a user who requires oxygen therapy). Resident #110 did not have any complaints and was not in any respiratory distress. According to the admission record/face sheet Resident #110 was admitted to the facility with congestive heart failure (occurs when the heart can't pump enough blood to meet the body's needs, often leading to fluid buildup int the lungs and other tissues). A review of the Active Order Sets/Admission, Transfer, Discharge orders, Resident #110 had the following physician order: 06/27/2025 Start 1015 (10:15 AM) Oxygen Therapy - Device: Nasal Cannula Continuous PRN (as needed) 2 liters/minute titrate by 0.5 liter/minute. Keep O2 (oxygen) Sat (saturation) between 92% and 100%. Up to every 15 minutes. Notify physician/APP (advanced practice nurse) if oxygen requirement greater than 2 liters/minute. A review of the Plan of Care - Baseline, dated 6/25/25 and effective from 6/25/2025 to 7/3/2025 did not address the use of supplemental oxygen via nasal cannula. On 06/27/2025 at 10:09 AM the facility Director of Nursing (DON) was asked to assist the surveyor in finding a physician order for supplemental oxygen for Resident #1110 because the surveyor could not find one in the electronic medical record (EMR). The DON stated that it should be in orders. the DON then proceeded to review Resident #110's orders via the EMR. The DON stated, I don't see it at the moment, but I remember at report they told me that some orders needed to be updated. The DON further stated that there was no oxygen order at the moment and that she would check with the nurse and see if we need to order it continuous or prn. Resident #110 had been in the facility for approximately 48 hours at that time. On 06/27/2025 at 10:13 AM the DON responded to the surveyor and stated, They have a call out to the doctor to get an order for the oxygen right now. On 06/27/2025 at 11:28 AM the DON provided the surveyor with a copy of Resident #110's oxygen order and stated that it was a prn order because we are in the process of weaning the patient. On 06/30/2025 at 09:04 AM Resident #110 was observed lying in bed with oxygen via nasal cannula at 2 liters/minute. On 06/30/2025 at 11:08 AM the surveyor interviewed the Registered Nurse (RN #) assigned to Resident #110's unit. The surveyor asked RN # if a physician order was required for a resident to receive supplemental oxygen. RN # told the surveyor, Correct, yes. A physician order is required for a patient receiving oxygen. On 07/01/2025 at 10:31 AM during a meeting with the facility administration the surveyor asked the facility DON if a physician order was needed to provide supplemental oxygen to a resident. The DON replied, Yes. A resident receiving supplemental oxygen should have a physician order. A review of the facility provided policy and procedure titled [facility name] Oxygen administration, long term care. Revised: November 18, 2024. The following was revealed under the heading Implementation: Verify the practitioner's order. N.J.A.C. 18:39-27.1(a) .

Based on observation, interview, and review of facility documents, it was determined that the facility failed to follow policy and procedure to provide a rationale for rejection of consultant pharmacist recommendations. This deficient practice was observed for 1 of 5 residents (Resident #105) reviewed for unnecessary medications and was evidenced by the following: On 06/27/2025 at 09:41 AM the surveyor observed Resident #105 lying in bed. Resident #105 offered no complaints and did not display any maladaptive behaviors. According to the admission record/face sheet, Resident #105 was admitted to the facility with a diagnosis of acute kidney injury. A review of the Admission, Transfer, Discharge Orders (From admission on ward) revealed the following physician orders: Metoprolol succinate XL (Toprol XL) 24 hr (hour) tablet 75 mg (milligrams) Freq: 2 times daily with meals Route: Oral Start: 06/27/2025 0800 End: 06/29/2025 2059. Reason to hold? HR (heart rate) < 55 BPM (beats per minute). Tamsulosin (Flomax) 24 hr capsule 0.4mg Freq: Nightly Route: Oral Start: 06/27/2025 End: 06/29/2025 1854 (12:54 PM). On 06/27/2025 at 12:55 PM the facility Director of Nursing (DON) alerted the surveyor that consultant pharmacist (CP) had been in the facility yesterday (06/26/2025) and completed an EPIC for Resident #105 and had also made (3) physician recommendations to be addressed. The surveyor reviewed the documents, and the physician had not had an opportunity to respond as of that time. The surveyor told the DON that he would follow up on 6/30/2025 (Monday) after the physician had the opportunity to address the CP recommendations for Resident #105. On 06/30/2025 at 09:41 AM the surveyor reviewed the 6/26/2025 EPIC (Electronic Pharmacist Information Consultant) review for Resident #105. The following recommendations were made for the physician: 1. Tamsulosin is being administered for an off-label use. Please review risk/benefit and if continued, please document clinical effectiveness. The physician responded on 6/29/2025 and checked the box Not Accepted. The form included a space for Comment or Reason for not accepting. This area was blank, and no comment or reason was provided for not accepting the CP recommendation concerning the use of Tamsulosin. 2. Toprol XL is recommended once daily per manufacturer. Consider changing Toprol XL 75 mg twice daily to 150 mg once daily which would result in drug cost savings, nursing time savings, and possibly medication compliance. The physician responded and checked the box Not accepted on 6/29/2025. No comment or reason for not accepting was provided. The surveyor then reviewed the electronic medical record (EMR) for Resident #105. Review of the EMR did not reveal any rationale provided by the attending physician for not accepting the EPIC/physician recommendations by the CP. On 7/1/2025 the surveyor reviewed the E.P.I.C. New Admissions Policy and Procedure, dated 2020, provided by the facility DON. The following was revealed under POLICY: All newly admitted residents will have their Physician Orders (POS) evaluated by the pharmacy consultant upon admission to the facility. The MAR (medication administration record) and Hospital Discharge Medications will also be evaluated if reasonably provided. In addition, the following was revealed under PROCEDURE: G. When a response is requested from the attending physician, the facility will contact the attending physician in a timely manner, per facility policy, unless it is a Clinically Significant irregularity which needs to be addressed by the midnight of the next calendar day (24 hours). The physician's response needs to be noted on the E.P.I.C. consult sheet. If the response is in the negative, the attending physician will indicate a short statement of the rationale for rejecting the recommendation. N.J.A.C. 18:39-29.3(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to develop and implement care plans that are comprehensive and individualized for a.) residents who were placed on Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in skilled nursing facilities) and b.) residents who received antianxiety medications. This deficient practice was identified for 4 of 16 residents reviewed (Resident #157, Resident #158, Resident #163, and Resident #166) and was evidenced by the following: 1.) On 6/27/2025 at 10:55 AM, the surveyor observed Resident #157 sitting in room with their shirt half-covering a urostomy bag (a bag used to collect urine after an opening is created in the abdomen to divert urine) filled with reddish colored liquid. A urinary drainage bag was observed anchored to the resident's bedframe filled with reddish colored liquid and tubing exposed to air. The resident stated that they drain the urine from the urostomy bag to the urine bag by themselves. Inside the door of the resident's room was signage posted for EBP. Outside the resident's door was a green star sign with a round orange magnet on the wall next to the doorframe. The surveyor reviewed the electronic medical record (EMR) for Resident #157. A review of the face sheet revealed that Resident #157 was admitted to the facility with diagnoses including but not limited to malignant neoplasm of the lung (cancer of the lung) and carcinoma in situ, bladder (pre-cancerous condition in urinary bladder). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/27/2025, indicated that it was still in progress. A review of the physician orders as of 6/30/2025 revealed there was no order for the care of urostomy including the resident's management of their own urostomy bag. There was also no physician order for EBP. A review of the resident's care plan with focuses on infection and urinary incontinence did not address the resident's management of their own urostomy bag. The interventions did not specify the use of EBP. On 6/30/2025 at 11:01 AM, during an interview with the surveyor, the Director of Patient Care Services (DPCS) stated that the EBP practice needs to be in the care plan. The DPCS also stated that Resident #157's self-management of urostomy bag should be part of the care plan. On 7/1/2025 at 10:30 AM, during an interview with the survey team, the DPCS confirmed that the resident was on EBP for urostomy. 2.) On 6/27/2025 at 11:07 AM, the surveyor observed Resident #158 sitting in a recliner in their room. A urinary drainage bag was observed attached to the recliner inside a privacy bag. Inside the door of the resident's room was a signage for EBP. Outside the resident's door was a green star sign with a round orange magnet posted on the wall. On 6/27/2025 at 11:25 AM, the surveyor reviewed the resident's EMR which revealed the following: A review of the face sheet indicated that the resident was admitted to the facility with diagnoses including but not limited to iron deficiency anemia and chronic urinary retention/ obstruction. A review of the most comprehensive Minimum Data Set (MDS), an assessment tool dated 6/30/2025, indicated that it was still in progress. A review of the physician orders as of 6/27/2025 included insertion and maintenance of foley catheter for chronic urinary retention/ obstruction started on 6/23/2025. A review of the resident's care plan included a focus for indwelling catheter maintenance. The care plan did not specify the use of EBP. On 6/30/2025 at 11:01 AM, during an interview with the surveyor, the Director of Patient Care Services (DPCS) stated that EBP practice needs to be in the care plan. On 7/1/2025 at 10:30 AM, during an interview with the survey team, the DPCS confirmed that the resident was on EBP for indwelling foley catheter. 3.) On 6/26/2025 at 10:46 AM, the surveyor observed Resident #166 in bed. The resident showed the surveyor their wound dressing along the upper right quadrant of the abdomen and stated that they had surgery in the area. Inside the door of the resident's room was a signage for EBP. Outside the resident's door was a green star sign with a round orange magnet posted on the wall. On 6/27/2025 at 10:36 AM, the surveyor reviewed the resident's EMR which revealed the following: A review of the face sheet indicated that the resident was admitted to the facility with diagnosis that included but not limited to malignant neoplasm of the right breast (cancer of the breast). A review of the most comprehensive MDS dated [DATE], indicated that it was still in progress. A review of the admission assessment dated [DATE] indicated the resident had surgical wound on the medial right upper abdominal area. A review of the physician orders as of 6/30/2025 did not include an order for EBP. A review of the resident's care plan included a focus for infection related to problem list condition but did not specify the practice of EBP. On 6/30/2025 at 11:01 AM, during an interview with the surveyor, the Director of Patient Care Services (DPCS) stated that EBP practice needs to be in the care plan. On 7/1/2025 at 10:30 AM, during an interview with the survey team, the DPCS confirmed that the resident was on EBP for surgical wound. 4.) On 6/26/2025 at 10:21 AM, the surveyor observed Resident #158 sitting in a recliner inside their room. On 6/27/2025 at 10:45 AM, the surveyor reviewed the resident's EMR which revealed the following: A review of the face sheet indicated that the resident was admitted to the facility with diagnosis including but not limited to iron-deficiency anemia. A review of the most comprehensive MDS dated [DATE], indicated that it was still in progress. A review of the physician orders as of 6/27/2025 included an order for alprazolam tablet 0.25 mg nightly as needed for anxiety which was started on 6/23/2025. A review of the Medication Administration Record (MAR) revealed that the resident received alprazolam tablet 0.25 mg on 6/24/2025 at 8:32 PM, and on 6/28/2025 at 8:17 PM. A review of the resident's care plan did not address the potential adverse effects of anti-anxiety medication use. On 7/1/2025 at 10:30 AM, during an interview with the survey team, the Director of Patient Care Services (DPCS) stated that unless the resident had adverse effect from psychotropic medications (medications that affect the mind and nervous system including anti-anxiety medications), the psychotropic medication use does not need to be care planned. 5.) On 6/26/2025 at 10:45 AM, the surveyor observed Resident #163 in bed. The resident stated that they were fine. On 6/27/2025 at 10:30 AM, the surveyor reviewed the resident's EMR which revealed the following: A review of the face sheet indicated that the resident was admitted to the facility with diagnosis including but not limited to atrial fibrillation (a heart condition where the heart beats irregularly and rapidly). A review of the most comprehensive MDS dated [DATE], indicated that it was still in progress. A review of the physician orders as of 6/30/2025 included an order for alprazolam tablet 0.25 mg nightly as needed for anxiety which was started on 6/21/2025. A review of the MAR revealed that the resident received alprazolam tablet 0.25 mg on the following dates: 6/20/2025 at 8:54 PM, 6/21/2025 at 9:21 PM, 6/22/2025 at 9:04 PM, 6/23/2025 at 11:06 PM, 6/25/2025 at 10:12 PM, and 6/26/2025 at 9:39 PM. A review of the resident's care plan did not address the potential adverse effects of anti-anxiety medication use. On 7/1/2025 at 10:30 AM, during an interview with the survey team, the Director of Patient Care Services (DPCS) stated that unless the resident had adverse effect from psychotropic medications (medications that affect the mind and nervous system including anti-anxiety medications), the psychotropic medication use does not need to be care planned. A review of the facility-provided policy and procedures titled Initial Assessment of Resident included under Care Plan Preparation, Long-Term Care Introduction the following: A care plan is an individualized, written action plan for a resident's care, treatment, and services that is based on the resident's medical, nursing, physical, mental, and psychosocial needs and preferences. The care plan must be person-specific and include measurable objectives and time frames in order to reflect the resident's progress toward goals. Under the Elements of a Care Plan, the following are included: .Per CMS, each care plan should: . organize information to identify potential issues or conditions, such as triggers, for the resident .clarify potential issues by looking at causes and risks using the care area assessment process .include information regarding ways to address causes and risks associated with issues and conditions to allow for the resident's highest level of well-being . Under Special Considerations, the following is included: Customize a standardized care plan to avoid 'standardizing' the resident's care and to enable you to address individual resident concerns. N.J.A.C. 8:39 - 27.1 (a)

Based on observation and interview it was determined that the facility failed to: a.) maintain sanitation in cooking areas in a safe consistent manner; b.) label, date, and store potentially hazardous foods appropriately to prevent food borne illness; c.)maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth; and d.) maintain kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 1/26/24 at 11:05 AM, the surveyor in the presence of the Administrative Director Hospitality Services (ADHS) and Quality Coordinator (QC), toured the kitchen and observed the following: 1. On a preparation table, one large light blue cutting board that was deeply pitted and discolored black. The ADHS confirmed the facility should not be using that cutting board. 2. On a rack, two small light blue, two large tan, one large red, and one large yellow cutting boards all pitted and discolored black. The ADHS acknowledged the cutting boards needed to be changed; that bacteria could grow in the grooves. 3. On a drying rack adjacent to the pot washing room, four full six-inch pans, three four-inch plastic pans, and three large plastic full lids all wet nested (stacked on top of each other while still wet). The ADHS stated that wet nesting could harbor bacterial growth. 4. On a drying rack adjacent to the pot washing room, three six-inch full deep pans with a yellowish debris caked on. The ADHS confirmed the pans should not have debris on it. 5. In reach-in nourishment refrigerator RU 56, the surveyor observed the following: one half-gallon of fat-free milk dated expired 2/8/24, was opened with no date of when opened. The ADHS stated it was facility policy to use the manufacturer's expiration date on all products even after opened. One opened half-gallon fat-free lactose milk with a manufacturer's expiration date of 2/14/24, there was no date of when opened; the packaging indicated to use within seven days of opening. One opened gallon of 2% milk with an expiration date of 1/31/24, with no date of when opened. Two quart containers of heavy cream with an expiration date of 2/14/24, opened with no date of when opened. The packaging indicated to use within seven days of opening. The tray that held the milk containers as well as portioned containers of milk had a white liquid puddle. The ADHS acknowledged the tray should not have spilled liquid on it. 6. On the spice rack, one opened forty-eight ounce lemon juice with no date of when opened. The packaging indicated to refrigerate after opening. The ADHS confirmed it should have been refrigerated. 7. In the cook's preparation area, one large yellow cutting board that was deeply pitted and discolored black. 8. The steam table contained a white cutting board that was deeply pitted and discolored black/yellow/reddish colors. 9. In the reach-in refrigerator RU 63, sixteen vanilla and ten chocolate health shakes that were thawed. The packaging indicated to use within fourteen days of thawed. There was no date when the health shakes were thawed or when to use by. The ADHS acknowledged the health shakes were thawed and only had a fourteen day period they could be served within. On 1/31/24 at 11:09 AM, the ADHS in the presence of the Licensed Nursing Home Administrator (LNHA), Manager Quality Resource Services, and survey team acknowledged the above findings. The ADHS stated milk should be used within seven days of opening. A review of the facility's Food Labeling and Dating policy dated 5/27/22, included health shakes will be postdated for fourteen days and discarded on the expiration date . A review of the facility's Dietary Department Safety and Sanitation policy dated 5/22/22, included the Nutrition and Food Service Department will comply with all State, Federal and Local Health Codes; sanitary food handling procedures will be practiced in the preparation, storage and serving of food according to Dietary Department policies .clean pots and pans will be stored in a manner to promote air drying of equipment and prevent wet nesting of pots and pans . A review of the facility's Food and Nutrition Equipment policy dated 5/23/22, included cutting boards .all cutting boards wear out over time. After cutting boards become excessively worn or develop hard-to-clean grooves, they should be discarded . NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of documentation, it was determined that the facility failed to a.) properly clean and store dishes and food service equipment and b.) label and date food in a manner to prevent food-borne illness and cross contamination. This deficient practice was evidenced by the following: On 9/8/2021 at 9:58 AM, during the initial tour of the kitchen in the presence of the Hospitality Services Administrative Director (HSAD) and the Quality Resource Services Outcomes Coordinator, the surveyor observed the following: 1. There was a two-compartment plastic dolly holding disposable resident meal trays in one of the compartments. The empty compartment adjacent to the clean trays was visibly soiled with dust and debris. 2. There was a three-compartment, heated plate lowerator that was plugged in and turned on with two of the compartments heating clean dishes. The stainless-steel surface of the empty compartment had visible food particles and appeared greasy. 3. In the dry storeroom, there were three gallons of Honey Mustard dressing, two gallons of Golden Italian dressing, one gallon of Creamy French dressing, one gallon of Creamy Caesar dressing, one gallon of Yasou Feta Cheese Vinaigrette and one gallon of South [NAME] Cilantro Lime Vinaigrette. None of these unopened gallons of salad dressing were labeled with a date of any type. The HSAD stated that the cases they were delivered in would have had dates. However, there were no dates on the individual gallon jugs. The HSAD stated that there were codes on each container, and he could find out the dates. In addition, there were two gallons of mayonnaise that were not dated. The ASHD stated that they came in on 9/3/2021 and that the facility used six gallons of mayonnaise a week. The ASHD further explained that they rotated the stock. Once a product was taken out of the container it was delivered in, the facility would use it first. Once they opened the food containers, they would date that item. 4. In one of the walk-in refrigerators, there was an unopened five-pound container of potato salad with a manufacturer's Use by date of 9/1/2021 printed on the rim. The ASHD discarded the salad and stated, that's out of date. We'll bring it up in our huddle. 5. In another walk-in refrigerator, there were two plastic dish dollies that could accommodate five stacks of plates. One dolly had a torn plastic cover protecting the plates. The second dolly had two stacks of plates, was uncovered and the top plate on each stack was not turned over to protect the other plates from dust. There was visible dirt and debris in the three sections of this dolly that were not in use. The ASHD stated that the covers were very brittle, and he had ordered new covers. 6. In one reach-in freezer, there were approximately 31 cases of frozen Kosher dinners and some baked goods that were not labeled with any type of a date. The ASHD stated that he ordered the Kosher meals twice a week. He would have to contact the distributor to determine a packing or expiration date. 7. The can opener blade was visibly worn and sticky. The ASHD immediately replaced the dirty can opener along with its tabletop holder, which was also visibly soiled. 8. The wire rack on the conveyer toaster was soiled with baked on food debris according to the ASHD. 9. The rack of clean cutting boards contained two that were visibly soiled with food particles. Five additional cutting boards had black stains on their surfaces. The ASHD stated that the black stains resulted from pots resting on them. The ASHD also stated that he would replace all of the cutting boards. 10. There was a large trash can and lid that were heavily soiled. The ASHD stated that the can was used for soiled linen but, it needs to be cleaned. 11. There was one ice scoop resting on a black plastic surface on a shelf on the side of the ice machine. There was a second scoop held in a non-draining container on the wall next to the machine. The clear plastic container was visibly soiled with dust and debris. 12. The rack holding clean pots and steam table pans was visibly soiled and greasy and sticky to the touch. The ASHD agreed that it felt sticky. On 9/9/2021 at 10:43 AM, in the presence of the ASHD and the Administrative Director for Ancillary Services, the surveyor observed the following: In the dry storage room, the ASHD explained the codes that were stamped on the bottles of dressing and mayonnaise corresponded to a production date. He stated that the [NAME] dressings were good for 180 days from the production date. The bottles of [NAME] mayonnaise were within their 180-day shelf-life. The ASHD stated that the dressing produced by Sysco had a shelf life of 240 days and then he added, I did not know that. Neither the ASHD nor the surveyor were able to read the code printed on the bottle of the Sysco Feta Cheese dressing, therefore an expiration date could not be determined. The codes indicated that the gallon of Creamy French dressing was produced in 2019. The ASHD stated that would be expired. I don't use those. I didn't know how to read the codes until today, so those would be expired. The ASHD acknowledged that four gallons of Honey Mustard dressing were also expired. He stated that the facility had not used those gallons of dressing since they closed the salad bar before the Covid -19 pandemic. After surveyor inquiry, the ASHD stated they had one employee to stock shelves who came in twice a week on delivery days. He also stated that most equipment in the kitchen was cleaned on the weekends. A review of the facility's Food Labeling and Dating policy dated approved 3/19/2021, included: Bulk condiments and dressings will be dated on the date on which they were opened and discarded after 30 days or 1 month. The policy did not include labeling and dating of foods upon delivery or when taken out of the original case and placed on a storeroom shelf. A review of the facility's undated Cleaning Procedures for Kitchen Equipment policy included the following procedures: Conveyor Toaster .Using a damp cloth wipe the wire conveyor from the outside to the center .Clean the crumb tray, wire feeder rack, and the return chute with mild soap and warm water .Rinse when clean. Can Opener .Scrub shank, paying special attention to blade and moving parts. Use sanitizing solution and brush or run through dish machine .Inspect blade and replace if notched .Scrub base plate (attached to table). Tray Carts, Dish Carts, Utility Carts .After each meal to .Wash inside; rinse . allow to air dry .Weekly .Follow steps 1-3 above or take to cart wash area (and) wash wheels and castors with sanitizing solution. Cabinets and Drawer .Weekly .Use a mild detergent and water .Rinse shelves and drawers with a clean sponge and dry. A review of the facility's Main Kitchen: Saturday Cleaning Sheet and Sunday Cleaning Schedule indicated that the following items had been cleaned on 9/4 and 9/5/2021: garbage cans, lowerators, all carts and racks, dish dollies, toaster and the pot shelves. A review of the facility's monthly Safety and Sanitation Inspection dated 9/2/2021, reflected the following: Lowerators clean and in good repair. This section had the following comment written beside it: Need (unintelligible word) cleaning when not hot. Cutting boards clean and allowed to air dry. This area was not checked at all. Freezers: Foods are properly wrapped and labeled and dated. This area was checked Yes. Food Preparation Area: Toaster was checked as clean. Pot Room: Walls, racks and floors are clean. This section was checked Yes. NJAC 8:39 17.2 (g)