**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one out of three resident (Resident (R) 79) with a Level I PASARR (Preadmission Screening and Resident Review), who later was identified with a serious mental disorder, was evaluated through the Level II PASARR process in a total sample of 38 residents. This deficient practice resulted in R79 not being evaluated for and/or provided specialized care and treatment for a serious mental illness. Findings include: Review of a Resident Face Sheet found in R79's electronic medical record (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document titled New Jersey Department of Human Services . Pre- admission Screening and Resident Review (PASRR) Level 1 Screen. located under the Misc (Miscellaneous) tab dated 9/17/20 indicated the resident was negative for mental health screening. Review of R79s' EMR tab titled Med (Medical) Diag (Diagnosis) indicated the resident was diagnosed with borderline personality disorder on 05/30/25. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/25 indicated R79 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which revealed the resident was cognitively intact. Review of R79's EMR titled Behavioral Solutions, P.C. dated 03/31/25 revealed the resident was diagnosed with borderline personality disorder. Review of R79's EMR failed to contain a referral for Level II PASARR. During an interview conducted on 07/24/25 at 9:00 AM, the Director of Social Services (DSS) stated if there was a new mental health diagnosis that a Level II referral would be made to ensure that the resident received appropriate services. During an interview conducted on 07/24/25 at 10:56 AM the Director of Nursing (DON) confirmed she was not aware of R79's new diagnosis of borderline personality disorder and a referral for a Level II should have been done and confirmed the referral was not completed.NJAC 8:39-5.1(a)

Complaint #NJ00158428 Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to honor the recreational needs and preferences of a resident who was not provided with a remote control for their television upon admission to the facility and was not assisted to change the channel to a preferred station. This deficient practice was identified for 1 of 1 residents (Resident #155) reviewed for accommodation of needs. This deficient practice was evidenced by the following: On 01/22/24 at 10:21 AM, the surveyors, who were accompanied by Certified Nursing Assistant (CNA) #1 during an incontinence tour of dependent residents, observed Resident #155 lying in bed awake. Resident #155 immediately stated that he/she had not had a television remote for two to three days. The resident stated that they asked a couple of people, whose names were unknown by the resident, for a television remote control and still had not received one. The resident stated that he/she had to watch nothing but sports during that time. The surveyors observed the television was turned on and was set to the sports channel. Review of the admission Record (an admission summary) revealed that the Resident #155 was admitted to the facility with diagnosis which included but were not limited to: Chronic respiratory failure with hypoxia (a condition that occurs when there is an insufficient amount of oxygen in the blood), and anxiety disorder unspecified. The Minimum Data Set (MDS), an assessment tool, was not yet completed and was not available for review. Review of a General Nurse's Note dated 01/20/24 at 6:41 AM, indicated that Resident #155 was able to make his/her needs known. Review of Resident #155's Care Plan revealed an entry dated 01/22/24, with a Focus of Solitary Activities. The Goal included that resident would have the opportunity to enjoy solitary activities of choice through the next review date. The sole intervention included: Enjoys the following solitary activities, watching TV. During an interview with the surveyor on 01/22/24 at 12:14 PM, CNA #1 stated that when a resident's television remote control was missing she ensured that they received a new one timely. CNA #1 stated that she had not worked over the past weekend. During an interview with the surveyor on 01/22/24 at 2:19 PM, LPN/UM #1 stated that when a television remote control was needed over the weekend all that staff had to do was inform the supervisor and a replacement remote control was then provided. LPN/UM #1 stated that it was not fun to be unable to turn the channel on the television when desired. During an interview with the surveyor on 01/22/24 at 3:12 PM, the Director of Nursing (DON) stated that she would have expected that if a resident requested a television remote control, they would have received a new remote. The DON stated that staff could have reached out to Maintenance or herself if needed. The DON stated that it was a resident right issue if a television remote control was not provided when requested. The DON stated that she did not have a policy that was directly related to resident television services when requested. During an interview with the Maintenance Director (MD) he stated that if a resident needed a television remote control over the weekend, all the staff needed to do was to call him to get another. Review of the policy, Resident Rights (Reviewed and Updated October 2023) revealed the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These right include the resident rights to: A dignified existence, to be treated with respect, kindness and dignity, .Self-determination . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. According to the admission record, Resident # 50 was admitted with diagnoses which included but were not limited to COPD (chronic obstructive pulmonary disease), a disease affecting the breathing and acute respiratory failure with hypoxia, a disease affecting the breathing resulting in low blood oxygen levels. A review of the physician order summary revealed an order for oxygen at 2 liters/minute via nasal cannula every shift for shortness of breath dated 10/10/23. A review of the medication administration records for December 2023 indicated that the oxygen order was signed for on all three shifts from December 1, 2023, through December 11, 2023. A review of the MDS dated [DATE], section O, oxygen therapy while a resident was not checked off as having been administered for the fourteen days prior to December 11, 2023. On 1/24/223 at 12:42 PM the surveyor reviewed Resident #50's medical record and MDS with the MDS Coordinator. The MDS Coordinator stated that Resident #50 was on oxygen during that time, and she would modify the MDS to reflect same. A review of a facility policy titled; Resident Assessments, reviewed and updated October 2023, included that all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. N.J.A.C. 8:39-11.1 Based on interview, and record review it was determined that the facility faciled to accurately code the Minimum Data Set (MDS) for 3 of 29 residents reviewed, Residents # 94, #93, and #50. This deficient practice was evidenced by the following: 1. a. According to the admission Record, Resident #94 was admitted to the facility with diagnosis which included but were not limited to pneumonia. A review of the resident's progress notes dated, 10/21/23 at 11:30 AM, revealed that the resident's family member was present for wound care teaching and supplies were provided for home care. Further review of the resident's progress notes dated, 10/21/23 at 12:02 PM revealed a discharge note that indicated that the resident was scheduled for discharge, and that prescriptions, paperwork, belongings and discharge instructions were given to the resident's family member. A review of the resident's discharge MDS dated [DATE] revealed that the MDS section A2105 Discharge Status was coded 11, Critical Access Hospital instead of 01 which was discharge to home or community. b. According to the admission Record, Resident # 93 was admitted to the facility with diagnosis which included but were not limited to dementia. A review of the progress notes dated 11/17/23 at 2:18 PM revealed that Resident # 93 went to the hospital from dialysis. Further review of the progress notes dated 11/17/23 at 7:11 PM revealed that the resident was admitted to the hospital for shortness of breath. A review of the resident's discharge MDS dated [DATE], indicated on section A2105 Discharge Status that the resident was coded 01 which was discharge to the home or community instead of 04 Short-Term General Hospital (acute care hospital). On 01/22/24 at 10:22 AM, the surveyor reviewed Resident #94's and Resident #93's medical record and MDS with the MDS Coordinator. The MDS coordinator stated she would have to complete a modification to correct the MDS's.

Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to follow professional standards of nursing practice by incorrectly transcribing a physician's order for laboratory blood work. This deficient practice was identified for 1 of 2 residents (Resident #90) reviewed for nutrition. This deficient practice was 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 state: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing a medical regimen as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 1/17/24 at 11:21 AM, the surveyor observed Resident #90 lying awake in bed. The resident stated to the surveyor concern of abdominal discomfort and constipation. A review of the admission Record reflected that Resident #90 was admitted to the facility in with diagnoses which included, but not limited to: cerebral infarction (stroke), essential primary hypertension (high blood pressure), hypomagnesemia (low levels of magnesium in the blood), constipation, and dysphagia (difficulty swallowing foods or liquids). A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 1/6/24, identified that Resident #90 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment, and dependent on staff for all aspects of care. A review of the resident's individualized resident-centered care plan initiated on 12/19/2023, included a focused care area of weight loss, with interventions including monitor laboratory/diagnostic work as ordered and report results and follow up as needed. A review of Resident #90's progress notes (PN) revealed a nutritional change noted by the dietician dated 12/26/23 at 2:44 PM indicating Resident #90 had a significant weight loss of 11% of body weight in one month and was put on a regular liberal diet. The dietician recommended a new order for Remeron (a medication used to increase appetite) and Boost VHC eight (8) ounces (oz) (a nutritional supplement) by mouth twice a day to provide more calories and protein, and bloodwork for complete blood count (CBC) (to check blood count), basic metabolic panel (BMP) (to check nutritional values and electrolytes), and pre-albumin (to check blood protein levels). A review of the physician's order summary report (POS) indicated an order with an order date of 12/26/23 for CBC, BMP, and prealbumin labs to be drawn 12/28/23 and 1/2/24. A review of a PN dated 1/9/24 at 2:07 PM, indicated the dietician assessed Resident #90, and a nutrition note was initiated stating Resident #90 continued to show an undesired weight loss, and the dietician again recommended labs for complete metabolic panel (CMP) (to check nutritional values and electrolytes) and pre-albumin. Further review of physician's orders indicated an order dated 1/9/24 at 2:05 PM for a physician's verbal order for CMP and prealbumin. Review of Resident #90's laboratory medical records revealed new lab results for CMP and pre-albumin collected on 1/17/2024 and CBC with collection date of 1/24/24. On 1/23/24 10:50 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager #1 (LPN/UM1) on who confirmed Resident #90 was on her unit when the labs were ordered and stated that it was not carried out. On 1/23/24 at 10:44 AM, the surveyor interviewed Resident #90's attending physician (MD), who reviewed his notes and was unable to find the lab results. On 1/23/24 at 12:57 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed that the labs were not collected as recommended and ordered because they were not transcribed correctly. On 1/24/24 at 10:50 AM, the surveyor conducted a phone interview with the dietician. The dietician stated that on 12/26/24 she recommended labs then nurses took it from there. The dietician further stated she followed up to review the lab results on 1/9/24 and saw it was not there. On 1/26/24 at 9:51 AM, in the presence of the survey team and the facility's administration, the DON stated that she cannot deny that the labs were missed. Review of the facility policy titled, Laboratory Service and Reporting with a revised date October 2023, included but was not limited to: the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The facility must provide or obtain services to meet the needs of the residents. The facility is responsible for the appropriateness of the laboratory services. NJAC 8:39 27.1(a)

Deficiency Text Not Available

Complaint #NJ00156885 Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure hygienic incontinent care was provided to prevent urinary tract infection. This deficient practice was identified for 1 of 5 residents (Resident #155) reviewed for incontinence care. This deficient practice was evidenced by the following: On 01/22/24 at 10:21 AM, the surveyors observed Certified Nursing Assistant (CNA) #1 as she provided incontinence care to Resident #155 with resident permission. The surveyors observed that the resident had an indwelling urinary catheter (an internal device inserted in the bladder that collects urine that is drained into an attached urinary drainage bag) and wore an adult incontinence brief. On 01/22/24 at 10:48 AM, CNA #1 used disposable cleansing cloths as she proceeded to clean the resident's genitalia and wiped in an upward motion from the back to front. CNA #1 then used a wash rag to clean the area and patted the area dry with a towel. CNA #1 then proceeded to turn the resident onto their left side. CNA #1 then washed the resident's buttock fold and used a forward motion and proceeded to wipe from the back toward the front of the resident's genitalia. Review of Resident #155's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: Acute cystitis with hematuria (acute cystitis is an infection that affects the bladder, with presence of blood in the urine). Resident #155's Minimum Data Set (MDS), an assessment tool, was not completed or available for review. Review of Resident #155's Care Plan revealed an entry dated 01/21/24, with a Focus that included: Urinary Tract Infection. The Goal was for no complications related to urinary tract infection through the next review date. The Interventions included: Current urinary tract infection, and observed for any of the following: increased frequency of urination, urgency, pain with urination, foul smelling urine, fever, side/lower back pain, dark or concentrated urine, change in mental status or orientation etc .Administer antibiotics as ordered by the physician. Assess effectiveness and notify the physician if symptoms are not resolving. During an interview with the surveyor on 01/22/24 at 12:14 PM, the surveyor interviewed CNA #1 who stated that she provided perineal (washing the genital and rectal areas of the body) with disposable wipes so that she did not get germs on the resident's towel. CNA #1 stated that she was required to cleanse the resident's private area from the front to the back because if you wiped from back to front you could cause the resident to get an infection. CNA #1 stated that she had not recalled that she used improper technique of wiping from back to front during the observation. During an interview with the surveyor on 01/22/24 at 2:19 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) #1 stated that when perineal care was provided staff were required to cleanse the area from front to back or it would be possible for the resident to get a urinary tract infection, ecoli (escherichia coli is a gram-negative bacteria) or yeast infection. During an interview with the surveyor on 01/22/24 at 3:12 PM, the Director of Nursing (DON) stated that when perineal care was provided the aide was required to wipe from front to back to prevent the spread of infection. During an interview with the surveyor on 01/24/24 at 10:59 AM, the Infection Preventionist (IP) stated that the correct way to perform perineal care was to wipe from front to back to prevent urinary tract infection that could be introduced if the resident were wiped in the wrong direction. Review of the facility policy, Perineal Care (Implemented 12/14/2022) revealed the following: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Perineal care refers to the care of the external genitalia and anal area. .Wet washcloth and apply perineal cleanser. If using prepackaged product, open package and .cleanse the perineum .wiping in direction from front to back (from pubic area toward anus) . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review it was determined that the facility failed to a.) ensure appropriate storage for respiratory equipment and b.) obtain a physician's order for a BIPAP machine (a machine that can help push air into your lungs). This deficient practice was identified for 1 of 3 residents reviewed for respiratory equipment (Resident #31) and was evidenced by the following: On 1/18/24 at 9:53 AM, the surveyor toured the subacute unit and entered Resident #31's room. Resident #31 was awake and in bed. The surveyor observed the resident's nebulizer mask face down on top of the nebulizer machine. There was a plastic drawstring bag that was hung from the side of nebulizer machine. The surveyor observed a BIPAP machine placed on the resident's side table with a mask inside of the bag. At that time, the surveyor interviewed Resident #31 who stated she/he received his/her BIPAP every night since readmission to the facility on [DATE] and the BIPAP mask was removed daily by the 05:00 AM nurse. The surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN1) regarding usage of BIPAP who stated nursing staff have been applying BIPAP since the resident's readmission on [DATE]. A review of the admission Record (an admission summary) reflected that Resident #31 was admitted to the facility with diagnoses which included but were not limited to chronic respiratory failure with hypoxia (high blood levels or low levels of carbon dioxide in the blood) and heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs). A review of the resident's Quarterly Minimum Data Set, included that the resident had a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident's congition was intact. A review of the resident's care plan initiated on 06/18/23, revealed the resident had a focus for BIPAP. The goal was that the resident would have no complications related to respiratory distress through the next review. Interventions included assist as needed to position to facilitate breathing, elevate head of the bed as tolerated, and cleanse BIPAP mask daily in the morning when removing it. A review of the active physician orders did not include an order for the resident's BIPAP machine. A review of the January 2024 Medication Administration Record (MAR) did not include the BIPAP machine. A review of the respiratory therapy progress note dated 01/19/24 revealed the resident's BIPAP setting were 12/6 and the machine, tubing, and mask were in good working condition. On 01/22/24 at 9:39AM, the surveyor entered Resident #31's room and observed the nebulizer mask out of bag, face down on top of the nebulizer machine. At that time, the surveyor interviewed the resident who stated the Certified Nursing Assistant (CNA) removed the mask when the treatment was finished. On 01/22/24 at 10:00 AM, surveyor #1 and surveyor #2 interviewed UM/LPN#1 regarding policy and procedures on nebulizer treatment and storage. UM/LPN #1 acknowledged that the mask should have been washed and placed in the plastic bag. At that time, surveyor #1 accompanied by surveyor #2 asked UM/LPN #1 to go to Resident #31's room. UMLPN #1 observed the resident's nebulizer mask out of the bag, placed her hands inside the storage bag, removed her hands, grabbed the nebulizer mask, enter the resident's bathroom, and closed the door. The surveyors heard water running. UM/LPN #1 opened the bathroom door, holding the nebulizer mask and medication reservoir while drying it with a paper towel. UM/LPN #1 then placed it back into the resident's storage bag. During an interview with the surveyor on 1/22/24 at 11:51AM, the Director of Nursing (DON) stated the nebulizer treatments were administered by the nurses. After the treatments were completed, the mask should be washed, dried, and placed into a storage bag. The DON stated that a physician's order was required for a resident who was using a BIPAP machine. The surveyor reviewed Resident #31's medical record with the DON who confirmed there was no order. A review of a facility policy titled, Oxygen tubing and Respiratory Products policy with a revision date of October 2023. The policy included that all nebulizer tubing and equipment should be cleaned after each use and kept in a bag and dated. A review of a facility policy titled, Noninvasive Ventilation (CPAP, BIPAP,) with a revision date of August 2023 included that all CPAP/BIPAP vary by manufacturer, common equipment including machine, tubing, mask, headgear/straps, disposable/non-disposable filter and humidifier and the facility will obtain an order for the use of the device and settings from the practitioner. NJAC 8:39-25.2 (b), c (4)

Based on observation, interview, and record review it was determined that the facility failed to ensure a pain management regime was followed in accordance with physician orders. This deficient practice was identified in 1 of 1 resident reviewed for pain (Resident #5) and was evidenced by the following: On 01/17/24 at 10:52 AM, during the initial tour of the facility the surveyor observed Resident #5 in bed and awake. The surveyor asked the resident if he/she were having any pain. Resident #5 told the surveyor that he/she had knee pain and that x-rays were completed at the facility. The resident told the surveyor he/she was currently receiving pain medications as ordered by the physician. The surveyor asked if the medication was effective and the resident responded, Sometimes. The surveyor reviewed Resident #5 admission Record which indicated the resident had medical diagnoses which included but were not limited to encephalopathy (any brain disease that alters brain function), hypertension (high blood pressure), pain in knee, and major depressive disorder. The surveyor then reviewed the 5-day Medicare Minimum Data Set (MDS), an assessment tool dated 11/27/23. Section J titled health conditions indicated that the resident was on a scheduled pain regime. Section J also revealed that the resident's pain was almost constantly. Further review of the MDS revealed the resident had a Brief Interview of Mental Status (BIMS) of 15, meaning the resident was cognitively intact. On 01/23/24 at 09:36 AM, the surveyor reviewed the physician orders which revealed the resident was prescribed the following orders: Acetaminophen (pain medication for minor aches and pains and to reduce fever) 325 milligrams (mg) two tabs every six hours for mild pain, Oxycodone (narcotic to treat moderate to severe pain) 10/325 mg tabs every 6 hours for severe pain and oxycontin (narcotic to relieve severe ongoing pain) ER 20 mg every 12 hours around the clock. All the medications were ordered on November 20, 2023. Review of the graphic sheet with pain assessments indicated that the resident was being assessed for pain four times daily and pain levels on the numeric scale (zero for no pain to 10 for severe pain) went from a zero to a nine. On 01/23/24 at 09:41 AM, the surveyor reviewed the Medication Administration Record (MAR) which showed that the resident received the Acetaminophen (ordered for mild pain) one time on 01/09/24, for a pain level of a four (moderate pain). Further review of the MAR showed that in the month of January 2024 the resident received Oxycodone (narcotic pain reliever ordered for severe pain) on 01/12/24 when the residents' pain was mild, on 01/02/24 when pain was a four (moderate), on 01/15/24 when pain was a five (moderate) and 14 times when the residents' pain level was a six (moderate). The Oxycodone was ordered for severe pain. On 01/23/24 at 09:50 AM, the surveyor reviewed Resident #5 care plan which showed a focus of opioids (narcotic pain medication). The care plan was initiated on 10/06/23 with the goal of the resident having no reaction or side effects to the opioids. The interventions were to administer pain medication(s) as ordered by the physician and to monitor the effectiveness of the medications and notify the physician if ineffective. On 01/23/24 at 11:49 AM, the surveyor interviewed the unit Licensed Practical Nurse (LPN #5) regarding pain scales and assessments. LPN #5 told the surveyor, We use verbal pain scale, numerical, I will ask pain levels from one to 10. I will then ask where the pain is. The surveyor asked LPN #5 to define the numeric pain scale, and she responded, One to four is mild, four to six could be moderate, and seven to 10 is severe pain. The surveyor asked LPN5 what she would do if someone came to her with pain of nine and only had pain medication ordered for mild pain. The nurse responded, I would offer the Tylenol for mild pain, but I will definitely call the doctor for something else. The surveyor then asked what if a resident's pain was a three but only had medication ordered for severe pain. LPN5 responded, I would call doctor and see what else we can get them. I would also do repositioning for comfort. During interview with the surveyor on 01/26/24 at 09:31 AM, the Director of Nursing (DON) stated that the nursing staff ask the resident's their pain scale prior to medicating the residents. On 01/29/24 at 01:15 PM, the surveyor reviewed the policy titled, Pain Management dated October 2023. Under the section titled, Pain Management and Treatment, number seven indicated that pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. Under number eight, it revealed that if reassessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure all medications were administered without error of 5% or more, and b.) ensure medications were properly stored, dispensed, prepared for administration and administered. This deficient practice was observed during the medication administration observation on 1/18/24, and during medication storage observations on 1/17/24. The surveyor observed three (3) nurses administer medications to four (4) residents with a total of 34 opportunities, and two (2) errors were observed which calculated a medication administration error rate of 5.88% during medication administration observation. This deficient practice was identified for 2 of 4 residents (Resident #96 and Resident #36) that were administered medications by 2 of 3 nurses on the second-floor nursing unit, and 1 of 3 medication carts observed during medication storage observation. The deficient practice was evidenced by the following: a.) On 1/18/24 at 9:43 AM, during medication administration observations, the surveyor observed Licensed Practical Nurse #2 (LPN #2) dispensing and preparing to administer medication to Resident #96. During the process of medication administration, after showing the surveyor the medication cards (Bingo card containing individually packaged pills), one at a time, for observation, the LPN dispensed the first two medications into a small plastic medication cup. After the LPN showed the surveyor the third and fourth bingo cards, she placed the cards back down on top of the medication cart without dispensing those two medications. After the fifth medication was shown to the surveyor, the LPN then stated to the surveyor, I forgot to pop these last two. She then dispensed the two previous medications which were forgotten and continued the process. The LPN then asked Resident #96 if they had any pain, to which Resident #96 confirmed they had pain. At 9:55 AM, LPN #2 identified the resident was ordered acetaminophen (a pain medication) as needed for pain, she obtained the stock supply bottle of acetaminophen from the top drawer of the medication cart, gave it to the surveyor for confirmation, and when given back to the LPN, she did not dispense the ordered dose into the medication cup with the other medications, and placed the bottle back into the medication cart. The LPN signed the computerized medication administration record (MAR) as having administered the acetaminophen, she then administered the other medications not including acetaminophen to Resident #96 (error 1). At that time, the surveyor inquired with LPN #2 about not having dispensed the acetaminophen, to which LPN #2 stated she was sure she administered it and questioned the surveyor stating, you're human too. On 1/18/24 at 9:58 AM, the surveyor observed LPN #3 during medication administration. LPN #3 prepared and administered the ordered medications for Resident #36, which included metoprolol tartrate (a medication used to lower blood pressure) 25 milligrams (mg). That medication had a pharmacy sticker on the bingo card which instructed to give with or IMMEDIATELY after meal. The surveyor observed Resident #36 in their room as LPN #3 administered the medication, the surveyor did not observe any meal trays, snacks, or other food in the vicinity of the resident to indicate any meal was recently eaten. LPN #3 did not offer the resident any food with the medication. Once completed and back at the medication cart with the LPN, the surveyor inquired about when meals were delivered to the resident. The LPN stated breakfast was delivered at 8:00 AM. The LPN then confirmed the pharmacy instructions for this medication to be taken with meal and acknowledged that 9:58 (1 hour and 58 minutes) from the last meal would not be considered with or immediately after meal (error 2). The LPN then asked another staff member to have the kitchen send the resident crackers. Review of Resident #96's admission Record reflected the resident was admitted to the facility with diagnosis which included but was not limited to cerebral infarction (stroke). Review of Resident #96's Physician Order Summary (POS) included an order for Tylenol (acetaminophen) oral capsule 325 mg give two tablets by mouth every six hours as needed for pain with start date 1/9/24. Review of Resident #36's admission Record reflected the resident was admitted to the facility with diagnosis which included but was not limited to primary hypertension (HTN) (high blood pressure). Review of Resident #36's POS included an order for metoprolol tartrate oral tablet 25 mg give 0.5 tablet by mouth two times a day for HTN with start date 7/13/23. b.) On 1/17/24 at 10:54 AM, the surveyor, in the presence of LPN #3, observed the Ashland nursing unit's medication cart 2. In the top drawer of the cart, the surveyor observed two unlabeled medication plastic cups, one containing six pre-dispensed unidentifiable medication pills of various colors and shapes, the other containing four pre-dispensed unidentifiable medication pills of various colors and shapes. LPN #3 quickly removed the cups and stated, you didn't see this. The surveyor asked the LPN to place these cups on top of the medication cart for observation. The LPN complied and upon surveyor inquiry, the LPN informed that these were medications she pre-dispensed from the bingo cards for two different residents (Resident #32 and Resident #61), whom she was waiting to be ready to receive their medications. At 11:25 AM, the surveyor inquired if this was appropriate procedure for administration, to which the LPN stated no and would not administer. At that time, the surveyor stepped back from the medication cart, and observed LPN #3 place the medication cup with four pills back in the drawer of the cart, secured the drawer, and took the second cup with six pills to Resident #32 to administer. On 1/18/24 at 12:48 PM, the surveyor interviewed the Director of Nursing (DON). The DON acknowledged that medications should be administered to residents as ordered, she also stated that medications required to be given with meals should not be given any later than 30 minutes after a meal to be considered immediately after meal, and two hours after a meal was not considered to be given with meal. Regarding pre-dispensing of medications from bingo cards for later administration, the DON stated this should absolutely not happen stating this could cause risk of medications being administered to the wrong resident, and that doing this is all around not a good practice. Review of the facility's Administering Medications policy with a review and updated date of October 2023 included but was not limited to, medications are administered in a safe and timely manner, and as prescribed . medications are administered in accordance with prescriber orders, including any required time frame .medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of the facility's Storage of Medications policy with a review and updated date of October 2023 included but was not limited to, drugs and biologicals are stored in the packaging containers or other dispensing systems in which they are received . the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. NJAC 8:39- 29.2(d)

2. On 1/18/24 at 9:40 AM, the surveyor observed Licensed Practical Nurse 2 (LPN #2) while she administered medication to Resident #96. LPN #2 prepared to initiate medication administration to the resident by first obtaining a rolling vitals machine (a machine used to check blood pressure (BP), heart rate, blood-oxygen saturation, and temperature), rolled it to the room where the resident was sitting in a wheelchair by the room entrance. The LPN donned (put on) disposable gloves, took out a container of sanitizing wipes from the medication cart, used a single wipe to wipe down the components of the vitals machine, then disposed of the wipe in the trash, doffed (took off) the gloves and disposed of them in the trash, then without performing hand hygiene opened the medication cart drawer and began to take out the medication cards for this resident and placed them on the cart surface to begin medication administration. The LPN then, without using gloves placed the BP cuff on the resident's arm and began to obtain the resident's vitals. Once completed, the LPN removed the equipment off the resident, without performing hand hygiene, then began the process of dispensing and administering the resident's medication. On 1/18/24 at 12:41 PM, the surveyor interviewed LPN #2. She acknowledged that there should have been hand hygiene performed after sanitizing the equipment, doffing the gloves, and before handling the medications, stating, I should have. On 1/18/24 at 12:48 PM, the surveyor interviewed the Director of Nursing (DON), who confirmed that hand hygiene should be performed between doffing and donning gloves, after sanitizing medical equipment and before handling resident's medications stating the purpose is to ensure no cross contamination and infection control. Review of the facility's provided Hand Hygiene policy with accessed date of April 2023 included but was not limited to: hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, .after touching a patient or the patient's immediate environment . immediately before putting on gloves and after glove removal . Alcohol-based hand sanitizers effectively reduce the number of germs that may be on the hands of healthcare workers after interacting with patients. Hand hygiene technique when using soap and water: Wet hands with water. Avoid using hot water to prevent drying of skin. Apply to hands the amount of soap recommended by the manufacturer. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers, Rinse hands with water. Dry thoroughly with a single-use towel. Use clean towel to turn off the faucet. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility's provided Handwashing/Hand Hygiene policy (Reviewed and Updated October 2019) revealed the following: This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors Use an alcohol-based hand rub containing at least 62% alcohol: or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .before moving from a contaminated body site to a clean body site .After contact with a resident's skin. Hand hygiene is the final step after removing and disposing of personal protective equipment (equipment worn to protect the body from disease or injury). The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. NJAC 8:39-19.4(a)(n) Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain proper infection control practices by performing appropriate hand hygiene: a.) during incontinence care and b.) during medication administration. This deficient practice was identified for 2 of 2 Certified Nursing Assistants (CNAs) observed on 1 of 2 nursing units (Medbridge) and for 1 of 3 nurses observed during medication administration on 1 of 2 nursing units (Ashland). This deficient practice was evidenced by: 1. On 01/22/24 at 10:03 AM, the surveyors observed CNA #1 as she provided incontinence care to an unsampled resident with resident permission. When finished, CNA #1 doffed (removed) her gloves and washed her hands for 13 seconds. CNA #1 then donned gloves and assisted the resident to sit on the edge of the bed before she assisted the resident out of bed to the wheelchair. CNA #1 then assisted the resident into the bathroom and set the resident up with the necessary supplies for the resident to brush his/her teeth. CNA #1 then removed the resident's bed linens from the bed and placed them in a plastic trash bag to be laundered. CNA #1 then proceeded to push the resident in their wheelchair back to the bedside. CNA #1 used her gloved hands to hand the resident the television remote and over bed table. CNA #1 then doffed her gloves and washed her hands for 14 seconds. At 10:17 AM, CNA #1 took the soiled laundry and trash bags from the resident's room and placed them in the soiled utility room. When finished, CNA #1 washed her hands for 10 seconds. On 01/22/24 at 10:21 AM, the surveyors observed CNA #1 as she prepared to perform incontinence care on Resident #155 with resident permission. CNA #1 washed her hands under the stream of running water for 22 seconds before she donned (put on) gloves. CNA #1 first washed the resident's upper body. At 10:40 AM, she doffed her gloves and washed her hands for eight seconds under running water. CNA #1 then donned gloves and washed the resident's bilateral lower extremities. CNA #1 then emptied the basin in the sink and refilled it with water and then proceeded to rinse the resident's legs with clean water. CNA #1 then dried the resident's lower extremities and applied lotion to both of resident's legs. CNA #1 then proceeded to perform perineal care (care of the area between the anus and the genitalia) without first doffing her gloves and performing hand hygiene. On 01/22/24 at 10:58 AM, the surveyors observed CNA #2 use alcohol based hand rub (ABHR) prior to being interviewed by the surveyors. CNA #2 stated that she planned to provide incontinence care to Resident #154. The surveyors observed the care with resident permission. At 11:06 AM, CNA #2 obtained a basin, filled it with water in the sink and then donned gloves. CNA #2 then proceeded to wash the resident who was incontinent of both urine and stool. At 11:25 AM, CNA #2 placed the basin in the bathroom sink and doffed her gloves. She failed to perform hand hygiene after. CNA #2 then returned to the resident and assisted the resident to reposition in bed and handed the resident their bed control. At 11:28 AM, CNA #2 double bagged the resident's linens and garbage. She then proceeded to donn gloves without first performing hand hygiene. At 11:29 AM, CNA #2 emptied the basin in the toilet and flushed the toilet with her gloved hand. CNA #2 then reached into her uniform pocket with her gloved hand and obtained a trash bag. CNA #2 then proceeded to dry the basin with a paper towel and hung it in a trash bag from the towel rack. At 11:32 AM, after the observation CNA #2 washed her hands for 20 seconds. During an interview with the surveyor on 01/22/24 at 12:14 PM, CNA #1 stated that she was required to wash her hands for 20 seconds under the running water. CNA #1 stated that she sang the happy birthday song to determine the correct amount of time to wash her hands. During an interview with the surveyor on 01/22/24 at 12:44 PM, CNA #2 stated that she was required to perform hand hygiene when she doffed her gloves. CNA #2 stated that if she changed her gloves instead of performing hand hygiene after doffing it could lead to contamination. During an interview with the surveyor on 01/22/24 at 2:19 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 stated that staff were required to wash their hands both before and after resident care. LPN/UM #1 stated that hand washing was required after gloves were doffed for infection control purposes. LPN/UM #1 stated that hands were required to be washed with soap and water out of the stream of running water to kill all germs on the hands. During an interview with the surveyor on 01/22/24 at 3:12 PM, the Director of Nursing (DON) stated that hands should be washed for 20 to 30 seconds and make sure to get absolutely everything, including the nails out of the stream of running water. DON further stated that when gloves were doffed you were supposed to wash your hands for infection control. During an interview with the surveyor on 01/24/24 at 10:59 AM, the Infection Preventionist (IP) stated that the process to wash hands was to: Turn on warm water, wet hands, get soap and wash hands out of the running water, in a downward fashion for twenty seconds, then rinse hands separately. Then dry your hands on a paper towel and discard it after. Then turn off the faucet with a clean paper towel and discard it. IP stated that if hands were washed under running water then you would just transfer the germs back and forth on your hands. IP stated that if hands were not washed for twenty seconds or better then your hands were not clean and you were spreading bacteria that was on your hands. IP further stated that you must wash your hands after you doffed your gloves. IP explained that you had to wash your hands rather than change gloves so that you did not contaminate, because your hands were still dirty and someone could get sick from whatever was on your hands. The DON provided the surveyor with Hand Washing Competencies that were completed by both CNA #1 and CNA #2 on 10/12/23, 01/18/24, and 01/23/24.

Complaint #NJ00158428 Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 2 of 4 residents (Residents #54 and #156) observed for incontinence care on 1 of 2 nursing units (Medbridge) and for 1 of 3 residents (Resident #20) reviewed for bowel and bladder incontinence on 1 of 2 nursing units (Second Floor). This deficient practice was evidenced by the following: 1. During an interview with the surveyor on 01/22/24 at 9:40 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 stated that the census on the unit was 42 and there were four Certified Nursing Assistants (CNAs) and three nurses present on the unit to provide resident care. On 01/22/24 at 9:44 AM, the surveyors completed an incontinence tour on the Medbridge Unit and observed the following: During an interview with the surveyor on 01/22/24 at 9:44 AM, Certified Nursing Assistant (CNA) #1 stated that she worked at the facility for eight years and was assigned to 10 residents. CNA #1 stated that she had not yet completed her AM care. During an interview with the surveyor on 01/22/24 at 10:58 AM, CNA #2 stated that she worked at the facility for seven months and was assigned to 12 residents. CNA #2 stated that she had not yet completed her AM care and agreed to allow the surveyors to observe care rendered to residents who were dependent for incontinence care. On 01/22/23 at 11:00 AM, the surveyors accompanied CNA #2 into Resident #154's room. The Director of Nursing (DON) was in the room and was observed attempting to adjust the bed controls for the resident. The surveyor observed a strong odor of feces within the resident's room. The resident raised their voice at staff and pointed to an empty plastic cup of water on the table. CNA #2 left the room and returned with a cup of ice water. The DON also left the room and returned with a beverage for the resident and then proceeded to leave the room. The resident granted permission for the surveyors to observe incontinence care. At 11:04 AM, when CNA #2 informed the resident that she intended to wash the resident. Resident #154 stated, Getting washed was a first. At 11:15 AM, CNA #2 unfastened Resident #154's brief and proceeded to clean the resident's frontal area. CNA #2 stated that the resident was new to her and she had not cared for the resident prior to this observation. At 11:17 AM, CNA #2 turned Resident #154 towards the right side and the surveyor observed that the brief that the resident had worn was saturated with both urine and feces. CNA #2 stated that the resident's draw sheet (folded flat sheet placed beneath the resident to aid in bed mobility) was saturated with urine. When CNA #2 moved the draw sheet and the surveyor noted that the fitted sheet that covered the mattress was stained with a brown liquid. When the surveyor asked CNA #2 what the brown liquid represented she stated that it meant that the resident had not been changed for awhile. The resident stated that he/she was not always able to tell staff when he/she was incontinent. CNA #2 stated that there was no skin protectant in the resident's room to protect the skin from moisture. Review of Resident #154's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included: essential hypertension (high blood pressure) and hyperglycemia (an excess of glucose in the blood stream). The surveyor attempted to review Resident #154's admission Minimum Data Set (MDS), an assessment tool, which was not yet completed or available for review. Review of Resident #154's Progress Notes (PN) revealed an entry dated 01/21/24 at 01:43 AM, which revealed that the resident required extensive assistance with bed mobility of two persons. Further review of the PN revealed that there was no documented evidence to indicate that the resident had refused care on 01/21/24 or 01/22/24. Review of Resident #154's Care Plan revealed an entry dated 01/16/24, Urinary Incontinence, Goal included: Will be free from skin breakdown related to incontinence through the next review date. Interventions included: Cleanse and dry the skin thoroughly before applying barrier cream (skin protectant) after each episode of incontinence .Provide incontinence care upon arising, before and after meals, at bedtime and as needed to help promote increased continence. Review of Resident #154's CNA Task Report revealed that the resident's assigned CNA documented that toilet use, bladder continence, and bowel continence care was signed as completed on 01/22/24 at 2:06 AM. There was no documented evidence that toilet use, bladder continence, and bowel continence was documented as completed after 18:23 (6:23 PM) on 01/21/24. During an interview with CNA #2 on 01/22/23 at 11:37 AM, CNA #2 stated that while she had not observed any other residents saturated with urine today, it was typical to find residents who were saturated when she reported to duty in the morning. On 01/22/24 at 11:39 AM, the surveyors accompanied CNA #2 into Resident #156's room. CNA #2 stated that someone must have started the resident's care because there was a towel in the sink and the water was still running. When interviewed at that time, Resident #156 stated that he/she reported that he/she needed to be changed an hour prior. CNA #2 stated that no one had told her that the resident awaited care. The resident agreed to permit the surveyors to observe incontinence care. At 11:46 AM, CNA #2 exposed Resident #156's brief which was saturated with urine. When the surveyor asked the resident when he/she was last changed the resident stated that it had been a while. CNA #2 stated that the resident's brief was saturated. The sheets beneath the resident the resident were noted to be heavily soiled with urine. At that time, the resident requested to use a urine collection device to urinate in. At 11:51 AM, the surveyor asked CNA #2 to call LPN/UM #1 into Resident #156's room. LPN/UM #1 presented and observed the resident's brief and sheets with the surveyors and she stated that they were saturated. LPN/UM #1 stated that they were not brown in color, and the color was clear. When the surveyor asked what the saturation meant LPN/UM #1 stated that it meant that the resident was saturated and needed to be changed. The surveyor asked LPN/UM #1 if she noted any odor? LPN/UM #1 stated that she was unable to smell anything as she wore a surgical mask. The surveyor noted a very strong smell of urine with mask usage. CNA #2 who was present and also wore a mask stated, the smell was strong. LPN/UM #1 stated that it was unusual to find residents saturated with urine. When interviewed at that time, LPN/UM #1 was unsure of the state mandated CNA staffing rations and deferred any further questions regarding staffing to the staffing coordinator. Review of Resident #156's admission Record revealed that the resident was admitted with diagnosis which included but were not limited to: Spinal stenosis, lumbar region without neurogenic claudication (narrowing of the spinal canal in the lower part of your back), benign prostatic hyperplasia with lower urinary tract symptoms (when prostate gland, a small, walnut size gland that produces seminole fluid that nourishes and transports sperm enlarges potentially blocking or slowing the urine stream), and malignant neoplasm of prostate (cancer of the prostate gland). Review of Resident #156's admission MDS revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which meant that the resident was fully, cognitively intact. Further review of the assessment revealed that the resident was occasionally incontinent of urine and frequently incontinent of bowel. Review of Resident #156's Care Plan revealed an entry dated 01/22/24, with a Focus of Urinary Incontinence which detailed that interventions included: .Offer incontinence care upon arising, before and after meals, at bedtime and as needed to help promote increased continence . Review of Resident #156's CNA Task Report revealed that there was no documented evidence that toilet use, bladder continence or bowel continence care was rendered on 01/22/24 as the entries were left blank and were not signed out as completed to indicate that care was rendered. During a later interview with the surveyor on 01/22/24 at 2:19 PM, LPN/UM #1 stated that incontinence rounds should be done every two hours unless needed sooner. LPN/UM #1 stated that if CNA #2 did not change the residents prior to the incontinence tour, then the 11-7 shift did resident changes before they left at 6:30 AM. LPN/UM #1 stated that she arrived at the facilty today at 5:45 AM and there were three CNAs and two nurses assigned to work overnight. LPN/UM #1 stated that the nursing staff who worked on the unit today were from the second floor nursing unit and were not usual staff. During an interview with the surveyor on 01/22/24 at 3:12 PM, the DON stated that if a resident were a typical wetter then they should be checked for incontinence every two hours. If the resident were a heavy wetter than the resident should be checked more frequently. DON stated that the CNA should round every two hours if they were not familiar with the residents. The DON stated that if the sheets were stained brown, then it must have exceeded a period of two hours since the resident became wet. The DON stated that she would have expected for there to have been barrier cream in use for incontinent residents as it was a standard of practice and did not require a doctor's order. 2. During the initial tour of the facility on 01/17/24 at 11:29 AM, the surveyors observed Resident #20 lying in bed awake. The resident stated that approximately one week ago, he/she wet themselves after the call bell was not answered for one half hour. The resident stated that the incident was reported to the executor, who the resident could not identify by name. The resident stated that he/she went to the Resident Council Meeting but was too embarrassed to mention the incident. Review of Resident #20's admission Record revealed that the resident was admitted with diagnosis which included but were not limited to: unspecified diastolic (congestive) heart failure (chronic condition in which the heart does not pump blood as well as it should) and chronic kidney disease stage three unspecified. Review of Resident #20's most recent Minimum Data Set (MDS) revealed that the resident's Brief Interview for Mental Status (BIMS) score was 13 out of 15 which indicated that the resident was fully, cognitively intact. Further review of the MDS revealed that the resident was frequently incontinent of urine and bowel. Review of Resident#20's Care Plan revealed an entry dated 12/05/23, with a Focus of Toileting. The Goal included: Toileting needs will be met through the next review date. Interventions included: Needs extensive assistance of two with toileting, Assist to bathroom upon arising, before and after each meal, before bedtime and as needed, Remind me to use the call bell when assistance is needed to get up to use the bathroom . On 01/22/24 at 9:27 AM, the surveyor requested all incident/accident reports that pertained to Resident #20 and there were none. During an interview with the surveyors on 01/23/24 at 9:43 AM, Certified Nursing Assistant (CNA) #3 stated that a couple of weeks ago Resident #20 rang the call bell and was incontinent of stool. CNA #3 stated that the resident was upset because he/she had to wait a little bit. When the surveyor asked CNA #3 if she reported the incident she stated, Everybody knew as the resident was very upset. CNA #3 stated that she did not report the event herself. CNA #3 further stated that the resident was incontinent at times. During an interview with the surveyors on 01/23/24 at 10:08 AM, Licensed Practical Nurse/Unit Manager (LPN/UM) #2 stated that she was not aware of an incident that involved Resident #20 being incontinent due to delayed call bell response. LPN/UM #2 stated that call bells should be answered within the first five seconds with no time delay because anyone could answer the call bell to see what the resident needed. On 01/23/24 at 10:23 AM, LPN/UM #2 questioned CNA #3 regarding the incident in the presence of the surveyors. CNA #3 stated that a couple of weeks ago the call bell went off and the resident was upset because he/she had an accident in the bed. CNA #3 stated that the resident informed her that someone came into the room and told the resident that someone would be in to assist the resident. CNA #3 stated that she knew that she was supposed to let the nurse know, but she was unsure who she may have reported the incident to. During an interview with the surveyor on 01/23/24 at 1:40 PM, the Director of Nursing (DON) stated that the call bell response time should be within ten to fifteen minutes and staff should not shut off the call bell. DON explained that staff should try and find the nurse, the unit manager or herself so that we could address the issue. Review of the facility policy, Incontinence (Implemented 12/13/22) revealed the following: .Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. NJAC 8:39-27.1(a), 27.2 (h)

2. On 01/22/24 at 9:44 AM, the surveyors completed an incontinence tour on the Medbridge Unit. The surveyors were accompanied by two CNAs and an Licensed Practical Nurse/Unit Manger during the care of four residents for incontinence care. Of the four residents observed, two residents (Resident #154 and Resident #156) were found with saturated incontinence briefs and bed linens. On 01/17/24 at 11:29 AM, Resident #20 reported that he/she had an episode of incontinence after a delayed call bell response that was later confirmed by the resident's assigned CNA. During an interview with the surveyor on 01/22/24 at 9:40 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 stated that the census on the unit was 42 and there were four Certified Nursing Assistants (CNAs) and three nurses present on the unit to provide resident care. LPN/UM #1 was unable to state the mandated CNA staff ratios and deferred further questioning to the staffing coordinator. During an interview with the surveyor on 01/24/24 at 09:45 AM , the staffing coordinator stated she was aware of the staffing ratios, and staffing has always been a struggle. A review of the facility staffing policy updated 2/2023, titled, Staffing included that the facility provided sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. One CNA to every eight residents for the day shift, One direct care staff member (RN, LPN,or CNA) to every 10 residents for the evening shift and one direct care staff member (RN, LPN, or CNA) to every 14 residents for the night shift. NJAC 8:39-5.1(a) Complaint # NJ 156885, NJ 158428, NJ 159346, NJ 160533, NJ 163074, NJ 163435 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to: a. maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey and b.) provide adequate staff to ensure all residents were provided with timely incontinent care for 2 of 4 residents reviewed for incontinence care (Resident #154 and Resident #156) on 1 of 2 units (Medbridge) and for 1 of 3 residents (Resident #20) reviewed for bowel and bladder incontinence on 1 of 2 units (Second Floor). This deficient practice was evidenced by the following: Refer to F677E 1. Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio (s) were effective on 02/01/2021: One (1) Certified Nurse Aide (CNA) to every eight (8) residents for the day shift. One (1) direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One (1) direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. A review of New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Reports requested revealed the following: For the week of Complaint staffing from 07/31/2022 to 08/06/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -07/31/22 had 9 CNAs for 110 residents on the day shift, required at least 14 CNAs. -08/01/22 had 7 CNAs for 109 residents on the day shift, required at least 14 CNAs. -08/02/22 had 12 CNAs for 106 residents on the day shift, required at least 13 CNAs. -08/03/22 had 11 CNAs for 106 residents on the day shift, required at least 13 CNAs. -08/04/22 had 11 CNAs for 102 residents on the day shift, required at least 13 CNAs. -08/05/22 had 11 CNAs for 102 residents on the day shift, required at least 13 CNAs. -08/06/22 had 10 CNAs for 102 residents on the day shift, required at least 13 CNAs. For the week of Complaint staffing from 08/14/2022 to 08/20/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -08/14/22 had 7 CNAs for 105 residents on the day shift, required at least 13 CNAs. -08/15/22 had 10 CNAs for 105 residents on the day shift, required at least 13 CNAs. -08/16/22 had 10 CNAs for 105 residents on the day shift, required at least 13 CNAs. -08/17/22 had 10 CNAs for 105 residents on the day shift, required at least 13 CNAs. -08/18/22 had 8 CNAs for 104 residents on the day shift, required at least 13 CNAs. -08/19/22 had 12 CNAs for 104 residents on the day shift, required at least 13 CNAs. -08/20/22 had 11 CNAs for 104 residents on the day shift, required at least 13 CNAs. For the week of Complaint staffing from 10/23/2022 to 10/29/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -10/23/22 had 8 CNAs for 98 residents on the day shift, required at least 12 CNAs. -10/24/22 had 8 CNAs for 95 residents on the day shift, required at least 12 CNAs. -10/25/22 had 10 CNAs for 95 residents on the day shift, required at least 12 CNAs. -10/26/22 had 9 CNAs for 95 residents on the day shift, required at least 12 CNAs. -10/27/22 had 11 CNAs for 95 residents on the day shift, required at least 12 CNAs. -10/28/22 had 9 CNAs for 99 residents on the day shift, required at least 12 CNAs. -10/29/22 had 10 CNAs for 97 residents on the day shift, required at least 12 CNAs. For the week of Complaint staffing from 12/25/2022 to 12/31/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -12/25/22 had 7 CNAs for 91 residents on the day shift, required at least 11 CNAs. -12/26/22 had 10 CNAs for 91 residents on the day shift, required at least 11 CNAs. -12/27/22 had 10 CNAs for 91 residents on the day shift, required at least 11 CNAs. -12/28/22 had 9 CNAs for 91 residents on the day shift, required at least 11 CNAs. -12/29/22 had 7 CNAs for 93 residents on the day shift, required at least 12 CNAs. -12/30/22 had 10 CNAs for 93 residents on the day shift, required at least 12 CNAs. -12/31/22 had 8 CNAs for 93 residents on the day shift, required at least 12 CNAs. For the week of Complaint staffing from 03/26/2023 to 04/01/2023, the facility was deficient in CNA staffing for residents on 5 of 7 day shifts as follows: -03/26/23 had 7 CNAs for 99 residents on the day shift, required at least 12 CNAs. -03/28/23 had 10 CNAs for 98 residents on the day shift, required at least 12 CNAs. -03/29/23 had 11 CNAs for 98 residents on the day shift, required at least 12 CNAs. -03/31/23 had 9 CNAs for 98 residents on the day shift, required at least 12 CNAs. -04/01/23 had 10 CNAs for 102 residents on the day shift, required at least 13 CNAs. For the week of Complaint staffing from 04/16/2023 to 04/22/2023, the facility was deficient in CNA staffing for residents on 6 of 7 day shifts and deficient in CNAs to total staff on 1 of 7 evening shifts as follows: -04/16/23 had 10 CNAs for 95 residents on the day shift, required at least 12 CNAs. -04/17/23 had 10 CNAs for 95 residents on the day shift, required at least 12 CNAs. -04/17/23 had 6.25 CNAs to 14.25 total staff on the evening shift, required at least 7 CNAs. -04/18/23 had 10 CNAs for 95 residents on the day shift, required at least 12 CNAs. -04/20/23 had 11 CNAs for 98 residents on the day shift, required at least 12 CNAs. -04/21/23 had 10 CNAs for 98 residents on the day shift, required at least 12 CNAs. -04/22/23 had 10 CNAs for 98 residents on the day shift, required at least 12 CNAs. For the week of Complaint staffing from 09/24/2023 to 09/30/2023, the facility was deficient in CNA staffing for residents on 2 of 7 day shifts as follows: -09/24/23 had 10 CNAs for 103 residents on the day shift, required at least 13 CNAs. -09/30/23 had 11.5 CNAs for 102 residents on the day shift, required at least 13 CNAs. For the 2 weeks of staffing prior to survey from 12/31/2023 to 01/13/2024, the facility was deficient in CNA staffing for residents on 3 of 14 day shifts as follows: -12/31/23 had 10 CNAs for 97 residents on the day shift, required at least 12 CNAs. -01/01/24 had 9.25 CNAs for 95 residents on the day shift, required at least 12 CNAs. -01/13/24 had 11 CNAs for 100 residents on the day shift, required at least 12 CNAs.

Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the narcotic shift count logs were completed in accordance with facility policy and accurately account for and document the administration of controlled medications. This deficient practice was identified on 3 of 3 medication carts and was evidenced by the following: On 1/17/24 at 9:58 AM, the surveyor, interviewed Licensed Practical Nurse #4 (LPN #4) who stated all nurses assigned to carts were responsible for the organization, and maintenance of the medication cart. She further stated that narcotic shift to shift count logs were to be completed by two nurses (the incoming and outgoing nurses) at the same time once they confirmed an accurate count of the narcotics in the cart. She also confirmed that logs should not be missing any documentation, signatures, or have a pre-signed field for future count times. The surveyor, in the presence of LPN #4, then reviewed the Strawbridge nursing unit's medication cart 1 narcotic log binder. The log binder contained a Narcotic and Controlled Substance Shift-to-Shift Count Sheet which revealed the following: The second shift - afternoon count column for 1/14/24 was missing a count number. The second shift - afternoon count off-going nurse column for 1/17/24 was pre-signed. On 1/17/24 at 10:54 AM, the surveyor, interviewed LPN #3 who stated all nurses assigned to carts were responsible for the organization, and maintenance of the medication cart. She further stated that narcotic shift to shift count logs were to be completed by two nurses (the incoming and outgoing nurses) at the same time once they confirmed an accurate count of the narcotics in the cart. She also confirmed that logs should not be missing any documentation, signatures, or have a pre-signed field for future count times. The surveyor, in the presence of LPN #3, then reviewed the Ashland nursing unit's medication cart 2 narcotic log binder. The log binder contained a Narcotic and Controlled Substance Shift-to-Shift Count Sheet which revealed the following: 1/4/24 third shift - night count off-going nurse signature was not completed. The second shift - afternoon count off-going nurse column for 1/17/24 was pre-signed. On 1/17/24 at 11:33 AM, the surveyor, interviewed LPN #2 who stated all nurses assigned to carts were responsible for the organization, and maintenance of the medication cart. She further stated that she did not complete the individual patient's controlled drug record (declining inventory) log at the time of dispensing the controlled substance, but rather after she administered the controlled medication. She confirmed that logs should not be missing any documentation, signatures, and the count on the log should match the number of medications on hand for that controlled substance. The surveyor, in the presence of LPN #2, then reviewed the Ashland nursing unit's medication cart 3 narcotic log binder. The log binder contained a declining inventory log for diphenoxylate with atropine (a controlled medication used to treat inflammatory bowel disease) 2.5-0.025 milligrams (mg) for Resident #71, which was reflected a missing nurse administering signature for the dose administered 1/17/24 at 9 AM. Review of Resident #71's admission Record reflected that Resident #71 was admitted to the facility with diagnosis which included but was not limited to gastritis (inflammation of the stomach lining) with bleeding. Review of Resident #71's Physician Order Summary (POS) included an order with a start date of 12/26/23 for Lomotil Oral Tablet 2.5-0.025 mg (diphenoxylate with atropine) Give 1 tablet by mouth two times a day for inflammatory bowel disease. Review of Resident #71's January 2024 Medication Administration Record (MAR) indicated this medication was signed off by the nurse as being administered on 1/17/24 at 9:00 AM. On 1/18/24 at 8:37 AM, the surveyor observed LPN #1 during medication administration on the first floor nursing unit. The LPN dispensed and administered medications to Resident #95, which included a controlled pain medication oxycodone HCl 10 mg, which she dispensed at 8:51 AM. The LPN confirmed the medication in the MAR as well as in the controlled substance log binder and the declining inventory log for that medication. At 9:26 AM, the LPN completed the medication administration for Resident #95, and had not yet signed the dispensed oxycodone dose out in the declining inventory log. The LPN informed the surveyor she was complete with this resident's administration and would be moving on to the next resident. At that time, the surveyor interviewed LPN #1, who stated that she does not sign the declining inventory log until she goes back to assess the efficacy of the medication, in about 20-25 minutes. The surveyor inquired of the purpose of the declining inventory log, at which point the LPN acknowledged that it was intended to be completed to indicate the medication was dispensed and should be completed once dispensed from the packaging. Review of Resident #95's admission Record indicated the resident was admitted to the facility with diagnosis which included but was not limited to peripheral vascular disease (a slow and progressive circulation disorder). Review of the POS indicated a physician's order with a start date of 1/13/24 for oxycodone HCl 10 mg give one tablet by mouth every four hours as needed for severe pain. On 1/18/24 at 12:48 PM, the surveyor interviewed the Director of Nursing (DON) who stated controlled substance shift to shift logs were to be completed with two nurses (incoming and outgoing nurse) at the change of shift together after they both complete a count of the controlled substances in the medication cart and were accounted for. She stated the purpose was for accountability of the controlled medications. The DON further stated that declining inventory logs were expected to be signed out when a narcotic was removed from its packaging and not when waited until administered with the purpose to indicate the narcotic was removed from the packaging. Review of the facility's Controlled Substances policy with a reviewed and updated date of October 2023 included but was not limited to: controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift .the nurse administering the medication is responsible for recording: name of the resident receiving the medication; name, strength, and dose of the medication; time of administration; method of administration; quantity of the medication remaining and signature of nurse administering medication . controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. NJAC 8:39-29.7(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, it was determined that the facility failed to properly store medications, maintain clean and sanitary medication storage areas, and properly label opened multidose medications. This deficient practice was observed in 3 of 3 observed medication carts on 2 of 2 nursing units and 1 of 1 medication storage rooms and was evidenced by the following: On 1/17/24 at 9:58 AM, the surveyor interviewed Licensed Practical Nurse #4 (LPN #4) who was assigned to the [NAME] nursing unit medication cart 1. LPN #4 stated that all nurses assigned to the medication carts were responsible for maintaining the cart and keeping it organized and clean. She further stated that all opened multi-dose medication containers should be labeled with date opened as well as with the resident's name on the actual medication containing device or container and there should be no loose pills in the cart. At that time, the surveyor reviewed [NAME] medication cart 1 in the presence of LPN #4 and observed the following: One (1) Incruse Ellipta inhalation powder 62.5 micrograms (mcg) (medication used to treat lung disease) inhaler which was opened and dated 1/17 but was not labeled with resident's name on the inhaler device. One box of albuterol sulfate inhalation solution 0.083% 2.5 milligrams (mg) per 3 milliliters (ml) (medication used to treat lung disease) undated with an opened date, containing seven single use vials not in the manufacturer's foil pouch. LPN #4 stated this is no good, have to discard that. Two boxes of albuterol ipratropium bromide and albuterol sulfate inhalation solution (medication used to treat lung disease) 0.5 mg/3 mg per 3 ml containing opened foil pouches one pouch contained 24 single dose vials, the other 21 single dose vials. Both were not dated with an opened date and had manufacturer's instructions to use within two weeks of opening. Five (5) unidentifiable loose pills of various colors, shapes, and sizes. At that time, LPN #4 disposed of the three undated albuterol medication boxes containing the medication vials in the trash bin attached to the side of the medication cart. On 1/17/24 at 10:54 AM, the surveyor interviewed LPN #3 who was assigned to the Ashland nursing unit medication cart 2. LPN #3 stated that multi-dose, single resident medications should be labeled with the resident's name and the date it was opened once it is opened for use by the nurse. The surveyor at this time reviewed the Ashland medication cart 2 with LPN #3 and observed the following: One box lebalbuterol inhalation solution (medication used to treat lung disease) 1.25 mg/ 3ml containing an opened foil pouch containing seven single dose vials labeled by the manufacturer to use within two weeks of opening and labeled with an opened date of 12/16/23. One box budesonide inhalation suspension (medication used to treat lung disease) 0.5mg/2ml containing an opened foil pouch with six single dose vials with no opened date and labeled by manufacturer to use within two weeks of opening. On 1/17/24 at 11:33 AM, the surveyor interviewed LPN #2 who was assigned to the Ashland nursing unit's medication cart 3. LPN #2 stated single resident multi-dose medications and containers should be labeled with the resident's name and date opened once opened for use. She also stated that there should not be any loose medications in the cart and all nurses assigned to the cart are responsible for maintaining the organization and cleanliness of the medication cart. She stated that medications should be disposed of in the drug buster bottle. At that time, the surveyor reviewed the Ashland medication cart 3 in the presence of LPN #2, and observed the following: One opened foil pouch of ipratropium bromide and albuterol sulfate inhalation solution (medication used to treat lung disease) 0.5mg/3mg per 3ml labeled by the manufacturer to use within two weeks of opening and dated with a 11/28 opened date containing six single dose vials. Two opened foil pouch of ipratropium bromide and albuterol sulfate inhalation solution (medication used to treat lung disease) 0.5mg/3mg per 3ml containing 13 vials in one pouch and 29 vials in the other neither of which were dated with an opened date. 15 unidentifiable loose pills of various colors, shapes, and sizes. On 1/17/24 at 12:17 PM, the surveyor, in the presence of LPN/Unit Manager #1 (LPN/UM #1), reviewed the first-floor nursing unit's medication storage room. The following was observed: The medication refrigerator temperature monitoring log was not completed for 1/7/24 and 1/16/24. The medication freezer temperature monitoring log was not completed for 1/16/24. At this time, LPN/UM #1 stated that the 11 PM - 7AM nursing shift were responsible for checking and documenting the temperature of the medication refrigerator and freezer, and she double checked with them once she arrived in the morning. On 1/18/24 at 12:48 PM, the surveyor interviewed the Director of Nursing (DON). She stated that the expectation was that medications were labeled with resident name and dated once opened. She confirmed that the 11-7 nursing shift was responsible for checking the medication refrigerators for temperature monitoring daily to ensure the temperature stayed in the appropriate range for storing medications, otherwise it could affect the medication's efficacy. She acknowledged that if it's not documented, it's not done. The DON stated that all medications should be discarded in the drug buster bottles that were kept on each medication cart. She stated if the one on the cart runs out, there are drug buster bottles on the nursing floor, and it was never appropriate to throw medications of any kind in the trash. Review of the facility's Storage of Medications policy with a reviewed and updated October 2023 included but was not limited to drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls . the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the facility's Storage of Medication Requiring Refrigeration policy with a reviewed and updated date of March 2023 included but was not limited to, temperature should be maintained between 36-46 degrees F . temperature to be monitored daily to ensure proper temperature control and documented on the temperature log. Review of the facility's Administering Medications policy with a reviewed and updated date of October 2023 included but was not limited to the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. N.J.A.C. 8:39-29.4

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure appetizing and palatable temperature of food for 1 of 1 lunch meals observed on 1 of 2 nursing units (Medbridge). This deficient practice was evidenced by the following: On 01/18/24 at 11:00 AM, the surveyor conducted a Resident Council meeting which included five residents (Residents #14, #37, #53, #71, and #74). All five residents informed the surveyor that the food was served cold on all shifts. On 01/23/24 at 11:15 AM, the surveyors informed the Dining Director (DD) that they wanted to observed the lunch meal service for that day including food temperatures. The DD acknowledged the request and stated that the lunch service began at 11:20 AM. On 01/23/24 at 11:20 AM, the [NAME] informed the surveyor that he had already calibrated (procedure used to confirm accuracy) his thermometer prior to the surveyors arrival. The [NAME] then proceeded to obtain food temperatures from the food that was on the steam table. The temperature were recorded as follows: chopped spinach 178 degrees Fahrenheit (F), mashed potatoes 177 F, breaded veal 165 F, creamed spinach 171 F, pureed bread 80 F, chopped veal 175, pureed veal 184 F, roasted potatoes 139 F were replaced with an alternate pan from the oven and were 177 F. The [NAME] utilized plastic insulated domes and bases and heated plates to maintain temperature and an induction heating device was used to heat the plastic base prior to assembly. On 01/23/24 at 11:43 AM, the surveyor requested to have a regular tray placed on the first food truck for Medbridge Unit as a test tray. The surveyor also requested that the DD record temperatures of the food in the presence of the surveyors on the nursing unit using a calibrated thermometer. The DD calibrated a digital, thin probe thermometer in an ice bath to 32 F. The DD and the surveyors immediately proceeded to leave the kitchen at that time and followed the food cart to the Medbridge nursing unit. On 01/23/24 at 11:45 AM, the DD and Regional Director (RD) arrived on the Medbridge nursing unit with the food truck. The nursing staff began to deliver meal trays to the residents at 11:54 AM. On 01/23/24 at 12:05 PM, the DD confirmed that the last resident's meal tray had been served. The surveyor asked the [NAME] what the temperature should hot foods and cold foods be served at, and the DD responded that hot food should be served above 135 F and cold food should be served below 40 F. At this time, the surveyor observed the DD obtain the following temperatures using the calibrated thermometer for the regular lunch meal tray: Breaded Veal 136 F Potato Wedge 129 F Spinach 138 F Milk 48 F Fruit Cocktail 49 F At that time, the DD stated that the tray pass should have occurred immediately when the food truck arrived to the nursing unit. The DD further stated that it took about fifteen minutes for the staff to begin to pass the trays. The DD acknowledged that the potato wedge was below the acceptable temperature of 135 F or above and both the milk and the fruit cocktail were both above 40 F and should have been below 40 F. The DD stated that he had received some complaints of cold food recently and noted that there have been some issues related to maintaining food temperature. On 01/25/24 at 2:45 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) in the presence of the survey team, and shared their concerns regarding food temperatures. Review of an undated policy, Food Preparation Guidelines revealed the following: It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. .Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk for scalding or burns. .Foods shall be prepared by methods that conserve nutritive value flavor and appearance. This includes, but is not limited to: .Minimizing holding time prior to meal service Foods and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: .Serving hot foods/drinks hot and cold foods/drinks cold, Addressing resident complaints about food/drinks . Review of the facility policy, Food Preparation and Service (Reviewed and updated January 2024) revealed the following: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. .Appropriate measures are used to prevent cross contamination. These include: Storing raw meat separately and in drip-proof containers, and in a manner that prevents cross-contamination from other foods in the refrigerator .Cleaning and sanitizing work surfaces (including cutting boards) and food-contact equipment between uses, following food code guidelines. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Handwashing sinks are located near food preparation and clean dish areas and are separate from ware washing sinks . Food Preparation, Cooking and Holding Time/Temperatures: The danger zone for food temperatures in between 41 F (degrees Fahrenheit) and 135 F. This temperature promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods (PHF) include meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese. The longer foods are in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41 F or above 135 F .Fresh, frozen or canned fruits and vegetables are cooked to holding . NJAC 8:39-17.4(a)(2)

Based on observations, interviews, and other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner. This deficient practice was evidenced by the following: On 01/17/24 from 9:40 AM until 10:31 AM, the surveyor observed the following in the presence of the Dietary Director (DD): 1. A rolling rack of plastic bowls was stored in front of the handwashing sink. At that time, a Dietary Aide (DA) retrieved the rack and proceeded to place salad inside of the bowls. When interviewed, the DD stated that since the bowls were stored upside down it did not pose a risk of contamination. 2. In the galley the kitchen: Caribbean Jerk Seasoning, Poultry Seasoning, and Old Bay Seasoning were not labeled with an opened date and a use-by date. DD stated that when the spices were opened they should have been labeled and dated with a use by date. DD then proceeded to place labels on the spices with an opened date of 12/01/23 and an expired date of 05/01/24. When asked how he knew when the spices were opened, he stated that he labeled them according to the holiday menu change. 3. The main deck oven was in use and the bottom of the oven was noted to be soiled with a black substance and food debris was noted on the bottom of the oven. The DD stated that it was cleaned last week. 4. In the walk-in refrigerator: On the top shelf of a four-tiered rack, a two quart container of chocolate pudding was dated with an opened date of 01/10/24 and a use-by date of 01/14/24. DD stated that the item should have been discarded. 5. On the bottom shelf of a four-tiered rack a container that had three, five pound turkey logs was stored in a plastic container next to lettuce. DD stated that they should be separated to avoid the chance of cross-contamination. 6. In the food preparation area, a can opener was mounted on the counter. The DD pulled the can opener out of the sleeve and revealed that there was a dried, dark red substance on the blade of the can opener. DD stated that it should have been washed as it posed a chance of cross-contamination if used. 7. In the galley of the kitchen: The [NAME] wore a baseball hat instead of a hair net which left his hair exposed on both sides and in the lower portion of the back of his head during food preparation. DD stated that the [NAME] should have had a hair net on. 8. Two plastic spatulas hung above the food preparation area and both had pitting and cracks in them. DD stated that they should have been discarded to prevent plastic from getting into the food. On 01/23/24 from 11:15 AM until 11:43 AM during a return visit to the kitchen, the surveyor observed the following in the presence of the DD: 1. The [NAME] obtained food temperatures from the steam table and did not first perform hand hygiene prior to food handling and did not donn gloves. At 11:25 AM, the [NAME] donned gloves without first performing hand hygiene. 2. There were multiple ice cream scoops and a metal spatula that were placed on the stainless steel food prep area in front of the steam table. The [NAME] picked up the ice cream scoops and spatula and placed them directly into the food to be served on the steam table. 3. The [NAME] scratched his head and removed his glasses and set them down on the counter with his gloved hands before he obtained a plate from the plate warmer and proceeded to plate the lunch meal. When interviewed, the [NAME] stated that he washed his hands after he went to the bathroom before the surveyor arrived in the kitchen. At 11:46 AM, the surveyor interviewed the DD who stated that the [NAME] should have washed his hands before he donned gloves, and after he removed his glasses and scratched his head to avoid contamination. DD further stated that the serving utensils should have been placed directly into the food instead of on the stainless steel food prep area to avoid contamination. The surveyor reviewed the undated policy, Date Marking for Food Safety which revealed the following: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety food. Definitions: Time/temperature control for food safety food (formerly potentially hazardous food) includes animal food that is raw or heart treated . The Head Cook, or designee, shall spot check refrigerators weekly for compliance, and document accordingly . The Dietary Manager, or designee shall spot check refrigerators weekly for compliance, and document accordingly . The surveyor reviewed an undated policy, Maintaining a Sanitary Tray Line which revealed the following: Policy: The facility prioritizes tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness. .During tray assembly, staff shall: .Wear gloves when handling food items .Wash hands before and after wearing or changing gloves .Change gloves after sneezing, coughing or touching face, hands, or hair with gloved hand. Wear hair restraints (bonnets, caps, nets to cover hair) when preparing or handling food. NJAC 8:39-17.2(g), 19.4 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 09/10/21 at 11:50 AM, the surveyor observed Resident #7 lying in bed with eyes closed. According to the Medical Practitioner Note, completed by the Advanced Practice Nurse (APN) on 09/07/21 at 17:07 (5:07 PM), Resident #7 had a past medical history of End Stage Renal Disease, orthostatic hypotension (low blood pressure when standing up from a lying or sitting position) and sustained a fall with no injury on 09/03/21. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], an assessment tool used to facilitate the management of care, reflected that Resident #7 had short and long term memory problems with poor decision making and required cues/supervision from staff. The MDS further reflected the resident sustained a fall with no injury. The surveyor reviewed an Incident Report - Patient Involved report dated 09/03/21, which reflected that Resident #7 sustained a fall without injury. Review of the General Progress Note, dated 09/03/21 at 22:16 (10:16 PM), reflected that the resident was sitting in the wheelchair and slid down on the floor on the buttocks. Resident #7 was assessed with no injuries noted. Resident was able to move all extremities and denied pain. Review of the General Progress Notes dated 09/04/21 at 6:37 AM and 09/07/21 at 4:54 AM reflected that Resident #7 left for dialysis via wheelchair. Review of the Medical Practitioner Note, signed by the Advanced Practice Nurse (APN), dated 09/07/21 at 17:07 (5:07 PM) reflected the Abnormal Findings: Guarding RIGHT ARM/SHOULDER, C/O PAIN WITH SLIGHT PASSIVE ROM [range of motion]/ADDUCTION [movement of limb toward midline of the body]/EXTENSION, TENDERNESS OVER RIGHT CLAVICLE. NO VISIBLE ABNORMALITY. The note further reflected Today with acute right shoulder and clavicle pain, s/p fall on 9/3 but no reported injury at that time and spoke with UM [Unit Manager], STAT X-ray Right shoulder and clavicle 2-views written and to continue with oxycodone 5 mg PRN [as needed] for acute pain relief. Review of the X-ray dated 09/07/21 reflected Conclusion: Acute distal right clavicle fracture. On 09/17/21 at 9:15 AM, the Director of Nursing (DON) provided the surveyor with the following: Witness Statement of the Hemodialysis Nurse conducted by the Registered Nurse/Unit Manager (RN/UM) which reflected the Date and Time of Interview was 09/16/21 at 1:20 PM via phone. This Witness Statement did not reflect complaints of pain in the right arm/clavicle prior to 09/07/21. Four undated Witness Statements of Certified Nursing Assistants (CNA). These Witness Statements did not reflect complaints of pain in the right arm/clavicle prior to 09/07/21. Two Witness Statements of CNAs dated 09/16/21. These Witness Statements did not reflect complaints of pain in the right arm/clavicle prior to 09/07/21. Two Witness Statements of Licensed Practical Nurses dated 09/16/21. These Witness Statements did not reflect complaints of pain in the right arm/clavicle prior to 09/07/21. Two undated Witness Statements with no identified Name and Title of Person Being Interviewed with an undecipherable signature. These Witness Statements did not reflect complaints of pain in the right arm/clavicle prior to 09/07/21. During an interview with the surveyor on 09/17/21 at 9:50 AM, the RN/Unit Manager (RN/UM) stated that the physician assessed Resident #7 because he/she complained of pain to the clavicle area and the physician ordered an X-ray, which came back with a right clavicle fracture. The RN/UM stated that the resident sustained a fall on 09/03/21, which resulted with no injury and that Resident #7 never complained of pain to him between 09/03/21 when the resident fell until the physician saw the resident on 09/07/21. The RN/UM further stated that when a resident receives a bruise or fracture, that a 72-hour investigation prior to the incident would be completed. The RN/UM stated that he verbally spoke with staff, who worked over the last 72 hours on 09/07/21, but did not obtain statements from them. The RN/UM stated that per policy, because the resident sustained a fracture, that an incident report should have been completed, and that staff would be interviewed over the last 72 hours, prior to the incident. The RN/UM confirmed that he did not complete an incident report and that the verbal interview staff statements were not written. The RN/UM further stated that he called the dialysis nurse on 09/16/21 and asked about Resident #7 from 09/07/21 to the present and confirmed that he did not ask anything prior to the fracture on 09/07/21. The RN/UM stated that when the staff wrote their statements on 09/16/21, he interviewed staff if Resident #7 had been complaining of pain, how did the resident react with care and had the resident been abnormally positioned since 09/07/21, when the fracture occurred. The RN/UM confirmed that he did not interview the staff concerning the 72 hours prior to the fracture. The RN/UM confirmed that he did not know where the fracture came from and it was possibly an injury of unknown origin. On 09/17/21 at 12:47 PM, the surveyor attempted to contact the APN who assessed the resident on 09/07/21. The surveyor did not receive a call back from the APN. During an interview with the surveyor on 09/17/21 at 12:25 PM, the Administrator stated that as of right now, we cannot correlate the fracture and the fall. It was a breakdown in the system. The Administrator further stated that she did not report this incident to the Department of Health. Review of the Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention (Patient Protection), with an issue date of 11/2016 reflected When investigating whether abuse has occurred, the center identifies and considers events such as behavior changes, bruising of patients, suspicious patient patterns, unexplained injuries, communication or social interaction changes and other trends that may signify abuse. Any allegation requires an investigation and to Have evidence that all alleged violations are thoroughly investigated. The Patient Protection further reflected that Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two (2) hours after the allegation is made . NJAC 8:39-9.4(f)

Based on observation, interview, and record review, it was determined that the facility staff failed: A). to administer medication according a physician's order and B). to order labs according to a physician's order, both in accordance with professional standards. This deficient practice was identified for 1 of 4 residents observed during medication pass (Resident #94) and in 1 of 5 residents reviewed for unnecessary medication use (Resident #45). These practices were 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 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 09/14/21 at 8:47 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medication to Resident #94, which included Hydrochlorothiazide (HCTZ) 12.5 milligrams (mg), a medication used to treat high blood pressure. The surveyor obtained and reviewed physician's orders for Resident #94, which revealed an order for HCTZ 25 mg to be given by mouth one time a day for HTN (hypertension, high blood pressure). The surveyor obtained and reviewed the Medication Administration Record (MAR) for Resident #94, which indicated that HCTZ 25 mg was given to the resident. During an interview with the surveyor on 09/14/21 at 11:51 AM, the LPN showed the surveyor the resident's medication supply, at the request of the surveyor. The medication label on the supply of medication was labeled as HCTZ 12.5 mg and to give 25 mg by mouth one time a day. The LPN then confirmed that the physician's order was for HCTZ 25 mg, acknowledged the error, and stated the order should have maybe indicated to give two 12.5 mg doses, to yield a total dose of 25 mg. The LPN stated that she did not know the reason for the discrepancy between the physician's order and labeled product. During an interview with the surveyor on 09/16/21 at 1:36 PM, the Director of Nursing (DON) acknowledged the error and further stated that the LPN should have noticed the discrepancy and followed-up with the DON and/or physician for further clarification. The DON further stated that the pharmacy label should have indicated for the nurse to give two doses of 12.5 mg, to yield a total dose of 25 mg, as ordered by the physician. The facility's policy, Medication and Treatment Administration Guidelines revealed the policy was written on 07/2006 and last updated on 03/2018. According to the policy, a complete medication order includes a dosage or strength, and medications are administered in accordance with the right dose. 2). The surveyor obtained and reviewed medical records for Resident #45. According to the admission Record Report, Resident #45 was admitted to the facility with diagnoses that included urinary tract infection (UTI), and infection of any part of the urinary system, possibly including the kidneys (which filter blood), ureters (the pathway by which urine travels from kidney to bladder), bladder (the area where urine collects), or urethra (the pathway in which urine exits the body). A review of the resident's progress notes revealed the resident had signs and symptoms of a UTI on 07/06/21 and a consultation with the physician was requested. Further review of the progress notes for Resident #45 revealed the Nurse Practitioner gave orders on 07/08/21 as follows: start Keflex 500 milligrams (mg) by mouth every 12 hours x7 days (an antibiotic which may be used to treat UTI and other infections) and to call with culture and sensitivities. A review of the resident's Mediation Administration Record (MAR), confirmed that the resident received the Keflex 500 mg regimen as referenced, beginning on 07/08/2, ending on 07/15/21, and consisting of a total of 14 doses. A review of the resident's Treatment Administration Record (TAR) revealed an order for UA CS one time only for UTI on 07/07/21 (Urinalysis with Culture and Sensitivities). A urinalysis test is an evaluation of the urine and a culture and sensitivity are taken to determine the type of bacteria involved in the infection, to use the most effective antibiotic, while decreasing the chances of antibiotic resistance. Antibiotic resistance is the process by which inappropriate antibiotic use allows a disease-causing bacterium or organism to adapt over time and survive exposure to an antimicrobial agent (medication therapy), causing the bacteria to become stronger over time and less likely to be cured by antibiotics in the future. The surveyor obtained and reviewed a copy of the lab results, dated 07/07/21, for Resident #45. The lab results report revealed that a urinalysis with microscopy was completed, without the culture and sensitivity test. During an interview with the surveyor on 09/19/21 at 12:30 PM, the Registered Nurse (RN) who also serves as the Unit Manager (UM), explained the process taken when a resident has a suspected UTI. The RN/UM stated a resident is assessed for symptoms of UTI and details are provided by the resident, where applicable. Nursing staff obtains vital signs (such as blood pressure), temperature, and report them to the physician and/or his/her representative. The physician or representative usually orders a UA with culture and sensitivity (C&S) and in some cases, an antibiotic is started to prevent the infection from worsening. Once the results of the C&S become available, they are reported to the physician/representative and the therapy is modified as necessary, to ensure the appropriate antibiotic is given for the bacteria involved in the infection. The RN/UM further stated that the C&S report is usually completed after two to three days and if it is not available for some reason, the nurse would call the lab for results. If there were no C&S results for a resident receiving antibiotics, this would be a problem because the resident would be getting unnecessary medication. In this case, the RN/UM stated he did not know anything further regarding the lack of C&S report for Resident #45, he would investigate the matter further, and follow-up with the survey team. During an interview on 09/17/21 at 1:12 PM, the RN/UM confirmed that only a UA without C&S was done for Resident #45. He further stated that there should have been a C&S completed and that someone should have followed-up with the physician regarding this problem. He also confirmed that the order for the UA input on 07/07/21 was incorrect and not consistent or complete with the physician/representative's order, which included a C&S. During an interview with the surveyor on the same day at 1:48 PM, the Director or Nursing (DON) stated there are pathways (directions) for UTI care on each unit and nursing staff should have followed them accordingly. During an interview with the survey team and Licensed Nursing Home Administrator (LNHA) at 2:30 PM, the surveyor asked the DON regarding her expectations regarding the matter at hand, as it relates to standards of practice. The DON confirmed that a UA and C&S should be done together, especially when an antibiotic is started for preventative measures. Furthermore, if a UA and C&S is ordered by a physician/representative, the DON stated there is an expectation that both tests would be completed as ordered, and nursing staff would follow-up if a problem such as the one described existed. The DON then confirmed there were multiple nurses working at this time and were able to do so. The surveyor obtained the facility document, Care Path Symptoms of Urinary Tract Infection (UTI) and reviewed it. The pathway includes urine culture and sensitivity, if indicated by UA for the further evaluation and management for UTI. The surveyor also obtained the facility document, Antibiotic Stewardship and reviewed it. Antibiotic stewardship involves a set of commitments and actions to optimize treatment of infections, reduce adverse effects with antibiotic use, and implement practices that ensure individuals receive the right dose, of the right antibiotic, for the correct amount of time, and only when necessary. This approach is used with the goal of combating an increase in the resistance of organisms, because the World Health Organization (WHO) considers antibiotic resistance one of the major threats to the future of human health. The policy also emphasizes the importance of monitoring antibiotic prescribing, use, and resistance. It includes an option to do so through adherence to cultures obtained before antibiotics are initiated or changed after culture results are received. The facility's policy, Medication and Treatment Administration Guidelines referenced that medications should be administered in accordance with standards of practice. NJAC 8:39-29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to detect and remove expired medication in 1 of 2 medication storage rooms. This deficient practice was evidenced by the following: On 09/14/21 at 11:35 AM, the surveyor inspected the medication storage room, located on the Second Floor Nursing Unit, in the presence of the Registered Nurse (RN), who also serves as the Unit Manager (UM). The surveyor found the following expired medications: two bottles of Cranberry Supplement 450 milligram (mg) tablets (a dietary supplement), which expired on 07/2021; one bottle of Aspirin Enteric Coated 325 mg tablets (a pain and heart medication), which expired on 07/2021; and one bottle of Vitamin B-12 100 microgram (mcg) tablets (a vitamin supplement), which expired on 08/2021. During an interview with the surveyor on 09/14/21 at 11:44 AM, the RN-UM acknowledged that the medication bottles were expired as referenced and further stated that nurses should dispose of expired medication when they are retrieving new supplies of medication. In addition, he stated, there is a supply person that also oversees medication expiration dates, and this person works in the central supply room. The RN-UM could not provide any additional information regarding this individual and did not know why expired medications were present in the cabinet. During an interview with the surveyor on 09/14/21 at 12:37 PM, the Certified Nursing Aide (CNA) who oversees medication in the central supply room, provided further detail to the survey team. The CNA stated he supplies house stock medication to the individual nursing units as they are requested by staff. A house stock medication is an over-the-counter item that is used with such great frequency, that multiple supplies are kept by nursing staff, so that they are readily available for administration to residents. He further stated that he is not responsible for disposing of expired medication, once it leaves the central supply room, but does provide the nursing staff with a drug buster liquid, a substance contained in a bottle, in which the nurse disposes of a medication that is no longer to be given to a resident. The CNA did not know why expired medication were in the cabinet and stated he had been employed at the facility recently, within the past two to three weeks. During an interview with the surveyor on 09/16/21 at 1:42 PM, the Director of Nursing (DON) stated that there should be no house stock medication in the storage room and that such medication should only come from central supply. Furthermore, the nurses should have removed the items from the cabinet and that staff was specifically hired to monitor central supply items and expiration dates. The surveyor obtained and reviewed the facility's policy, Medication Disposal/Destruction with an effective date of 06/26/2019 and a revision date of 08/2018. According to the policy, the Nursing Center staff should destroy and dispose of medications in accordance with Nursing Center policy and the law, when it should not be returned to the pharmacy. The surveyor also obtained and reviewed the facility's policy, Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles with an effective date of 01/01/2008 and a revision date of 08/2018. According to the policy, the Nursing Center should ensure drugs and biologicals have an expiration date on the label or medication container and not be retained longer than recommended by manufacturer or supplier guidelines. The policy also indicated that the Nursing Center should destroy or return, where applicable, all outdated/expired drugs. NJAC 8:39-29.4(c)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to notify the NJ Department of Health (NJDOH), within the appropriate deadline, of a.) a fire alarm system that was not operational in dispatching the fire department, in case of a fire; This deficient practice was identified for all residents, staff, and visitors, and b.) an injury of unknown origin for 1 of 1 resident (Resident #7) reviewed for injuries of unknown origin. This deficient practice was evidenced by the following: 1. On 09/09/21 at 9:30 AM, the Life Safety Code (LSC) Surveyor observed the fire alarm annunciator panel located in the front entrance between the two sets of entrance doors. The panel indicated TROUBLE MODE and flashed COMMUNICATION ERROR. During an interview with the LSC surveyor on 09/09/21 at 10:00 AM, the Maintenance Director (MD) stated that the fire alarm annunciator panel had been in trouble mode since the storm on 09/03/21. The MD further stated that the fire alarm company emailed him on 09/03/21 to inform him that there was no phone service to the fire alarm panel, and it would not notify the authorities in the event of a fire. When asked if a fire watch was implemented, the MD stated, no. Review of the email, dated 09/03/21 at 3:15 PM, from the fire alarm company to the MD included that the facility's fire panel is unable to notify the authorities and contact list at this time, and, until [the provider company] is able to correct the problem, there will be no phone service to that panel. Further review of the email included that the MD forwarded the email to the facility's Administrator (LNHA) and Regional Plant Operations Director (RPOD) on 09/03/21 at 3:25 PM. During an interview with the Surveyor on 09/09/21 at 10:15 AM, the LNHA stated that the issue with the fire alarm notification system was not reported to the NJ DOH. Review of the facility's Fire Watch Procedure, dated 05/01/19, included, Where a required Fire Alarm System is out of service for more than four (4) hours in a 24-hour period, or a Fire Sprinkler System is out of service for more than ten (10) hours in a 24 hour period, the authority having jurisdiction shall be notified and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the system(s) have been returned to service. 2. The surveyor reviewed an Incident Report - Patient Involved report dated 09/03/21, which reflected that Resident #7 sustained a fall without injury. A review of the General Progress Note dated 09/03/21 at 22:16 (10:16 PM) confirmed the findings within the referenced report. According to a Medical Practitioner Note, signed by the Advanced Practical Nurse (APN) on 09/07/21 at 17:07 (5:07 PM), Resident #7 was assessed and evaluated due to complaints of acute right shoulder and clavicle pain, prompting the APN to order an X-ray of the right shoulder and clavicle and to use Oxycodone 5 milligrams (mg) PRN (as needed) for pain relief. The X-ray results, dated 09/07/21, revealed the resident had an acute distal right clavicle fracture. During an interview with the surveyor on 09/17/21 at 9:50 AM, the Registered Nurse/Unit Manager (RN/UM) stated the APN assessed Resident #7 because Resident #7 complained of pain in the clavicle area, prompting the need for an X-ray and confirming the presence of a right clavicle fracture. The RN/UM also stated that the resident sustained a fall on 09/03/21, and it was deemed to be a fall without injury because the resident did not complain of pain until seen by the APN on 09/07/21. The RN/UM further stated that he did not know where the fracture originated, and it was probably an injury of unknown origin. The surveyor attempted to contact the APN who assessed Resident #7 on 09/17/21 at 12:47 PM, without success or follow-up from the APN. During an interview with the surveyor on 09/17/21 at 12:25 PM, the Licensed Nursing Home Administrator (LNHA) stated that the facility could not determine any correlation between the fall and the fracture for Resident #7, also acknowledging there was a breakdown in the system. The LNHA confirmed that this incident was not reported to the New Jersey Department of Health. A review of the Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention (Patient Protection), with an issue date of 11/2016 reflected to Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two (2) hours after the allegation is made . NJAC 8:39-9.4(f)

Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility was in compliance with the following regulatory requirement which affected all residents' safety in the facility. The LNHA failed to follow their Emergency Response policy and procedure and implement a Fire Watch when notified that the fire alarm system was unable to notify the authorities in the event of a fire. This posed a serious and immediate threat to the safety and well-being of all the residents, staff, and visitors in the facility, which resulted in an Immediate Jeopardy (IJ) situation. The facility Administration was notified of the Immediate Jeopardy situation on 09/09/21 at 2:00 PM. The immediacy was removed on 09/09/21 at 5:17 PM. The removal plan was accepted and verified by surveyors on 09/10/21 at 2:00 PM. This deficient practice was evidenced by the following: A review of the Administrators' job description provided by the facility included but not limited to the following: - Manages all business related to achieve the HCR ManorCare vision and supporting strategies and assure that the company image as an ethical and high-quality provider of health services is maintained. - Safety and sanitation duties include to follow established policies and procedures, ensure potential safety/health hazards are eliminated and demonstrates job-specific knowledge of fire and disaster preparedness during drills and actual situations. - Manages safety according to HCR ManorCare procedures/guidelines; ensures that potential safety/health hazards are eliminated or controlled through regular reviews of work activities, materials and facilities; provides employees with training and instructions on safe work practices in all aspect of their employment. - Acts as the Chief Compliance Officer for the facility/business unit - Installs and manages facility procedures/systems consistent with HCR ManorCare needs - Oversees completion of forms, reports, etc, - Develops all facility policies consistent with corporate guidelines On 09/09/21 at 9:30 AM, the Life Safety Code (LSC) Surveyor observed the fire alarm annunciator panel located in the front entrance between the two sets of entrance doors. The panel indicated TROUBLE MODE and flashed COMMUNICATION ERROR. During an interview with the LSC Surveyor on 09/09/21 at 10:00 AM, the Maintenance Director (MD) stated the fire alarm annunciator panel had been in trouble mode since a storm on 09/03/21. The MD further stated that the fire alarm company emailed him on 09/03/21 to inform him that there was no phone service to the fire alarm panel and it would not notify the authorities in the event of a fire. When asked if a fire watch was implemented, the MD stated, no. Review of the email, dated 09/03/21 at 3:15 PM, from the fire alarm company to the MD included that the facility's fire panel is unable to notify the authorities and contact list at this time, and, until [the provider company] is able to correct the problem, there will be no phone service to that panel. Further review of the email included that the MD forwarded the email to the facility's Administrator (LNHA) and Regional Plant Operations Director (RPOD) on 09/03/21 at 3:25 PM. During an interview with Surveyor #1 on 09/09/21 at 10:15 AM, the LNHA stated that issue with the fire alarm notification system was not reported to the New Jersey Department of Health (NJ DOH). During an interview with the LSC Surveyor and Surveyor #1 on 09/09/21 at 10:30 AM, the LNHA reviewed the referenced email and stated a fire watch was not implemented because we still have service and it definitely rings to the fire company. On 09/09/21 at 11:00 AM, Surveyor #1 asked the MD to activate the fire alarm in the facility. Upon activation, the annunciator panel indicated, Dialer Reporting. On 09/09/21 at 11:04 AM, in the presence of the LSC Surveyor and Surveyor #1, the MD called the fire alarm company and the dispatcher stated that they received a signal that the fire alarm was ringing, but the phone lines were down, so the Central Station would not be notified and no emergency response from the police or fire department would occur. The dispatcher further stated that this was because the communication hub is currently under 2-feet of water since 09/03/21. When asked what the facility should do, the dispatcher stated the facility should have implemented a fire watch and would have to call the fire and police departments themselves. On 09/09/21 at 11:14 AM, in the presence of the LSC Surveyor and Surveyor #1, the MD called the fire department because there was no emergency response to the activated fire alarm. When asked what the facility should have done after receiving notification of the downed communication lines, the Fire Commander stated the facility should have set up a fire watch since 09/03/21, when the communication system was compromised due to the flood of the hub. During an interview with Surveyor #4 on 09/09/21 at 11:37 AM, the LNHA stated that on 09/03/21 she received an email from the fire alarm company indicating the fire alarm would not notify the authorities. She further stated she notified the RPOD, but that the fire alarm company and RPOD did not provide any recommendations. The LNHA also stated she did not notify the fire department or initiate a Fire Watch because she was under the impression the fire alarm would function correctly and that the fire alarm company would receive a signal. She further stated, I should have started a Fire Watch knowing what I know now. The LNHA also stated that she should have reported the fire alarm to the NJ DOH. Review of the facility's Emergency Response Manual Chapter 2 Fires, dated 01/2020, included, A plan of action (Attachment C Fire Watch Procedure) is to be implemented should the Fire Alarm System or Automatic Fire Sprinkler System fail to work properly so continuous facility-wide detection and alarm capabilities continue. The center will implement a fire watch under the following circumstances: 1. A fire system failure and is inoperable for a combined time-period of four hours or more in a 24-hour period . 6. Other circumstances determined by the Administrator or designee or as recommended by the local police/fire agency. Review of the facility's Fire Watch Procedure, dated 05/01/19, included, Where a required Fire Alarm System is out of service for more than four (4) hours in a 24-hour period, or a Fire Sprinkler System is out of service for more than ten (10) hours in a 24 hour period, the authority having jurisdiction shall be notified and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the system(s) have been returned to service. Refer to K346 NJAC 8:39-27.1 (a)