Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of other pertinent facility documents, it was determined that the facility failed to provide the resident and/or the resident's representative written notification of the reason for transfer to the hospital for two (2) of two (2) resident's (Resident #93 and #97) reviewed for hospitalization. This deficient practice was evidenced by the following: 1. A review of Resident #93's electronic medical record included the following: Resident #93's discharge assessment-return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, dated 4/08/24 and 5/01/24, reflected that the resident was transferred to the hospital. A review of Resident #93's hybrid (a combination of paper, scanned, and computer-generated records) medical record did not include a written notification of the reason for transfer to the resident or resident representative for each transfer to the hospital. 2. A review of Resident #97's closed medical record included the following: Resident #97's DRAMDS dated [DATE] and 4/26/24, reflected that the resident was transferred to the hospital. A review of Resident #97's hybrid medical record did not include a written notification of the reason for transfer to the resident or resident representative for each transfer to the hospital. On 5/08/24 at 12:55 PM, the surveyor interviewed the Director of Social Services (DoSS) regarding written notification of the reason for transfer. The DoSS stated that the facility did not send written notification to the resident or resident representative when the resident was transferred to the hospital. She added that the facility did send out a notice to the ombudsman that was faxed every month. On 5/09/24 at 12:22 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), [NAME] President of Operations (VPoO), Registered Nurse VP of Clinical Operations (RNVPoCO) the concern that the residents and/or their representatives did not have written notification of the reason they were transferred to the hospital. On 5/14/24 at 11:51 AM, in the presence of the survey team, DON, Infection Preventionist/Registered Nurse (IP/RN), VPoO and RNVPoCO, the LNHA stated that he educated the DoSS in regard to the written notification and that the residents should have had the written notification for each transfer to the hospital. A review of the facility provided policy titled, Transfer/Discharge Notification with a last reviewed date of 02-2024, included the following: Protocol 1. Transfers and discharges include the movement of a resident/patient to a bed outside of the certified section whether that bed is in the same physical plant or not . 3. Transfers and discharges will be conducted according to State and Federal regulations. Procedure 1. Provide the resident/patient with the Bed Hold and In-House Transfer Policy form as follows: At the time of admission At the time of transfer . 4. Inform the resident/patient, legal representative, and family member of the right of appeal. N.J.A.C. 8:39-4.1(a)31,32

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of the medical record and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy prior to transfer to the hospital for two (2) of two (2) resident's (Resident #93 and #97) reviewed for hospitalizations. This deficient practice is evidenced by the following: 1. A review of Resident #93's electronic medical record included the following: Resident #93's discharge assessment-return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, dated 4/08/24 and 5/01/24, reflected that the resident was transferred to the hospital. A review of Resident #93's hybrid (a combination of paper, scanned, and computer-generated records) medical record did not include a written notification of the facility's bed hold policy to the resident or resident representative prior to each transfer to the hospital. 2. A review of Resident #97's closed medical record included the following: Resident #97's DRAMDS dated [DATE] and 4/26/24, reflected that the resident was transferred to the hospital. A review of Resident #97's hybrid medical record did not include a written notification of the facility's bed hold policy to the resident or resident representative prior to each transfer to the hospital. On 5/08/24 at 01:05 PM, the surveyor interviewed the Admissions Director (AD) regarding bed hold policy notification. The AD stated that residents received the bed hold policy on admission and that she did not send out a written notification at time of transfer to the hospital. She added that the residents know that they have a ten day hold and that the facility always accepted them back even if it was past ten days. On 5/09/24 at 12:22 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), [NAME] President of Operations (VPoO) and Registered Nurse VP of Clinical Operations (RNVPoCO) the concern that the residents and/or their representatives did not have written notification of the bed hold policy when they were transferred to the hospital. On 5/14/24 at 11:51 AM, in the presence of the survey team, DON, Infection Preventionist/Registered Nurse (IP/RN), VPoO and RNVPoCO, the LNHA stated that he educated the AD in regard to the written notification of the bed hold policy and that the residents should have had the written notification for each transfer to the hospital. A review of the facility provided policy titled, Bed Hold Notice Upon Transfer with a last reviewed date of 02-2024, included the following: Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy A review of the facility provided policy titled, Bed Hold and In-House Transfer with a last reviewed date of 02-2024, included the following: Protocol 1. A written notification of bed hold and in-house transfer policy form will be given to the resident/patient and his/her family member/legal representative upon admission. 2. A written notification (signed and dated by the resident/patient and family member) must be given to the resident/patient and family member each time of transfer for hospitalization or therapeutic leave. 3. The bed hold and in-house transfer policy form to be completed and issued as instructed on the document . A review of the facility provided policy titled, Transfer/Discharge Notification with a last reviewed date of 02-2024, included the following: Protocol 1. Transfers and discharges include the movement of a resident/patient to a bed outside of the certified section whether that bed is in the same physical plant or not . 3. Transfers and discharges will be conducted according to State and Federal regulations. Procedure 1. Provide the resident/patient with the Bed Hold and In-House Transfer Policy form as follows: At the time of admission At the time of transfer . 4. Inform the resident/patient, legal representative, and family member of the right of appeal. N.J.A.C. 8:39-5.1 (a); 5.2 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of medical records, and other facility documentation, it was determined that the facility failed to adhere to acceptable standards of nursing practice in regards to the documentation of a resident's expiration. This deficient practice was identified for one (1) of three (3) residents (Resident #126) reviewed for closed records and evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The surveyor reviewed the medical record for Resident #126: A review of the admission Record face sheet (an admission summary) reflected that Resident #126 was admitted to the facility with diagnosis that included, but not limited to, malignant neoplasm (cancer) of bladder and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). A review of the electronic medical record (eMR) Nursing Progress Notes included a note dated [DATE] at 6:18 PM that indicated, [4:50 PM] Spoke with [ .] regarding ETA of pick up. Will call back to inform. Body post mortem care rendered. Tag placed on Right big toe, and lower body wrapping. [5:39 PM .] called to notify of pick up window 45 min to one hour. responsible party [ .] notified of ETA (estimated time of arrival) of pick up. Family will pick up patient belongings. Belongings gathered for family. [5:55 PM] Resident picked up by [ .] body release form filled and signed, placed in chart. responsible party [ .] notified of body being picked up. Pending pick up of belongings. There was no documentation of a change in the resident's clinical condition, including patient condition, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a resident's essential body functions), along with time of death, physician notification, and family notification. On [DATE] at 12:03 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the Licensed Home Nursing Administrator (LNHA), who confirmed that the required documentation for a resident's death included the time of death, change in condition assessment, physician notification, and family notification. The DON acknowledged that the resident's time of death was important information for the electronic death registration system. The DON further stated that all documentation should be entered as soon as it happens. At that same time, the DON confirmed that, the nurse documented the body pick up but not the time of death. When asked if there was further information that should have been documented the DON responded, the time the physician was made aware, if the family was at bedside, and change of condition. At the end of the interview, the DON inquired if the nurse could submit a late entry. On [DATE] at 10:06 AM, the surveyors met with the LNHA in the presence of the DON, Registered Nurse [NAME] President (VP) of Clinical Operations, and VP of Operations, the facility management acknowledged that, based on the electronic medical record, the resident's death could not be determined, who pronounced the death, and if the physician/family were made aware. A review of the facility's Nurse's Notes policy, last reviewed 2/24, included: .Nurse's notes upon expiration should include: date, time of death, physician notification, death pronouncement by physician or RN, family notification and visitation, disposition of eyeglasses, dentures, valuables, personal belongings, and medications. Name and location of mortician or funeral home, post-mortem care given to resident, religious rites performed, if applicable release of body . A review of the facility's Death of a Resident/Patient policy last reviewed 12/2023, included: Assess the resident/patient for vital signs: apical pulse; respirations; blood pressure .Call the physician and report your assessment of absence of vitals signs. Write the pronouncement and release as a telephone order .Notify the resident/patient's family, guardian, and/or representative .Document the following in the nurse's notes: time of absence of vital signs as determined; time and name of physician notified; time and name of family member notified; name of designated funeral home and time notified; name of the funeral home representative and time body released; status of deceased resident/patient personal possessions and what was sent with the body (i.e.: glasses, dentures, etc. A review of the facility's undated Job Description and Performance Standards included: to assess resident treatment needs and take appropriate action and to maintain resident's medical records. NJAC 8:39-11.2(b)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily. This failure could affect the knowledge of the availability of staff to care for the 120 residents, their family members, or their representatives. This deficient practice was evidenced by the following: On 5/07/24 at 8:35 AM, the surveyors entered the facility (on a Tuesday) and observed that the Nursing Home Resident Care Staffing Report (NHRCSR) posted in the front lobby was dated 5/02/24 (Thursday). The census (total number of residents) that was posted on 5/02/24 NHRCSR was 120. A review of the facility submitted Nurse Staffing Report for the week of 4/28/24 to 5/04/24 that was provided by the Director of Nursing (DON) showed that the census on 5/02/24 was 119. Further review of the above revealed that the census posted on 5/02/24 NHRCSR in the front lobby did not match the submitted Nurse Staffing Report. On 5/09/24 at 11:56 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Registered Nurse [NAME] President of Clinical Operations (RNVPoCO), and VP of Operations (VPoO). The surveyor notified the facility management of the findings regarding the inaccurate posting of the NHRCSR on 5/07/24. On 5/14/24 at 11:22 AM, the survey team met with the LNHA, DON, Infection Preventionist/Registered Nurse (IP/RN), VPoO, and RNVPoCO. The LNHA stated that the NHRCSR should be posted daily at 8 AM. The VPoO stated and clarified that the NHRCSR should be accurate, updated, and posted at the beginning of each shift. On 5/16/24 at 8:31 AM, the surveyor interviewed the Human Resource and Business Office Manager (HR/BOM). The HR/BOM informed the surveyor that she was responsible for posting the NHRCSR in the front lobby of the facility. The HR/BOM stated that she prepares the NHRCSR Monday through Friday and makes sure that it is posted before 8 AM. She further stated that she prepares the NHRCSR in advance for weekends and it is the responsibility of the weekend supervisor to correct if there will be changes in the census. She also stated that the NHRCSR should be updated at the beginning of each shift. On that same date and time, the surveyor notified the HR/BOM of the above findings and concerns. The HR/BOM had no response as to why the posted NHRCSR on 5/07/24 was not accurate. Later on, the HR/BOM stated that the posted NHRCSR should have been updated and accurate. A review of the facility's Nurse Staff Posting Information Policy with a reviewed date of 11/2023 that was provided by the LNHA included that it is the policy of the facility to have sufficient staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The nurse staffing information will contain the following information: facility name, the current date, the facility's current census, and the total number and actual hours worked by the RN, Licensed Practical Nurses, and Certified Nurse Aides. On 5/17/24 at 10:51 AM, the surveyors met with the LNHA, DON, RNVPoCO, VPoO, IP/RN, and VP of Clinical Compliance for Exit Conference and the facility management did not provide additional information. N.J.A.C. 8:39-41.2 (a)(b)(c)(d)

**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 ensure each resident was offered pneumococcal vaccination according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations. This deficient practice was identified for two (2) of five (5) residents reviewed for immunization status (Resident #75 and Resident 80). The deficient practice was evidenced by the following: Reference: A review of the CDC guidelines for Pneumococcal vaccination included: For adults 65 years and older who only received the Pneumococcal polysaccharide vaccine (Pneumovax/PPSV 23),Give (1) dose of Pneumococcal conjugate vaccine (PCV 15 or PCV20) at least one year after the most recent PPSV23 vaccination. Reference: A review of the ACIP included: On October 21, 2021, the ACIP recommended use of 20-valent pneumococcal conjugate vaccine (PCV20 [Prevnar 20) alone or 15-valent pneumococcal conjugate vaccine (PCV15) in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23) [Pneumovax23) for all adults aged 65 years. 1. The surveyor reviewed the hybrid (combination of paper and electronic) medical record (HMR) for Resident #75. According to the admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and hypertensive heart disease (high blood pressure). Resident #75's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 3/16/24, reflected that the resident was rarely/never understood, and a Brief Interview for Mental Status (BIMS) was not conducted. Further review of the qMDS dated [DATE], under section O0300 A. Was the resident's Pneumococcal vaccine to date? The response was marked 1, which reflected No. Section B. If Pneumococcal vaccine not received, state reason: The response was blank for the following: not eligible, offered and declined and not offered. A review of the electronic Medication Administration Record (eMAR) under Immunization indicated the resident received Pneumovax on 02/05/21. A review of the paper chart did not reflect a record that PCV 15 or PCV20 was offered to the resident. 2. The surveyor reviewed the HMR for Resident 80. The AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to major depressive disorder and mild cognitive impairment (memory or thinking problems). Resident #80s most recent qMDS dated [DATE], reflected that the resident had a BIMS score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the qMDS dated [DATE], under section O0300 A. Was the resident's Pneumococcal vaccine to date? The response was marked 1, which reflected No. Section B. If Pneumococcal vaccine not received, state reason: The response was blank for the following: not eligible, offered and declined and not offered. A review of the eMAR under Immunization indicated the resident received Pneumovax on 11/18/23. A review of the paper chart did not reflect a record that PCV 15 or PCV20 was offered to the resident. On 5/13/24 at 11:34 AM, during an interview with the surveyor, the Infection Preventionist/Registered Nurse (IP/RN) stated that the facility and the facility policy followed the CDC guidelines of the Pneumococcal vaccination schedule for adults. The IP/RN stated that the residents who were [AGE] years old and older received PPSV-23 unless contraindicated. The IP/RN informed the surveyor that she was not part of the team that reviewed the facility policy for the Pneumococcal vaccination. On that same date and time, the surveyor notified the IP/RN the concern regarding the Pneumococcal vaccine schedule for Resident # 75 and #80 that were not up to date, and the policy and procedure for pneumonia that did not reflect the current CDC guideline. On 5/13/24 at 12:34 PM, during a follow-up meeting with the surveyor, the IP/RN stated that she had reviewed the current CDC guidelines, Resident #75 and #80's Pneumococcal immunization schedule. The IP/RN further stated that both residents should have received PCV 20 one (1) year after receiving PPSV 23. At that time, IP/RN also stated she should have reviewed the resident's immunization schedule. The IP/RN stated she would call the prescriber to discuss the missing Pneumococcal vaccination, discuss with the resident (when appropriate), discuss with the family, obtain a consent or refusal. She also stated she would conduct an audit of all the immunization. Lastly, the IP/RN stated that she would meet with the Registered Nurse [NAME] President of Clinical Operations (RNVPoCO) to discuss the current CDC guideline for Pneumococcal vaccine. On 5/14/24 at 12:13 PM, during a meeting with the survey team, the RNVPoCO, the [NAME] President of Operations (VPoO), Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the IP/RN, the surveyor discussed the concern regarding the outdated vaccination status for Resident #75, #80 and the outdate policy. On 5/14/27 at 12:37 PM, in the presence of two surveyors, the IP/RN acknowledged that both residents should have received one dose of the PCV 20, one year after receiving PPSV 23 as outlined by the current CDC and ACIP recommendations. A review of the facility provided policy dated reviewed/revised on 02/2024 reflected under Policy: It is the policy of this facility that all residents will be evaluated at the time of admission for the appropriateness of receiving the Pneumonia Vaccine as per CDC Recommendations. The Procedures included the following: 1. No more vax (vaccine) will be offered to all residents unless it is medically contraindicated, or the resident has already been immunized. There are two types of pneumococcal vaccines available in the country: A. Pneumococcal conjugate vaccine (PCV12 or Prevanar 13) B. Pneumococcal polysaccharide vaccine (PPSV23 Pneumovax 23) N.J.A.C. 8:39-19.4(h), (i), (j)

Reference F-756 Based on observation, interview, record review, and review of other pertinent facility documentation it was determined that the facility failed to ensure a resident with history of post-traumatic stress disorder (PTSD) received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. This deficient practice was identified for one (1) of five (5) residents (Resident #80) reviewed for unnecessary medications and was evidenced by the following: Reference: 13:44G-3.3 PRACTICE AS A CSW; SCOPE c) A CSW shall not engage in clinical social work services. 13:44G-1.2 DEFINITIONS Clinical social work means the professional application of social work methods and values in the assessment and psychotherapeutic counseling of individuals, families, or psychotherapy group. On 5/07/24 at 11:05 AM, during the initial tour, the surveyor observed Resident #80 resting on the bed, in a fetal position with a monitoring device [for residents at risk of wandering] on the left ankle. The resident spoke [language redacted]. At that time, the house keeping staff (HK) translated for the resident. The resident stated he/she felt no discomfort from the monitoring device and wanted to rest. On 5/09/24 at 11:23 AM, during an interview with the surveyor, the Director of Social Services (DSS) stated she was a Certified Social Worker (CSW). The DSS stated her responsibilities included scheduling meetings for the residents, their family, and the Interdisciplinary team to discuss the patient centered care. On 5/13/24 at 10:19 AM, the surveyor entered the room, observed the resident lying in bed, and was not responsive to conversation conducted in [language redacted]. At that time, the surveyor also observed the Certified Nursing Assistant (CNA) standing across the room. At that time, the CNA stated he was assigned to watch the resident. The CNA stated he was a one (1) to one (1) assignment and could not describe the reason for the one-on-one surveillance. On 5/13/24 at 10:20 AM, Resident #80 and the CNA were observed walking the hallway into the dayroom where activities were being held. The surveyor reviewed the hybrid (a combination of paper-based and electronic medical records that primarily involves tracking and storing a patient's health records in several formats and places) medical records of Resident #80. According to the resident's admission Record (AR, or face sheet, an admission summary) reflected that resident was a long-term care (LTC) resident at the facility and had diagnoses which included but were not limited to major depressive disorder, psychotic disorder (a mental disorder characterized by a disconnection from reality), anxiety disorder, mild cognitive impairment, and unspecified dementia. Further review of the above AR, PTSD was not listed. A review of Resident #80's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 02/28/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that Resident #80's cognition was moderately impaired. Further review of the qMDS section I-Active Diagnoses under Psychiatric/Mood Disorder reflected anxiety disorder, depression and psychotic disorder (other than schizophrenia). PTSD was not marked. A review of the Pre-admission Screening and Resident Review (PASRR) level 1 Screen, a screening tool that must be completed for all applicants to a nursing facility (NF), prior to admission included the following: Under Section 2 - Mental Illness Screen: MDD [Major Depressive Disorder], Severe with Psychotic symptoms/PTSD. According to the PASRR Level 2 Determination Notification Form, it was determined that the resident had mental treatment needs that can be met in the NF. The following recommendation were made: 1. Psychiatric consult upon admission to Nursing Facility 2. Routine follow up visits with Primary Care Physician and Psychiatrist 3. Medication Monitoring 4. Supportive Counseling 5. Routine laboratory testing 6. Formulate and implement a behavioral modification plan to address any behavioral disturbances 7. provide education to client and family on mental illness and medication 8. Develop a Crisis Intervention/Safety Plan with the client A review of Resident 80's Care Plan (CP; person centered plan) did not include a focus for PTSD. A review of the electronic Medical Record (eMR) under Miscellaneous did not reveal consultation with the Psychologist or Supportive counseling. A review of the Social Services Progress Notes (PN) did not reflect documentation that emotional counseling services was provided in relation to PTSD. A review of the electronic Medical Record under PN where the Consultant Pharmacist (CP) documented a brief note that a Report would be provided to the facility. The PN did not reveal a monthly Medication Regimen Review (MRR) for March 2024. The April 2024 reflected a late entry that was created on 5/09/24 by the CP. A review of the CP Report did not reflect an MRR for March and April 2024. A review of the initial Psychiatric Consult from the previous provider dated 11/29/21, did not reflect PTSD was addressed. A review of the initial and subsequent Psychiatric Consult with the new provider dated 01/16/24, 02/13/24 and 4/02/24 did not reflect that the provider identified, determined the underlying cause, developed, implemented approaches such as determining the target behaviors and non-pharmacological interventions to address the resident's PTSD. A review of the Monthly Psychotropic Summary (Behavior Monitoring Summary) for January 2024, February 2024, March 2024, April 2024 and the current May 2024, did not show identified triggers, associated intervention for PTSD. On 5/14/24 at 9:56 AM, during an interview with the surveyor, the Doctor of Nursing Practice (DNP)/Psychiatric Mental Health Nurse Practitioner (PHNP) informed the surveyor that the company she had worked for had taken over the facility for Psychiatric services less than a year ago. The DNP/PHNP stated she had conducted an initial evaluation of the resident on 01/16/24, and only had three total visits. At that time, the DNP/PHNP confirmed she had not addressed the PTSD on the resident's psychiatric evaluation even though it was identified as part of the Resident #80's chief complaint. At that time, the DNP/PHNP stated that the resident did not appear to need psychotherapy and acknowledged that ruling out the need was not documented on the three previously conducted visits. At that time, the surveyor had asked the DNP/PHNP if target behaviors and non-pharmacological interventions were part of the diagnosis and plan. The DNP/PHNP stated that it was nothing that she had placed on the note. On 5/14/24 at 12:13 PM, in the presence of the survey team, the Registered Nurse [NAME] President of Clinical Operations (RNVPoCO), the [NAME] president of Operations (VPoO), the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Infection Preventionist/Registered Nurse (IP/RN), the surveyor discussed the concern regarding the failure to provide services that included development of an individualized care plan, monitor and provide ongoing assessment of Resident #80's behavior to address the resident's history of PTSD from admission. On 5/16/24 at 12:40 PM, in the presence of the survey team, the RNVPoCO, the VPoO, the LNHA, and the IP/RN, the DON stated, regarding Resident #80 and PTSD we should have looked at the diagnosis, we did not identify it. The DON also stated that Psych (Psychiatrist) did not evaluate and treat Resident #80 for PTSD. At that time, the DON acknowledged that the resident should have also been care planned for PTSD. On 5/16/24 at 02:35 PM, the DON had informed the surveyor that Resident #80 was scheduled to meet with the psychologist that afternoon. A review of the facility policy provided, Care Plan dated/revised 01/2024, included the following: Policy: It is the policy of [facility name redacted] that all residents admitted to the facility will have adequate person-centered care plans that provide for all their needs in a timely manner. Procedure: 1. Baseline Care Plans for all new admission will be initiated within 48 hours of admission 2. They will include goals, MD (Medical Doctor) orders, medications, treatments, dietary orders, therapy orders, social services and PASARR [PASRR] recommendations. 4. If PASARR [PASRR]recommends any special services for specialized rehabilitation services, it will be included in the care plan. If the facility disagrees with the findings of the PASSAR [PASRR] it will indicate its rationale in the residence medical record A review of the facility policy provided; Trauma Informed Care dated/reviewed 2/2024 included the following: Purpose: 3. The Level 1 PASARR Screen will be reviewed upon admission as well as upon any newly diagnosed mental illness and/or intellectual disability/ developmental disability. The recommendations from the PASARR Level 2 determination will assist in the completion of the resident's assessment, care planning and transition care. 10. Trauma specific interventions for a resident will be placed in their individualized person-centered care plan upon admission and assessment . 11. The facility will evaluate the progress of the trauma informed program by reviewing quarterly the changes in behavior of our residents who have been identified as having traumatic experiences during our multidisciplinary care plan and other 1-1 meeings. NJAC 8:39-27.1 (a), 28.1 (c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) to consistently maintain accurate reconciliation, accountability of dispensed, and administered controlled dangerous substance (narcotic medication) for Resident #16, b.) ensure expired narcotic medications were detected, removed, and disposed from active inventory which was stored within the electronic back-up machine (EBM). The deficient practice was identified for one (1) of one (1) of the EBM observed during medication storage inspection. The evidence was as follows: 1.) On [DATE] at 8:57 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that she conducted the narcotic reconciliation (cycle counts) daily with a nurse supervisor or with the Infection Preventionist/Registered Nurse (IP/RN). The DON also stated she received a daily report of the narcotic inventory which detailed which the inventory on-hand, the nurse who removed the narcotic and for which resident. At that time, the surveyor requested for the daily transaction inventory report of the EBM. The surveyor reviewed the medical record for Resident #16. According to the resident's admission Record (or face sheet, an admission summary) reflected that that resident was a long-term care (LTC) resident at the facility and had diagnoses which included but were not limited to heart failure, and chronic pain (long standing pain that persists). Resident #16's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that Resident #16's cognition was intact. On [DATE] at 10:46 AM, the DON informed the surveyor that the pharmacy provider was having issues with the report, and she had not received the daily report from the pharmacy [via electronic mail]. The facility did not keep a paper log of the EBM inventory. At that time, the DON stated that she did not work seven days a week and there were no tracking or reconciliation of the narcotic medications (meds) within the EBM on the weekend that she was off. On [DATE] at 11:03 AM, while waiting for the pharmacy provider inventory report, the DON stated that there were no super users (staff that can remove a narcotic med from the EBM without a witness) in the facility. On [DATE] at 12:25 PM, the surveyor and the DON reviewed the EBM report for Transactions by Employee from [DATE] to [DATE]. The report did not reflect a daily reconciliation of all the narcotic meds daily. At that time, the DON confirmed that the narcotics were not reconciled daily. On [DATE] at 01:11 PM, in the presence of the IP/RN and the DON, the surveyor reviewed another facility provided report; Transaction log by department (TLD). The report showed the inventory for the Morphine (narcotic pain med) 30 mg (milligram) on [DATE], was 13 tablets then on [DATE], the inventory on hand was seven (7) tablets, with no other transactions in between. Further review of the TLD did not reflect the witnesses' names when the narcotic meds were removed. At that time, in the presence of the DON and the IP/RN, the surveyor discussed the concerns regarding the missing witnesses name and the declining inventory count of the Morphine 15 mg tablets (tabs) without transactions in between. On [DATE] at 11:57 AM, in the presence of the survey team, the Registered Nurse [NAME] President of Clinical Operations (RNVPoCO), [NAME] President of Operations (VPoO), Licensed Nursing Home Administrator (LNHA), and the DON, the surveyor discussed the concern regarding the facility's failure to consistently maintain accurate reconciliation, accountability of dispensed, and administered narcotic meds. On [DATE] at 12:49 PM, the DON provided the surveyor a third report, the Controlled Substance by Container Report (CSCR). A review of the CSCR report reflected the witnesses' names, enumerated transaction by date/time with the declining inventory count of the Morphine 15 mg tabs from 13 to 7. Further review of the Morphine 15 mg tab CSCR reflected the following: -On [DATE] at 12:34 PM, the DON removed two (2) tabs, for Resident #16 with witnessed by LPN #1 -On [DATE] at 6:54 PM, the IP/RN removed two (2) tabs for Resident #16, witnessed by LPN #2 -On [DATE] at 8:35 AM, the DON removed (2) tabs for Resident #16, witnessed by LPN #3 -On [DATE] at 9:27 PM, the RN/Supervisor (RN/S) removed 2 tabs for Resident #16, without a witness -On [DATE] at 10:03 PM, the RN/S replaced 2 tabs back name into the EBM utilizing Resident #16's name, without a witness -On [DATE] at 10:15 AM, the RN/Unit Manager (RN/UM) removed two (2) tabs for Resident #16, witnessed by LPN #4 -On [DATE] at 9:49 PM, RN/S removed two (2) tabs for Resident #16 without a witness -On [DATE] at 9:09 AM, LPN #1 removed two (2) tabs for Resident #16 witnessed by IP/RN The CSCR revealed that the facility had a staff that did not require a witness to remove a narcotic med. A review of the Order Summary Report (OSR) for [DATE] reflected an order for Morphine 30 mg, give 1 tab by mouth every 12 hours for pain management. The OSR did not reveal an order for Morphine 15 mg, 2 tablets. The electronic Medication Administration Record (eMAR) did not reflect administration of the Morphine 15 mg on the following dates and time: 1. On [DATE] at 6:54 PM 2. On [DATE] at 8:35 AM 3. On [DATE] at 10:15 AM 4. On [DATE] at 9:49 PM 5. On [DATE] at 9:09 AM On [DATE] at 01:48 PM, the surveyor discussed with the DON the concern regarding the inconsistent accounting, dispensing, and administration of the Morphine 15 mg, five (5) times, in a span of four (4) days without a physician's order; the concern involved eight (8) nursing staff. At that time, the DON acknowledged that a med should not be administered without a physician's order. At that time, the DON stated she was not aware that a facility staff was granted access to the narcotic EBM machine in which a witness was not required. The DON also stated that a nurse should have not had this type of access. At that time, the DON confirmed that she was not aware that the Morphine 15 mg was dispensed and administered without a physician's order. At that time, the DON could not explain how the facility process for accountability and reconciliation missed identification of the removal of the Morphine 15 mg, five (5) times in a span of four (4) days. On [DATE] at 11:22 AM, in the presence of the survey team, the RNVPoCO, the VPoO, the LNHA, and the IP/RN, the DON stated a new process was placed to easily track the on-hand and reconciliation of the narcotics in the EBM. The DON acknowledged that a physician' order was required prior to administration of a med. The DON acknowledged all the concerns and stated education was provided to the nursing staff. 2.) On [DATE] at 01:35 PM, during the observation of the cycle count for the EBM, by the DON and the IP/RN, the surveyor observed the following expired narcotics meds in the EBM: -Oxycontin (narcotic pain med) 10 mg #13 tabs that expired on 9/2023 (at that time, expired for seven months), -Zolpidem (narcotic sleeping pill) 10 mg #2 tabs that expired on [DATE]. -Zolpidem 10 mg #3 tabs that expired on [DATE]. On that same date and time, the DON and the IP/RN confirmed they also observed the expired meds. At that same time, the DON stated she was unable to remove the expired narcotics from the active inventory stored in the EBM until she received a letter from the CDS (Drug Enforcement Agency, Controlled Dangerous Substance). Furthermore, the DON stated that the nurses would have to look at the expiration date prior to removing a med from the active inventory in the EBM. In addition, the surveyor asked the IP/RN, should an expired narcotic med be intermingled with the active inventory that was stored in the EBM. The IP/RN stated that the correct protocol would be to remove the expired narcotic from the active inventory to avoid med administration error. At that time, the DON acknowledged that the expired narcotic should have been removed from the active inventory. On [DATE] at 11:22 AM, in the presence of the survey team, the RNVPoCO, the VPoO, the LNHA, and the IP/RN, the DON acknowledged the concerns and stated that education was provided to the nursing staff. A review of the provided facility policy; Medication Storage dated/revised [DATE], included the following: Policy: Meds will be stored in a manner that maintains the integrity of the product ensures the safety of the residents and is on accordance with NJ Department of Health guidelines. Procedure F. Expired, discontinues and/or contaminated meds will be removed from the med storage area and disposed of in accordance with facility policy. A review of the undated facility policy; Loss or Theft of Drugs included under Policy; Any theft or loss of drugs must be reported immediately to facility management and appropriate actions taken. A review of the facility policy provided, ADS [Automatic Dispensing System] Station Med Policies and Procedures, effective date of [DATE] included the following: Policy: Nursing and Pharmacy will use the ADS Station as an inventory, charging, and information system for the control and distribution of meds for Emergency, First-Dose use and other situations where meds are not available from the pharmacy. (Not to be used for continuous dosing). NJAC 8:39-11.2(b), 27.1(1), 29.2(a,d), 29.4 (g), 29.7(c)

3. On 5/07/24 at 11:02 AM, during the initial tour, the surveyor observed Resident #49 asleep with the head of the bed elevated. The resident was covered with a blanket. The surveyor reviewed the HMR of Resident #49. The AR reflected that that resident was a long-term care (LTC) resident at the facility and had diagnoses which included but were not limited to schizoaffective disorder (is a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), adjustment disorder (unhealthy or excessive reaction to a stressful event in a person's life), depression and cognitive communication deficit (difficulty with thinking and how someone uses language). A review of the PCN where the CP documented a brief note that a Report would be provided to the facility. The PN did not reveal an MRR for March 2024. The April 2024 reflected a late entry that was created on 5/09/24 by the CP. A review of the CP Report did not reflect an MRR for March and April 2024. 4. On 5/07/24 at 9:46 AM, the surveyor observed Resident #75 walking up and down the low side of the hallway while using a walker. The resident was pleasant and spoke in [language redacted]. The surveyor reviewed the HMR of Resident #75. The AR reflected that that resident was a LTC resident at the facility and had diagnoses which included but were not limited to major depressive disorder, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), unspecified psychosis and adjustment disorder with anxiety. A review of the PCN where the CP documented a brief note that a Report would be provided to the facility. The PN did not reveal an MRR for March 2024 and April 2024. A review of the CP Report did not reflect an MRR for March and April 2024. 4. On 5/07/24 at 11:05 AM, during the initial tour the surveyor observed Resident #80 resting on the bed, in a fetal position with a monitoring device [for residents at risk of wandering] on the left ankle. The resident spoke [language redacted]. The surveyor reviewed the HMR of Resident #80. The AR reflected that that resident was a LTC resident at the facility and had diagnoses which included but were not limited to major depressive disorder, psychotic disorder, anxiety disorder, mild cognitive impairment, and unspecified dementia. A review of the PCN where the CP documented a brief note that a Report would be provided to the facility. The PN did not reveal an MRR for March 2024. The April 2024 reflected a late entry that was created on 5/09/24 by the CP. A review of the CP Report did not reflect an MRR for March and April 2024. NJAC 8:39-29.3 (a)(1) 2. On 5/07/24 at 10:29 AM, the surveyor observed Resident #17 asleep in his/her bed. The surveyor reviewed Resident #17's HMR. The AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), unspecified psychosis and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). Resident #17's PCN revealed that the last MRR was on 02/15/24. Further review of Resident #17's hybrid MR showed that there were no MRRs for March 2024 and April 2024. On 5/14/24 at 12:16 PM, in the presence of the survey team, the surveyor notified the LNHA, DON, IP/RN, VPoO and RNVPoCO the concern that Resident #17 did not have a MRR done after 02/15/24. On 5/15/24 at 12:53 PM, the DON confirmed that Resident #17 did not have a MRR for the two months and that there should have been. The facility did not provide any additional information. Based on interviews, record review, and a review of pertinent facility documents, it was determined that the facility failed to a.) provide oversight by a licensed Consultant Pharmacist (CP) in March 2024 for four (4) of five (5) residents, (Residents #17, #49, #75, and #80) and the entire month of April 2024, for five (5) of five (5) residents, (Residents #17, #22, #49, #75, and #80), b.) identify the irregularity with regard to physician's order for antipyschotic medication for one (1) of five (5) residents, (Resident #22) reviewed for unnecessary medications in accordance to facility's practice and policy. This deficient practice was evidenced by the following: 1. On 5/07/24 at 11:16 AM, the surveyor observed Resident #22 in the dayroom. The surveyor reviewed Resident #22's hybrid (a combination of paper-based and electronic medical records that primarily involves tracking and storing a patient's health records in several formats and places) medical record (HMR). According to the admission Record (AR, an admission summary), the resident was admitted to the facility with diagnoses that included but were not limited to major depressive disorder, recurrent, unspecified, essential hypertension (occurs when abnormally high blood pressure that's not the result of a medical condition), unspecified psychosis (a mental disorder characterized by a disconnection from reality) not due to a substance or known physiological condition, anxiety disorder unspecified, and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). A review of the May 2024 Order Summary Report (OSR) included a physician's order (PO) dated 3/26/24 of Seroquel (an antipsychotic medication) oral tablet (tab) 25 mg (milligrams) to give 0.5 mg by mouth at bedtime (HS) for psychosis. The above order for Seroquel was transcribed and signed by nurses as administered from 3/26/24 through 3/31/24, the whole month of April 2024, and from 5/01/24 through 5/08/24. A review of the Progress Notes (PN) created on 3/26/24 at 02:51 PM by the Licensed Practical Nurse (LPN) included that the order for Seroquel 25 mg give 0.5 mg by mouth at HS was outside of the recommended dose or frequency, the daily dose of 0.5 mg was below the usual dose of 12.5 to 1,200 mg. Further review of the PN revealed that there was no Pharmacy Consultant Note (PCN) for March 2024. There was a late entry PCN dated 4/30/24 that included Medications were reviewed. Report provided. A review of the CP monthly Medication Regimen Review (MRR) binder that was provided by the Director of Nursing (DON) showed that there was no report for March, April, and May 2024. On 5/09/24 at 10:50 AM, the surveyor asked the DON why CP's review for March, April, and May 2024 was not in the blue binders that the DON had provided for the surveyor to review. The DON stated that the facility had not received the CP's review yet. The surveyor then asked the DON for the CP's phone number and she said that she will get back to the surveyor. On 5/09/24 at 11:07 AM, the surveyor interviewed Consultant Pharmacist #1 (CP#1). CP#1 informed the surveyor that she was covering CP. CP#1 stated that the assigned CP, CP#2 was on leave and unable to respond to the surveyor's inquiry which was why CP#1 was the one who called back. On that same date and time, CP#1 informed the surveyor that CP#3, the regular CP of the facility left in early March 2024, and CP#2 was the designated CP then. CP#1 stated that there was a March 2024 MRR review by CP#2 for the 3rd floor but was unable to find or state if the 4th and 5th floor reviews were done. She further stated that there were no MRR reviews for April 2024 for the 3rd, 4th, and 5th floors. CP#1 also stated that she would do the reviews and put it as a late entry after the surveyor's inquiry. She indicated that the May 2024 MRR was still to be done. She acknowledged that MRR for all residents should have been done monthly as required by the facility and regulations. On 5/09/24 at 11:56 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Registered Nurse [NAME] President of Clinical Operations (RNVPoCO), VP of Operations (VPoO), and the DON. The surveyor notified the facility management of the above concerns and findings. On 5/09/24 at 01:45 PM, the DON provided a copy of the printed CP's MRR for the date 3/24/24 (printed 5/09/24) for the 3rd floor residents which included Resident #22. The 3/24/24 MRR did not include recommendations or notes that the irregularity for the Seroquel order was identified for Resident #22. There were no March 2024 MRR for the 4th and 5th floors. A review of the facility's Medication Regimen Review Policy with a created date of 11/23 that was provided by the DON included that it is the facility policy to provide an MRR for all residents admitted to the nursing facility. MRR is a thorough evaluation of the medication (med) regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences associated with med. The review includes preventing, identifying, reporting, and resolving medication-related problems, med errors, or other irregularities, and collaborating with other members of the interdisciplinary team. The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. On 5/14/24 at 11:22 AM, the survey team met with the LNHA, DON, Infection Preventionist/Registered Nurse (IP/RN), VPoO, and RNVPoCO. The DON stated and acknowledged that there was no March 2024 MRR for the 4th and 5th floors and for the whole of April 2024 for the 3rd, 4th, and 5th floors according to the facility's practice, policy, and regulations. The DON further stated that the facility was unaware of the reason why there was no MRR done in March and April 2024 not until the surveyor's inquiry. The DON also stated that it was her responsibility to make sure that the MRR was done timely by the CP. At that same time, the DON informed the surveyor that the resident received the right dose of half a tablet (0.5 tab) of 25 mg Seroquel even though the order was wrong because the pharmacy sent the bingo card (a method of packaging meds in which a blister pack is enclosed in a folded-over card) of half a tab med.

REPEAT DEFICIENCY Based on observation, interview, and review of documentation provided by the facility, it was determined that the facility failed to a) maintain proper kitchen sanitation practices and clean equipment, b) properly store foods in a safe manner to prevent the development of food borne illness, and c) maintain three (3) of three (3) nursing unit pantry used for residents in a sanitary manner. This deficient practice was evidenced by the following: On 5/07/24 at 10:16 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD), the FSD Trainer (FSDT) and the Regional FSD (RFSD), and observed the following: ~In the walk-in freezer, several boxes of opened food items that were opened, unlabeled and exposed to freezer with freezer burn and frost on them. Those items were as follows: chicken tenders, salisbury beef steaks, opened loose corn, and pizza. All listed items were opened, unsealed, unlabeled with open date or expiration dates. The FSD manager was unable to say when the packages were opened. ~The food preparation area had a trash can filled with garbage and food debris that was uncovered. ~Two (2) steamer tables with three (3) sections each totaling six (6), was noted to have opaque water with sediment at the bottom which the FSD was able to scoop up and it was determined it was rice and that had not been used this day for a meal. The FSD stated the table water was supposed to be cleaned between meals and daily. The FSD acknowledged that it had not been done per policy. On 5/07/24 at 10:30 AM, the surveyor interviewed the FSD, who stated that labeling of food was a requirement in his kitchen. The food should be labeled with expiration date and if opened it should be labeled with open date and the package should be resealed to keep the contents fresh. Labeling allows for first in first out concept which saves food integrity, prevents freezer burn, and waste production. She further stated, The cooking equipment is on a cleaning schedule and the findings of the kitchen equipment (steamer table) should have all been cleaned and water changed. On 5/08/24 at 11:47 AM, the surveyor observed 3 of 3 pantry, one on each nursing unit (3rd, 4th and 5th floor). The purpose of the pantry was for residential use. Each pantry was equipped with a refrigerator, microwave, sink and ice machine. The surveyor observed in the presence of the Registered Nurse/Unit Manager (RN/UM), the pantry on the 3rd floor nursing unit had build-up of white sediment on the outer lip of the door flap that was wipeable. On the interior back panel where ice dispenses it had a yellowish film that was wipeable by the RN/UM. The 3rd floor pantry had a rectangular plastic bucket that the staff put the ice scoop in. The bottom had a build up of water and orange film in the interior corners that the scoop was sitting in. On 5/08/24 at 12:10 PM, the RN/UM acknowledged that the ice machine needed to be cleaned and the scoop should not be sitting in stagnant water. She also stated, it should not be like this because the residents use this ice for their drinks, and it can cause an infection or make them sick. On 5/08/24 at 12:28 PM, the surveyor observed in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM) pantry on the 4th floor nursing unit had build-up of white sediment on the outer lip of the door flap that was wipeable. On the interior back panel where ice dispenses it had a yellowish/ orange film covering the whole panel and on the right side of the interior panel and in the hinge, flap was coated with black sediment. All were wipeable by the LPN/UM. On that same date and time, both the surveyor and the LPN/UM observed the 4th floor pantry had an ice scoop holder mounted to the wall behind the ice machine. The mounted holder was composed of two (2) separate pieces that attached to each other. Neither piece was equipped with drainage holes. The ice scoop was sitting in stagnant water and the bottom of the interior piece was coated with brown and black sediment. When the LPN/UM removed the piece and placed in sink and filled it with water the sediment started to flake off. The scoop tip had cracks in the plastic that were discolored gray. At that same time, the surveyor observed the 4th floor sink, which had black sediment around the sink, caulk, and backsplash areas. On 5/08/24 at 12:55 PM, the Housekeeping Director (HD) came to the 4th floor pantry. The surveyor observed in the presence of the LPN/UM and HD the ice machine, scoop mount, scoop, and the sink, which had black sediment around the sink, caulk, and backsplash areas. On 5/08/24 at 12:58 PM, the surveyor interviewed the HD, he acknowledged that it should be cleaned and further stated, I am shutting the unit down and having it cleaned right now. He further stated, It should be cleaned daily. The surveyor reviewed the black sediment behind, on, and around the sink with the HD and asked to see the Director of Maintenance (DM). The HD stated, I am the HD and the DM in a dual capacity position. The HD acknowledged the sink area and stated, he would have it cleaned and fixed. He further stated, I would need to notify the Licensed Nursing Home administrator (LNHA). On 5/08/24 at 01:03 PM the surveyor, in the presence of the HD toured the 5th floor pantry. The 5th floor pantry had an ice scoop holder mounted to the wall behind the ice machine. The mounted holder was composed of two (2) separate pieces that attached to each other. Neither piece was equipped with drainage holes. The ice scoop was sitting in stagnant water and the bottom of the interior piece was coated with brown and black sediment. On 5/08/24 at 01:06 PM, the HD acknowledged that the holder should have drainage holes to prevent stagnant water buildup which can cause bacteria and mold. On 5/09/24 at 10:34 AM, the surveyor interviewed the DON, who stated I acknowledge the issues in the 3rd, 4th and 5th floor pantry. I was informed by my UM's and the HD. The DON further stated that the cleaning process was in place to prevent bacteria and possible illnesses that can happen. She also stated that it was everyone's responsibility to keep the units clean. In addition, the DON stated that if a Certified Nursing Assistant (CNA) sees something, they should report to the nurse, the UM, or myself to have it reported to the appropriate department to get fixed or cleaned. The DON further stated that the UM should be doing audits on their floor to make sure items are cleaned and in working order according to policy. On 5/09/24 at 12:42 PM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN) who stated, the reason to have a clean and unsoiled pantry is to prevent pest, rodents, and bacteria. It should be maintained and clean for the residents because this is their home. I will have to do more in-services on the cleaning process. I will set those up with the HD. A review of an updated Dining Services, Food Storage Policy, included: Food items will be stored, thawed, and prepared in accordance with good sanitary practice. Procedures: All products shall be dated upon receipt or when they are prepared. Use date shall be marked on all food containers according to the timetable in dry, refrigerated and freezer storage chart found in this section. Frozen Meat/ Poultry /and Foods: Storage: Foods shall be stored in their original containers if designed for freezing. Foods to be frozen shall be stored in airtight containers or wrapped in heavy duty aluminum foil or special laminated papers. Labels and date all food items. A review of the undated Labeling and Dating System Protocol Policy included: ~follow manufactures expiration date on all un-opened or opened products. If there is no printed date on the product, follow below dating protocol: All frozen foods allowed three days to defrost in cooler. Add those three days to the expiration date on the open/prep and expiration label. All food in freezer storage six months A review of the undated Dining Services, Steam Table Policy which revealed: 1. It is the responsibility of ALL cooks to keep the steam table clean and sanitized every meal. 2. The morning cook will make sure that steam table wells are filled with adequate amount of water (clean) before turning it on. 3. The nighttime cook is responsible for always changing the water in each well and to refill each well with adequate amount of water. 4. The steam table must be turned off at night, filled with clean water and each well is covered. A review of the undated Dining Services, Garbage and Trash cans Policy which included: Sanitation of Equipment. All food waste must be placed in covered garbage and trash cans. A review of the Infection Control, Cleaning and Disinfecting Ice Machines and Ice Chest Policy, last revised dated 10/01/23, included: To minimize the potential for infection from proper cleaning and maintenance of ice machines and ice chests. The facility is committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infections. 2. Ice Scoops: Surfaces of the scoop should be smooth and unbroken. If scoops are cracked or have irregular surfaces, they should be discarded and replaced. Store the scoop in a container with drainage area at the bottom when not in use. Do not rest the scoop in/on any other surface. 3. Ice Machines: Disinfect the drop opening of the ice machine once a month with an appropriate disinfectant. A review of the undated Ice Machine Policy included: Sanitation of equipment: Frequency: Daily Wash exertion of machine. Use sanitizing solution and clean cloth. A review of the Policy: Daily Pantry Room Cleaning, dated 01/2024, included: Steps to be done. 2. Dust all horizontal surfaces with a cloth and disinfectant, wipe all horizontal (flat) surfaces. 4. Spot Clean with a cloth and disinfectant spot clean all vertical surfaces. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C #: NJ00166740 Based on observation, interviews, and record review, as well as review of pertinent facility documents on 9/8/23, it was determined that the facility staff failed to document that the medication was administration in accordance with the professional standards of practice and to follow the facility policy Medication Administration for 1 of 3 sampled residents (Resident #2) reviewed medication administration documentation. This deficient practice is evidenced by the following: According to the admission RECORD, Resident #2 was admitted to the facility on [DATE], with diagnosis that included but were not limited to: Anemia. The Minimum Data Set (MDS), an assessment tool dated 8/2/23, indicated the Brief Interview for Mental Status (BIMS) interview was not conducted due to Resident #2 was rarely/never understood. The MDS also indicated that the Resident required assistance from staff with Activities of Daily Living (ADLs). According to Resident #2's Care Plan (CP), initiated on 3/31/23, indicated that Resident #2 had Anemia. The CP included interventions not limited to: Give medications are ordered. A review of the form Order Summary Report (OSR), dated 9/8/23, revealed an order for Epoetin Alfa Injection Solution 1000 unit/ millimeter (ml), inject 1 ml subcutaneously in the evening every Monday, Wednesday, Friday for Anemia. A review of the Resident #1's Medication Administration Record (MAR), for the month of 9/2023, confirmed the aforementioned order from the OSR. The MAR also confirmed that the medication was administered on 9/6/23 at 6:00 pm. Review of the form Location of Administration Report (LAR) from 9/1/2023 thru 9/30/2023 revealed the abovementioned medication had Scheduled Time of 6:00 pm and Administered Time was on 9/8/23 at 11:30 am documented by the Unit Manager Licensed Practical Nurse (UMLPN) which was not according to the MAR schedule. The surveyor reviewed the Resident's progress notes (PN) from 9/6/23 to 9/8/23, there was no indication in the PN the reason why the medication was not administered or documented on 9/6/23. The surveyor conducted an interview with the UMLPN on 9/8/23 at 12:56 pm, the UMLPN stated that the facility administration protocol was according to the Physician order. In addition, the UMLPN stated that the nurse should document that the medication was administered right away prior to moving to the next resident. The UMLPN also stated that when the nurse signed the MAR, it indicates that the medication was administered as scheduled. The UMLPN was unable to explain the reason as to why her signature appeared on the LAR on 9/8/23 at 11:30 am. The surveyor conducted on interview with the Director of Nursing (DON) in the presence of the License Nursing Home Administrator on 9/8/23 at 3:29 p.m. The DON stated that the protocol for the administering nurse was to sign the MAR to show that the medication was administered according to the doctor's order. The DON was unable to explain that the medication was scheduled to be given on 9/6/23 at 6:00 pm and the UMLPN signed the LAR on 9/8/23 at 11:30 am. A review of the facility policy titled, Medication Administration, revised on 4/2023, indicated PURPOSE To administer the following: Right documentation .15. Document the following as applicable: Administration of medication on the MAR [Medication Administration Record] as soon as medications are given . NJAC 8:39-35.2 (d) (6)

Based on interview and record review, it was determined that the facility failed to ensure that staff were completely vaccinated on their COVID-19 vaccinations for 1 of 9 staff reviewed for compliance. This deficient practice was evidenced by the following: Reference: According to the Centers for Medicare and Medicaid Services (CMS) QSO-23-02-ALL Revised Guidance for Staff Vaccination Requirements, dated 10/26/22 . A process for tracking and securely documenting information provided by those staff who have requested, and for whom the facility has granted, an exemption from the staff COVID-19 vaccination requirements And establish Contingency plans for staff who are not fully vaccinated for COVID-19. Reference: According to the New Jersey Executive Directive NO. 21-011 (2nd Revision), dated 9/2/22 'Up to date with COVID-19 vaccinations' means that covered workers in health care and high-risk congregate settings received a primary series (either a 2-dose primary series of a COVID-19 vaccine or a single-dose primary series COVID-19 vaccine) and the first booster dose for which they are eligible as recommended by the CDC. .Each such covered setting (e.g., employer) shall maintain the following information .: a. Exemptions from COVID-19 vaccination participation: i. Number of covered workers who have a documented medical exemption from COVID-19 vaccination . On 12/28/22 at 10:15 AM, during an entrance conference, the surveyor met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Infection Preventionist Nurse (IPN). The Administration team informed the surveyor that the facility's IPN was responsible for the infection control program as well as oversight of the COVID-19 vaccination effort. On 12/28/22 at 1:00 PM, the surveyor met with the DON and requested documentation for the vaccination status of nine staff members. On 12/29/22 at 10:00 AM, the surveyor reviewed the COVID-19 immunization documentation provided by the DON which reflected that 1 of the 9-sample staff reviewed for vaccine compliance was not completely vaccinated for COVID-19. On 12/29/22 at 11:30 AM, the surveyor interviewed the DON and LNHA regarding the concern with one of the staff member who was reviewed as part of a sample of staff members for vaccination status. The surveyor was concerned that a Certified Nursing Assistant (CNA#1) was only documented as getting one shot of the Pfizer COVID-19 vaccine on 2/18/22. The surveyor asked the DON and LHNA if they can supply the surveyor team with either an exemption or an updated COVID-19 Vaccination Record card for CNA#1. 12/29/22 at 11:45 AM, the surveyor team interviewed the IPN regarding her role as the Infection Preventionist. She stated that she started working at the facility on 9/22/22 and that she works 40 hours every 2 weeks at the facility. She stated that she's responsible for overseeing the facility COVID-19 vaccination and booster program. She further stated that the Director of Human Resources will provide her with the status of staff vaccinations including new hires. It was her responsibility to make sure that all staff members are completely vaccinated. On 12/29/22 at 12:15 PM, the DON met with the surveyor team and was unable to provide either a medical exemption or updated COVID-19 Vaccination Record card for CNA#1. The DON provided the surveyor a copy of CNA#1 COVID-19 Vaccination Record card which revealed that she only received one dose of the Pfizer COVID-19 vaccine on 2/18/22. On 12/29/22 at 2:00 PM, the surveyor met with the LNHA, DON, IPN, [NAME] President of Operations and the Corporate Clinical [NAME] President. The surveyor informed the administration team with his concerns. No further information was provided. A review of the facility's policy Employee COVID-19 Vaccination with a revised date of 10/29/22, that was provided by the DON reflected that It is the policy of this facility that all employees will be offered COVID-19 vaccine as recommended by CDC. All employees are mandated to receive the complete series of the vaccine except for those who have approved medical or religious exemption. NJAC 8:39-5.1(a); 19.4(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 evaluate residents for advance directives (AD) and/or Physician Orders for Life Sustaining Treatment (POLST) related to end of life preferences. This deficient practice was observed for 3 of 26 residents reviewed for Advance Directives and POLST, Residents #94, #95, and #98 and was evidenced by the following: 1. The admission Record for Resident #94 indicated that the resident was admitted to the facility with diagnoses which included but were not limited to Malignant Neoplasm of the Pancreas, Gastrointestinal Hemorrhage, and alcohol dependence. Review of Resident #94's Significant Change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 1/28/22 reflected that the resident had a brief interview for mental status (BIMS) score of 11 which indicated Resident #94 had moderate cognitive impairment. Review of the March 2022 physician's orders (PO) revealed that the resident was a Full Code Status, indicating that all life saving measures should be implemented if the person's heart stopped beating and or if they stopped breathing. The surveyor was unable to locate any documentation that would indicate that the resident's end of life wishes had been discussed or addressed with the resident or resident's representative. During an interview on 2/28/22 at 10:53 AM, Resident #94 told the surveyor that no one at the facility had asked them about their end of life wishes. On 3/1/22 at 11:37 AM, during an interview with the Director of Social Services (DSS), she could not explain why the POLST, or an AD was not discussed with Resident #94. 2. The admission Record for Resident #95 indicated that the resident was admitted to the facility with diagnoses which included but were not limited to Dementia, Protein-Calorie Malnutrition, and dehydration. Review of Resident #95's admission MDS dated [DATE] reflected that the resident had a BIMS score of 3 which indicated that Resident #95 had severe cognitive impairment. Review of the March 2022 PO revealed that the resident was a Full Code Status. The surveyor was unable to locate any documentation that would indicate that the resident's end of life wishes had been discussed or addressed with the resident or resident's representative. On 3/1/22 at 11:14 AM, during an interview with the DSS, she could not explain why the POLST, or an AD was not discussed with Resident #95's representative. 3. The admission Record for Resident #98 indicated that the resident was admitted to the facility with diagnoses which included but were not limited to Spinal Stenosis, Diabetes Mellitus, Schizophrenia, and acute pancreatitis. Review of Resident #98's admission MDS dated [DATE] reflected that the resident had a BIMS score of 10 which indicated Resident #98 had moderate cognitive impairment. Review of the March 2022 PO revealed that the resident did not have a Code Status documented. The surveyor was unable to locate any documentation that would indicate that the resident's end of life wishes had been discussed or addressed with the resident or resident's representative. During an interview on 2/28/22 at 1:29 PM, Resident #98 told the surveyor that no one at the facility had asked them about their end of life wishes. On 3/1/22 at 12:57 PM, during an interview with the DSS, she could not explain why the POLST, or an AD was not discussed with Resident #98. Review of the Procedure section of the Facility's policy and procedure entitled, Practitioner Orders for Life-Sustaining Treatment (POLST) reviewed by the facility on August 2021 indicated: 1. At the time of admission the facility will determine whether the individual has completed a POLST form. 3. If the individual does not have a POLST form at the time of admission, the facility will introduce POLST within 14 days of admission. 10. If the individual, or when the individual lacks decision-making capacity, the legally recognized health care decision-maker, expresses concern about the POLST form, or if there has been a significant change in the individual's condition or wished, then the physician/nurse practitioner will be notified with 24 hours to discuss the potential changes with the individual or, if the individual lacks decision-making capacity, the legally recognized decision-maker. On 3/7/22 at 1:40 PM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator and DON. No further information was provided by the facility. N.J.A.C. 8:39-4.1 (a) 4

Based on observation, interview, and record review it was determined that the facility failed to accurately transcribe a physician's order (PO) onto the March 2022 Medication Administration Record (MAR) and failed to accurately document proper placement on the Enteral Protocol (feeding directly by way of intestines) sheet in accordance with professional standards of practice. This deficient practice was identified for 1 of 24 residents reviewed for standards of practice, Resident #212 and was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 2/28/22 at 11:12 AM, the surveyor observed Resident #212 in bed. The surveyor observed the resident had a Gastrostomy Tube (G-tube; a flexible tube surgically placed through the abdominal wall into the stomach for feeding). The tube was observed with Jevity1.2 Cal formula infusing at 60 milliliters (ml) per hour via an enteral feeding (a tube that allows liquid food to enter the stomach or intestine) pump. On 3/7/22 at 10:15 AM, the surveyor observed Resident #212 in bed. The surveyor observed Jevity1.2 Cal formula infusing at 60 ml per hour via a pump. The surveyor reviewed the admission Record which reflected Resident #212 was admitted to the facility with diagnoses which included but were not limited to Gastrostomy Tube Malfunction, Pressure Ulcer of Sacral Region and Fecal Impaction. Review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/28/22 assessed that Resident #212 was rarely/never understood, indicating severely impaired cognition. Review of the Enteral Protocol dated 2/23/2022 and signed by the Physician documented that Jevity1.5 liters 30 ml/hour (hr.) via G-tube to run continuous until seen by dietician was ordered. Review of the NutrasourceRD dated 2/24/2022 and signed by the Physician documented that Jevity1.2-Goal rate of 60 ml/hr. was ordered. The surveyor reviewed the resident's March 2022 Enteral Protocol documentation sheet (EP). The EP documented, Jevity 1.5 infused at a rate of 30 ml/hr. via G-tube to run continuously. The EP was signed by nursing daily, from 3/1/22-3/7/22 as administered. 2. A further review of the EP documented Check tube for proper placement prior to each feeding, flush, medication administration. The EP required recorded entries for all three nursing shifts daily. Review of the EP indicated that nursing failed to document proper placement checks on 3/6/22 and 3/7/22 for the 11:00 PM-7:00 AM shift. The EP also indicated that there was no documented evidence that proper placement was checked from 3/1/22 to 3/7/22 on the 7:00 AM to 3:00 PM shift. Further review of the same EP indicated that nursing failed to document proper placement checks on 3/1/22, 3/4/22, and 3/6/22 for the 3:00 PM to 11:00 PM shift. The surveyor reviewed the March 2022 EP with the Registered Nurse (RN), who acknowledged that he should have clarified the PO and should be signing for the Jevity 1.2 Cal, which was being administered. The RN further acknowledged that nursing should have documented checking the proper placement of the enteral tube on the EP daily and every shift. On 3/7/22 at 12:25 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the EP should have been updated when the Jevity 1.5 Cal ordered on 2/23/22 was changed to Jevity1.2 Cal on 2/24/22. The DON acknowledged that nursing should sign for the formulation that was being administered and the placement check of the enteral tube daily, every shift. On 3/7/22 at 12:39 PM, the surveyor interviewed the Registered Dietitian (RD) who stated that she had faxed her recommendation for Jevity 1.2 Cal at 60 mL/hr. to the Physician. Review of the subsection Procedure of the Policy and Procedure titled, Enteral Feeding, last revised and reviewed by the facility on 1/2/22 documented: 1. Verify physician's orders. 3. Prepare enteral feeding as ordered by physician. 6. Assess placement of feeding tube. 16. Document administration of feeding on Medication Administration Record including Date, Formula, Rate. On 3/7/22 at 1:40 PM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator and DON. No further information was provided by the facility. NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to report a witnessed fall incident, complete a thorough fall investigation, implement safety measures and revise interventions for a resident who had a history of falls. This deficient practice was identified for 1 of 6 residents, Resident #49, reviewed for falls and was evidenced by the following: On 2/28/22 at 11:32 AM, the surveyor observed Resident #49 out of bed seated in a wheelchair in the day room watching TV and conversing with another resident. The resident informed the surveyor, that they had a seizure disorder and that before they were admitted to the facility, they had a bad seizure and fell. The resident stated that when they were admitted to the facility after their fall, they were confused and unable to care for themselves. Resident #49 further stated that they had regained a lot of their cognition, but still had periods of confusion. Resident #49 informed the surveyor that their main mode of locomotion on the unit was the wheelchair due to their unsteady gait. Review of the resident's admission Record revealed that the resident was admitted to the facility with diagnoses which included but were not limited to seizure disorder, alcohol dependence, bipolar disorder, and depression. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/24/21, reflected the resident had a brief interview for mental status score of 3, which indicated severe cognitive impairment. Review of section G of the MDS for functional status, indicated the resident required extensive assistance with one-person assistance for transfers, dressing, toilet use and bathing and minimal assistance with one-person assistance for bed mobility, locomotion on the unit and eating. On 3/2/2022 at 10:35 AM, the surveyor interviewed Resident #49 who explained that their wheelchair flipped backwards, and they hit their head. Review of the Incident Report (IR), provided by the Director of Nursing (DON) revealed the resident had a fall on 2/16/22 at 3:30 PM. The IR included that, Resident #49 stated that they were going into the elevator and their wheelchair tipped backwards when pulling themselves onto the elevator. Review of the Licensed Practical Nurse/ Unit Manager (LPN/UM) Employee Statement dated 2/16/22, documented that Resident #49 stated that they were backing into the elevator when the wheelchair tipped over backwards. The statement documented that there were no apparent injuries noted. The resident was returning from an activity on the 2nd floor. Included in the statement was an entry that at around 4:30 PM the resident complained of head pain. The statement added that the Medical Doctor was made aware, and the wife was informed. Vital signs were documented as follows: Blood Pressure 130/80, Pulse 80, Respirations 18, Temperature 97.6. The Physician ordered the resident sent out to the ER for a Computerized Tomography (CT) scan of the resident's head. Review of the DOR employee statement reflected that she and a recreation aide (RA) were transporting members from the Resident Council Meeting to their respective floors. The statement documented that the DOR and RA reversed Resident #49's wheelchair and attempted to pull them backwards into the elevator. The statement further explained that the wheelchair tilted backwards after the front wheels became stuck in the elevator gap and the resident's wheelchair fell backward. On 3/2/22 at 10:00 AM, the surveyor interviewed the Licensed Practical Nurse/ Unit Manager (LPN/UM) who stated that it was Resident #49 who informed her that they had a fall on 2/16/22 and that neither the DOR nor the RA informed her of the incident. On 3/2/22 at 10:09 AM, the surveyor interviewed the DOR who stated that she witnessed the resident fall backward; assisted the resident back up; asked if they were okay. The DOR added that the resident seemed fine, was alert and oriented. The DOR stated that she continued to transfer Resident #49 to the 5th floor and then continued bringing the other residents to their respective floors, without reporting the incident to the nurse. The DOR explained that when she returned to the 5th floor about 15 minutes after dropping off Resident #49, the LPN/UM informed her that Resident #49 complained of hitting their head. The DOR then confirmed that the resident had fallen in the elevator. The DOR acknowledged that she should have immediately reported the incident to the nurse. On 3/2/22 at 10:35 AM, the surveyor interviewed Resident #49 who stated that a staff member pulled the wheelchair backwards and assisted the resident into the elevator. Resident #49 explained that the wheels got stuck and caused the wheelchair to fall backwards. Resident #49 stated that they hit their head and informed the staff member of the injury. Resident #49 added that when they were left on their residing floor, they told the LPN/UM of the incident. Resident #49 included that when they felt dizzy, the LPN/UM then transferred the resident to the emergency room (ER) where they had a CT scan of the head. The resident stated that the CT scan revealed that there were no injuries. Resident #49 added that they stayed overnight for observation and transferred back to the facility the next day. A review of the resident's individualized, comprehensive care plan (CCP) for History of falls, degenerative disease of the nervous system and history of seizures, revised on 2/16/22 had the following interventions, Assess fall risk on admission, quarterly and when necessary; sent to ER; Refer to Physical Therapy. On 3/2/22 at 12:37 PM, the survey team interviewed the DON who stated that the RA assisting with the transportation of the resident should have written an employee statement regarding the incident. She further indicated that the DOR statement was incomplete and should have had more details. The DON added that the DOR should have immediately notified the LPN/UM and nursing supervisor. The DON explained the procedure for Incident/Accident investigations (I/A) a Registered Nurse should be notified immediately and should assess the resident. The DON added that the nurse and staff should complete employee statements and notify the physician as well as the family. The surveyor requested the completed investigation. The DON searched the computer and stated that she was unable to locate the completed investigation. On 3/2/22 at 12:58 PM, the surveyor interviewed the Recreation Aide (RA) who stated she was holding the handles of the wheelchair while pulling Resident #49 backwards into the elevator when the wheels got stuck and the resident in the wheelchair fell backwards. The RA further stated that she wasn't asked to complete an employee investigation statement. The RA stated that the DOR completed the employee investigation statement, My boss completed the employee statement since it wasn't my fault. The surveyors asked the RA if she had any formal transport of resident's training. The RA replied that she did not. On 3/2/22 at 1:45 PM, during the resident council meeting, Resident #49's roommate informed the surveyors that Resident #49 couldn't attend the meeting because they had fallen in the elevator. On 3/2/22 at 2:55 PM, the surveyor interviewed the Rehabilitation Director (RD) who stated that he was not aware that Resident #49 fell on 2/16/22 and that the resident needed to have their wheelchair evaluated. The RD stated that he was asked to put anti tippers on the resident's wheelchair after the resident's 3/2/22 fall in the elevator. The RD stated that when he evaluated Resident #49's wheelchair for fall risk, the outcome led the RD to provide Resident #49 with a new wheelchair with anti-tippers on it. On 3/2/22 at 3:15PM, the surveyor interviewed the 3 PM-11PM shift RN/S, who stated that she made a mistake with her late entry regarding the fall on 2/16/22. The RN/S further stated that at first, she didn't believe the resident because the DOR told her the resident didn't fall. The RN/S further investigated the fall and after further discussion with Resident #49 concluded that the fall did take place. On 3/3/22 at 8:56 AM the DON provided the surveyor with a one-page investigation summary from Resident #49's 2/16/22 fall, which did not include interviews of the RA and failed to reflect that a thorough investigation had been completed for the incident. On 3/7/22 at 1:40 PM, the surveyor interviewed the DON who stated that she intended to refer Resident #49 to the Rehabilitation Department after the first fall on 2/16/22 but didn't. The surveyor reviewed the Policy section of the Incident and Accident Policy, last reviewed by the facility on 1/2022 which reflected: It is the policy of this facility that accidents/ incidents involving resident care will be investigated and documented on the Resident Incident Report, to enable the facility to evaluate care given to residents, to assist in prevention of incidents, and evaluate interventions implemented in the event of an incident. An accident /incident is any unusual event, occurrence, or happening which may or may not result in injury or illness to a resident. Review of the Protocol section of the Incident and Accident Policy documented: 1. Accident/Incident reports are initiated by a clinician as soon as the occurrence is discovered or reported. 2. A thorough investigation and follow-up will be completed within five working days. A summary of the accident/incident will be documented. Review of the Procedure section of the Incident and Accident Policy documented: 1. Licensed nurse/supervisor will complete an assessment of the resident/patient and protect resident/patient from further immediate harm or potential harm. 5. Licensed nurse/supervisor initiates the investigation to determine cause. Examples may include, but are not limited to: -Interview affected resident if possible. -Interview all potential witnesses, to include roommate, other residents, visitors, family members and staff. -Observe the immediate surrounding environment. -Review medication regimen 6. Review of the accident/incident report will be completed by the DON and/or Nurse Manager within 24 hours. 8. Nurse Manager/DON completes follow-up and resolution to the investigation. 9. DON/designee completes report with findings and conclusions. Review of the Fall Prevention and Management Program policy and procedure last reviewed by the facility on January 10, 2022, reflected: Documented under the section titled, Purpose: The purpose of the Falls Prevention and Management Program is to develop, implement, monitor, and evaluate an interdisciplinary team falls prevention approach and management strategies that foster resident independence and quality of life while ensuring safety for the resident and other residents and staff. The program focuses on reducing the incidence of residents' falls and mitigating risks of falls through a resident focused, team approach which ensures that a resident's environment and social, physical, cognitive, and emotional strengths are supported. The program ensures team training, communication, and effective care planning. Documented in the Fall Prevention and Management Program under the section titled, Program Objectives: 1.To improve and maintain a resident's optimal functional level and quality of life. 2. To identify and reduce or eliminate environmental risk factors for residents. 3. To identify and reduce or eliminate health risk factors for residents 4. To reduce the frequency of falls. 5. To reduce the severity of injuries from falls. 6. To ensure best practice interventions for residents who have fallen. 5. To monitor and track trends related to resident falls. Documented under the section titled, A. Fall Prevention of the Fall Prevention and Management Program subsection, Registered Nursing Staff: 4. Refer the resident to the interdisciplinary team based on their level of risk and/or as deemed appropriate and initiate strategies/activities to reduce/minimize the risk of falls. 5. Assess for and implement nursing restorative/rehabilitation activities as part of care planning. Documented under the section titled, B. Fall and Post Fall Assessment and Management When a resident has fallen, the resident will be assessed regarding the nature of the fall and associated consequences, the cause of the fall and the post fall care management needs. Documented under the section titled, B. Fall and Post Fall Assessment and Management subsection, Person witnessing the fall or finding the resident after the fall: 3. Notify the registered nursing staff/Nursing Supervisor. Documented under the section titled, B. Fall and Post Fall Assessment and Management subsection, Registered Nursing Staff: 1. Complete the head to toe assessment. 5. Initiate neuro-checks for all unwitnessed falls and witnessed falls that have resulted in a possible head injury. Follow neuro-check protocol unless otherwise specified by the MD. 9. Redo the Fall Risk Assessment and modify the plan of care in collaboration with the interdisciplinary team. Documented under the section titled, B. Fall and Post Fall Assessment and Management subsection, Staff Training and Education 1. Provide orientation and training on the falls prevention and management program (policy, procedures, tools) including the importance of the program and the risk to residents' health due to falls On 3/7/22 at 1:45 PM, the survey team met with the Licensed Nursing Home Administrator and DON to discuss the above observations and concerns. No further information was provided by the facility. NJAC: 8:39-27.1

Based on observation, interview, and record review, it was determined that the facility failed to maintain necessary respiratory care and services for a resident who was receiving continuous oxygen (O2) and nebulizer treatment according to the standards of practice. The deficient practice was identified for 1 of 3 residents (Resident #54) reviewed for respiratory care. This deficient practice was evidenced by the following: On 2/28/22 at 10:41 AM, the surveyor observed Resident #54 in bed in their room, with O2 in use via nasal cannula (N/C) at 2 LPM (liters per minute) attached to the humidified O2 concentrator (a medical device used for delivering O2). There was no date indicated in the O2 tubing when it was last changed. The surveyor also observed a nebulizer mask placed inside the drawer next to the plastic bag. The nebulizer mask was dated 1/31/22 indicating the date when it was changed. A review of the resident's face sheet (an admission summary) reflected that Resident #54 was admitted to the facility with diagnoses that included Pneumonia, Atrial Fibrillation and Congestive Heart Failure. A review of the 2/17/22 Comprehensive Minimum Data Set, an assessment tool used to facilitate care management, revealed a Brief Interview for Mental Status score of 99 indicating that the resident was unable to complete the interview. Cognitive skills for daily decision revealed that Resident #54 had severely impaired cognition. On 2/28/22 at 11:05 AM, the nurse assigned to Resident #54 was brought inside the room and during the interview, the nurse stated that she does not know when the O2 tubing was last changed. The nurse further stated that the O2 tubing must be dated when it was changed. The surveyor showed the nebulizer mask with a date of 1/31/22 to the nurse. The nurse stated that when the nebulizer mask is not in use, it must be placed inside the plastic bag for proper storage. The nurse also stated that the tubing was not changed since the date indicated. A review of the March 2022 Physician's Order Form revealed that there was an order dated 12/13/21 for O2 at 2 LPM via N/C continuous; change O2 tubing weekly on Sundays on 11-7 shift. Further review of the physician's order revealed an order dated 1/28/22 for Duoneb Inhaler, give TID (three times a day) via nebulizer x 30 days. The surveyor reviewed the facility's Policy and Procedure titled, Oxygen Administration under #12 Care and Use of Reusable Humidifiers (g.) Change humidifier and tubing weekly. On 3/7/22 at 1:30 PM, the surveyor brought the above concern to the Administrator and Director of Nursing. No additional information was provided. NJAC 8:39-11.2 (b) 27.1(a) 19.4 (k)

Based on observation, interview, and record review, it was determined that the facility's physician failed to conduct a face-to-face visit at a required interval and to assure that the physician responsible for supervising the care of the residents signed and dated the monthly physician's orders to ensure that the residents current medical regimen was appropriate. This deficient practice was observed for 2 of 24 Residents reviewed, Resident #48 and #50 and was evidenced by the following: 1.) On 2/28/22 at 10:23 AM, the surveyor observed Resident #48 in bed, awake, watching TV. The surveyor verified the last time the physician visited the resident. Resident #48 responded it's been a long time. A review of the resident's face sheet (an admission summary) reflected that Resident #48 was admitted to the facility with diagnoses that included Hypertension, Rhabdomyolysis, Cardiovascular Accident with left Hemiparesis. A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate care management dated 2/11/22, indicated a Brief Interview for Mental Status (BIMS) scored at 14, which indicated that the resident was cognitively intact. A review of Resident #48's Physician's Order Sheets (POS), from January 2022 through February 2022, revealed that the resident's physician did not sign and date the monthly Physician's Orders indicating that the resident's medications were never reviewed. A review of the Physician's Progress Notes revealed that the last progress note and face to face visit from the Physician was dated 9/24/21. There were no further progress notes located in the resident's medical records. 2.) On 2/28/22 at 10:43 AM, the surveyor observed Resident #50 in the day room attending an activity. The surveyor interviewed the resident who can only speak and understand Spanish. A review of the resident's face sheet reflected that Resident #50 was admitted to the facility with diagnoses that included Dementia, Anxiety and Depression. A review of the QMDS, an assessment tool used to facilitate care management dated 12/7/21, indicated that the resident was unable to complete the BIMS interview due to memory problems for both short-term and long-term memory. Cognitive skills for daily decision making revealed moderately impaired. A review of Resident #50's POS, from January 2022 through February 2022, revealed that the resident's physician did not sign and date the monthly Physician's Orders indicating that the medications were never reviewed. A review of the Physician's Progress Notes revealed that the last progress note and face to face visit from the Physician was dated 11/29/21. There were no further progress notes located in the resident's medical records. On 3/8/22 at 10:08 AM, the surveyor interviewed the Physician via a phone conversation. The Physician stated that he missed signing the POSs for both Residents #48 and #50. The Physician informed the surveyor that the progress notes were stored in his personal computer and was not accessible to the facility. A review of the facility's policy titled, Physician Visits: Initial Medical Assessment and Routine follow up visits under Routine follow up visit #1. The physician will visit the resident as follows: At least every 60 days thereafter. A Policy titled, Physician Order indicated that Physician orders will be dated and signed according to state and federal guidelines. On 3/7/22 at 1:30 PM, the surveyor brought the concern to the Administrator and the Director of Nursing regarding the physician visits. There were no additional information provided. NJAC 8:39-27.1

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain acceptable labeling and dating of foods in the dry storage room including discarding food items past their recommended expiration dates. This deficient practice was observed during kitchen tour and was evidenced by the following: On 2/28/2022 at 9:20 A.M., the surveyor toured the kitchen with the Dietary Director (DD). During the tour of the dry storage area with the DD, the surveyor observed: 1. Five boxes of 32 ounce (oz.) Baking Soda with an expiration date of 12/18/2021 on the shelf. 2. Five cans of 106 oz. Fruit Mix dated with an expiration date of 1/21/21. 3. Seven cans of 6 pounds (lbs.) 10oz Pineapple Chunks with an expiration date of 10/1/21. 4. Multiple items were noted received from the distributor without labels indicating, use by and/or expiration dates. Instead, these items were labeled with a manufacture's code. When interviewed by the surveyor, the DD was unable to state the date the item was received and/or the use by date of the following items: a. Four cans of 6 lbs. Mashed Potatoes b. Seven cans of 105 oz. Diced Tomatoes c. Six cans of 6 lbs 5oz Three Bean Salad d. One can of 104 oz. Sliced Beets e. Four cans of 110 oz. Chickpeas f. Four cans of 6 lbs. 12oz Vegetarian Beans g. Five cans of 3 lbs 14oz Sliced Mushrooms h. Six cans of 117 oz. Cranberry Sauce i. Two cans of 108 oz. Breakfast Skillet j. Two containers of 1 gallon each Buttermilk Ranch Dressing k. Two containers of 1 gallon each Creamy Ranch Dressing l. One container of 5 lbs Peanut Butter During the interview with the surveyor, the DD could not identify the expiration dates based on the manufacturing code system. The DD could not explain why the expired baking soda was not removed from the dry storage area. The DD was unable to produce a facility policy for storage of food and supplies. On 3/3/2022 at 2:30 PM. The surveyor discussed kitchen concerns with the Administrator and Director of Nursing. NJAC 8:39-17.2(g)

Based on facility staff interviews and review of pertinent facility documentation on 3/3/2022, it was determined that the facility failed to provide a designated qualified Infection Prevention and Control Nurse. This deficient practice is evidenced by the following: During an interview on 3/2/2022 at 2:59 P.M., the Assistant Director of Nursing (ADON), stated that she has been certified as the Infection Prevention and Control Nurse (IPC) since 9/23/2021, and that she is the only Infection Prevention and Control Nurse at this time in the facility. The ADON further stated that she is working full time as the ADON and the IPC. She stated that on September 23, 2021, she completed her Centers for Disease Control and Prevention training, receiving her certification as a Nursing Home Infection Preventionist. On 3/3/2022 at 10:40 AM, the Director of Nursing (DON) supplied the surveyor with the paperwork for the IP designee, ADON. The ADON was also practicing as the IPC and received her IP certification on 9/23/21. During an interview on 3/3/2022 at 1:17 P.M. with the Regional Registered Nurse (RRN), DON and ADON, the surveyor identified that the ADON did not meet the qualifications to be the IPC. The ADON did not have the required 5 years of experience as an IPC, and it was not her only designated job title. Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following: ii. Required Core Practices for Infection Prevention and Control: Facilities are required to have one or more individuals with training in infection prevention and control employed or contracted on a full time basis or part-time basis to provide on-site management of the Infection Prevention and Control (IPC) program. The requirements of this Directive may be fulfilled by: An individual certified by the Certification Board of Infection Control and Epidemiology or meets the requirements under N.J.A.C. 8:39-20.2;or b. A Physician who has completed an infectious Disease fellowship; or c. A healthcare professional licensed and in good standing by the State of New Jersey, with five (5) or more years of Infection Control experience. NJAC 8.39-20.2

Based on observation, interview and record review, it was determined that the facility failed to don appropriate Personal Protective Equipment (PPE) and to follow appropriate infection control practice regarding housekeeping equipment used in a room that was on contact isolation precautions. This deficient practice was identified in 1 of 3 nursing units, and for 1 of 3 housekeeping staff observed as evidenced by the fallowing: On 11/13/19 at 11:21 AM, the surveyor observed a Housekeeper (#1) as he used the buffing machine (Burnisher) to buff the floor in Resident #28's room on the third floor nursing unit. The surveyor noted a sign on Resident #28's door which reflected to see the nurse before entering the room. The surveyor also observed an isolation cart next to the entrance to the room which contained PPE (yellow gown, gloves and mask). The surveyor noted that Housekeeper #1 was not wearing any PPE as he buffed Resident #28's room. When he finished buffing the room, the surveyor interviewed him on 11/13/19 at 11:25 AM. Housekeeper #1 stated that he had been working at the facility for one year. When asked about the use of PPE in an isolation room, he stated that he only needed to wear PPE if the resident had like air borne isolation and that for contact isolation, he did not need to wear PPE. Housekeeper #1 stated that he wore gloves if he needed to change the trash bag in the trash can. He stated that their department supervisor went over infection control when he was first hired, and had told them to watch out for isolation rooms and to check with the nurse. When asked if he checked with the nurse, House keeper #1 stated that he did not ask the nurse before going into the room to clean, and that no one said anything to him while he was in the room cleaning. When asked how he knew that the resident was on isolation precaution, he stated that he knew because there was an isolation cart by the doorway to the room. When asked how he knew the type of isolation precaution the resident was on, he stated that he did not know the type of isolation the resident was on. The surveyor observed Housekeeper #1 as he wheeled the Burnisher through the hall, past the nurses's station and into the central shower room and stored it at a corner where other equipment (wheelchair, shower chair) were stored near a whirlpool sink. He did not clean/sanitize the Burnisher before wheeling it through the hallway and storing it in the shower room. After he stored the Burnisher, the surveyor interviewed Housekeeper #1 again at 11:30 AM. He stated that he stored the Burnisher in the shower room because he still had other rooms to buff after lunch, and that he did not want to take the Burnisher all the way to the basement since he was going to use it again after lunch. When asked about their process for the use of the Burnisher between rooms and in isolation rooms, he stated that they apply disposable cleaning pads under the Burnisher and that he usually used one side of the disposable pad for several rooms until the one side was visibly dirty. He stated that when one side of the pad was visibly dirty, he would turn to the other side of the pad to continue cleaning till all the rooms were done including the isolation room. When asked about how he cleaned the Burnisher before storing, Housekeeper #1 stated that he did not switch out the pad before he stored the Burnisher, except if the Burnisher was visibly dirty. Housekeeper #1 did not seam to know and did not explain how he was supposed to maintain/sanitize cleaning equipment that was used in an isolation room, before using the same equipment in other rooms. On 11/14/19 at 12:26 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) that cared for Resident #28. The LPN stated that she was not aware of the instructions or process housekeeping followed for cleaning an isolation room and to ask the Director Of Nursing (DON) for the information. On 11/14/19 at 01:51 PM, the surveyor interviewed the DON. The DON stated that housekeeping staff were supposed to check with the nurse on the unit before going into any room with an isolation sign at the door and that the nurse was supposed to make sure that housekeepers and all the non-nursing departments, were informed when there was an isolation room on the unit. The DON stated that nurses on the unit should inform all staff of the proper PPE needed to wear while in the isolation room. On 11/14/19 at 2:00 PM, the surveyor interviewed the Housekeeping Director (HD). The HD stated that the housekeeping staff were supposed to go to the nurse for instruction before entering to clean any isolation room. When asked about the process for using the Burnisher, the HD stated that the Burnisher was used with disposable pads and that the disposable pad could be used to buff up to one half of the unit on one side of the pad, before switching to the second side of the pad. The HD stated that once a pad was used to clean an isolation room, the pad was supposed to be discarded and replaced with a new pad and the Burnisher would be sanitized before cleaning another room. The HD also stated that the disposable pad should be replaced after use, before storing it away. He stated that all housekeeping staff were educated about the process. When asked for the policy, the HD did not provide the policy. The HD provided a sign-in sheet titled, General in-service/review porters/housekeeper, dated 02/17/19. The HD stated that the general in-service day was when they reviewed the cleaning of isolation rooms in addition to all infection control practices related to housekeeping. On 11/15/19 at 10:40 AM, the surveyor interviewed Housekeeper #2 regarding isolation rooms and the use of the Burnisher. Housekeeper #2 stated that she always went to the nurse for instruction, whenever she saw an isolation set up at any room. Housekeeper #2 stated that she usually wore gown, gloves and masks when she cleaned an isolation room and that she received in-service education twice a year about infection control. She stated that she sanitized equipment used in an isolation room before using the equipment in another room. On 11/15/19 at 10:45 AM, the surveyor interviewed Housekeeper #3. Housekeeper #3 stated that he started at the facility two weeks ago and that he knew he was supposed to wear PPE when he cleaned an isolation room. Housekeeper #3 did not provide information regarding changing the pads on the Burnisher after cleaning the isolation room or sanitizing the equipment before storage. On 11/15/19 at 1:00 PM, the Administrator provided the surveyor with an undated one-page document titled, Infection Room Cleaning Policy and Procedures. The policy reflected that the housekeeper must contact the nurse and the department head to ascertain the type of infection and that the housekeeper must wear appropriate PPE and equipment when entering isolation rooms. The policy also included that the housekeeper should remove detachable equipment from the machine and bag them while in the room, and to disinfect the machine outside the isolation room before transporting the machine elsewhere. NJAC 8:39-19.1