**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C #: NJ00170177 Based on interviews, medical record review, and review of other pertinent facility documents on 2/5/2024, it was determined that the facility failed to: document according to the facility policy when the resident's Responsible Representative (RR) was notified of a change in the resident's medication regimen for 1 of 3 residents reviewed (Resident #2) and consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status, and care provided to the resident according to facility policy and protocol for 2 of 3 residents (Resident #2 and #3) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the facility admission Record (AR), Resident #2 was admitted with diagnoses that included but were not limited to: Dementia (disease that affects the ability to remember, think, or make decisions), Hypertension (blood pressure higher than normal), Atrial Fibrillation (irregular rapid heartbeat). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 12/13/2023, revealed a Brief Interview of Mental Status (BIMS) of 0 which indicated the resident's cognition was severely impaired. The MDS further revealed, included a diagnosis of Depression (mood disorder that causes a persistent feeling of sadness) and that the resident needed assistance with Activities of Daily Living (ADL) including toileting. A review of the Order Summary Report (OSR), dated 2/5/2024, indicated an order, initiated on 11/22/2023, for Zoloft (a medication used to treat mental disorder) Oral Tablet 25 milligram (mg) and to administer 1 tablet by mouth one time a day for Depression targeting sadness (Give with 50mg =75mg). Further review of the OSR indicated an order initiated, on 11/22/2023, for Zoloft Oral Tablet 50 mg and to administer 1 tablet by mouth one time a day for Depression targeting sadness (Give with 25mg =75mg). Review of the 2/2024 MEDICATION ADMINISTRATION RECORD (MAR), revealed the aforementioned medication orders with the administration time of 9:00 a.m. Review of Resident #2's Progress Notes (PN) for the month of 11/2023, included a Psychiatry Note dated 11/21/2023, documented by the Physician Assistant (PA), that Resident #2 was on Zoloft 50 mg daily for depression. Further review of the Psychiatry Note revealed a recommendation to increase Zoloft to 75 mg daily for depression. A review of Resident #2's PN dated 11/22/2023 and documented by Licensed Practical Nursing/Unit Manager (LPN/UM), indicated that Resident #2 was seen by psychiatry on 11/21/2023 with recommendations to increase Zoloft to 75mg daily for depression. Further review of the PN had no documented evidence that Resident's #2's RR was notified that Zoloft was increase to 75 mg on 11/22/2023. 2. Review of Resident #2's Care Plan (CP) initiated on 9/21/22, documented an intervention that Resident #2 requires one assist with toileting and toilet hygiene. Review of Resident #2's DSR (ADL Record) and the PN for the month of 1/24 and 2/24, lack of any documentation to indicate that the care for toileting and toilet transfer was provided was provided and/or the resident refused care on the following dates and shifts: 7:00 a.m. to 3:00 p.m. shift on 1/6/24, 1/7/24, 1/9/24, 1/22/24, 1/29/24, 2/1/24, and 2/3/24. 3:00 p.m. to 11:00 p.m. shift on 1/14/24 and 2/1/24. 11:00 p.m. to 7:00 a.m. shift on 1/5/24, 1/8/24, 1/18/24, 1/19/24, 1/22/24, 1/24/24, 1/25/24, 1/27/24, 1/29/24, 1/31/24, 2/2/24, and 2/4/24. 3. According to the facility AR, Resident #3 was admitted with diagnoses that included but were not limited to: Diabetes (disease that occurs when your blood sugar is too high), Osteoporosis (bones become weak and brittle), Post Polio Syndrome (a disorder of the nerves and muscles). The Quarterly MDS, dated [DATE], revealed a BIMS of 15 which indicated the resident's cognition was intact. The MDS further revealed that the resident needed assistance with ADL including toileting. Review of Resident #3's DSR and the PN for the month of 1/24 and 2/24, revealed a lack of documentation to indicate that the care for toileting was provided and/or the resident refused care on the following dates and shifts. 7:00 a.m. to 3:00 p.m. shift on 1/4/24, 1/7/24, 1/12/24, 1/18/24 to 1/20/24, 1/22/24, 1/25/24, 1/25/24, and 1/27/24. 3:00 p.m. to 11:00 p.m. shift on 1/7/24, 1/8/24, 1/30/24, 2/1/24, and 2/2/24. 11:00 p.m. to 7:00 a.m. shift on 1/21/24, 1/22/24, and 1/28/24. During an interview with the surveyor on 2/5/24 at 10:39 a.m., the Certified Nursing Assistant (CNA) stated, she would document in computer that she provided care to the resident at the end of the shift. CNA explained that all CNA's are responsible for documenting the ADL care provided into the electronic medical record (POC). During an interview with the surveyor on 2/5/24 at 10:46 a.m., the Licensed Practical Nursing/Unit Manager (LPN/UM) stated when the CNA provide care to the resident, it would be documented in POC. LPN/UM further stated that documentation of ADL's should be completed right away. During an interview with the surveyor on 2/5/2024 at 11:34 a.m., the LPN/UM stated when there is a recommendation for a change of medication, the resident's primary physician and RR will be notified and documented in the PN. On 2/5/2024 at 1:08 p.m., during a follow up interview with the surveyors, the LPN/UM stated, I notified the family, but I forgot to document it. On 2/5/24 at 1:32 p.m., the surveyors interviewed the Director of Nursing (DON), who stated that CNAs are responsible for documenting the ADLs care provided at the end of the shift. The DON explained it is important to document because it was a proof that the care was administered to the resident. The DON further stated that the primary physician, and the RR would be notified of changes in a resident's medication. The DON explained that she expected the nurses to document who they notified in the PN. A review of the facility's policy revised on 1/24 titled, SUPPORTING ACTIVITIES OF DAILY LIVING (ADLS) revealed under Policy Interpretation and Implementation section that .7. ADL's provided will be documented in the resident's medical record, interventions will be monitored, evaluated, and revised as appropriate. A review of the facility's policy date 5/23 titled, Nurses' Notes under Procedure section that .4. Ongoing nurses notes should include, at a minimum .family/physician notifications .changes in treatments, medications . NJAC 8:39-35.2(d)(9)

Complaint NJ #:159091 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to notify the resident's representative of a change in condition for 1 of 35 residents (Resident #431) reviewed. This deficient practice was evidence by the following: According to the admission Record, Resident #431 was admitted to the facility with diagnoses which included, adult failure to thrive, dementia, and personal history of covid-19. A review of the individualized Care Plan (CP) created 12/9/21, reflected a focus area: the resident's family had established an advanced directive (to appoint a person other than yourself to make health care decisions for you) with an intervention to inform resident/representative of any changes in status or care needs. A review of the Progress Note (PN) reflected the following: -1/16/22 at 15:18 [3:18 PM], rapid covid test positive, + cough, Covid PCR [Polymerase chain reaction - good at detecting the covid virus] collected sent to lab. -1/29/22 at 18:47 [6:47 PM], spoke to daughter, they had been upset that they weren't notified the resident had covid. -10/7/22 at 20:20 (8:20 PM), refused in house dentist for routine check. Further review of the progress notes, dated 1/16/22 through 10/8/22, did not include notification to the resident's representative that Resident #431 tested positive for covid and refused the in-house dentist routine check. A review of the Resident/Visitor/Grievance/Complaint form dated 1/18/22, indicated that the resident's daughter stated she was not informed of the positive covid result. A further review included for staff to make follow up calls until they spoke to family. During an interview with the surveyor on 12/18/23 at 10:04 AM, the Registered Nurse/Infection Preventionist (RN/IP) stated the nurse managers were responsible for notifying the families of any changes. The RN/IP further stated that once they families were notified it was documented in the electronic medical record (EMR) and the CP was updated. The RN/IP stated that the nurses could also notify the family representative of any changes and that the family should be notified of any changes that occurred. During an interview with the surveyor on 12/18/23 at 10:11 AM, the Licensed Practical Nurse (LPN) stated that the nurses were responsible for notifying the family and the doctor of any changes. She stated that it was important to notify them because the responsible party needed to be informed of any changes that occurred with the resident. The LPN stated that any time they talked to the family it should be documented in the nursing notes in the EMR. During an interview with the surveyor on 12/19/23 at 10:17 AM, the Director of Nursing (DON) stated the process for notification to families was for the resident's representative should be notified for any change of condition. She explained if there were significant changes such as a fall, then the family would be notified and updated so they knew what was happening with the resident. The DON stated that if a resident tested positive for covid, the family would definitely be notified. The DON stated that at the height of covid they had designated staff to call the families. When asked if Resident #431's family was notified she stated she believed they were called because during that time the Unit Managers (UM) and the Social Workers (SW) notified the families. The DON further stated that once the family was notified then normally it would be documented in the EMR that they were notified. She stated that Resident #431's family was very involved and believed that the UM notified the family of any changes and that it would have been documented. During an interview with the surveyor on 12/19/23 at 10:44 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated the UMs were responsible for notifying the families of any changes and that it should have been documented in the EMR. The LPN/UM then stated that there were times when the families did not answer the phone, but they would still document in a PN that they left a message or there was no answer. She explained if there were any changes then the families were notified, but if there were no changes then they did not have to. The surveyor asked if there were issues such as with the resident's teeth would the family be notified? The LPN/UM stated that the families should be notified because it was a change in condition. She then stated that the families were involved with the care and should know what was going on, so they would not be surprised if anything happened such as the resident being sent out to the hospital. On 12/20/23 at 10:12 AM, the DON in the presence of the [NAME] President of Clinicals, the License Nursing Home Administrator (LNHA), and the survey team acknowledged that the resident's representative should have been notified of any changes. A review of the facility's Change in Condition Notification policy, reviewed 07/2023, included, 3. The responsible party/family member will be notified of changes in condition unless directed otherwise in the resident's chart. A review of the facility's Nursing Documentation/Nurse's Note policy, reviewed 07/2023, included, 4. Ongoing nurses notes should include, at a minimum: changes in status or behavior, family/physician notifications. NJAC 8:39-13.1(c)

Complaint #: NJ00159091 Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment by: a) ensuring that resident's clothing was laundered and returned in a timely manner and b) ensuring that repairs were made to damaged walls and moldings in a timely manner. This deficient practice was observed for 1 of 2 residents (Resident #69) observed for personal property and for 1 of 4 nursing units (Second Floor/East). This deficient practice was evidenced by the following: a. On 12/12/23 at 12:32 AM, during the initial tour of the facility the surveyor observed Resident #69 seated on the side of the bed. The resident stated that his/her clothing was missing and he/she was only able to be changed into clean clothing once in the past three days. The resident stated that the laundry was sent down to be laundered and never returned. The resident stated that he/she reported the issue to the Certified Nursing Assistant (CNA #1) and the CNA agreed to look into the matter further. Review of Resident #69's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: legal blindness, glaucoma (condition of increased pressure in the eyeball causing gradual loss of sight) secondary to eye inflammation and neurogenic bowel (inability to control defecation due to deterioration of or injury to the nervous system), and unspecified abnormalities of gait (walking) and mobility. Review of Resident #69's Quarterly Minimum Data Set (MDS), an assessment tool dated 10/10/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident was fully cognitively intact. Further review of the assessment indicated that the resident had no documented behaviors and was dependent for lower body dressing and personal hygiene. Review of Resident #69's Progress Notes within the electronic health record (EHR) failed to contain any documentation that pertained to the resident's allegation of missing clothing. On 12/13/23 at 2:09 PM, the surveyor observed Resident #69 seated at the bedside. The resident was well groomed and dressed. When interviewed, the resident stated that CNA #1 had resolved the issue with the laundry and the resident had a clean change of clothing available today. The resident stated that he/she had no idea how many articles of clothing they had. On 12/13/23 at 2:28 PM, the surveyor interviewed CNA #1 who stated that he worked at the facility for nine months. CNA #1 stated, There was a change in department heads and clothes were not delivered here at all. CNA #1 stated that he went down to the laundry room and picked up the resident's clothing himself. CNA #1 stated that he dropped the resident's bag of soiled laundry in the laundry chute and it was delivered within four days. CNA #1 stated that Resident #69 should have nine or ten outfits and now had none except for the pants that the resident wore now. CNA #1 stated that when he went down to the laundry he helped himself and found the resident's clothing. CNA #1 stated that the issue had been reported to the Unit Manager over and over and addressed in the morning meeting. On 12/13/23 at 3:25 PM, the surveyor presented to the Licensed Nursing Home Administrator (LNHA) and requested to see the laundry room. LNHA called for the Laundry and Housekeeping Director and stated that she had been in the position for one month. LNHA stated that the linens were outsourced to be laundered. The LNHA stated that another employee was previously responsible for the personal laundry and the resident's loved her. He further explained that the employee, butted heads with the new Director and demoted demoted herself from full-time to part-time. LNHA maintained that the issue was resolved. On 12/13/23 at 3:29 PM, the surveyor interviewed the Director of Environmental Services (DES) who stated that she began working at the facility one month ago. The DES stated, the employee who did the resident's personal laundry previously refused to tell us her system and downgraded herself to part-time. DES further stated that we were backed up with the laundry for three weeks and were getting caught up. At that time, the DES escorted the surveyor to the basement laundry area. The surveyor observed two laundry attendants folding clothing. DES spoke to the attendants in Spanish and confirmed that there was no clothing available for Resident #69. The surveyor took photos of a large bin filled with bagged cleaned clothing and a smaller bin filled with bagged clean clothing. The DES then took the surveyor to the area where the laundry chute was. The door to the room was closed, when opened, the surveyor observed many bags of soiled linens piled high from the floor to the level of the laundry chute. The DES stated that she had just opened the chute before the surveyor arrived. DES stated that personal clothing was bagged in mesh bags and was labeled with the resident's name and done separately. The DES stated that there were two functioning washing machines and two dryers. She stated that wash was done on the 7-3 and 3-11 shifts. The DES stated that if Resident #69's clothing was missing, they were missing before she started. DES stated that Unit Managers were responsible to inform her of missing personal laundry. DES stated that no aide came down today to look for clothing and if they did, they came down while my staff was out delivering laundry. On 12/18/23 at 10:43 AM, the surveyor interviewed CNA #1 who stated that he went to the laundry last Thursday and saw the resident's clothing on a rack and got four to five outfits himself. CNA #1 stated that Resident #69 had since worn all but one outfit. CNA #1 stated that he did not believe that Resident #69 wore an outfit for more than one day, unless it was on Monday when he was off. CNA #1 stated when he returned to work he changed the resident's clothing. CNA #1 stated that a lot of people on this side of the hallway have not received their clothing and the problem was not isolated to the resident. CNA #1 stated that the DES told him not to use the laundry chute because the laundry staff would pick up the laundry themselves. CNA #1 opened the resident's closet and showed me a pair of pants that had a different resident's name and room number written on the label. He stated, They are someone else's. CNA #2 stated I will go down to the laundry myself and get the resident's clothes. He stated that there was one sweater, and six shirts in the resident's closet. CNA #1 removed the pants from the resident's closet that belonged to someone else. On 12/18/23 at 10:57 AM, the surveyor interviewed the Second Floor Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that resident's soiled laundry had to be placed in a bin in their room. LPN/UM stated that the laundry was bagged and placed in the laundry chute and then it was washed and delivered back to the resident's room. LPN/UM stated that until just recently, after surveyor inquiry, there were no complaints of missing items. LPN/UM stated that if there were any other current complaints of missing laundry she was not aware. LPN/UM stated that if she was notified of missing clothing she would call the laundry and tell them that they had to find it. LPN/UM stated, CNA #1 should have told me. On 12/18/23 at 1:40 PM, the surveyor phoned the former Laundry Supervisor who reportedly down graded herself to Laundry Attendant (LA). She stated that she worked at the facility for one year. LA stated,The residents were ranting and raving since she stopped doing their personal laundry and she heard that residents were not getting any laundry back. LA explained that she was removed from doing any personal laundry because she was part-time. LA explained that sometimes when agency staff worked they sent clothing down the chute in plastic bags instead of mesh bags. LA stated when she did the resident's personal laundry, there was not a time when a person did not have laundry. On 12/18/23 at 2:35 PM, the surveyor interviewed the Social Worker who stated that she was not informed of any residents who had missing clothing. The Director of Social Services (DSS) was present at that time and stated that an unsampled resident from Unit 2 recently informed her of missing clothing and we reimbursed the resident for four shirts. DSS stated that there was no record of missing clothing for Resident #69, but if the family were unable to find the clothing in the laundry, the resident would be reimbursed. On 12/29/23 at 10:01 AM, the surveyor interviewed the Director of Nursing (DON) who stated she would call the DES to see where Resident #69's clothing was so the resident received the clothing in a timely manner. DON stated that she could go to the basement and look for them. DON stated that resident's on 2 East side liked to dress up. DON stated that she would address the issue with both the LNHA and the DES. DON further stated, Our laundry should be done in a timely manner. On 12/19/23 at 12:45 PM, the DES stated that eleven pieces of Resident #69's clothing were returned yesterday and ten pieces of the resident's clothing was returned today. DES stated that the clothing was placed in the laundry chute and were sent down in bags that were not labeled. DES stated that the clothing was labeled with the resident's name. On 12/19/23 at 2:13 PM, LNHA stated that he was not aware until yesterday how much clothing was missing. He stated that last week he reimbursed for missing clothing. LNHA stated that when the former Laundry Supervisor was here it was great. On 12/20/23 at 10:47 AM, the surveyor observed Resident #69 lying in bed awake. The resident stated that he/she was told that their clothing had been returned. The surveyor inspected the resident's closet with resident permission and noted that the closet was now full and the clothes were hung on hangers and additional clothing was bagged in plastic. b. On 12/12/23 at 11:32 AM, during the initial tour of the facility the surveyor observed that the wooden molding strip (moldings, material such as wood used for decorative purposes) behind Resident #64's bed was broken and jagged. The molding strip had a night stand placed in front of it. The resident was not in the room at the time of the observation. On 12/12/23 at 12:05 PM,the surveyor observed a large hole in the lower portion of the wall in front of Resident # 95's bed that was positioned to the right of the bathroom door frame. The resident was asleep at the time and was unable to be interviewed. On 12/13/23 at 2:35 PM, the surveyor interviewed Certified Nursing Assistant (CNA #1) who stated that Resident #95's room mate repeatedly made holes in the wall with his/her wheelchair. CNA #1 stated that it was an ongoing issue. On 12/13/23 at 3:00 PM, the surveyor interviewed Resident #64 who stated that the broken moldings behind his/her bed had been like that since the resident was admitted to the facility. Review of Resident #64's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: encounter for orthopedic (relating to branch of medicine dealing with bones or muscles) aftercare and cervical disc disorder (compression of the spinal cord in the neck) with myelopathy (disease of spinal cord), unspecified cervical (neck) region. Review of Resident #64's admission Minimum Data Set (MDS), an assessment tool dated 11/18/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident was fully cognitively intact. On 12/18/23 at 10:49 Am, the surveyor interviewed CNA #1 who stated that the broken moldings behind Resident #64's bed had been like that for awhile and maintenance was aware. CNA #1 stated that he was not assigned to the resident and had not placed a request for repair. CNA #1 stated that if he were assigned to the resident he would have called down to the maintenance department or went down there himself to inform them of the need for repair. On 12/18/23 at 11:20 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) of the Second Floor East/West Units, who stated that she put a request into the system for maintenance to repair the moldings in Resident #64's room and the hole in the wall in Resident #95's room. LPN/UM stated that the resident's room mate had a motorized wheelchair and kept bumping into the wall which caused it to break. The surveyor was provided with maintenance request log and noted that on 10/23/23, the LPN/UM placed the following request on behalf of Resident #95, Hole in wall, air conditioner issue The response was dated 10/30/23 as completed. On 11/14/23, LPN/UM informed the maintenance department on behalf of Resident #64, Walls need to get fixed and painted consult. The response was dated 11/14/23 and revealed, Fixed left brake. Which did not pertain to the repair request. On 12/19/23 at 9:58 AM, the surveyor interviewed the Director of Nursing (DON) who stated that staff needed to report things that required repair in the resident's environment. The DON stated that the facility used a 24 hour on call maintenance system and were able to communicate with maintenance electronically. On 12/19/23 at 10:35 AM, the surveyor requested that the Maintenance Director (MD) accompany the surveyor to the second floor to observe both Resident #64 and Resident #95's room. MD accompanied the surveyor into Resident #64's room and stated that the request to repair the moldings behind the resident's bed were not placed in the electronic system to his knowledge. MD stated that the broken molding was removed and spackled (a compound used to fill cracks in plaster and produce a smooth surface) today after surveyor inquiry. The surveyor and MD then went to Resident #95's room and viewed the hole in the wall. MD stated, We can definitely repair the hole and replace the sheet rock. On 12/19/23 at 12/20/23, the Licensed Nursing Home Administrator (LNHA) stated that he was aware of the repairs that were needed in both Resident #64 and Resident #95's room. LNHA further stated that the moldings in Resident #64's room were removed and needed to be replaced. Review of an untitled facility policy reviewed/revised 12/23, revealed the following: Policy: To assure that infection control measures are maintained during routine laundering of patient clothing and to prevent misplaced or lost articles. To provide patients with personal laundry services and to assure the proper handling and laundering of patient clothing. Procedure: .Patient's personal laundry will be laundered by the facility per the resident, legal representative and/or other family member's choice. Should the resident and/or legal representative choose to have his/her laundry done elsewhere: All soiled laundry must be kept in a laundry basket, Picked up at least weekly, preferably twice a week, Sufficient clothing must be maintained on the premises to keep the patient clean and dry at all times . Inquiries concerning laundry or services should be referred to Social Services or designee. The policy failed to detail the frequency at which the facility washed and returned the resident's clothing. Review of an untitled policy reviewed 12/23, revealed the following: To establish a system that assures, when possible, a patient's lost or misplaced clothing and personal articles are returned. The facility shall implement a policy to assure that a lost and found program is established to safeguard and return patient's personal property. Procedure: All lost articles found on the premises must be turned over to the Social Services Director or designee within twenty-four (24) hours. .Articles of clothing that are turned in to the Social Director or designee will be maintained in the laundry area for ease of identification by patients and/or family members. .Patient or family complaints of missing items must be reported to Social Services Director or designee. .Reimbursement for a lost clothing article is in accordance with facility protocol; requests should be forwarded to the administrator. NJAC 8:39-27.1(a), 4.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The surveyor reviewed the admission record for Resident #428 which reflected that the resident was admitted from acute care with diagnoses that included but were not limited to Parkinson's disease (a progressive disorder that affected the nervous system), chronic respiratory failure with hypercapnia (the lungs were not functioning properly resulting in too much carbon dioxide in the blood) and diabetes type 2 (a disorder resulting in a high blood sugar) with chronic kidney disease (the kidneys are not functioning properly). A review of Resident #428's progress notes indicated that on 1/7/22, While rounding observed resident laying on the floor in front of his/her wheelchair. Further review of the progress notes revealed that on 1/12/22, Resident received in bed this am. Shortly after resident noted on the floor sitting with his/her back against the bed. A review of Resident #428's discharge MDS, dated [DATE], revealed section J1800 was coded 0 indicating that the resident had no falls since the previous MDS on 1/2/22. When interviewed on 12/18/23 at 1:20 PM, the MDS Coordinator acknowledged the MDS was inaccurate at this time and stated that she needed to modify the discharge MDS to include two falls without injury. 4. The surveyor reviewed Resident #132's the admission record which indicated that the resident was admitted in 2021 from acute care with diagnoses that included but not limited to: colostomy (an opening on the abdomen for bowel discharge), parastomal hernia (part of the bowel pushed through the abdominal muscle around the colostomy opening) and irritable bowel syndrome (condition with recurring abdominal pain with constipation or diarrhea) without diarrhea. A review of Resident #132's MDS dated [DATE], indicated the resident had a colostomy for bowel function. Review of the same MDS, indicated section H0400 was coded 0 indicating always continent. When interviewed on 12/18/23 at 1:22 PM, the MDS Coordinator stated that section H0400 should be coded as 9 (indicating that the resident had an ostomy) and would be modified. A review of the policy RAI Process-MDS Completion, revised 10/2023, 4. The MDSs will be filled out accurately, after proper collection of data, in a timely manner according to the RAI manual standards . N.J.A.C. 8:39-11.1 2. The surveyor observed Resident #19 returning to their room. When interviewed, the resident informed the surveyor that they were returning from eating and a smoke break and smoked three times a day. The surveyor reviewed the admission Record for Resident #19 which reflected that the resident was admitted with diagnoses that included but was not limited to chronic obstructive pulmonary disease (COPD, a chronic lung disease). The surveyor reviewed Resident #19's care plan which included care focus area created on 1/24/2020, and indicated the resident had emphysema (a lung disease)/COPD related to smoking and pollutants. Further review of the care plan revealed a care focus area created on 12/12/2023, which indicated the resident liked to smoke. Further review of the Resident #19's medical record revealed a Smoker's Contract addendum 2020 smoking agreement signed and dated by the resident on 6/30/21, and a progress note dated 1/11/23 at 1:53 PM, that indicated the resident attended every smoke break. Review of a smoking assessment dated [DATE], indicated Resident #19's use of cigarettes. The surveyor reviewed Resident #19's annual MDS dated [DATE], which indicated under section J - Health Conditions no for tobacco use. On 12/20/23 at 9:32 AM, the surveyor interviewed the MDS coordinator who acknowledged that the MDS was coded incorrectly for tobacco use for this resident. Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 4 of 29 residents reviewed (Residents #23, #428, #132 and #19). This deficient practice was evidenced by the following: 1. The surveyor reviewed the admission Record for Resident #23 which reflected that the resident was admitted with diagnoses that included pancreatitis (an inflammation of the pancreas). The surveyor reviewed the Weights and Vitals Summary which reflected a weight of 142 pounds on 11/21/23 which was corrected on 11/27/23 to reflect a weight of 127.2 pounds. The surveyor reviewed Resident #23's admission MDS, an assessment tool utilized to facilitate the management of care, dated 11/27/23 and reflected a weight of 146 pounds. When interviewed on 12/14/23 at 1:36 PM, the part-time Dietician in the presence of the Corporate Dietician stated that Resident #23 was seen by the full-time Dietician when the resident was admitted to the facility. The part-time Dietician stated when she saw the resident, she believed the weight of 142 pounds was incorrect as she knew the resident from previous admissions. Resident #23 at that time weighed 127.2 pounds. The dietician acknowledged that the weight documented on the admission MDS dated [DATE], was coded incorrectly. When interviewed on 12/18/23 at 1:34 PM, the MDS coordinator acknowledge that Resident #23's weight was incorrect on the admission MDS dated [DATE].

b. On 12/12/23 at 12:01 PM, during the initial tour of the facility, the surveyor observed Resident #84 sitting in a wheelchair at the nurses' station. The resident smiled and waved but the surveyor was unable to interview the resident at that time. According to the admission Record, Resident #84 was admitted to the facility with the diagnoses which included, dysphagia (difficulty in swallowing), unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of the annual Minimum Data Sheet (MDS), an assessment tool, dated 11/16/23, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident had severe cognitive impairment. A further review of the MDS in Section N revealed: Medications, included the resident was taking antipsychotic, antianxiety and antidepressant medications. A review of the Order Summary Report (OSR) for December 2023, reflected the resident had a physician order for Zoloft tablet 100 milligrams (mg) for depression. A review of the Consultant Pharmacist's Medication Regime Review (MRR) revealed the following: -9/20/23: Please do the monthly quantitative behavioral summary. -11/14/23: Zoloft was not included in the monthly psych summary from 11/5/23. Please review and correct psych summary. -12/13/23: Zoloft was not included in the monthly psych summary from 12/1/23. Please review and correct psych summary. A review of the Psychotropic Monthly Summary revealed for July 2023, August 2023, September 2023, October 2023, November 2023, and December 2023 signed 12/11/23, the Antidepressant medications sections was left blank. A review of the Psychiatry Progress note dated 10/24/23 at 16:54 [4:54 PM] indicated the resident was taking Zoloft for depression. During an interview with the surveyor on 12/19/23 at 10:26 AM, the Director of Nursing (DON) stated that the Unit Manager (UM) was responsible for completing the monthly psychotropic (psych) summary. The DON stated the UM on the fourth floor just started on 12/11/23 and was just getting adjusted. The DON stated that the Assistant Director of Nursing (ADON) was covering as UM on the fourth floor, but she was also longer here at the facility. The surveyor asked what was the Psychotropic Monthly Summary? The DON stated that the monthly psych summary was a look back at the resident behaviors over the month, so it could be discussed with the psychiatrist to determine if the medications needed to be adjusted. She stated it was important to accurately complete the monthly psych summary because it gave a full picture of the resident. She further stated that it should have included all psych meds and was completed monthly due to any changes. The DON reviewed the monthly psychotics summary in the electronic medical record (EMR) and acknowledged that Zoloft was not listed. The surveyor asked was there a supervisor on the fourth floor that could have completed the Psychotropic Monthly Summary? The DON confirmed that the previous UM was there during that time and acknowledged it could have been completed accurately and that it should have been. During an interview with the surveyor on 12/19/23 at 10:39 AM, Licensed Practical Nurse/Unit Manager (LPN/UM) for the second floor stated that the UM was responsible for completing the monthly psych summary. The LPN/UM stated that it included the psych meds, the last time the resident was seen by the consultant, if a gradual dose reduction (GDR) was done, and then they wrote in the comments any behavior issues, problems, if the interventions were effective, if there were any side effects, and if the physician needed to be notified. She further stated that all psych medications should be reflected on the monthly psych summary and how many behaviors occurred that month. The LPN/UM stated that the UM was responsible for ensuring any notes reflected from the pharmacy consultant should be reflected on the following month. During an interview with the surveyor on 12/19/23 at 10:51 AM, the Registered Nurse/Unit Manager (RN/UM) for the fourth floor stated that the UM was responsible for the monthly psych summary. She stated as the UM she was responsible to ensure the care plans were up to date, the target behaviors, any GDRs (gradual dose reductions), the medications and all mood and behaviors were captured on the monthly psych summary. She further stated as a UM she was responsible for ensuring that the pharmacy consultant recommendations were followed through each month. The RN/UM stated that it was important to assure that the Psychotropic Monthly Summary was accurately completed and that they followed up on the pharmacy consultant recommendations for the resident's safety and that they were getting the care needed. On 12/20/23 at 10:14 AM, the DON in the presence of the [NAME] President of Clinicals, the License Nursing Home Administrator (LNHA), and the survey team stated she in-serviced the unit managers on ensuring that the monthly psych summary was done. She further stated that the monthly psych summary should have been completed and reviewed to ensure they were accurate. A review of the facility Psychotropic Medication Use reviewed 07/2023, included, 8. Nursing will complete a monthly psychotropic summary describing resident progress or deterioration, including a summary of psychotropic medications being used and their subsequent effects to the resident/patient. Include the last visit with the Psychologist/Psychiatrist and any plans for reduction and/or continuation of medications. A review of the facility Medication Regime Review policy, reviewed 07/2023, included, 7. Upon completion of the MRR, the facility designee and or physician, will respond to the recommendations in a timely manner. A review of the facility Medication Administration policy, reviewed 07/2023, revealed the following: .Administer oral medications with a full glass of water unless otherwise ordered. Remain with the resident until all medication is taken . N.J.A.C. 8:39-27.1 (a) (c) (3i) Based on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to consistently follow appropriate professional standards of practice for: a) medication administration and b) accurately completing the Psychotropic Monthly Summary for 1 of 5 residents (Resident # 84) reviewed for unnecessary medications, psychotropic medications, and medication regime review for 1 of 3 nurses on 1 of 2 nursing units (2 East) reviewed for the medication administration observation. 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 and 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. This deficient practice was evidenced by the following: a. On 12/18/23 at 8:03 AM, the surveyor observed Licensed Practical Nurse (LPN #1) as she prepared medications to be administered to Resident #95 which included Acetaminophen (drug used to relieve mild or chronic pain) 325 mg (milligrams) two tablets as needed for pain, Metoprolol (a beta-blocking drug used to treat hypertension (high blood pressure) 25 mg (half tablet) 12.5 mg, and escitalopram (used to treat depression and general anxiety disorder) 20 mg. LPN #1 then proceeded to enter the room of Resident #95, and handed the resident a plastic cup filled with the previously mentioned medications and walked out of the room before she observed the resident take the medications. LPN #1 returned to the medication cart and documented the medications as administered after. Review of Resident #95's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: major depressive disorder, recurrent, moderate, anxiety disorder, and hypertension (high blood pressure). Review of Resident #95's Annual Minimum Data Set (MDS), an assessment tool dated 11/07/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected that the resident was fully cognitively intact. Review of Resident #95's Order Summary Report for December 2023, revealed that Resident #95 was ordered the following medications: Acetaminophen Tablet 325 mg Give two tablets by mouth every six hours as needed for mild pain (1-3) and for Temp (temperature) 101 and above ., Metoprolol Tartrate Oral Tablet 25 mg Give 0.5 table by mouth two times a day for HTN (hypertension) 12.5 mg total and Lexapro Oral Tablet 20 mg (Escitalopram Oxalate) Give one tablet one time a day for depression targeting anxiety. On 12/18/23 at 9:02 AM, in an interview with LPN #1 she stated, I am supposed to make sure that the resident took their medications. LPN #1 further stated, It was just a habit. On 12/18/23 at 11:05 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) of the Second Floor 2E/2W Unit who stated that nursing was required to remain with the resident during medication administration until they ensured that the resident swallowed the medication, in order to be one hundred percent sure the resident had taken the medications. On 12/19/23 at 9:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated that nursing was required to ensure when medications were administered to a resident that the resident swallowed the medications. DON stated that if the nurse did not directly observe the resident take blood pressure medications for example, and the resident did not take it, there may be consequences that resulted for the resident. DON stated, You must stay with the resident and ensure that all of the medications were taken.

Based on observation, interview, and review of facility documentation it was determined the facility failed to ensure that physician orders were obtained to change a resident's inner cannula of a tracheostomy (opening surgically created through the neck into the windpipe and inserting a tube to allow air to fill the lungs). This deficient practice was identified in 1 of 1 resident reviewed for tracheostomy care (Resident #433) and was evidenced by the following: On 12/12/23 at 01:06 PM, during the initial tour of the facility the resident was observed sitting at the bedside. The resident had a tracheostomy and oxygen was being provided with a trach collar (a device to deliver humidified oxygen to a tracheostomy). During the observation the resident was with the speech therapist and discussed swallow evaluations and the possibility of diet advancement following the swallow evaluation. Review of the admission Record revealed that Resident #433 was admitted to the facility with medical diagnoses which included but were not limited to tracheostomy, muscle wasting, hyperlipidemia (high cholesterol), and anxiety. The admission Minimum Data Set (MDS), an assessment tool was in progress. On 12/14/23 at 09:24 AM, the surveyor observed Resident #433 in a wheelchair being pushed by family exiting the physical therapy room. The resident's trach collar (used to hold a tracheostomy) was in place with oxygen tubing to a portable oxygen tank on the back of the resident's chair. The resident had a clean white dressing behind the tracheostomy and trach collar. On 12/14/23 at 10:01 AM, the surveyor reviewed the physician orders for Resident #433 which showed the following orders: CHANGE OXYGEN TUBING every night shift every Sunday for monitoring, CHANGE TUBING every night shift every Sunday for monitoring, and Tracheotomy Care every shift, Check Oxygen Saturation every shift for monitoring. They were active orders dated 12/02/23. Further review indicated the resident had a tracheostomy with a disposable inner cannula (meaning the inner cannula was required to be changed as ordered by the physician and to be completed by the nursing staff caring for the resident). On 12/14/23 at 10:27 AM, the surveyor observed Resident #433 in the room. The resident was in a wheelchair with oxygen to trach collar at the prescribed dosage. All oxygen tubing had dates on them. On 12/18/23 at 10:15 AM, Resident #433 was observed in the therapy room. Trach collar was in place to trach and oxygen was provided to the resident who was participated in therapy. On 12/19/23 at 09:54 AM, the surveyor interviewed the unit charge nurse for the day regarding trach care as the resident was not available. She stated that trach care included cleaning the skin and inspecting the skin around the trach and changing the dressing. She stated that the resident had minimal secretions and did not require suctioning. The surveyor asked how frequently the inner cannula was changed and she responded, I think it's changed once per day, but I have to look at the policy. The surveyor asked if the changing of the inner cannula should be on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) and the nurse said, All trach care should be on the TAR. The surveyor asked if the resident had inner cannulas in the room and the nurse said, They should be in there. The surveyor entered room with the nurse and there was a box of inner cannulas on the night stand. On 12/19/23 at 0950 AM, the charge nurse approached the surveyor and stated, I reviewed the policy, the inner cannula should be changed every shift, I will make sure it is added on the TAR. On 12/19/23 at 10:47 AM, the surveyor reviewed the Minimum Data Set (MDS), an assessment tool, list in the Electronic Medical record (EMR) which showed that the five-day MDS was in progress as resident was a new admission. Review of the care plan included a respiratory and trach focus, and the interventions included trach care every shift. On 12/19/23 at 11:32 AM, the surveyor interviewed the Director of Nursing (DON) regarding caring for a resident with a tracheostomy. The surveyor asked the DON to define trach care. The DON stated, Trach care is to make sure to suction the trach, clean the area, make sure it's not clogged. The surveyor asked how often tracheostomy care was performed and she responded, It's done once daily but if a resident has a lot of secretions they will suction extra. The surveyor then asked about the changing of the Inner cannula. The DON told the surveyor, It gets changed when it was soiled and clogged and we change it as needed. The surveyor asked the DON if changing the inner cannula was on the MAR or TAR and she stated, I believe it's on the MAR. The surveyor made the DON aware it was not on the MAR, TAR, or physician orders at that time. The surveyor then asked the DON if the staff should be signing a MAR or TAR when they changed the inner cannula and she stated, Yes. On 12/21/23 at 11:35 AM, the surveyor reviewed the policy titled, Tracheostomy Care, a policy with a reviewed date of 07/2023. The policy was to provide guidance in the preventive measures for controlling common infections for residents with a tracheostomy as part of the overall infection control program. Under the procedure section of the policy, it indicated that the staff would change the tracheostomy cannula as indicated, and as per facility policy. NJAC 8:39-25.4 (c) (4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/12/23 at 10:56 AM, during the initial tour of facility the surveyor observed Resident #132 lying in bed. The resident stated that all was well except for pain and the resident lifted his/her shirt to show a colostomy bag (an opening on the abdomen for bowel discharge). The surveyor reviewed Resident #132's admission Record (an admission summary) which showed that the resident was admitted to the facility with diagnoses that included but not limited to: colostomy, parastomal hernia (part of the bowel pushed through the abdominal muscle around the colostomy opening) and irritable bowel syndrome. A review of the MDS dated [DATE] revealed that Resident #132 had a Brief Interview of Mental Status (BIMS) score of 11 out of 15, which meant the resident had mild cognitive impairment. Review of Section J, titled Health Conditions revealed the resident had a pain assessment completed. It indicated that the resident was on a pain regimen, had pain almost constantly,,,, had pain that interrupted sleep and limited day to day activities. Pain intensity for the five days prior to the assessment was a seven, meaning it was severe, on the scale of one to ten. The surveyor reviewed Resident #132 physician orders which included, but were not limited to Tylenol Tablet 325 MG (Acetaminophen, a pain/fever reducer), Give 2 tablet by mouth every 6 hours as needed for pain (1-3) and Oxycodone Tablet 10 MG, Give 1 tablet by mouth every 6 hours as needed for moderate breakthrough pain (4-6). There were no orders found for medication for breakthrough pain of 7-10. A review of the MAR for December 2023 showed Resident #132 received the Oxycodone 10 mg for pain of seven on 12/4/23 at 6:10 AM and for pain of nine on 12/12/23 at 4:19 AM. On 12/18/23 at 11:27 AM, the surveyor interviewed licensed practical nurse (LPN), who stated that if Resident #132 complained of a pain level above a 6, she would call the physician to discuss this. On 12/18/23 at 12:42 PM, the surveyor interviewed the DON who stated that if the resident complained of seven to ten pain, the nurse should call MD and ask for different medication appropriate for the pain level. She acknowledged that there was no order for pain level seven to ten. She also stated that medication ordered for four to six pain level should not be given for a pain level of seven or nine without speaking to the physician. A review of policy Pain Management revised 7/2023, indicated treatment: 1. If the resident's pain is not controlled by the current treatment regimen the practitioner should be notified. NJAC 8:39-27.1(a) Based on observation, interview, and record review it was determined that the facility failed to ensure a pain management regimen was followed in accordance with physician orders. This deficient practice was identified in 2 of 3 residents reviewed for pain (Resident #99 and #132). This deficient practice was evidenced by the following: 1. On 12/12/23 at 10:15 AM, during the initial tour of the facility Resident #99 was observed in the bed. The resident told the surveyor that he/she was at the facility for rehabilitation and had come to the facility from the hospital. The surveyor reviewed Resident #99's admission Record (an admission summary) which showed that Resident #99 was admitted to the facility with diagnoses which included but were not limited to infection of knee prosthesis (device used to replace a body part), hyperlipidemia (high cholesterol), anxiety, and difficulty walking. Review of the admission Minimum Data Set (MDS), an admission summary, dated [DATE] indicated the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of Section J, titled Health Conditions, revealed that the resident had a pain assessment completed. It showed that the resident was on a pain regimen, had pain frequently, had pain that interrupted sleep frequently, and had pain that had interfered on day-to-day activities frequently. Pain intensity for the five days prior to the assessment was a seven, meaning it was severe pain on the one to ten scale. On 12/13/23 at 11:04 AM, the surveyor reviewed Resident #99's physician orders which showed an order for Oxycodone 10mg/325 mg tablets (narcotic pain reliever), one tablet every six hours as needed for moderate pain (four to six on the one to ten numeric pain scale). The surveyor then reviewed the Medication Administration Record (MAR) which showed that the resident received Oxycodone on 12/2/23 for a pain level of seven at 4:47 PM, on 12/8/23 for a pain level of eight at 2:30 AM, on 12/9/23 for a pain level of seven at 1:59 PM, on 12/10/23 for a pain level of seven at 11:50 AM and again for a pain level of seven at 7:42 PM, and on 12/11/23 for pain level of eight at 4:38 AM and a pain level of eight at 6:04 PM. Pain of seven to ten on the numeric pain scale indicated severe pain. On 12/14/23 at 10:38 AM, the surveyor observed Resident #99 in their room in bed. The surveyor asked the resident what type of pain he/she had, and the resident stated, My back and leg. The surveyor asked the resident how he/she would describe the pain mild, moderate or severe, and the resident stated, Severe at times. The resident continued to tell the surveyor that the pain medication only helped, Sometimes. On 12/18/23 at 09:43 AM, the surveyor went to see Resident #99 and was told by the staff he/she was admitted to the hospital. On 12/18/23 at 09:47, the surveyor reviewed the residents MAR which showed that on 12/15/23 the resident received Oxycodone (ordered for moderate pain) twice with severe pain levels (seven and eight). On 12/18/23 at 12:32 PM, the surveyor interviewed the Sub-acute unit nurse who cared for Resident #99 regarding pain. The LPN told the surveyor that they used a scale of one to ten, a numeric scale. The surveyor asked the LPN to explain the numeric pain scale and the LPN stated, One to three is mild pain, four to six is moderate pain and seven to ten is severe pain. The surveyor asked the LPN what she would have to do if a resident said they have severe pain but only had medication for moderate pain. The LPN responded, I would have to call the doctor because the pain is out of the moderate range, and they would need something else. On 12/19/23 at 11:29 AM, the surveyor interviewed the Director of Nursing (DON) regarding pain scales for the oriented residents. The DON stated they used a numeric scale, one to three for mild, four to six for moderate pain and seven to ten for severe pain. The surveyor asked the DON what if a resident's pain was a nine, meaning severe and the resident only had moderate pain medication ordered. The DON responded, I would call the doctor to get something for severe pain. The surveyor asked why that would be important and the DON stated, the resident would be asking for more pain medicine very soon because we are not treating the resident's pain correctly. On 12/21/23 at 10:30 AM, the surveyor reviewed the facility policy titled, Pain Management with a reviewed date of 07/2023. The policy stated that the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident goals and preferences. Under the section titled, Treatment, number one revealed that if the residents pain is not controlled by the current treatment regimen, the practitioner should be notified. NJAC-8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) properly store medications and properly label opened multidose medications. This deficient practice was observed in 4 of 4 medication carts and 1 of 2 medication storage rooms reviewed for medication storage and labeling and was evidenced by the following: On [DATE] at 9:58 AM, the surveyor, in the presence of the Licensed Practical Nurse #1 (LPN #1) reviewed the fifth floor's east side medication cart. The surveyor observed one opened 10 milliliter (ml) bottle of Refresh gel eye drops, and one opened 15 ml bottle of GenTeal Tears eye drops stored in the space as opened containers of over the counter (otc) medications. One opened undated and not labeled 2.5 ml bottle of latanoprost ophthalmic solution 0.005% (prescription eye drops used to treat glaucoma, increased pressure in the eye) and one 10 ml opened bottle of timolol maleate ophthalmic solution 0.5% (prescription eye drops used to treat glaucoma) were both stored alongside insulin pens and vials (injectable medication for diabetes). One opened and undated albuterol sulfate inhaler (medication used to treat lung disease) and one opened and undated foil pouch of albuterol sulfate 0.083% 2.5 milligrams (mg)/3 ml (medication used to treat lung disease), and 13 loose pills of various shapes, colors, and sizes. At this point the surveyor interviewed LPN #1. When asked about the undated and unlabeled latanoprost ophthalmic solution, the LPN stated she could not identify which resident it belonged to or when it was opened. LPN #1 further stated that these undated medications should have been labeled with the date opened as well as resident's name to whom it belonged. LPN #1 acknowledged that there should have been no loose pills in the cart, and medications should have been separated according to the method of their administration (eye drops, oral medication, injectables, liquids, inhalers). She then collected and disposed of the identified loose pills in the drug buster (solvent used to dissolve medication) bottle. On [DATE] at 10:50 AM, the surveyor, in the presence of LPN #2 reviewed the fourth-floor east side's medication cart. The surveyor observed a total of 85 loose pills of various shapes, colors, and sizes which included two pills located in the locked controlled substance box within the cart. At this point LPN #2 acknowledged that there should have been no loose pills in the medication cart, collected them and disposed of them in the medication drug buster bottle. On [DATE] at 11:32 AM, the surveyor, in the presence of LPN #3 reviewed the third-floor west medication cart. The surveyor observed a total of 78 loose pills of various shapes, colors, and sizes. At this point LPN #3 acknowledged that there should have been no loose pills in the medication cart, collected them and disposed of them in the medication drug buster bottle. On [DATE] at 12:06 PM, the surveyor, in the presence of LPN #4 reviewed the fifth-floor's medication storage room. The surveyor observed one expired bottle of 200 tablets of acetaminophen (a medication used to treat pain) 325 mg which was dated by the manufacturer with expiration date 10/23. On [DATE] at 12:40 PM, the surveyor, in the presence of LPN #5 reviewed the second-floor east side's medication cart. The surveyor observed a total of 23 loose pills of various shapes, colors, and sizes. At this point LPN #5 acknowledged that there should have been no loose pills in the medication cart, collected them and disposed of them in the medication drug buster bottle. On [DATE] at 2:03 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team and the Licensed Nursing Home Administrator (LNHA), who stated that a contracted pharmacy consultant comes on a monthly basis to check medication storage and carts and was present in the facility last week. Review of the facility's Medication Storage policy with effective date 2023 included but was not limited to: medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with NJ Department of Health Guidelines . medications for external use will be stored separately from medications for internal use. Ophthalmic, otic and nasal products will be stored separately from other medications for internal use. Medications will be stored in an orderly and organized manner in a clean area . medications will be stored in the original, labeled containers received from the pharmacy. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. N.J.A.C. 8:39-29.4

Complaint #NJ00156539 and NJ00156915 Based on observation, interviews, and review of pertinent facility documentation it was determined that the facility failed to serve hot foods at an acceptable temperature for the residents. This deficient practice was identified in the kitchen tray line during the plating of the lunch meal service for the 4th floor high side. The deficient practice was evidenced by the following: On 12/19/23 at 12:22 PM, the surveyor met with the Food Services Director (FSD) to obtain food temperatures on the kitchen tray line. The FSD obtained a thermometer and stated that it was the thermometer that was used to check the lunch meal. The FSD and surveyor approached the cook area where steam was observed coming from the steam table. The FSD tested the temperature of spaghetti which read 85 degrees Fahrenheit (F). The FSD instructed the cook to mix up the pasta and the FSD rechecked the temperature which read 85 degrees F. The FSD checked the temperature of a meatball which read 127 degrees F and checked the temperature of a hot dog which read 118 degrees F. When asked what the temperature for the spaghetti and the meatball should have been, the FSD stated 135 degrees F and above, and when asked what the temperature for the hot dog should have been, the FSD stated 140 degrees F and above. On 12/19/23 at 12:35 PM the surveyor met with the [NAME] President of Dining Services (VPDS) who was made aware of the food temperatures at the steam table. At that time, in the presence of the VPDS and FSD, the Food Temperatures log was reviewed and the VPDS stated that the recorded temperatures for the lunch meal service were done at 11:25 AM. Per the log, the recorded lunch meal temperatures read: meat 180 F, potato/rice 177 F, gravy 186 F, vegetables 0 F, pureed meat 189 F, pureed vegetable 187 F, mashed potato 177 F, ground meat 180 F, coffee 187 F, milk 40 F, juice 39 F. During an interview at that time, the VPDS stated, the temperature at the steam table should have been 140 degrees F and above but usually on the steam table it was 160 degrees and above. A review of the facility's policy, Food Temperatures, revised 10/2023, revealed: Procedure: Acceptable serving temperatures are: Meat, entrees >140 degrees but preferably 160-175 degrees. Potatoes, pasta >140 degrees but preferably 160-175 degrees. NJAC 8:39-17.4(a)2

Complaint #NJ00156539 Based on observations, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) failed to maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 12/12/23 from 10:19 AM-11:47 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. A dietary aide (DA#1) was sorting silverware and placing them into clear plastic bags that contained a napkin. He stated that he was bagging clean silverware for the meal trays. The DA was wearing a hairnet on his head with hair exposed behind each ear. DA#1 had long chin hair and was not wearing a beard guard. During an interview at that time, DA#1 acknowledged that no hair should have been exposed and that he was not wearing a beard guard. He stated that hair nets were to have been worn in the kitchen and that no hair should have been visible outside of the hairnet. DA#1 stated that it was important to wear hair coverings correctly, so hair did not get into the food. 2. A dietary aide (DA#2) was placing applesauce into plastic cups on a large tray. DA#2 stated that she was prepping applesauce cups. DA#2 was observed wearing a hairnet on her head with shoulder length hair exposed behind each ear. She acknowledged that her hairnet was not fully covering her hair and stated that it was important to wear a hairnet correctly so that no hair fell into the food. During an interview at that time, the FSD stated that the policy on hairnets in the kitchen was that all staff were to cover their hair when in the kitchen, and acknowledged they were not wearing the hairnets correctly. 3. On a rolling metal rack in the walk-in refrigerator there were three full trays of cooked ribs that were partially covered with clear plastic wrap with the ribs visible and exposed to air on each tray. There was one full size deep pan that contained four 10 pound (lb) sealed bags of defrosted chicken that were resting in cloudy pink liquid. One of the bags of chicken had a sticker marked pull date 12/10/23 use by 12/15/23, and there was no pull date or use by stickers on the other three bags of chicken. There was one half size roaster pan that contained two 10 lb sealed bags of diced beef cubes with one bag that had a sticker marked pull date 12/11/23 use by 12/15/23, and there was no pull date or use by sticker on the other bag of diced beef cubes. There was another half size roaster pan that contained two 10 lb sealed bags of diced beef cubes with one bag that had a sticker marked pull date 12/11/23 use by 12/15/23, and there was no pull date or use by sticker on the other bag of diced beef cubes. During an interview at that time, the FSD acknowledged that the ribs were not covered correctly with clear plastic wrap and that the chicken and the beef cubes were not marked. He stated that food could only be defrosted for five days and that it was important to mark the food items with pull dates and use by dates so that everyone knew the life of the food as it could have been spoiled past the date. 4. On the same rolling metal rack, there was one defrosted 8 lb sealed package of cooked roast beef marked with a manufacturer's stamp use or freeze by 11/29/23. The roast beef was soft to touch with liquid observed contained in the packaging. The FSD acknowledged there was no pull date and was unable to state when it was received or pulled. He further stated that the roast beef should have had a use by and received date and that it was important to label and date all food items to ensure the products were not expired. The FSD told a DA to discard the roast beef. 5. On a metal shelf in the walk-in freezer, there was one half pan partially covered with clear plastic wrap that contained sliced pieces of white meat that had two uncovered areas, with the meat visible and exposed to air. There were several pieces of chunks of ice on the plastic wrap and on the meat. There was a sticker on the plastic that was marked prep 12/5/23, use by 12/7/23, and a second sticker marked open 12/6/23, use by 6/3/24. The FSD identified the meat as sliced pork and acknowledged the pork was not covered correctly and stated it was freezer burnt. The FSD further stated that it should have been completely covered to prevent freezer burn and so that taste was maintained. There was one half pan of pasta that was partially covered with clear plastic wrap, that the FSD identified as stuffed shells. There were several pieces of chunks of ice on the plastic wrap and on the shells. There was a sticker on the plastic that was marked open 10/29/23, use by 4/26/24. The FSD acknowledged the ice and stated that they were garbage and threw away the shells and the pork. Resting on the bottom shelf of a metal rack there was one sealed 10 lb frozen log of ground beef with a manufacturer's stamp marked best before or freeze by 11/10/23. There was no received date marked on the ground beef. When the surveyor inquired as to whether the meat was still good, the FSD stated yes but stated he did not know when it was received or frozen. The FSD acknowledged that the ground beef should have had a received date on it and told the DA to discard it. 6. On the bread rack there was one half loaf of rye bread in an unsealed bag that was open to air. There was one 12 pack of English muffins that had no received or expiration date. The FSD acknowledged that the rye bread should not have been stored unsealed and that he did not know when the English muffins came in. The FSD removed the bread from the rack. 7. On the can rack in the dry storage room, there were two dented 106 ounce (oz) cans of fruit mix and one dented 7 lb 5 oz can of jellied cranberry sauce. The FSD acknowledged the dents and stated that the dented cans should have been in the dented can section. He further stated that it was important that dented canned foods were not used because they could have contained bacteria. 8. On the bottom shelf of a metal table at the cook's area there was a green bucket that contained soapy liquid which the FSD identified as the cleaning bucket. There was a red bucket that contained clear liquid that the FSD identified as sanitizer. The FSD stated that after the cook used the metal table that it would have been washed and then wiped with the sanitizer. The FSD tested the sanitizer liquid with a Hydrion test strip which resulted in an orange color and read zero. The FSD stated that it should have been between 200 and 400 parts per million (ppm.) The FSD removed the red bucket, refilled it, and retested it. It then read 200 ppm. 9. On a rack in the dry storage area, there was: one green cutting board with scrapes and gouges; two large green cutting boards with black smudges and gouges; and one blue cutting board with scrapes, gouges, and large amounts of white debris that the FSD scraped off with his fingernail. The FSD acknowledged that the cutting boards should not have scrapes, gouges, and smudges and stated that it was important not to use them because dirt could have gotten stuck on them and transferred to the food. The FSD removed the cutting boards from the area and stated they would be replaced. 10. The slicer was covered with a clear plastic bag which the FSD stated meant the machine was clean. The FSD removed the bag and there was a small amount of clear liquid noted on the base and a large amount of stuck on brown debris noted on the underside of the rocker tray. The FSD acknowledged the debris and stated that it should not have been there. The FSD further stated that it was important to keep equipment clean to prevent bacterial contamination. 11. In the emergency food closet, there were two 108 oz cans of ravioli, six 108 oz cans of chili con carne, one case of applesauce, two cases of pureed chicken broth, one case of three bean salad, three cases of diced fruit, two cases of fruit mix, one case of dry milk. During an interview at that time, the FSD acknowledged the food items and stated that there should have been enough food for a three-day supply for all the residents. The FSD stated there were 220 residents in house and that he did not think there was enough food in the emergency storage. He stated there was more in the paper room. 12. In the paper room, for emergency food storage, there were three cases of nectar thickened orange juice and one case of mashed potatoes. The FSD stated that it was his responsibility to keep track of the emergency food and that it was checked every month and stated, but sometimes if they need something they will take it from here and not tell me. On 12/12/23 at 01:36 PM, the surveyor met with the FSD and again toured the emergency food storage. The surveyor requested to have the Licensed Nursing Home Administrator (LNHA) join the tour. On 12/12/23 at 01:44 PM, the surveyor escorted the LNHA to the kitchen to tour the emergency food and water. In the presence of the FSD, the surveyor told the LNHA of the emergency food observations and asked if this was all the food that should be here. The FSD stated no, that it was not an adequate emergency supply for all the residents and that he had to restock. The LNHA stated, It seems like there should be more. When the surveyor inquired if there was enough emergency water, both the FSD and LNHA stated no. The FSD stated that there should have been one gallon per day for three days for each resident. The LNHA stated that he was not sure of the policy and that it was important to have enough emergency food and water because you never know what can happen. On 12/13/23 at 11:58 AM, in the presence of the FSD, the surveyor toured the kitchen and observed DA#1 at a prep table scooping cinnamon apples. DA#1 was wearing a hairnet on his head and was not wearing a beard guard on his long chin hair. DA#1 stated he was scooping apples for dessert, acknowledged he was not wearing a beard guard, and stated that he should have been wearing a beard guard. DA#1 left the area. During an interview at that time, the FSD stated that it was the FSD and assistant FSD's responsibility to ensure the staff were wearing appropriate hair coverings but stated, They don't listen. The FSD further stated it was important to wear hairnets and beard guards in the kitchen so hair would not get into the food. On 12/19/23 at 12:35 PM, the surveyor interviewed the [NAME] President of Dining Services (VPDS) who was made aware of the emergency food observation from 12/12/23 with photographs provided. When the surveyor inquired as to whether that was enough emergency food, the VPDS stated, No, for 3 days, no that is not enough. and that the facility should have had a lot of emergency food. The VPDS further stated, we need at least three day's emergency supplies. On 12/19/23 at 02:05 PM, the Administration team was made aware of all the kitchen concerns. A review of the facility document, Inventory Checklist-Emergency Food Supply, dated 12/14/23, revealed a list of emergency foods on hand. The document also revealed, *FSD/Supervisor will do an inventory every month and was signed by the FSD. On 12/20/23 at 11:15 AM, the surveyor requested from the [NAME] President of Dining Services (VPDS) the last three months of inventory checklist for the emergency food supply. He stated that the FSD was unavailable and would provide the document. On 12/20/23 at 11:17 AM, the surveyor requested from the FSD the last three months of inventory checklist for the emergency food supply. The FSD stated, I don't think we have that. No further documentation provided. A review of the facility's policy, Personal Hygiene, reviewed 10/1/2023, revealed Procedure: 3. Head covering worn: if hair is long and not covered properly with a cap, a hairnet must be worn, Beards or any body hair that may be exposed (i.e., arms) must be covered. A review of the facility's policy, Sanitation Policy, reviewed 10/1/2023, revealed Policy and Procedure [sic] 4. [NAME] containers contain water and soap solution; the red container contains sanitizing solution. The sanitizing solution should have a PPM between 200-400. A review of the facility's undated policy, Dented Can Policy, revealed 1. Dented cans which were received damaged or dented, will be placed on a designated area strictly for dented cans . A review of the facility's policy, Emergency Food Supply, reviewed 10/1/2023, revealed Policy: The dietary department will maintain a three day inventory of water and staple food products that require minimal preparation. A review of the facility's policy, Food Storage, reviewed 10/1/2023, revealed Procedure: All products shall be dated upon receipt or when they are prepared. Use Date shall be marked on all food containers according to the timetable in the Dry, Refrigerated and Freezer Storage Chart .Leftovers shall be dated according to the Leftovers policy. Raw meat: 4. Fresh meats shall be cooked or frozen within three to four days of purchase depending on the type of meat. 5. All cooked meat shall be used within 3-4 days of cooking. Frozen Meat/Poultry and Foods: Storage: Foods to be frozen shall be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers. Label and date all food items. Canned Fruits: Dented or bulging cans shall be placed on Damaged Goods Shelf . NJAC 8:39-17.2(g)

Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to maintain proper infection control practices during the Medication Administration Observation. This deficient practice was identified on 1 of 4 nursing units (Second Floor East/West) and for 2 of 3 nurses observed during the medication pass. This deficient practice was evidenced by the following: On 12/18/23 at 8:03 AM, the surveyor observed Licensed Practical Nurse (LPN #1) who was assigned to the 2 East Medication Cart as she prepared medications and administered them to Resident #95. When finished, LPN #1 failed to perform hand hygiene before she returned to the medication cart and charted the medications as administered. At 8:09 AM, LPN #1 obtained the automated blood pressure machine and entered the room of Resident #31. LPN #1 was observed placing the blood pressure cuff on the resident's upper arm and obtained a reading. LPN #1 removed the blood pressure cuff from the resident and failed to clean the blood pressure cuff or perform hand hygiene when finished. At 8:10 AM, LPN #1 returned to the medication cart, obtained the keys to the medication cart from her pocket and opened the medication cart. LPN #1 then proceeded to prepare medications for Resident #31, which the resident refused. LPN #1 returned to the medication cart with the resident's medications, opened the bottom drawer of the cart and obtained a canister of drug solvent (used to dissolve medications) and placed the medications in the solvent and returned the canister of solvent to the bottom drawer of the medication cart. On 12/18/23 at 9:02 AM in a later interview with LPN #1, she stated that she should have performed hand hygiene between residents and cleaned the blood pressure cuff after use to prevent cross-contamination. On 12/18/23 at 8:14 AM, the surveyor observed LPN #2 who was assigned to the 2 [NAME] Medication Cart. The surveyor observed LPN #2 as she placed a blood pressure cuff on Resident #179's upper arm and a pulse oximeter (measures the percentage of oxygen in the blood) probe on the resident's index finger and obtained a reading. When finished, LPN #2 removed the blood pressure cuff and pulse oximeter probe and proceeded to clean them with disinfectant wipes without first donning (putting on) gloves. LPN #2 failed to perform hand hygiene when she finished cleaning the equipment before she proceeded to access the computer to view the resident's scheduled medications. At 8:25 AM, LPN #2 then proceeded to wash her hands for 21 seconds in the presence of the surveyor after she medicated the resident. At 8:26 AM, the surveyor observed LPN #2 as she placed a blood pressure cuff on Resident #28's upper arm and pulse oximeter probe on the resident's index finger and obtained a reading. When finished, LPN #2 removed the blood pressure cuff and pulse oximeter probe and proceeded to clean them with disinfectant wipes without first donning gloves. LPN #2 failed to perform hand hygiene when she finished cleaning the equipment before she proceeded to access the computer to view the resident's scheduled medications. At 8:38 AM, LPN #2 performed hand hygiene with alcohol based hand rub (ABHR) after she returned to the medication cart. LPN #2 then proceeded to prepare Resident #192's medications. LPN #2 noted that the resident's Lidocaine 4% Patch (topical agent used to relieve pain) was not available in the medication cart. LPN #2 administered all oral medications to the resident and signed them out in the computer as administered. When finished, LPN #2 went to the medication room and opened the locked door with a key that was in her pocket to look for the Lidocaine 4% Patch. LPN #2 opened and closed the medication refrigerator door while in the medication room. LPN #2 obtained two Lidocaine 4% Patches from stock medications and proceeded to return to the medication cart after. LPN #2 then opened the Lidocaine packaging and wrote her initials, date and time on the back of the patch. LPN #2 then donned gloves without first performing hand hygiene, entered the resident's room, pulled up the resident's shirt and adjusted the resident's pants and applied the patch to the resident's lower back as ordered. When finished, LPN #2 doffed her gloves and washed her hands for 22 seconds before she signed out the medication as administered. At 8:52 AM, in a later interview with LPN #2, she stated that she did not think to wash her hands before she donned her gloves and administered the Lidocaine 4% Patch to Resident #192 as she did not think that it was necessary to wash her hands before she donned gloves. LPN #2 further stated, It was not necessary. On 12/18/23 at 11:05 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) of the Second Floor 2E/2W Unit who stated that nursing was required to wash their hands prior to medication preparation and administration because failure to do so was an infection control issue. LPN/UM stated that nursing should also wash their hands between residents to prevent contamination. LPN/UM stated that if the blood pressure cuff and pulse oximeter probe were not cleaned after use it could result in cross-contamination. LPN/UM stated that she would wear gloves when the blood pressure cuff and pulse oximeter probe were cleaned and perform hand hygiene after as the resident may have something that was contagious. LPN/UM further stated that nursing should wash their hands and donn gloves prior to Lidocaine Patch application to protect both the nurse and the resident from sickness. On 12/19/23 at 9:18 AM, the surveyor interviewed the Infection Preventionist Registered Nurse (IP/RN) who stated, Hand hygiene was the most important thing during the medication pass because it was the number one tool to prevent infection. He stated that hand washing should be done after medication administration and vital signs (blood pressure and pulse oximeter values) were obtained because there was a possibility to transmit something to the next resident. IP/RN stated that gloves should be worn when the blood pressure machine was cleaned because the dirt that may be on the hands reduced the effectiveness of the cleaning agents. IP/RN stated that if the equipment were cleaned without gloves and hand hygiene not performed prior to medication administration both the computer equipment and medications may be cross-contaminated. IP/RN stated that hand hygiene was basic and glove use was not to be substituted in lieu of hand washing which was the golden rule. On 12/19/23 at 9:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated that nursing should wash their hands before they accessed the computer to review the resident's medications and obtained all necessary items before seeing the resident. The DON stated that nursing was required to make sure that equipment was disinfected and hand hygiene was completed to prevent cross-contamination to another resident. She stated that you must wear gloves and perform hand hygiene after when the blood pressure machine was cleaned because it was a standard of practice and failure to do so could result in cross-contamination. The DON stated that nursing was required to perform hand hygiene prior to donning gloves and after doffing (removing) gloves during medication administration. Review of the facility policy, Hand Hygiene (Reviewed 07/23) revealed the following: .In this facility, hand hygiene is performed by using either alcohol-based hand rub (ABHR) or washing hands with soap and water. Purpose: Hand hygiene is a simple and effective method for preventing the spread of pathogens, such as bacteria and viruses, which cause infections. Pathogens can contaminate the hands of a staff member during direct contact with residents or contact with contaminated equipment and environmental surfaces within close proximity of a resident. Failure to clean contaminated hands can result in the spread of these pathogens to residents, staff (including the person whose hands were contaminated), and environmental surfaces. To Protect our residents, visitors and staff, our facility promotes hand hygiene practices during all care activities when working in all locations within the facility. .Hand washing with a non-antimicrobial soap and water or with anti-microbial soap and water is indicated for the following: Before having contact with patients .After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) .After contact with inanimate objects (including medical equipment in the immediate vicinity of the patient) After removing gloves . Review of the facility policy, Medication Administration (Reviewed 07/23) revealed the following: Procedure: Wash hands .Perform necessary assessments prior to administering specific medications. Example: pulse, blood pressure . .Wash hands, Proceed to the next resident/patient as indicated. NJAC 8:39-19.4 (a)

Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure: a) accountability of the Narcotic Shift Count logs were completed in accordance with facility policy and accurately accounted for and documented the administration of controlled medications and b) medications were administered in accordance with the medication's cautionary statement and manufacturer specifications. This deficient practice was identified on 5 of 5 medication carts observed on 4 of 4 nursing units and for 2 of 3 nurses who administered medications to 2 of 6 residents (Resident #95 and Resident #179) observed during the medication observation pass. This deficient practice was evidenced by the following: 1. On 12/14/23 at 9:58 AM, the surveyor, in the presence of Licensed Practical Nurse #1 (LPN #1), reviewed the controlled substance logs for the fifth-floor east side medication cart. The surveyor observed the following: Resident #160 was administered Diazepam (anti-anxiety medication) 5 milligram (mg) at 9:00 AM and the LPN stated she did not sign it out in the Individual Patient Controlled Substance Administration Record (declining inventory log). Resident #105 was administered oxycodone-acetaminophen (a pain medication) 5-325 mg at 9:17 AM and was not signed out on the declining inventory log. At this time, LPN #1 acknowledged that these medications should have been signed out immediately once dispensed and stated, I forgot to sign it out. LPN #1 was able to show that the medication was given and signed in the residents' electronic medication administration record (MAR). On 12/14/23 at 10:50 AM, the surveyor, in the presence of LPN #2, reviewed the controlled substance logs for the fourth-floor east side medication cart. The surveyor observed the following: The Record of Narcotic Barbiturate Abuse Drug Count (shift change log) was pre-signed by LPN #2 for 12/14/23 3:00 PM nurse - outgoing. At this time, LPN #2 acknowledged that this log should not have been pre-signed, and this was to be signed at the time of the narcotic count with the incoming and outgoing nurses at shift change. Resident #156's MAR indicated the resident was administered oxycodone (pain medication) 10 mg tablet at 9:09 AM and was not signed out in the declining inventory log. The declining inventory log for Resident #60 was pre-signed for a 2:00 PM administration of alprazolam (a medication used to treat anxiety disorder) 0.5 mg indicating there should have been seven tablets remaining , but the medication card contained eight tablets, which indicated one was not given yet. At this time LPN #2 acknowledged that this was pre-signed and the medication was not yet administered. On 12/14/23 at 11:32 AM, the surveyor, in the presence of LPN #3, reviewed the controlled substance logs for the third-floor east side medication cart. The surveyor observed the following: The shift change log outgoing nurse signature was blank for 12/13/23 3:00 PM. At this time, LPN #3 acknowledged that there should have been no missing signatures. On 12/14/23 at 12:40 PM, the surveyor, in the presence of LPN #4, reviewed the controlled substance logs for the second-floor east side medication cart two. The surveyor observed the following: Resident #170's prescription cards (BINGO cards, in blister packs) containing oxycodone IR 5 mg tablets contained 31 tablets, but the declining inventory log indicated 32 tablets should have been present. At this point, LPN #4 stated she administered the medication to the resident, but did not sign it out in the declining inventory log or in the resident's MAR. After surveyor's observation, LPN #4 signed the MAR for this dose at 1:07 PM. Resident #147's hydrocodone-acetaminophen (pain medication) 5-325 mg BINGO card contained three tablets, while the declining inventory log indicated four should have been present. LPN #4 was able to show the surveyor that this dose was signed in the MAR and informed the surveyor the 2:00 PM dose was also accidentally signed out in the MAR as well. At this time, LPN #4 informed the surveyor that the remaining narcotic BINGO cards for the logbook were stored in a second east medication cart. On 12/14/23 at 1:15 PM, the surveyor and LPN #4 continued the review of the second-floor east narcotics count and logs in medication cart two. The following was observed: Resident #2's declining inventory log for lorazepam (a medication used to treat anxiety disorder) 1 mg tablet was missing a nursing signature for the 12/14/23 9:00 AM dose. Resident #2 had oxycodone HCl 10 mg tablet signed in the MAR as administered 12/14/23 at 11:41 AM and was not signed out in the declining inventory log. Resident #56 had oxycodone HCl 15 mg tablet signed in the MAR as administered 12/14/23 at 11:42 AM and was not signed out in the declining inventory log. Resident #5's MAR indicated the resident was administered one dose of Dilaudid (pain medication) oral 2 mg tablet on 12/14/23 at 8:10 AM which was not signed out on the declining inventory log, a dose signed on the declining inventory log on 12/14/23 at 6:00 AM and not signed as administered in the MAR. Resident #21's pregabalin (medication used to treat nerve pain) 200 mg BINGO cards contained 40 capsules; the declining inventory log indicated 60 capsules were documented as received from the pharmacy by the nursing staff with 58 capsules remaining on hand. At this time the surveyor interviewed the LPN Unit Manager (LPN/UM) who stated that this was a clerical error in documenting how many capsules were received. The LPN/UM provided a packing slip indicating the facility received 42 capsules for Resident #21. On 12/14/23 at 2:03 PM, the surveyor, in the presence of the survey team and the Licensed Nursing Home Administrator (LNHA), interviewed the Director of Nursing (DON). The DON acknowledged that narcotics were to be signed out at the time of dispensing on the declining inventory logs, and there should be no pre-signing or missing signatures on narcotic count logs. The DON further stated that upon receiving of narcotics from the pharmacy, the nursing supervisor and a nurse should confirm the count and document it accurately. The DON provided no answer as to how the incorrect count was documented if two staff members were required to confirm the count together. The DON acknowledged that the incorrect count should have been caught during shift change narcotic reconciliation. 2. On 12/18/23 at 8:03 AM, the surveyor observed Licensed Practical Nurse (LPN#1) prepare three oral medications for Resident #95 which included Metoprolol Tartrate Oral Tablet 25 mg (milligrams) give one 0.5 tablet, by mouth two times a day for HTN (hypertension, high blood pressure) 12.5 mg Total. Start date 04/03/23 .LPN #1 reviewed the label that was on the bingo card (blister pack) in the presence of the surveyor and failed to acknowledge a pharmacy cautionary statement that specified, Take after a meal . prior to administration. When asked if the resident had eaten yet? LPN #1 stated that breakfast was not served yet. LPN #1 failed to offer the resident any food at the time of the observation. On 12/18/23 at at 8:17 AM, the surveyor observed Licensed Practical Nurse (LPN #2) prepare four oral medications for Resident #179 which included Metformin HCL oral tablet 1,000 mg Give one tablet by mouth two times a day for DM (diabetes mellitus, a disease in which body's ability to produce or respond to hormone insulin was impaired). LPN #2 reviewed the label that was on the bingo card in the presence of the surveyor and failed to acknowledge a pharmacy cautionary statement that specified, Take with food . prior to administration. LPN #2 stated, I give it with a little pudding and proceeded to put one teaspoonful of pudding in the 30 milliliter (ml) plastic medication cup with the oral medications. The surveyor observed a food cart in the hallway and noted that the meal trays had not yet been distributed to the residents. LPN #2 failed to offer the resident any food at the time of the observation. On 12/18/23 at 8:52 PM, when interviewed LPN #2 stated that Resident #179 was going directly to the dining room to eat breakfast after he/she received their medications. LPN #2 further stated, That is why I gave the the medications with pudding. On 12/18/23 at 9:02 AM, the surveyor interviewed LPN #1 who stated, She did not normally wait until a resident had eaten before she administered their medications. LPN #1 further stated that she did not observe the cautionary statement that specified, Take medication with food or immediately after a meal. LPN #1 stated, She should have waited until the tray arrived to administer the medication to avoid stomach upset or dizziness. On 12/18/23 at 11:05 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) of the Second Floor 2 East/West Unit who stated, If the medication label cautioned to administer a medication with food the nurse should ensure that the resident had a meal tray prior to medication administration. LPN/UM stated that one spoonful of pudding was not enough food and was not sufficient enough to give with medications. On 12/19/23 at 8:33 AM, the surveyor interviewed the Consultant Pharmacist (CP) via speaker phone with permission. The CP stated that we always told the nurses to give Metoprolol with a meal when we do in-services (education) due to the side effects of hypotension (low blood pressure) if the medication was absorbed in the body too quickly. CP stated that a spoonful of pudding was not a meal, and was not enough. CP stated that nursing usually knew when the trays were expected to be delivered to the nursing unit. CP stated, I know that nursing anticipated trays, but they do not always know when that will happen. CP stated, The pharmacy put a lot of cautionary labels on the medications, but I am not fond of that because the writing was very small. CP stated that when she did classes with nursing, she spoke to the classes of medications that needed to be administered with food. CP stated, The professional should know. On 12/19/23 at 9:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated that nursing should make sure that they followed protocol during medication administration. The DON stated that the nurses should look at those residents with diabetes mellitus first and ensured that they had breakfast so that medications were given with meals. She stated that nursing should read the precautionary instructions for residents who were on specialized medications to ensure that medications were administered at the right time. The DON stated that Metoprolol should not be administered until the meal was in front of the resident. She stated that it was not appropriate to give Metoprolol with a spoonful of pudding because it must be given with food, even if the resident was going to the dining room after. The DON stated that she would ensure that Metoprolol was instead administered with a meal. The surveyor reviewed the facility policy, Hand Hygiene (Revived 07/23) which failed to provide documentation that pertained to adherence to the cautionary statements during medication administration. Review of the facility's Schedule II Controlled Substance Medication policy with effective date 2023 included but was not limited to: a declining inventory sheet will be provided with each dispensed prescription for controlled dangerous medications. The form will contain the following information: patient name, medication name, medication strength, dosage form, name of prescribing physician, amount dispensed, prescription number and date dispensed. When the licensed staff member/nurse receives a CDS medication from the pharmacy, he/she will verify the contents with the label and will note the date received and quantity on the declining inventory form. When a CDS medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials. An inventory count of all CDS medications stored on each nursing unit shall be performed at each change of each shift by both the incoming and outgoing nurse. Both nurses are responsible for the count and must sign the inventory count form. NJAC 8:39-29.7(c);29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ165964 Based on observation, interview, and review of pertinent facility documents on 7/31/2023 and 8/1/2023, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of a resident (Resident#2) exposing himself/herself to other residents (Resident #3 and #4). The facility also failed to implement its policy titled Incident and Accident Report and Investigation. This deficient practice involved 3 of 4 residents reviewed for reporting reportable events, and was evidenced by the following: During a tour of the 5th floor on 7/31/2023 at 9:55 A.M., Resident #3 and Resident #4 told the Surveyor, There is a resident (Resident #2) down the hall who came to our doorway and exposed himself/herself showing the private part. He/She is sometimes loud in the hallways and screams out sexually inappropriate comments to the staff. Resident #3 denied being touched by Resident #2 during this exposure incident. The Resident stated he/she informed the Director of Nursing (DON) Administrator and Social Worker a few days after the incident had occurred. During the interview, Resident #3 could not recall the exact day/date Resident #2 exposed himself/herself to him/her. Resident #3 also could not provide the date the incident was reported to the facility's staff. Resident #3 further stated he/she was offered a room change but declined. 1. According to the admission Record (AR), Resident #2 was admitted on [DATE] with diagnoses that included but were not limited to Neurocognitive Disorder with Lewy Bodies Dementia, Major Depressive Disorder, Alcohol Abuse Uncomplicated, and Essential Hypertension. According to the Minimum Data Set (MDS), an assessment tool dated 6/9/2023, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of12 /15, which indicated the Resident had moderate cognition. The MDS also showed Resident #2 needed extensive one-person physical assistance with most Activities of Daily Living (ADLs). 2. According to the AR, Resident #3 was admitted on [DATE] with diagnoses that included but were not limited to Acute Chronic Systolic Heart Failure, Morbid (Severe) Obesity, unspecified anemia, and Weakness. According to the MDS, dated [DATE], Resident # 3 had a BIMS score of 15/15, which indicated that Resident #3 was cognitively intact. The MDS also showed Resident #3 needed extensive one-person physical assistance with most ADLs and total dependence with locomotion on and off the unit. 3. According to the AR, Resident #4 was admitted on [DATE] with diagnoses that included but were not limited to Chronic Kidney Disease Stage 3, Major Depressive Disorder, and Muscle Weakness. According to the MDS, dated [DATE], Resident #4 had a BIMS score of 15/15, which indicated that Resident #4 was cognitively intact. The MDS also showed Resident #3 needed extensive one-person physical assistance with most ADLs and total dependence with locomotion on and off the unit. During an interview on 8/1/2023 at 12:18 P.M., the Surveyor asked if the incident of Resident #2 exposing himself/herself was reported to the NJDOH, the Director of Nursing (DON) stated, We did not report the incident to the NJDOH. When asked if the event should have been reported, the DON responded, Yes, we should have reported the incident to the NJDOH. During an interview on 8/1/2023 at 1:27 P.M., the Administrator stated the incident would not be reported because it does not fall under the category of abuse or neglect to report to the NJDOH. A review of the facility policy titled Incident and Accident Report and Investigation, Reviewed date: 1/23, revealed the following: Under Policy: include All incidents and accidents will be recorded, investigated, and reported accordingly. Necessary interventions will be put in place to prevent reoccurrence. Under Procedure/Responsibility: Director of Nursing /Designee- He/she will be responsible for reviewing all written statements from all parties involved in the incident or accident. The DON/Designee will also be responsible for assessing the risk factors that may have contributed to the incident or accident. He/she may delegate this responsibility to the unit manager of the unit. The Unit Manager/ supervisor/ designee will be responsible for completing the Final Disposition/Conclusion form if needed. Any measure done regarding the incident or accident, including reporting to the DOH, must be included in the final report. All incidents and accidents with a possibility of an alleged mishandling or neglect will be reported to the DOH or the Office of the Ombudsman by the Administrator or Director of Nursing. NJAC 8:39-9.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ165964 Based on observation, interview, record review, and review of pertinent facility documentation on 7/31/2023 and 8/1/2023, it was determined that the facility failed to thoroughly investigate an allegation of a resident (Resident #2) standing in the doorway of another resident's room and exposing his/her private part to the residents (Resident #3 and #4). The facility also failed to implement its Accident and Incident Report and Investigation policy. This deficient practice involved 3 of 4 residents (Resident #2, #3, and #4) and was evidenced by the following: During a tour of the 5th floor on 7/31/2023 at 9:55 A.M., Resident #3 and Resident #4 told the Surveyor, There is a resident (Resident #2) down the hall who came to our doorway and exposed himself/herself. He/She is sometimes loud in the hallways and screams out sexually inappropriate comments to the staff. Resident #3 denied being touched by Resident #2 during this exposure incident. The Resident stated he/she informed the Director of Nursing (DON) Administrator and Social Worker a few days after the incident had occurred. During the interview, Resident #3 could not recall the exact day/date Resident #2 exposed himself/herself to him/her. Resident #3 also could not provide the date the incident was reported to the facility's staff. Resident #3 further stated he/she was offered a room change but declined. 1. According to the admission Record (AR), Resident #2 was admitted on [DATE] with diagnoses that included but were not limited to Neurocognitive Disorder with Lewy Bodies Dementia, Major Depressive Disorder, Alcohol Abuse Uncomplicated, and Essential Hypertension. According to the Minimum Data Set (MDS), an assessment tool dated 6/9/2023, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of12 /15, which indicated the Resident had moderate cognition. The MDS also showed Resident #2 needed extensive one-person physical assistance with most Activities of Daily Living (ADLs). 2. According to the AR, Resident #3 was admitted on [DATE] with diagnoses that included but were not limited to Acute Chronic Systolic Heart Failure, Morbid (Severe) Obesity, unspecified anemia, and Weakness. According to the MDS, dated [DATE], Resident # 3 had a BIMS score of 15/15, which indicated that Resident #3 was cognitively intact. The MDS also showed Resident #3 needed extensive one-person physical assistance with most ADLs and total dependence with locomotion on and off the unit. 3. According to the AR, Resident #4 was admitted on [DATE] with diagnoses that included but were not limited to Chronic Kidney Disease Stage 3, Major Depressive Disorder, and Muscle Weakness. According to the MDS, dated [DATE], Resident #4 had a BIMS score of 15/15, which indicated that Resident #4 was cognitively intact. The MDS also showed Resident #3 needed extensive one-person physical assistance with most ADLs and total dependence with locomotion on and off the unit. During an interview on 7/31/2023 at 3:30 P.M., the DON stated she was informed by Resident #3 that Resident #2 exposed himself/herself. The DON could not provide the exact date she was notified of the incident. According to the DON, she asked Resident #3 if he/she was touched inappropriately by Resident #2, and the Resident denied being touched. When asked if there was an incident report and investigation done, the DON stated: No, because this is [the Resident's] behavior. She further stated she offered Resident #3 a room change, which the Resident declined. The DON gave Resident #3 a notebook and pen to recall dates and times and to call the police if the behavior is repeated. During the same interview, the DON stated, Resident #3 informed her that he/she was not afraid and felt safe on the unit. When asked if there should have been an investigation and documentation of the incident, the DON stated: Yes, they should have documented the incident and completed a thorough investigation for the incident. She indicated that the incident was 2-3 weeks ago. In addition, the DON told the Surveyor that Resident #2 was placed on 1:1 supervision on 7/12/2023 due to the Resident's behavior. During an interview on 8/1/2023 at 10:55 A.M., the Social Worker (SW) told the Surveyor that she was aware of the incident and did an investigation. The SW stated she spoke with Resident #3 after the Resident reported the incident and provided supportive counseling. The SW further stated, This was the first reported incident with Resident #2 exposing himself/herself to another resident. The Surveyor reviewed two statements written by the SW showing that residents were inteviewed and they reported to the SW that a resident exposed himself/ herself to the residents, per the statements the SW told the residents that an investigation will be completed. However, at the time of the survey the facility was unable to provide any other evidence that the investigation for the allegation has been completed. A review of the facility policy titled Incident and Accident Report and Investigation, Reviewed date: 1/23, revealed the following: Under Policy: include All incidents and accidents will be recorded, investigated, and reported accordingly. Necessary interventions will be put in place to prevent reoccurrence. Under Procedure: 1. The facility staff will document all incidents and accidents or unusual occurrences experienced by a resident on an Incident/Accident Report. 3. The form must be completed immediately or no later than the shift that the incident occurred or when the event had been discovered. Under Procedure and Responsibility: All completed investigation reports will be kept and filed by the Director of Nursing or designee. Appropriate tracking and trending, as well as the minutes of the Safety Committee Meeting, will be maintained by the Quality Assurance Director to identify additional interventions that can be implemented within the facility for similar incidents and accidents. Interventions and recommendations will be discussed in the Interdisciplinary meeting and the weekly Safety Committee meeting. NJAC: 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that an updated advance directive was accurately maintained within a resident's medical record, in accordance with the facility policy. This deficient practice was identified for 1 of 2 residents (Resident #48) reviewed for Advance Directives and was evidenced by the following: During the initial tour of the facility on [DATE] at 10:32 AM, the surveyor observed Resident #48 seated in a reclining wheelchair at the bedside. The resident was non-verbal and did not maintain eye contact when spoken to. Review of Resident #48's admission Record that was printed on [DATE] at 09:56 AM, revealed that the resident was readmitted to the facility in November of 2021 with diagnoses which included but were not limited to: Down's Syndrome, adult failure to thrive, sepsis (a life-threatening complication of infection), pneumonia and intestinal obstruction. Further review of the admission Record revealed that the resident's Advance Directive section of the form specified that the resident was a Full Code (Use all appropriate medical and surgical interventions as indicated to support life. If in a nursing facility, transfer to hospital if indicated). Review of Resident #48's most recent significant change Minimum Data Set (MDS), an assessment tool dated [DATE], revealed that the resident's Brief Interview of Mental Status (BIMS) score was 00, (which indicated that the resident was severely, cognitively impaired). Further review of the document revealed that the resident was non-verbal, was rarely understood, required extensive assistance of one person for activities of daily living and was dependent for feeding. Review of Resident #48's paper medical chart revealed a New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form that was labeled with the resident's name and date of birth that was dated and signed by the Nurse Practitioner on [DATE]. Further review of the POLST revealed that the resident's goal of care was to be a Full Code and receive full treatment. Further review of the POLST indicated that CPR (cardiopulmonary resuscitation) (any medical intervention used to restore circulatory and/or respiratory function that has ceased) and intubate/use artificial ventilation as needed (a tube is placed in the throat to help move air in and out of the lungs) should be provided if resident's condition warranted. Further review of the POLST revealed that a verbal signature was obtained from the resident's responsible party on behalf of the resident. Review of Resident #48's Order Summary Report that was contained within the resident's paper medical chart and was dated [DATE], revealed that an order was placed on [DATE] for DNI (Do Not Intubate) and DNR (Do Not Resuscitate). The surveyor was unable to locate any additional information within the resident's paper medical chart to explain the discrepancy between the POLST dated [DATE] which specified that the resident was a Full Code and required full medical treatment if resident's medical condition warranted and the current order for DNR/DNI which prohibited full treatment. Review of Resident #48's Care Plan revealed an entry dated [DATE] which indicated that the resident requested that CPR measures be performed (Full Code Status). A related intervention specified please follow my instructions as detailed inside my Advance Directives & /or Living Will if I have one. During an interview with the surveyor on [DATE] at 09:46 AM, the Director of Social Services (DSS) stated that the discrepancy between Resident #48's POLST form and Order Summary Report presented a conflict. The DSS stated that the resident should have been designated as a Full Code according to the latest IDT (Interdisciplinary Team) Meeting Notes dated [DATE] in which the resident's responsible party was a participant. During a follow up interview with the surveyor at 10:43 AM, the DSS explained that when Resident #48 returned from the hospital on [DATE] a hospital transfer order for DNR/DNI was implemented at the facility and Social Services was not aware of the order change in resident status from Full Code to DNR/DNI. She stated that after surveyor inquiry, the facility became aware of the discrepancy as the documentation and discussion with the resident's responsible party on [DATE] indicated that the resident was a Full Code. During an interview with the surveyor on [DATE] at 09:12 AM, the Registered Nurse/Unit Manager (RN/UM) stated that when she attended the family care conference on [DATE] she missed the order for DNR and DNI that was written on [DATE] and did not realize that the POLST did not reflect the current order. She stated that if Resident #48 had a medical emergency she would have administered CPR and initiated life sustaining treatment as that was what the POLST that was contained within the resident's paper medical record specified. She stated that the resident's admission Record also should have been updated to match the order for DNR/DNI and instead it indicated that the resident was a Full Code. She further stated that she took responsibility for the discrepancy as she missed the change in status at the IDT meeting. The RN/UM stated that the resident's responsible party was contacted in response to the discrepancy for clarification and a new POLST was drafted and awaited physician's signature which specified that the resident would remain DNR/DNI. During an interview with the surveyor on [DATE] at 11:57 AM, the Director of Nursing (DON) stated that when there was a change in order status that originated from a hospital transfer, the nursing staff should call the attending physician for clarification. She stated that once a new order was obtained nursing should have generated a new POLST and filed it as it was no longer considered active. She stated that they should have changed the computer dashboard and resident's admission Record to ensure that it accurately reflected the change in the Advance Directive status. She further stated that Social Services should have been notified when the change was originated by the nurse who took the order as they were responsible to upload the new POLST form into the Electronic Health Record (EHR). The Licensed Nursing Home Administrator (LNHA) who was present at that time, stated that SW does periodic audits to check for this type of discrepancy and the information has been monitored by Quality Assurance on an ongoing basis. Review of the facility policy titled, Advance Directive Policy and Procedure (Reviewed 12/21) revealed the following: During the quarterly RAI (Resident Assessment Instrument) process and with any significant changes of condition, facility staff will: Identify, clarify and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directive. Define and clarify medical issue, review the resident's condition and existing choices and present information regarding relevant health care issues to the resident or resident representative as appropriate to determine continuation or modification of choices of care. Changes to the resident choices for advance directives will be documented, included in the resident plan of care, State specific documents will be updated as necessary, physician orders will be obtained to reflect new choices as applicable, and all items will be communicated to staff providing resident care. The interdisciplinary team will identify, clarify, and review, as part of the comprehensive care planning process, the existing care instructions along with the resident's .wishes as the resident's medical condition changes. NJAC 8:39-4.1(a)4

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to administer a medication in accordance with a physician's orders and consistent with professional standards. This deficient practice was identified for 1 of 5 residents (Resident #108) reviewed for medications and 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 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. On 01/24/22 at 11:21 AM, the surveyor observed the Resident #108 in bed. During an interview with the surveyor at that time, Resident #108 stated that he/she could not sleep the night prior (01/23/22) because his/her medication, Ambien (a medication used to help one sleep, who otherwise has difficulty falling asleep or staying asleep) was not available. The resident further stated that staff have needed to obtain this medication from back-up supply for the past several nights which required two nurses, and there was only one nurse available the night prior. On 01/25/22 at 9:40 AM, the surveyor observed the resident sitting up in bed eating breakfast. During an interview with the surveyor at that time, Resident #108 stated that he/she did not receive his/her Ambien again the night prior (01/24/22) because there was only one nurse. The resident further stated that his/her Ambien is currently on order, but that he/she was used to taking it, so it was hard for him/her to sleep without it. Review of the resident's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/14/21, included that the resident had a Brief Interview for Mental Status of 15 out of 15, which indicated that the resident had a fully intact cognition. A review of the Face Sheet (admission record) for Resident #108 revealed a diagnosis including, but not limited to insomnia (a condition in which one has difficulty falling asleep or staying asleep). A review of the Physician's Order Sheet for January 2022 revealed an order for Ambien 10 milligrams (mg) (Zolpidem Tartrate), give one tablet by mouth at bedtime for insomnia, targeting poor sleep. In addition, Ambien is a controlled substance, a medication whose use must be accounted and tracked due to its potential for dependence and abuse. A review of the Medication Administration Record (MAR) (a recording document) revealed that the Ambien 10 mg tablet was not administered on 01/23/22 or 01/24/22 as ordered. A review of the resident's current Care Plan revealed that Resident #108 used Ambien for insomnia, targeting poor sleep at bedtime. A review of the back-up medication supply log for Ambien 5 mg revealed that 33 tablets were available at the time Resident #108's Ambien was due to be given on 01/23/22 and 01/24/22. During an interview with the surveyor on 01/26/22 at 12:36 PM, the Director of Nursing (DON) confirmed that Ambien 5 mg was available in the back-up medication supply. The DON further clarified that if a resident required a 10 mg dose, nursing staff should sign out two tablets for administration. During an interview with the surveyor on 01/27/22 at 11:34 AM, the Licensed Practical Nurse (LPN) addressed the process for obtaining medication for residents. The LPN stated that medication refill requests were to be completed by requesting them within the computer system or making a request on paper via facsimile (fax). The LPN further stated that if a particular medication was unavailable, it was necessary to determine if that medication was available in the back-up supply. If the medication was still unavailable, the nurse should notify the physician for further orders to either obtain the medication through special order, place the medication on hold, or substitute it with an alternative medication. In addition, the LPN stated that all facility nurses had access to back-up supply medication, but agency nurses do not. The LPN further stated that if a medication was a controlled substance, two nurses must sign the medication out of the back-up supply to verify the amount(s) removed and the amount(s) remaining. During an interview with the surveyor on 01/27/22 at 1:15 PM, the nursing Unit Manager (UM) addressed the procedure for obtaining medication. She stated it was necessary to check the back-up medication supply, indicating that agency nursing staff must check with a facility nurse or supervisor, as agency nurses do not have access to back-up medication supplies. The UM stated that if a medication was not available in back-up supply, to call the pharmacy for immediate delivery (within 4 hours), call the physician to advise him/her of the situation, and document the physician's response. The UM also described the process for refilling medication, indicating that it was best to refill medication supplies when there were six dosage forms remaining and reiterated that the refill process could be initiated electronically through the computer or by paper request via the fax machine. In addition, the UM stated that if a renewal prescription was needed, the pharmacy would fax the notice to the facility. If the medication was not delivered in a couple of days, it was important to follow-up with the physician for further instruction and the pharmacy to check the status of the refill processing, as there were sometimes insurance-related issues. In addition, the UM acknowledged that Resident #108 asked her about the missing medication (Ambien) and advised the resident that it was readily available in the back-up medication supply. The UM further stated that a new prescription for the Ambien was needed, obtained the day prior (01/26/22), and sent to the pharmacy. Finally, the UM acknowledged that she did not recall seeing any paperwork regarding Resident #108's Ambien and that the two agency nurses who worked 01/23/22 and 01/24/22 should have obtained the required doses out of the back-up supply, with the assistance of the nursing supervisor. In a follow-up interview with the surveyor on 01/27/22 at 1:45 PM, the UM repeated that the nurses should have obtained the doses of Ambien out of the back-up supply and if it was still unavailable, they should have notified the physician for an alternative medication. The UM also stated that doing so was important because the resident requires the referenced medication for sleeping. During an interview with the team, surveyor, and in the presence of administrative staff on 01/28/22 at 11:35 AM, the DON acknowledged that Ambien 10 mg should have been given as ordered, by the physician, to Resident #108 on 01/23/22 and 01/24/22. In addition, she stated that it was necessary to check the back-up medication supply for availability of the medication and if it was not available, it was necessary to follow up with the physician for further instruction. Although the medication was available in the back-up supply of medications, the DON could not offer any explanation as to why it was not obtained and subsequently administered to the resident. When asked about the details surrounding the refill process in this regard, the DON stated that she wanted to investigate matters further and would advise the survey team on her findings. During an interview with the team, surveyor, and in the presence of administrative staff on 01/28/22 at approximately 10:00 AM and at exit conference on the same date at 11:28 AM, the DON was not able to provide any additional details regarding the refill processes for the referenced medication. A review of the facility's policy titled, Medication Administration revised 09/2021, revealed it is important to notify the physician of any important changes to the resident, as related to medication. In addition, the policy references medication as ordered as a supply but does not provide further detail. A review of the facility's policy titled, Reordering, Changing, & Discontinued Medication Orders failed to reveal an effective date and a revision date. According to the policy, medication refill requests could be submitted to the pharmacy with a Refill Order Form faxed to the pharmacy or by making a verbal request. NJAC 8:39-29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of pertinent facility documentation it was determined that the facility failed to serve hot and cold foods at an acceptable temperature for the residents. This deficient practice was identified for 5 of 5 residents who attended a Resident Council group meeting, and on 1 of 4 nursing units during the lunch meal service and was evidenced by the following: During the initial tour of the 4th floor unit on 01/24/22 at 10:42 AM, Surveyor #1 interviewed Resident # 95 who stated that the food could be warmer. Resident #95 stated that when he/she eats in their room the breakfast meal is not hot. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/9/21, revealed Resident #95 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that the resident was cognitively intact. During the initial tour of the 4th floor unit on 01/24/22 at 10:48 AM, Surveyor #1 interviewed Resident #53 who stated that when he/she ate in their room, the food was cold. Review of the Quarterly MDS, dated [DATE], revealed Resident #53 had a BIMS of 15, which indicated that the resident was cognitively intact. On 01/25/22 at 08:53 AM, Surveyor #1 observed Resident # 95 sitting in bed, awake and alert, with the breakfast tray on the overbed table. The resident's breakfast consisted of eggs with peppers. Resident # 95 stated the eggs were warm, not hot. On 01/25/22 at 08:36 AM, Surveyor #1 observed Resident #53 sitting in bed with the breakfast tray on the overbed table. Resident #53's breakfast consisted of eggs with peppers. Resident #53 stated the eggs were cold. On 01/26/22 at 10:40 AM, the surveyors conducted a group meeting with 5 residents who regularly attended the facility resident council meetings. 5 out of 5 residents indicated the food was usually cold when they ate in their room. On 01/27/22 at 12:22 PM, two surveyors conducted a test tray with the Food Service Director (FSD). Surveyor #2 interviewed the FSD regarding the calibration of the FSD's thermometer and the FSD confirmed the thermometer he brought to take the food temperatures was calibrated. The test tray was plated and the temperatures were checked by the FSD which resulted in the following: Ham 140.4 degrees Fahrenheit (F) Peas/corn 126.5 degrees F Mandarin oranges 54.8 degrees F Coffee 136.5 degrees F At 12:28 PM, the dietary aide left the kitchen with the 4th floor [NAME] wing lunch trays. At 12:31 PM, two surveyors arrived on the 4th floor [NAME] wing with the test tray and the FSD. At 12:36 PM, the last resident tray was served and the surveyors observed the FSD take the following food temperatures: Ham 125.4 degrees F Peas/corn 105.5 degrees F Mandarin oranges 57.6 degrees F Coffee 128.6 degrees F At that time, Surveyor #2 interviewed the FSD regarding what the appropriate food temperatures should be when the food was served. The FSD stated the hot foods should be at least 130 degrees, Pinnacle says 125-130 degrees and the cold foods should be at least 38 degrees or lower. The FSD further stated that it was important to serve food at correct temperatures to prevent food borne illness. Review of the facility's Hot Food Policy, dated 6/3/2013, revealed Procedure: 3. Any food item not meeting the proper temperature will be reheated or quick chilled in the freezer to reach required temperature. 7.d. Hot food should be at 135 degrees F or above at the time food is served to the residents. Review of the facility's Cold Food Policy, dated 6/3/2013, revealed Policy: Kitchen will receive and deliver cold foods to residents at a temperature of 41 degrees Fahrenheit or lower. Procedure: 6. Food will be delivered to resident at a temperature of 41 degrees Fahrenheit or lower. NJAC 8:39-17.4 (a)

2. According to the facility's admission Record, Resident #682 was admitted to the facility in 01/2022 with diagnoses which included but were not limited to: Pneumonia (a lung infection which can cause shortness of breath (SOB)). Review of a Quarterly Minimum Data Set (MDS), an assessment tool dated 01/20/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident's cognition was intact. Review of the resident's Order Summary Report revealed an order dated 1/26/2022 for Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 ml inhale orally via nebulizer every 6 hours for SOB for 30 days. A nebulizer machine delivers aerosol medication to the person via a mouthpiece and chamber/cup that holds the medication, via tubing that is attached to the machine. It is used to treat respiratory conditions such as Pneumonia. Review of Resident #682's January 2022 Medication Administration Record (MAR) reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/ML 3 ml inhale orally via nebulizer every 8 hours was documented as administered from 01/15/2022 until 01/23/2022 and Albuterol Sulfate Nebulization Solution (2.5 MG/3 ML) 0.083% 3 ml inhale orally via nebulizer every 6 hours was documented as administered from 01/19/2022 until 01/26/2022. On 01/24/2022 at 1:03 PM, during the initial tour of the fifth floor, Surveyor #2 observed a nebulizer machine on a side table in Resident #682's room. The nebulizer mouthpiece with connected medication cup and tubing were exposed and resting in the top drawer of the side table with the tubing connected to the nebulizer machine. The resident stated that he put the nebulizer in the drawer when he was finished. On 01/26/2022 at 1:18 PM, Surveyor #2 observed a nebulizer machine on the resident's side table. The nebulizer mouthpiece with connected wet medication cup and tubing were exposed and resting in the top drawer of the side table with the tubing connected to the nebulizer machine. On 01/26/22 at 1:28 PM, the Licensed Practical Nurse (LPN) accompanied Surveyor #2 to Resident #682's room. The nurse acknowledged the nebulizer mouthpiece with connected medication cup and tubing were exposed and resting in the top drawer of the side table with the tubing connected to the nebulizer machine. The LPN stated that the mouthpiece should not be stored like that and that it should be stored in a bag. She further stated the mouthpiece should be cleaned before use then stored in a bag marked with the date to prevent bacterial growth that could cause infection. The LPN removed the mouthpiece, medication cup and tubing from the room and threw it in the trash. During an interview with Surveyor #2 on 01/26/2022 at 1:37 PM, the Director of Nursing (DON) was made aware of Resident #682's nebulizer mouthpiece with connected medication cup and tubing that were resting in the top drawer of the side table. The DON acknowledged that the nebulizer mouthpiece should not be stored that way and stated that after each use the mouthpiece should be washed with soap and water, dried with a paper towel and stored in a plastic bag marked with the date to prevent infection. Review of the facility's policy Nebulizer Treatment, with a revision date of 08/2021, revealed Policy and Procedure 17. When treatment is complete, turn off the nebulizer, remove the mask, disconnect the T-piece, mouthpiece, and medication cup. 19. Rinse and disinfect the nebulizer equipment according to manufacturer's recommendations or wash the pieces (except tubing) with warm water after each use. Allow the components to air dry completely on a paper towel. 21. When equipment is completely dry, store in a plastic bag marked with the resident's name and the date. NJAC 8:39-15.1(a), NJAC 8:39-19.4 Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure infection control practices were implemented in accordance with facility policy and accepted national standards to prevent the possible spread of infection by failing to: a) properly don (put on) and doff (take off) personal protective equipment (PPE) and b) perform hand hygiene after glove removal for 1 of 3 residents reviewed for transmission-based precautions (Resident #132) and c) ensure respiratory equipment was kept in a clean and sanitary condition, and stored properly for 1 of 2 residents reviewed for respiratory equipment (Resident #692). This deficient practice was evidenced by the following: 1. During the initial tour of the facility on 01/24/22 at 11:22 AM, the surveyor observed a clear plastic, three-drawer storage unit which housed Personal Protective Equipment (PPE) (garments or equipment used to protect the body from injury or infection) outside of Resident #132's room. There was no signage posted on the outside of the resident's door or door frame to detail required usage. At that time, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that both a gown and gloves were required to enter the resident's room as the resident was on contact isolation (measures used to prevent transmission of infectious agents spread by direct or indirect contact with the resident or resident's environment) for ESBL (Extended-spectrum beta-lactamase) (enzyme found in some strains of bacteria that are resistant to most beta-lactam antibiotics (penicillin's, cephalosporins, and monobactam aztreonam) in the urine. At 11:23 AM, the surveyor observed a physician who wore a face mask and a lab coat over her clothing outside of Resident #132's room. The surveyor greeted the physician who identified herself as a Podiatrist before she entered the resident's room and closed the door behind her. At 11:25 AM, the surveyor knocked on Resident #132's door. When the surveyor opened the door, the Podiatrist was observed at the foot of the resident's bed and the resident's feet were exposed. The surveyor observed that the Podiatrist wore gloves but did not wear a gown as required. When interviewed, she stated that it was her first time at the facility. She stated that when she arrived at the unit she checked in with the nurse at the desk. She stated that she sanitized her hands and wore gloves as she was here to cut the resident's toe nails. She stated that no one told her that the resident was on precautions or that a gown was required to enter the resident's room. The Podiatrist stepped out of the resident's room into the hallway and failed to doff her gloves beforehand. She then answered her cell phone with her gloved hands. When interviewed, she stated, I can put a gown on if you want me to. She opened the bottom drawer of the isolation cart with her gloved right hand which was empty. She then opened the middle drawer and removed a disposable isolation gown which she then donned. The Podiatrist did not doff her gloves and apply a clean pair before she returned to the resident's room and closed the door behind her. At 11:27 AM, the surveyor observed the Podiatrist as she exited Resident 132's room and wore a disposable isolation gown and gloves out into the hallway. A facility Certified Nursing Assistant (CNA) observed that the Podiatrist failed to doff the gown and gloves when she exited the resident's room and instructed her to return to the resident's room to both doff and dispose of the gown and gloves in the trash can that was within the resident's room. The Podiatrist doffed both the gown and gloves as instructed. She exited the resident's room and utilized alcohol-based hand rub (ABHR) that was available on top of the isolation cart and performed hand hygiene before she went to see another resident. The surveyor then visually inspected the isolation cart and noted that there was a canister of disinfectant wipes and a bottle of ABHR that was placed directly on top of cautionary signage related to PPE requirements needed to enter the resident's room which was obstructed from view and only the word STOP was visible. During an interview with the surveyor on 01/24/22 at 12:20 PM, the Registered Nurse Unit Manager (RN/UM) stated that when the Podiatrist arrived at the unit, she furnished her with a list of residents that needed to be seen but did not speak with her as she was assigned to the medication cart and administered medications at that time. She stated that both a gown and gloves were required to be worn into the resident's room when care was rendered as the resident was on contact isolation for ESBL. She further stated that the resident required intravenous (IV) antibiotics to treat the infection and was scheduled to have a midline catheter (a special type of catheter inserted in a major vein for a period of weeks for medication administration) placed today for IV antibiotic administration. The Infusion Nurse arrived at that time and the RN/UM advised him to donn a gown and gloves before he entered the resident's room to insert the midline catheter as Resident #132 was on Contact Precautions. The surveyor reviewed the Electronic Health Record (EHR) which contained laboratory results and indicated that on 1/23/22 at 11:47 AM, the RN/UM was notified that Resident #132 was ESBL positive and Contact Precautions were indicated. On 01/26/22 at 10:15 AM, the surveyor observed a sign posted on the outside of Resident #132's room, directly below the resident's name plate, which cautioned the following: STOP, Contact Precautions, Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person . During an interview with the surveyor on 01/28/22 at 9:53 AM, the LPN stated that when she went to work on 01/24/22, the isolation cart was already set up outside of Resident #132's room. She stated that there should have been a sign hung on the outside of the resident's door that informed if someone went into the room, they must wear a gown and proper protective equipment to prevent the spread of infection. She stated that the signage was required, and they must not have gotten around to hanging one up yet at that time. The LPN further stated that the Podiatrist should have spoken with the nurse before she entered the resident's room. During an interview with the surveyor on 01/28/22 at 10:40 AM, the Assistant Director of Nursing/Infection Control Nurse (ADON/ICN) stated that once ESBL was identified an isolation cart should be placed outside of the resident's room and a sign should have been visible and hung on the resident's door immediately to make sure that everyone knew to see the nurse first before they entered the resident's room. She stated that the Podiatrist was required to perform hand hygiene and donn both a gown and gloves before she entered the resident's room. She further stated that she was required to doff all PPE and perform hand hygiene before she left the resident's room to prevent the spread of infection. Review of Resident #132's Care Plan revealed an entry dated 01/24/22, which detailed that the resident required contact isolation related to urinary infection and included the following interventions: Place sign See nurse prior to entering on door, Dispose of all soiled products/garments per facility policy, Wash hands appropriately before/after caring for resident, donning/removing gloves to prevent spread of infection. On 01/28/22 at 11:30 AM, the surveyor reviewed the facility policy, Transmission Precautions-Contact (Reviewed 12/2021) which revealed the following: Policy: To provide guidance on when to implement contact precautions. The facility is committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infections. Procedure: .Gloves and hand washing: Wear clean, non-sterile gloves when entering the room .Remove gloves and discard properly before leaving the room and wash hands immediately with an antimicrobial agent. After removing gloves and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the resident's room. This will help to avoid transfer of microorganisms to other residents or environments. Gowns: Wear a clean, non-sterile gown upon entering the resident's room if you anticipate substantial contact between your clothing and the resident, environmental surfaces, or any items in the room .Remove the gown before leaving the resident's room. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other residents or surfaces. General Information: Direct contact with the resident includes hand or skin-to-skin contact that occurs when performing resident care activities that require touching the resident's dry skin.

Based on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) failed to maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 01/24/22 from 09:54 AM -11:55 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. The foot pedal trash can at handwashing sink #1 was not lined with a trash bag and both trash and debris were observed in the can. The FSD acknowledged the debris and stated they usually leave it like that as they empty it every day. The FSD stated they would put a bag in the can. 2. The cook prepping chopped turkey for lunch wearing a hairnet on the hair bun on top of her head leaving the bottom of her head exposed. The cook acknowledged the hairnet was not worn correctly and stated it should cover the whole head so no hair gets in the food. During and interview with the FSD at that time, he stated that hairnets should be worn over the whole head so no hair gets in the food. 3. In the walk-in refrigerator were four individual 17 ounce tofu packages with no received date and no expiration dates on the packages. 4. On the bottom shelf of a metal tiered food cart there was one box containing 10 pounds of ground chuck with no received by date and no use by date. The FSD stated it came in today and put a received sticker on it. 5. In the walk-in freezer, on the bottom shelf of a metal rack, there was one large plastic bag of frozen pink meat the FSD identified as ground beef with several tears in the bag with the meat exposed. The bag had no label and no dates. The FSD stated the bag should not be ripped and should have a label and threw the meat in the trash. 6. The FSD then walked to handwashing sink #2 to wash his hands. The surveyor observed the FSD wet his hands, lather his hands with soap, then rinse his hands with the whole process totaling 13 seconds. The FSD acknowledged he should have washed his hands for 20 seconds to remove bacteria and germs. 7. In the walk-in freezer, on the bottom shelf of a metal rack, there was a sealed bag of frozen dark red meat the FSD identified as beef cubes with no label and no dates. The FSD acknowledged there was no label or dates on the bag. The FSD stated that the meat was taken out of a box that was labeled and dated, that it came in a week ago, and that the staff should have left it in the box. The FSD put a dated sticker on the bag. 8. Resting on a large sheet pan was a clear plastic bag with frozen white dough that the FSD identified as pizza crusts. The bag was open and the crusts were exposed to air. The bag had a received sticker dated 1/19/22 and the FSD stated they were good for 30 days. 9. There were two sealed bags of frozen dark brown pieces of meat with no labels and no dates. The FSD identified them as spicy chicken tenders. There was one opened bag of dark brown pieces of meat the FSD identified as spicy chicken tenders. The bag was wrapped in clear plastic wrap and dated use by 12/9/21. The FSD stated it was the wrong date and that it should have been marked with the received by date. The FSD further stated that it was important to date food correctly so that residents were not served spoiled food. At 10:45 AM the Regional FSD (RFSD) joined the kitchen tour. During an interview with the surveyor at that time, the RFSD acknowledged the three bags of spicy chicken tenders that had no labels or dates and stated the bags should have a label identifying what the product was and that it should have had a received date and an open date. The RFSD further stated that the chicken would be thrown away. 11. There was one opened clear plastic bag of frozen light pink meat labeled tilapia that was wrapped with clear plastic wrap with the meat exposed. There was a sticker marked Healthshake use by 1/27/22. The RFSD acknowledged the open bag, stated it should have been wrapped correctly, removed the bag from the freezer, and stated it would be discarded. 12. There was one box labeled French fries with the inner clear plastic bag unsealed and opened with the French fries exposed. The FSD acknowledged the bag should not have been opened and stated that it should have been rolled up. 13. On the spice rack were one opened 3 ounce jar parsley flakes with no expiration, received or opened dates and one opened 5 ounce jar dill weed dated 11/25/20 with the expiration date marked 3/25/21. The RFSD acknowledged there were no dates on the parsley and that the dill weed was expired. The RFSD threw the spices away. 14. In the dry storage room on the can rack was one dented 6 pound can of mandarin oranges. The RFSD acknowledged the can should not have been there and moved it to the dented can section. 15. There was one opened 16 ounce jar of garlic powder with no expiration date and no opened date and one opened 3 ounce jar of parsley flakes with no expiration date and no opened date. The RFSD acknowledged there were no dates and stated that when something was received it should have been dated. 16. There was one bag of egg noodles opened with the noodles visible and exposed to air. 17. There was one box labeled lemon sugar free cookies with the inner clear plastic bag opened with the cookies exposed to air. 18. There was one box containing an opened bag of vanilla instant pudding wrapped in clear plastic wrap with the plastic wrap open and the pudding exposed to air. During an interview at that time, the RFSD stated that the egg noodles, lemon cookies, and vanilla pudding mix should not be exposed to air and should have been thrown away. 19. In the cooking area was one large covered white bin with contents the RFSD identified as rice and one large covered white bin with contents the RFSD identified as flour with no labels or dates on the bins. The RFSD stated they should be labeled and dated. 20. The foot pedal trash can at handwashing sink #3 was not lined with a trash bag and both trash and debris were observed in the can. The RFSD acknowledged the debris and stated that there should be a bag in the can. 21. On the third shelf on a metal rack in the drying area of the dish room was a white cutting board with brown gauges and black smudges. The FSD stated they were from use and that they use the other side of the board. 22. On an epoxy coated rack there were hotel pans wet nested. The FSD acknowledged the wetness and stated that the pans should not be wet in the dry area. The FSD further stated it was important that stagnant water not get into the food and that the pans would be sanitized. 23. On 01/24/22 at 11:50 AM, the surveyor observed the stock person loading dry plate lids onto the food line. The stock person was wearing a beard cover with facial hair exposed around the cover. The stock person stated the purpose of a beard cover was to not have hair show and that his beard should have been totally covered to prevent hair from getting on the dishes. 24. On 01/24/22 at 11:52 AM, the surveyor observed the starter on the food line setting up meal trays with utensils, hot plates, and condiments. The starter was wearing a beard cover with facial hair exposed around the cover. The starter stated the beard cover should be covering all of his facial hair for safety, hygiene and to prevent hair from getting into the food. 25. On 01/25/22 at 12:08 PM, on the second shelf of a metal table under the coffee area, the surveyor observed a pile of large coffee filters exposed to air. The FSD acknowledged the coffee filters and stated the filters should have been inside a bag. The FSD placed the filters in a clear plastic bag. 26. On 01/27/22 at 12:04 PM, the surveyor observed a dietary aide (DA) opening six large cans of apples for preparation of making cinnamon apple desserts. The DA was wearing a baseball hat with her hair in a bun outside of the hat with no hairnet worn. The DA acknowledged her hair was not covered with a hairnet and stated that she wasn't sure she had to wear a hairnet because she wore a hat. The DA further stated it was important to cover all hair so hair would not get in the food. Review of facility's Handwashing Policy, with a revision date of 2/14/2017, revealed Procedure: .Lather hands and wrists with soap for 20 seconds. Review of facility's Personal Hygiene Policy, with a revision date of 6/3/2013, revealed Procedure: 3. Cover all hair and facial hair with a restraint (hairnet, cap or hat). Review of facility's Receivable and Storage Policy, with a revision date of 6/3/2013 revealed Procedure: 11. Ensure that all foods are securely covered, dated, and labeled. Review of the facility's Dating and Labeling Policy, with a revision date of 4/2019, revealed Policy: Kitchen will assure food safety by maintaining proper dates and labels to all ready to eat food products. Procedure: 2. Label products in storage with date the package was opened or expiration date with no more than 48 hours after opening, whichever is appropriate. 3. Label all dry goods with date received. 4. Use the Pinnacle address label and dating and labeling system to date all items. 8. Discard all foods that expire immediately. Review of the facility's Dry Foods Policy, with a revision date of 6/3/2013, revealed Procedure: 4. Keep products in original packaging or in tightly covered, clearly labeled containers. Review of the facility's Dented Can Policy, with a revision date of 6/3/2013, revealed Policy: Account Manager or designee will identify cans with dents on the top or bottom lip of the can as well as any dents appearing on the vertical seam of the can .Procedure: 2. Purchasing Officer will verify that the Facility has followed the Dented Can Policy and that all cans have been labeled with the current date/vendor and cans have been placed on the appropriate shelf labeled Dented Cans. Review of the facility's Pot Washing Policy, with a revision date of 2/14/2017, revealed Procedure: 10. Air dry all clean and sanitized pots and wares (place in angles at least 20 degrees -30 degrees). Do not wipe dry. Do not stack. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview on 10/23/20, in the presence of facility Maintenance Director and Regional Plant Operation Director, it was determined that the facility failed to ensure that handrails were installed where required and free from sharp edges that could cause injury. This deficient practice is evidenced by the following: 1. At 10:30 A.M., the surveyor observed a missing handrail corner cover, exposing a sharp metal edge, by resident rooms [ROOM NUMBERS]. 2. At 10:40 A.M., the surveyor observed a missing handrail corner cover, exposing a sharp metal edge, by elevator #2. 3. At 10:42 A.M., the surveyor observed a missing 3 foot section of handrail between elevators 1 and 3. The surveyor interviewed the Maintenance Director during the observation. The Maintenance Director acknowledged the surveyor's findings, and stated that the corners for the handrails needed to be repaired to cover the sharp metal edges and the section missing by the elevators had to be replaced. The Administrator was informed of this finding at the Life Safety Code exit conference. NJAC 8:39-31.2(e)