**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 2 of 21 residents reviewed for the accommodation of needs (Resident #8 and #11), and was evidenced by the following: On 12/2/24 at 11:00 AM, the surveyor observed the door to room [ROOM NUMBER] was closed. The surveyor heard someone from 232 calling out for assistance. The surveyor knocked and with permission entered the room. The surveyor observed Resident #8 in their room seated in a wheelchair to the left of the bed. The surveyor observed that the resident's call bell (used to summon staff for assistance) was affixed to the right enabler, not within his/her reach. On 12/3/24 at 9:30 AM, the surveyor observed Resident #8 seated in a wheelchair to the left of the bed. The surveyor observed that the resident's call bell was affixed to the right enabler, not within his/her reach. On 12/4/24 at 8:40 AM, the surveyor observed Resident #8 seated in a wheelchair to the left of the bed. The surveyor observed that the resident's call bell was affixed to the right enabler, not within his/her reach. The surveyor reviewed the medical record for Resident #8. A review of Resident #8's admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure, diabetes mellitus, and hypertension. A review of Resident #8's quarterly Minimum Data Set, (MDS), an assessment tool dated 9/8/24 revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated a moderately impaired cognition. The MDS further assessed that the resident required maximum assistance from staff for Activities of Daily Living (ADL) care. A review of Resident 8's Individualized Care Plan (CP) included a focus that indicated the resident had an ADL self-care performance deficit with an intervention that included but was not limited to Encouraging the resident to use the bell to call for assistance. On 12/2/24 at 11:19 AM, the surveyor and Certified Nursing Assistant (CNA #1) assigned to Resident #8's care that day, entered the resident's room and observed the resident seated in a wheelchair to the left of the bed and the call bell affixed to the right enabler, not within the resident's reach. CNA #1 acknowledged that she should have placed the call bell within the resident's reach. On 12/4/24 at 9:25 AM, the surveyor and CNA #2 assigned to Resident #8's care on 12/3/24 and 12/4/24 (7am-3:00 pm shift) entered the resident's room and observed the resident seated in a wheelchair to the left side of the bed with the call bell was affixed to the right enabler, not within the resident's reach. CNA #2 stated that he should have ensured the resident's call bell was within the resident's reach when he made his rounds each morning. On 12/2/24 at 11:38 AM, the surveyor observed Resident #11 in bed on a specialty mattress with the call bell on the floor under the resident's bed. The resident did not respond to the surveyor's greeting. The surveyor reviewed the medical record for Resident #11. A review of the admission Record reflected Resident #11 was admitted to the facility with diagnoses that included but were not limited to hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body) and dementia. A review of Resident #11's quarterly MDS dated [DATE] reflected Resident #11 had a BIMS score of 5 out of 15 which indicated a severe cognitive impairment. The MDS further assessed that Resident #11 was dependent on staff for ADL care. A review of Resident #11's CP revealed a focus area that indicated the resident has an ADL self-care performance deficit related to a cerebral vascular accident (CVA) with interventions that included encourage the resident to use the call bell for assistance. On 12/2/24 at 12:00 PM, the surveyor and CNA #3 entered resident #11's room. CNA #3 confirmed that the call bell should not be on the floor and acknowledged that all call bells should be placed within the resident's reach. A review of the facility's Call System policy and procedure indicated .residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation . On 12/4/24 at 1:33 PM, the surveyor discussed the above observations and concerns with the Administration. The Licensed Nursing Home Administrator confirmed that the call bells should be placed within the residents' reach. NJAC 8:39- 31.8 (c)(9)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) blood pressure apparatus was utilized in accordance with the manufacturer's specifications, b.) an antibiotic treatment was administered as ordered by the physician, and in accordance with professional standards of practice. This deficient practice was observed during the medication pass observation of 1 of 5 nurses who administered to 1 of 6 residents (Resident #20) and identified for 1 of 1 resident investigated for abuse (Resident # 16). The evidence was as follows: 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. Reference: According to the manufacturer's specifications of the (brand name redacted) a blood pressure monitor machine, under measurement and procedure included the following: Wrap the cuff around upper left arm. Rubber tube should be on the inside of the extending arm. Ensure the cuff lies ½ to ¾ inches above the elbow. 2 fingers should fit between the arm and the cuff . Refer F759 1.) On 12/4/24 at 9:52 AM, the surveyor observed Licensed Practical Nurse (LPN #1) who asked Resident #20, if she can take their blood pressure (BP). Resident #20 was agreeable and informed the surveyor and LPN #1 that they felt shaky. At 9:53 AM, the surveyor observed LPN #1 place the BP cuff on the resident's left forearm (part of the arm extending from the elbow to the wrist or the fingertips), the rubber tube was on the outside of the extending arm. An error reading resulted. At that time, LPN #1 informed the surveyor that she used the same machine around 8 something, that morning for the same resident and received a reading. At 9:56 AM, the surveyor observed LPN #1 retake the BP on the same location, without an adjustment made to the BP cuff, and the rubber tube. LPN #1 received an error reading. At 9:57 AM, the surveyor observed LPN #1 place the BP cuff onto Resident #20's right forearm, the rubber tube was on the outside of the extended arm. LPN #1 received an error reading. At 9:58 AM, the surveyor observed LPN #1 place the BP cuff on the resident's left wrist. LPN #1 received an error reading. At 10:00 AM the Registered Nurse/Unit Manager (RN/UM) entered the room and observed LPN #1 take Resident #20's BP reading. At 10:01 AM, the surveyor and the RN/UM observed LPN #1 place the BP cuff onto Resident #20's left forearm, the rubber tube was on the outside of the extended arm. LPN #1 received an error reading. The surveyor asked LPN #1 if she had another machine in her cart. At that time, LPN #1 stated that she had only one machine which is the one she used with Resident #20. The RN/UM left the room to obtain another BP machine. At 10:04 AM, the surveyor observed RN/UM walking with another BP machine toward Resident #20's room. At that time, during an interview with the surveyor, the RN/UM stated that LPN #1 placed the cuff too loose, the ciff was at the wrong location, and that the rubber cord should have been on the inside of the extended arm. The RN/UM stated that she would provide education to LPN #1, on how to properly use the BP monitor device. On 12/4/24 at 10:49 AM, during an interview with the Director of Nursing, the surveyor discussed the concern with LPN #1's incorrect technique while using the BP device. On 12/4/24 at 1:33 PM, in the presence of the survey team, [NAME] President of Clinical Services, the Licensed Nursing Home Administrator, the Director of Nursing, the surveyor discussed the concerns regarding the incorrect technique used by LPN #1 while using the device for Resident #20 who had a physician ordered medication that had a BP parameter, prior to administration. No further information was provided. 2.) On 12/5/34 at 9:48 AM, the surveyor observed Resident #16 laying on their left side towards the side rail. Resident #16 stated that sometime in November a physician ordered Gentamycin (antibiotic used to treat bacterial infections) for their wound and there was a day or two, it was not administered. On 12/5/24 at 10:29 AM during an interview with the surveyor, LPN #2 stated that the pharmacy delivered the medications sometime between the 7:00 AM to 3:00 PM shift and sometime between the 3:00 PM to 11:00 PM shift; if an item was missing from the orders, the nursing staff called the pharmacy, and requested for the item to be delivered. The facility also had a stat (immediate) order available which arrived withing 4 hours. LPN #2 also stated that the nursing staff communicated with the pharmacy through a tablet and the estimated time of arrival of the medication would be communicated back to the nurses from the pharmacy, through the same tablet. The surveyor reviewed the medical record for Resident #16. According to the admission Record face sheet, an admission summary, reflected that Resident #16 was admitted to the facility with diagnoses that included: morbid obesity, and type 2 diabetes mellitus. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 9/13/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Further review of the MDS reflected that the resident had a stage 4 pressure ulcer/injury that was present upon admission with treatments that included applications of ointment medication. A review of the individualized comprehensive care plan included a focus of Resident #16's stage 4 pressure ulcer on the right trochanteric area (outside part of the hip) which was present during admission. The interventions included administer treatment as ordered and monitor for effectiveness. On 12/5/24 at 10:47 AM, the surveyor and the Registered Nurse/Unit Manager (RN/UM) reviewed the Order Audit Report together which reflected an order for Gentamicin Cream, to be applied to the right trochanter wound topically once a day for infected right trochanter wound for 10 days that was ordered by the physician on 10/31/24. The order was confirmed to be started on 11/1/24. The order supply summary reflected that the medication was on hand (in stock) on 11/1/24. The surveyor and the RN/UM reviewed the electronic Medication Administration Record (eMAR) for November 2024, which reflected that the doses on 11/1/24 and 11/10/24 were not administered. A review of the nurses' progress notes did not reflect that the physician, the wound physician, or the infectious disease consultant were notified of the missed doses and a request for a later administration time was also not found. A review of the packing slip reflected the pharmacy delivered the medication on 11/ 1/ 24, a replenishment was sent on 11/5/24 and another replenishment was sent on 11/10/24. A review of the 11/21/24 surgical note documented by the physician on 11/21/24 reflected that the resident's wound was stable and required continued topical wound dressing therapy. On 12/5/24 at 12:06 PM, the surveyor discussed with the DON the concern regarding the two doses of Gentamicin that was not administered to Resident # 16, and the failure of the nursing staff to ensure the resident's physicians were informed of the two missed doses. On 12/9/24 at 10:53 AM, in the presence of the survey team, the Director of Nursing stated that the facility policy did not require for the physician to be contacted unless two consecutive doses were missed which included antibiotics. The DON acknowledged that the physician order was for the administration of Gentamicin for 10 days and only 8 doses were administered. The DON could not provide evidence that the physicians were aware of the missed doses. At that time, the DON agreed that it was not the standard of practice for a physician not to be informed when the course of therapy ordered was not followed. A review of the provided facility policy, Medication Administration, dated 5/1/24, included the following under documentation: if a dose of regularly scheduled medication is withheld refused or given at other than the scheduled time . The administering person will document in the MAR an explanatory note is entered in the progress note. If two consecutive doses of a vital medication are withheld or refused the physician is notified. NJAC 8:39-11.2(b), 27.1(a)(b)

Complaint NJ#175927 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that incontinence care was provided to a dependent resident for 1 of 4 residents reviewed for incontinence care (Resident #71) on 1 of 2 nursing units, 2nd-floor unit. This deficient practice was evidenced by the following: On 12/2/24 at 11:00 AM, the surveyor observed Resident #71 in the bathroom seated in a wheelchair. The surveyor observed the resident exposed their incontinence brief. The surveyor observed two incontinence briefs were in place, both saturated with urine. At that time, the Hospitality Aide who was in Resident #71's room, stated that she was not assigned to provide direct care and left to summon the Certified Nursing Assistant (CNA) assigned to Resident #71's care. On 12/2/24 at 11:13 AM, the CNA entered Resident 71's room. The CNA observed the resident's two incontinence briefs were saturated with urine. The CNA stated that she had 12 Residents on her assignment and therefore had not provided any care for Resident 71 that morning. The CNA confirmed that double diapers were unacceptable. The surveyor reviewed the medical record for Resident #71. A review of the admission Record reflected the resident was admitted to the facility with diagnoses that included chronic kidney disease, fracture of the right femur (break in the thigh bone), and hypertension. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 9/26/24 reflected Resident #71 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated a severe cognitive impairment. Further review indicated Resident #71 required supervision with toileting and was frequently incontinent of urine. A review of the resident's Individual Care Plan (CP) revealed no care plans that addressed Resident #71's incontinence care. A review of the facility's Incontinent Care policy dated 5/1/24 included .the purpose is to provide consistent, compassionate, and effective care for residents with incontinence, ensuring dignity, comfort, and prevention of complications such as skin breakdown or infections .develop and document a care plan tailored to each resident's needs .staff must check and change incontinence products as needed, following the resident's care plan and at least every 2-4 hours or when soiled . On 12/4/24 at 1:33 PM, the survey team met with the Administration to discuss the above observations and concerns. The Director of Nursing (DON) acknowledged that two incontinence briefs should not be used unless requested by the resident due to the risk of skin breakdown. The DON confirmed that the CP for incontinence care and the resident preference for the use of two incontinence briefs had not been initiated until 12/2/24 after the surveyor's inquiry. NJAC 8:39-27.1(a), 27.2(h)

Based on observation, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication pass on 12/4/24, the surveyor observed five (5) nurses administer medications to six (6) residents. There were 26 opportunities and two (2) errors observed which calculated to a medication administration error rate of 7.6 %. The deficient practice was identified for 2 of 5 nurses for 2 of 6 residents, (Resident #97 and #20) as evidenced by the following: 1. On 12/4/24 at 08:46AM, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare medications for Resident #97. The medications included a physician's order for Sennosides - Docusate sodium 8.6 milligram (mg) - 50 mg (Senna Plus), 1 tablet by mouth every 12 hours for constipation with an order date of 10/28/24. At 8:51 AM, the surveyor observed LPN #1 pour one (1) tablet of Sennoside (Senna) 8.6 mg into a medication cup for administration to Resident #97. LPN #1 informed the surveyor that the container of Sennoside 8.6 mg was a house stock (facility supply) bottle. At 8:54 AM, the LPN #1 confirmed with the surveyor that she was ready to administer the resident's medication and walked toward the resident's room threshold. At 8:55 AM, the surveyor stopped the medication pass observation at the resident's room threshold and asked LPN #1 to walk back to the med cart parked at the hallway. At 8:56 AM, the surveyor and the LPN #1 reviewed the electronic Medication Administration Record (eMAR) against the house stock bottle from which the Sennoside 8.6 mg was poured from. At 8:58 AM, LPN #1 confirmed and acknowledged that she had poured the wrong drug and recognized the physician order was for Sennoside -Docusate sodium 8.6 - 50mg as opposed to the poured medication of Sennoside 8.6 mg. 2. On 12/4/24 at 9:37 AM, the surveyor observed LPN #2 prepare medications for Resident #20. The medications included a physician's order for Amlodipine 10 mg, 1 tablet by mouth one time a day for hypertension; hold for systolic blood pressure less than 110. At 9:40 AM, LPN #2 took out a small notebook that reflected the resident's room number and blood pressure (BP). LPN #2 entered the BP values from the notebook into the eMAR. At 9:48 AM, LPN #2 confirmed with the surveyor that she was ready to administer the resident's medication and walked toward the resident's room threshold. At that time, the surveyor stopped the medication pass observation at the resident's room threshold and asked LPN #1 to walk back to the med cart parked at the hallway. At 9:50 AM, during an interview with the surveyor, LPN #2 stated that she had taken Resident #20's blood pressure around 8 something that morning. At that time, LPN #2 acknowledged that the blood pressure should have been taken immediately before the administration of the Losartan in accordance with the physician's order. On 12/4/24 at 10:49 AM, during an interview with the Director of Nursing, the surveyor discussed the concerns regarding the medication pass observation. On 12/4/24 at 1:33 PM, in the presence of the survey team, [NAME] President of Clinical Services, the Licensed Nursing Home Administrator, the Director of Nursing, the surveyor discussed the concerns regarding the incorrect medication poured for administration for Resident #97 and the concern regarding the blood pressure that was not taken prior to administration in accordance with the physicians' order for Resident #20. A review of the provided facility policy, Medication Administration, dated 5/1/24, included: Medications are administered as prescribed in accordance with good nursing principles and practice. NJAC 8:39-11.2(b), 29.2(d)

Based on the interview and record review, it was determined that the facility failed electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment for 5 of 25 residents, (Resident #103, #92, #31, #76, and #107) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. Resident #103 was observed to have a Death MDS of 4/02/23 and was due to be transmitted no later than 4/16/23. The Death MDS was not transmitted until 4/28/23. 2. Resident #92 was observed to have an Entry MDS of 4/05/23 and was due to be transmitted no later than 4/20/23. The Death MDS was not transmitted until 4/28/23. 3. Resident #31 was observed to have an admission MDS of 3/31/23 and was due to be transmitted no later than 4/14/23. The Death MDS was not transmitted until 4/15/23. 4. Resident #76 was observed to have an admission MDS of 4/05/23 and was due to be transmitted no later than 4/20/23. The Death MDS was not transmitted until 4/28/23. 09/14/23 09:47 AM, the surveyor interviewed the facility's Registered Nurse (RN) MDS Coordinator who was responsible for completing and transmitting the MDS assessments who agreed that the above MDS assessments were transmitted late due to transition of the system in April this year. 5. The surveyor reviewed the closed medical records for Resident #107. On 9/21/23 at 9:38 AM, the surveyor reviewed the Progress Notes which revealed that the resident was discharged to the hospital on 8/18/23. The surveyor then reviewed the MDS assessment submissions which revealed that there was no MDS submission of a discharge assessment completed. In addition, the electronic records indicated that the MDS discharge assesssment was 19 days overdue. On 9/20/23 at 1:04 PM, the survey team met with the LNHA and DON to review the MDS records for Resident #107. The DON stated that she would check with the MDS Coordinator. On 9/21/23 at 9:30 AM, the surveyor interviewed the DON who stated that the MDS discharge was completed for Resident #107. The DON provided the surveyor with a CMS Submission Report MDS 3.0 NH Final Validation Report which reflected that Resident #107's discharge MDS had a Target Date of 8/18/23 and the Record Submitted Late: Submission date is more than 14 days after. NJAC 8:39-11.1

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to accurately document the administration of physician ordered medications in the electronic administration record by one (1) of three (3) nurses observed administering medications. The deficient practice occurred for four (4) unsampled residents (#1, #2, #3, and #4). 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 deficiency was evidenced by the following: On 9/12/23 at 9:16 AM, the surveyors, observed the Licensed Practical Nursing (LPN) at the medication cart. The LPN stated that he had already prepared medications for a resident and was just about to go and administer the medications. The LPN then left the medication cart and entered a resident's room. On 9/12/23 at 9:22 AM, the Unit Manager (UM)/LPN approached the surveyors at the medication cart and stated that she was completing the medication pass because she had been helping the LPN that day. On 9/12/23 at approximately 9:22 AM to 9:54 AM the surveyors observed the morning medication pass with the UM/LPN. On 9/12/23 at 9:54 AM, at the medication cart, the surveyors interviewed the UM/LPN who stated that the morning medication pass was complete for that medication cart. The surveyors with the UM/LPN reviewed the electronic medication administration record (EMAR) which revealed resident's names highlighted in yellow and red. The UM/LPN explained that the resident's names highlighted in yellow meant that something was due. The UM/LPN further explained that the resident names in yellow still needed documentation to be completed for either a pain assessment or behavior monitoring which could be completed throughout the 7 AM to 3 PM shift but the morning medications had been administered. The UM/LPN then stated that the resident names in red meant that something was overdue. The UM/LPN could not speak to why four (4) resident names were highlighted in red on the EMAR. At that time, the surveyors, with the UM/LPN, reviewed the EMAR for the four (4) unsampled resident names that were highlighted in red. The UM/LPN acknowledged that the four (4) unsampled residents each had medications with an administration time of 8AM highlighted in red which meant that the 8AM medications were not administered and were out of the administration time which should have been administered one hour before 8 AM or one hour after 8 AM. In addition, the UM/LPN acknowledged that there were 9 AM medications that were highlighted in yellow which meant that those medications were due to be administered to the four unsampled residents. The UM/LPN stated that she was helping with the medication pass that morning because the LPN had a personal matter that he had to attend to that day. The UM/LPN stated that she would have to check with the LPN to see if the medications for the four unsampled residents were administered. On 9/12/23 at 9:57 AM, the surveyors, with the LPN and the UM/LPN, reviewed the EMARs for the four unsampled residents. The LPN stated that for unsampled resident #1 and #2, he had administered the 8AM and 9AM medications but had not signed the EMAR. The LPN then stated for unsampled residents #3 and #4, he had administered the 8AM medications but had not signed the EMAR. The LPN added that for unsampled residents #3 and #4 he had not yet administered the 9AM medications and was about to do that. The UM/LPN stated that the EMAR was to be signed immediately following administration of a medication and was unaware that there were still residents who had to have their 9AM medications administered. The UM/LPN and LPN acknowledged that by not signing the EMAR immediately following administration of medications could be interpreted by another nurse that the medications were not administered and could have been administered twice. The surveyor reviewed the medical records for unsampled residents #1, #2, #3 and #4. A review of the EMAR for unsampled resident #1 had one (1) medication, Aspirin 81 MG chewable tablet, with an administration time of 8AM and four (4) medications with an administration time of 9 AM; Timolol Maleate Ophthalmic solution 0.5%(an eye drop medication used for glaucoma), Sertraline (Zoloft)(an antidepressant medication) 75 MG, Quetiapine (Seroquel) (a medication used to treat a disorder of the mind) 25 MG and Tobradex Ophthalmic ointment (an antibiotic/steroid eye ointment). According to the LPN, the 8AM and 9AM medications were administered and were not signed on the EMAR. A review of the Order Summary Report (OSR) for unsampled resident #1 reflected physician's orders (PO) for the medications listed above. A review of the EMAR for the unsampled resident #2 had one (1) medication, Metoprolol Tartrate (Lopressor) (a medication used to lower blood pressor) 25 MG, with an administration time of 8AM and seven (7) medications withan administration time of 9 AM; Seroquel 25 MG, Hydrochlothiazide (a diuretic) 25 MG, Losartan (a medication used for high blood pressure) 100 MG, Senna (a laxative) 8.6 MG, Depakote (a medication used for seizures and disorders of the mind) 250 MG, Docusate Sodium (Colace) (a stool softener) 100 MG, and Levetiracetam (Keppra) (an anticonvulsant medication) 500 MG. According to the LPN, the 8AM and 9AM medications were administered and were not signed on the EMAR. A review of the OSR for unsampled resident #2 reflected PO for the medications listed above. A review of the EMAR for the unsampled resident #3 had two (2) medications, Metformin (Glucophage)(a medication used for high blood sugar) 500 MG and Metoprolol Tartrate (Lopressor) (a medication used for high blood pressure) 25 MG, with the administration time of 8AM. According to the LPN, the 8 AM medications were administered and were not signed on the EMAR as administered. A review of the OSR for unsampled resident #3 reflected PO for the medications listed above. A review of the EMAR for the unsampled resident #4 had one (1) medication, Metoprolol Tartrate 25 MG half tablet, with an administration time of 8AM. According to the LPN, the 8 AM medication was administered and was not signed on the EMAR as administered. A review of the OSR for unsampled resident #4 reflected PO for the medication listed above. On 9/12/23 at 11:45 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON stated that the LPN had a personal issue that day and the UM/LPN was helping to pass the medications so that there was no delay. The DON added that the UM/LPN should have coordinated with the LPN to know which residents still needed medications to be administered. The DON acknowledged that the EMAR should be documented immediately following the administration of medications to prevent any discrepancy. The DON stated that the UM/LPN was responsible for the medication pass because the LPN had a personal issue that day. A review of a Medication Administration Observation dated 5/13/23 for the LPN completed by the Consultant Pharmacist (CP) and provided by the DON reflected that the LPN had followed that Medications are documented as per regulation. And that Nurses's initials are present for each scheduled time of medication administration per documentation on MAR after medication is administered. The form indicated that the LPN had an accuracy rate of 100%. On 9/15/23 at 1:05 PM, the surveyor interviewed the CP via the telephone. The CP stated that she had completed a medication observation with LPN, and he had done well. The CP stated that the nurses were to sign the EMAR immediately after administration of medications. The CP added that if the EMAR was not signed there was the possibility of the nurses not knowing whether a medication was administered already and administering the medication again. The CP added that she had done in-services in the past for the nurses and used a handout with the medication pass techniques to follow. A review of the Administration of Medication forms provided by the CP that were used for an in service which reflected Sign the EMAR/MAR after the medication has been administered. On 9/18/23 at 10:45 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she educates the nurses on medication pass techniques, along with the CP and completes competencies. The ADON stated that the protocol for medication administration was that the nurses were to give and sign meaning that the nurses were to sign the EMAR immediately after administration of medications. The ADON acknowledged that if the nurses had not signed the EMAR after administration that could lead to discrepancies and possible double dosing. A review of a medication administration in-service dated 7/13/23 completed by the facility that the LPN had attended reflected that All nurses make sure that meds are given on time and must check name of resident, right dose, right time, right drug, right route and sign that given after meds taken. A facility policy dated 2/2023 for Medication Administration reflected that It is the policy of the facility to provide appropriate medication administration to residents to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with State and Federal regulation. In addition, the policy reflected that the procedure was Document medication taken or refused by resident. NJAC 8:39-11.2(b), 29.2 (a)(d)

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to sanitize and air-dry steam table pans and sheets pans in a manner to prevent microbial growth and c.) failed to maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 9/13/23 at 10:49 AM, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. In the dry storage area, the surveyor observed a random sampling of dented cans which were in rotation for use. The surveyor observed the following: - One #10 sized cans of diced pears with 2-inch sized dent on the upper lip of the can, - One #10 sized can of diced pears with 1-inch sized dent on the upper lip of the can, The FSD stated that these cans are in rotation for use and should not have dents. 2. In the food preparation area, on shelf, the surveyor observed two sheet pans stacked with soapy water between them. The FSD stated should not be soapy or stacked when wet and that they should be air dried before stacking. 3. In the food preparation area, the surveyor observed four of six burner stove tops were soiled with a thick grease-like buildup. The surveyor also observed that five oven knobs were soiled with a cream-colored food substance, and one of three convection knobs soiled with a cream colored substance. 4. In the food preparation area, the surveyor observed food storage containers. The surveyor observed a container of bread-crumbs and food thickener with no dates on the items. The surveyor also observed another container with white powdered substance which had no no label and no date. The FSD stated that was sugar but that it should have been labeled and dated. On 9/13/23 at 1:10 PM Discussed concerns in kitchen with Administrator and Director of Nursing. A review of the Air Drying policy, dated 1/2023 revealed, All items must be inverted after cleaning and sanitizing and air dry all items in designated station. NJAC 8:39-17.2(g)