Every finding on record at Aristacare at Parkside

Based on observation, interview, and review of facility policy, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 07/01/2026 from 9:14 AM until 9:50 AM, the surveyor observed the following in the kitchen in the presence of the Dietary Director (DD): 1. In the dessert refrigerator, there was a chef salad on a plate wrapped in clear plastic with no label and no date. The DD said yes it should have been labeled and dated. 2. In the dessert refrigerator, there was an opened jar of kosher dill pickles with an opened date of 05/25/2026. The DD said the pickles were good for one month after opening and she would discard them.3. In the dessert refrigerator, there was an opened container of barbecue sauce that was dated 05/25/2026. The DD said it was good for 3 weeks once opened and she would discard the container.4. In the dry storage room, there was an opened and used container of mustard. The DD said the mustard should have been refrigerated after it was opened and she would discard it. 5. In the walk-in freezer, there was a pan of frozen biscuits with no label and no date. The DD said the biscuits should be dated.A review of the facility provided policy titled, Dating and Labeling Policy, revised 01/24/2017 reflected: kitchen will assure food safety by maintaining proper dates and labels to all goods and ready to eat food products. 2. Label products in storage with the date the package was opened. 4. Ready-to-eat food must be dated with a 72-hour use by date and discarded when expired. 9. Follow use by dating guideline chart for all perishable foods. 10. Discard all foods that expire immediately.A review of the facility provided policy titled, Labeling and Dating System Protocol/Policy, revised 11/18/2019 reflected: all fresh and frozen foods must be dated with the date it was received in the kitchen unless it has a purveyor shipping label on it. Refrigerated items opened, mayo, garlic, dressings, salsa .30 days. NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide a safe, clean, and homelike environment for 3 of 5 shower rooms observed on 2 of 3 units reviewed under the Environmental Task. The deficient practice was evidenced by the following:On 07/01/2026 at 12:15 PM, during initial tour, the surveyor observed a drop-down ceiling tile that was peeling with large water stains and unknown black growth across three tiles on the shower stall ceiling in the third-floor B side shower room.On 07/01/2026 at 12:22 PM, during initial tour the surveyor observed a drop-down ceiling tile with a water mark and black growth in front of the second shower stall to the right in the A side shower room. On 07/02/2026 at 10:24 AM, the surveyor observed a drop-down ceiling tile with water stains and peeling in the ceiling above the sink in the second-floor A side shower room. On 07/07/2026 at 11:24 AM, during an interview with the surveyor, the Unit Manager (UM) stated there should not be any black growth in the resident shower rooms. The UM stated this was important for infection prevention. On 07/08/2026 at 9:50 AM, during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated that there should not be any black growth or water stains on the bathroom ceiling tiles. The LNHA stated this was important for infection prevention and safety. The LNHA responded, no when asked if this was considered a homelike environment. A review of the policy titled Homelike Environment revised 04/2026 revealed under the policy statement, : Residents are provided with a safe, clean, comfortable and homelike environment. The policy further revealed under policy interpretation and implementation, number 2, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. clean, sanitary and orderly environment. N.J.A.C. S 8:39-31.4 (a)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that an indwelling catheter (tube inserted into the bladder to drain urine) drainage bag was secured in a manner that provided privacy for 2 of 2 residents reviewed for a urinary catheter, (Resident #2 and Resident # 124). This deficient practice was evidenced by the following: During the initial tour of the unit on 07/01/2026 at 09:34 AM, Resident #2 was observed in bed with an indwelling catheter drainage bag hung on the bed frame visible from the hallway not in a privacy bag. The privacy bag was next to the drainage bag. A review of the most recent Annual Minimum Data Set (MDS), an assessment tool used to manage care dated 05/29/2026, revealed Resident #2 had an indwelling catheter. The MDS also revealed that Resident #2 was diagnosed with but not limited to neurogenic bladder (a neurological conditions or injuries that interfere with the nerves that control bladder function). During rounds on 07/06/2026 at 10:17 AM, the surveyor observed Resident # 124 in bed with an indwelling catheter drainage bag hung on the bed frame visible from the hallway and not in a privacy bag. A review of the most recent Annual Minimum Data Set (MDS), an assessment tool used to manage care dated 06/26/2026, revealed Resident #124 had an indwelling catheter. The MDS also revealed that Resident #124 was diagnosed with but not limited to quadriplegia (paralysis affecting all four limbs both the arms and the legs as well as the torso.) During an interview on 07/06/2026 at 10:39 AM, with the surveyor, the Licensed Practical Nurse #1 said that all indwelling catheters should be in a privacy bag. During an interview on 07/08/2026 at 9:51 AM, with the surveyor, the Director of Nursing and Licensed Nursing Home Administrator said that all indwelling catheters should be stored in privacy bags to ensure privacy for the residents. A review of a facility policy Resident Rights revealed under, Privacy and Confidential Treatment that, To have physical privacy. N.J.A.C. 8:39-19.4(a)

Based on observation, interview, and clinical record review, the facility failed to ensure that a resident who required respiratory care received services consistent with professional standards of practice. This deficient practice affected 1 of 5 residents reviewed for respiratory care (Resident #124).This deficient practice was evidenced by the following: On [DATE] at 09:46 AM, the surveyor observed Resident #124 in bed. Resident #124 was observed receiving oxygen via a tracheostomy (a surgically created opening in the windpipe which allows air to bypass the nose and mouth and enter the lungs). The surveyor did not observe an artificial manual breathing unit (AMBU) bag, (a hand-held bag valve mask used to deliver positive pressure ventilation to patients who are not breathing or are not breathing adequately). On the same date at 10:17 AM, the surveyors asked the second-floor Registered Nurse Unit Manager (RNUM) where the AMBU bag was located. The RNUM searched the room and could not locate one. The RNUM said we usually keep them in the drawers, but we have one on the crash cart. The surveyors and the RNUM went to the end of the hall where the crash cart was located. The RNUM retrieved the AMBU bag which had an expiration date of [DATE]. The RNUM removed and discarded the expired AMBU bag then retrieved new AMBU bags and placed one in the crash cart and one in Resident #124's room.A Review of Resident #124's admission Record revealed that Resident #124 was admitted with but not limited to the following diagnoses, chronic respiratory failure, anoxic brain damage (occurs when the brain is completely deprived from oxygen, causing brain cells to die), and quadriplegia (paralysis of all four limbs and torso).A review of Resident # 124's Care Plan revealed a focus initiated on [DATE] which indicated the resident was at risk for respiratory complications due to: tracheostomy with an intervention to keep AMBU bag at bedside. On [DATE] at 10:45 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who stated that residents with tracheostomies should have an AMBU bag, suction and extra respiratory supplies at bedside at all times in case of any emergency. On [DATE] at 09:51 AM, the surveyor interviewed the Director of Nursing (DON), who stated that all residents with tracheostomies should have an extra trach, tubing, suction matching and AMBU bag in their rooms in case of an emergency. The DON also stated there should be no expired medical supplies in the crash cart.A review of a facility provided policy titled Medical Supplies and Equipment revealed, Our facility maintains sufficient medical supplies and equipment at all times. No policy was provided to address which supplies should be maintained in the room of a resident with a tracheostomy. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to routinely post the Nursing Home Resident Care Staff Report (NHRCSR) from 6/26/2026 until 07/1/2026 (four days) in a place within the facility which was readily accessible to both residents and visitors.This deficient practice was evidenced by the following:On 07/01/2026 at 9:06 AM, the surveyor observed the NHRCSR dated 06/26/2026 for the day, evening, and night shift, posted on a ledge behind the reception desk in the front lobby. The report indicated the census for each shift was 195. During an interview on 07/07/2026 at 10:56 AM, with the surveyor, the staffing coordinator (SC) stated she would bring the NHRCSR down to the lobby every day for the following day. The SC stated she must have forgotten on the 26th to post the report and she should have checked with the receptionist to ensure the report posted was up to date.During an interview on 07/08/2026 at 09:51 AM, with the survey team, the Licensed Nursing Home Administrator (LNHA) confirmed it was important to post the NHRCSR daily to make staff, family and residents aware of the daily staffing levels.The facility was unable to provide a policy which addressed daily posting of the NHRCSR. NJAC 8:39-41.2 (a)(b)(c)(1)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility staff failed to 1.) use appropriate infection control practices specifically by failing to wear a gown when providing wound care and 2.) implement appropriate transmission-based precautions specifically by applying precautions to a room that contained a resident with a potentially infectious wound. The deficient practice was identified for 1 of 1 (Resident #164 ) residents reviewed for Pressure Ulcer/Injury and 1 of 2 (Resident #9) residents reviewed for Transmission Based Precautions. The deficient practice was evidenced by the following:On 07/01/2026 at 10:19 AM during initial tour, observed staff outside of Resident #164's room with the wound treatment cart. The surveyor observed the room identification sign outside the resident's room to have a blue, paper shape of what was later identified as a bird on the room identification sign. On 07/06/2026 at 9:57 AM with permission from Resident #164 the surveyor observed his/her wound care provided by Licensed Practical Nurse (LPN) #1. LPN #1 prepared wound treatment supplies outside of Resident #164's room and entered the room with no gown. During the observation of the wound care, LPN #1 did not wear a gown throughout the entire process.A review of Resident #164's Electronic Medical Record (EMR) revealed diagnosis of but not limited to, pressure ulcer of sacral region stage 4 (full thickness wound to lower back from prolonged pressure that exposes muscle, tissue or bone).A review of Resident 164's EMR revealed physician orders that included enhanced barrier precaution in place for infection prevention, every shift for infection control with an order date of 06/02/2026.A review of Resident #164's resident centered care plan revealed focuses of a stage 4 pressure ulcer to the sacrum initiated on 09/22/2024 and enhanced barrier precautions for wound care initiated on 01/30/2025, that included an intervention to wear gown and gloves with all wound care initiated on 01/30/2025.On 07/06/2026 at 10:14 AM during an interview with the surveyor, LPN #1 confirmed Resident #164 is on Enhanced Barrier Precautions (EBP). LPN #1 stated that she did not know that Resident #164 was on any kind of precautions but further stated that after seeing the EBP physicians order she should have worn a gown. LPN #1 stated it was necessary to protect the resident and staff and prevent contamination. On 07/06/2026 at 10:27 AM during an interview with the surveyor, the Unit Manager (UM) stated that the facility utilizes a blue bird on the room identification sign to indicate the resident is on EBP. On 07/02/2026 at 10:18 AM the surveyor observed Resident #9 lying in bed with a dressing to the right foot and ankle. Resident #9 stated that they had an operation to the right foot and saw wound care for treatment. The surveyor observed no EBP signage at Resident #9's room identification sign.On 07/07/2026 at 12:56 PM the surveyor observed no EBP signage including a blue bird on Resident #9's room identification sign. A review of Resident #9's EMR revealed diagnosis of but not limited to, other acute osteomyelitis (infection of the bone), right ankle and foot, necrotizing fasciitis (infection causing rapid tissue destruction), encounter for orthopedic aftercare following surgical amputation and acquired absence of other right toe(s).A review of Resident #9's EMR revealed a physicians order for enhanced barrier precaution for infection prevention every shift for infection control with an order date of 06/02/2026 and cleanse the right foot with normal saline solution apply [foam dressing, absorbent pad and wrap dressing] every other day in the morning for wound dressing with an order date of 06/25/2026. A review of Resident #9's resident centered care plan revealed a focus for enhanced barrier precaution initiated on 05/21/2026 that included an intervention to wear gown and gloves with all high contact initiated on 05/21/2026.On 07/07/2026 at 12:57 PM during an interview with the surveyor, UM confirmed Resident #9 to be on EBP. UM stated that there is supposed to be a blue bird sign that indicated the resident was on EBP and confirmed that the blue bird sign was not present on Resident #9's room identification sign. On 07/07/2026 at 1:15 PM during an interview with the surveyor, the Infection Preventionist (IP) stated that residents on EBP are identified by a blue bird on the room identification sign. The IP stated that when providing wound care staff should don gown and gloves. The IP confirmed that Resident #9 should have had a blue bird on their room identification sign. The IP stated it was necessary to ensure proper personal protective equipment (PPE) is utilized to protect the resident and staff from infection and it was important to ensure the EBP signage was on the room identification sign to ensure the resident's needs are identified. A review of the policy titled, PPE for MDRO revised 06/2026 revealed, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities. The policy further revealed Examples of high-contact resident car activities that require gown and glove use for EBP include. wound care: any skin opening requiring dressing. Further review of the policy revealed under Implementation, Post clear signage on door or wall outside of the resident room indicated the type of precautions and required PPE. NJAC 8:39 -19.4 (a) (l)

COMPLAINT #NJ00186243, NJ00186326 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 5/15/25 and 5/20/25, it was determined that facility staff allowed a severely cognitively impaired resident to exit the secured locked unit and then exit the facility while wearing a Wander Guard (WG) device. Staff also failed to follow the facility's Secure Care/Wanderguard System and Elopements policies on 5/11/25 for 1 of 3 residents (Resident #1). The resident was located at an off-site location by a relative and returned to the facility on 5/11/25 at approximately 9:30 P.M. This deficient practice placed all cognitively impaired residents who were at risk for elopement in an Immediate Jeopardy (IJ) situation. The deficient practice was evidenced by the following: A Facility Reportable Event (FRE) sent to the New Jersey Department of Health (NJDOH), dated 5/13/25, indicated that the Receptionist notified the Nursing Supervisor (NS) at 5:29 P.M. that the, . alarm at front door was sounding after multiple visitors exited the front door . The NS then proceeded to check the building and initiated a code gray. A code gray is a message alert for the facility staff a resident has left the building. The FRE further revealed that the resident was located at a nearby grocery store by a relative, unharmed. Resident #1 was escorted back to the facility by the relative at 9:30 P.M. The FRE did not indicate how the resident exited the 4th Floor secure unit nor the facility. Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. According to the admission Record, Resident #1 was admitted to the facility with diagnoses which included but were not limited to: Alzheimer's Disease, Dementia, and unsteadiness on feet. A review of Resident #1's care plan (CP), revealed a Focus related to elopement, initiated on 5/9/25, that indicated, I am at risk for elopement [related to]: prior history of elopement, impaired judgement due to dementia [diagnosis], history of wandering, memory loss secondary to dementia [diagnosis], packing personal belongings, verbalization of such 'want to go home' etc. Further review of the elopement CP revealed a goal that indicated, I will not leave the building and its premises, dated 5/9/25. Review of Resident #1's Order Summary Report (OSR) for May 2025 revealed an active order for a WG placement at the right ankle, dated 5/9/25. Review of Resident #1's Treatment Administration Record (TAR) for May 2025, revealed an order for: Wanderguard at right ankle every shift -start date- 5/09/2025. The TAR revealed that Licensed Practical Nurse (LPN) documented that the resident was wearing the WG on the day shift on 5/11/25. A review of Resident #1's progress notes (PN) revealed a nursing note, dated 5/6/25, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident's cognition was severely impaired. Further review of the PN revealed a nursing note created by the NS on 5/11/25 at 11:04 P.M., which revealed, Patient is believed to have eloped from the building at around 5 pm - 5:30 pm. Staff at the front desk heard the alarm and saw the patient leave but did not believe it was a patient; she thought it was a visitor . The Director of Maintenance (DOM) stated during an interview with the surveyor on 5/15/25, at 10:45 A.M., that the 4th floor was designated as the dementia unit which he described as, [you] cannot leave unless you know the code or someone at the desk presses a button. He further stated that if someone wearing a WG entered the elevator, the elevator should not move, and an alarm should sound requiring a code to be entered. The DOM reported that he was informed of the incident the day after it occurred on 5/12/25. He stated that he came into the facility and checked the WG system and the doors and that everything was good. He further stated that he called the contracted provider and requested that they come to assess the system. The DOM provided an invoice from the contracted provider, dated 5/12/25, which revealed, inspection of the wanderguard control system. The inspection noted all tests performed found the system was working. The DOM further stated that he was not sure how the resident got out as the system was working. The DOM provided an email which confirmed this, dated 5/13/25. The email revealed that the [Contracted Provider] sent a technician out on 5/12/25 to test the doors. The technician tested every feature on the door. There are no repairs needed and everything is functioning properly. During an interview with the Director of Nursing (DON), Assistant Administrator (AA), Administrator, and Chief Clinical Officer (CCO) on 5/15/25 at 1:34 P.M., the AA stated that she arrived at the facility at approximately 7:15 P.M and that upon her arrival, the police and family were present, and the camera footage was reviewed. She stated that they observed the receptionist interacting with the resident in the vestibule and noted that the resident, exited the building at 5:30 P.M. She stated that the expectation was that if the alarm was sounding, staff should stop all people going out of the door to investigate. She further indicated that the footage showed the resident walking behind a group of people exiting the facility. The DON, the Administrator, and the CCO added that they all came in on the night of the incident and that the Administrator personally tested the WG system doors and elevators upon his arrival and found they were all working. In the presence of the AA and CCO, on 5/15/25 at 2:16 P.M., the CCO provided the camera footage from 5/11/25 for surveyor review. Both stated that the time stamp of the camera was off by 24 minutes. Surveyor noted that the camera footage started at 17:04 P.M., which they stated was actually 17:28 P.M. In the presence of the AA and CCO, the surveyor reviewed the footage which looked out into the lobby and a door was visible on the right hand side of the screen. The AA stated that beyond the door was a vestibule that had a double door that then lead to the outside of the facility. The following was noted: (Camera footage does not contain audio) -17:04 Receptionist was observed at the desk. -17:05:01 The AA identified to the surveyors Resident #1, by pointing at the screen when the resident appeared. Resident #1 was observed standing at the vestibule entrance with a visitor directly behind him/her pushing a person in a wheelchair. Resident #1 was wearing a straw hat, a pink long sleeve shirt, black pants, and pink shoes. -17:05:22 The door was observed opening -17:05:30 Resident #1 was observed walking out of the lobby behind the visitor and the person in the wheelchair into the vestibule. The receptionist was also observed getting up from the desk. -17:05:37 The receptionist was observed approaching the pin pad on wall to the left of the door. The AA stated that the receptionist punched in the numbers to silence the WG alarm. -17:06:03 Receptionist remained at the pin pad and footage ended. The AA further stated that the receptionist should not have let anyone in or out until it was determined why the (alarm) was going off. During an interview with the Receptionist on 5/15/25, at 3:51 P.M., she stated that receptionists are aware of the WG system and that, If a resident wearing a WG approaches the door, the alarm sounds and doors lock. The door can be opened via a button on the desk or a code entered on a pin pad next to the door. The Receptionist recalled the incident and stated that at around 5:30 P.M. she was at the [lobby] desk and the alarm went off. At that time, she recognized a visitor who was pushing a resident in a wheelchair. She pushed the button to open the door, and she heard the alarm sound while the door was opening. She immediately got up from the desk and walked over to the pin pad, where she saw the visitor with the wheelchair resident, and a gentleman/lady with a straw hat. She stated that she checked the resident in the wheelchair for a WG and she could not find one. She then observed the straw-hat's wrists and ankles and she did not see a WG. She further stated that she attempted to engage the person and asked if they were staying or leaving and the person stated leaving. She stated that the person then exited the building. The Receptionist stated that she immediately called the NS to report that the alarm sounded and was told that a search would be initiated. She stated that about an hour later she was asked if she had seen a resident and realized after inputting the name in the electronic system that she recognized Resident #1 as the person wearing the straw hat that exited the building. She further stated that Resident #1's picture was in the [elopement] binder and that, I should not have let anyone out and held the door until I checked that a resident was or wasn't there. During a telephone interview on 5/20/25, at 11:17 A.M., Certified Nursing Assistant (CNA) stated that she recalled observing a person near the elevator at around 5 P.M. and that he/she, did not look like a patient. The CNA stated that she asked the resident if he/she was okay, and did not engage any further. She stated that Resident #1 was not on her assignment, and it was after she returned from her break that she realized that it was Resident #1 that she saw by the elevator. The CNA denied hearing the alarm as well as entering the code on the pin pad. She further stated that she was agency and that she did not have the code. During a follow-up interview with the Administrator and the DON on 5/20/25, at 2:55 P.M., the Administrator stated that the 4th Floor unit was a Dementia locked unit, vigilance is required. The DON stated that, Residents should be monitored per their care plan. The Administrator also stated that he, Has yet to determine how the resident was able to leave the secure unit. He further stated that interviews were conducted of the staff that worked that night and all of them denied hearing an alarm [WG] or entering the code to bypass it. The Administrator provided copies of the witness statements to the surveyor. During a follow-up interview with the Administrator, the DON, and the CCO on 5/20/25, at 4:06 P.M., the Administrator stated that, The camera screen on the 4th Floor was not functioning and I was unable to view footage of the night of the incident. He further stated that the footage was not available for surveyor review. Review of the facility's undated Secure Care/Wanderguard System policy, revealed under Section 6 of the Procedure for Wanderguard Program, it reflected that the appropriate response for a resident who passed through a Secure Care/Wander Guard Doorway, was to redirect the resident. Review of the facilities Elopements policy, revised April 2023, revealed under Section 2 of the Policy Interpretation and Implementation, it reflected that if a staff member observed a resident leaving the facility that they should, Attempt to prevent the departure . A removal plan was provided to the surveyor on 5/22/25. The plan revealed what actions the facility took to prevent serious harm from occurring or reoccurring. The facility initiated a corrective action plan to remediate the deficient practice. The surveyor verified that the (IJ) F689 removal plan was implemented onsite on 5/27/25 at 2:42 P.M. The non-compliance continued from 5/11/25 for no actual harm with the potential for minimal harm that is not an IJ. The Removal Plan was as follows: -On 5/11/25 at 11:10 P.M., a Telehealth visit was conducted upon Resident #1's return to the facility. -On 5/11/25 at 11 P.M., facility initiated 30 Minute Monitoring of Resident #1 -On 5/11/25 at 11 P.M., facility initiated 30 Minute Monitoring of the elevator -On 5/12/25, In-services for all staff were initiated on Door Alarms, Elopement, and Code Gray and if an alarm sounds staff were to investigate prior to entering a code. -On 5/12/25, Contracted Provider completed a WG control system inspection -On 5/12/25, Facility contacted their Information Technology (IT) Department to inform them of the camera screen not working. -The facility updated the Secure Care/Wanderguard System policy, that included that a photograph be maintained at the reception desk. -Facility initiated audits on WG placement and function, admitted and discharged residents that were assigned a WG, reception area and nursing station. N.J.A.C. 8:39-27.1(a)

Based on observations, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner to prevent food borne illness. This deficient practice was observed by the following: On 3/6/2025 from 10:02AM to 10:55 AM, the surveyor observed the following in the presence of the Food Service Director (FSD): Prep Area: 1. Upon washing hands in the prep area, the surveyor did not observe a self-closing waste receptacle next to the handwashing station. When asked if a waste receptacle was required next to the hand washing sink, the FSD responded that there was trash can upon entrance to the room that the kitchen staff use. The surveyor did not observe a lid to the garbage receptacle. 2. The table-mounted manual can opener was observed to be dirty with an unknown brown substance around the cutting blade. The FSD stated that the can opener should be clean at all times. Reach in Refrigerator #1: 1.The Refrigerator/Freezer Temperature Log the 3/6/2025 PM section was filled out identifying the temperature as 36 degrees for the refrigerator and 0 degrees for the freezer. The FSD confirmed that the log should not be pre-filled for the PM section. 2. A gallon jar of mayonnaise with no open date. When asked if there should be an open date, the FSD responded, yes, and threw away the item. 3. A knotted black bag of unknown items and a glass container with teal lid with unidentified food. The FSD identified the items as employee flood and confirmed that staff should not be putting personal food in the refrigerator. Reach in Refrigerator #2: 1. The Refrigerator/Freezer Temperature Log the PM section was filled out identifying the temperature as 36 degrees for the refrigerator and 0 degrees for the freezer. 2. A gallon jar of duck sauce with no open date. The FSD removed and threw away the item. 3. A gallon jar of barbeque with no open date. The FSD removed and threw away the item. 4. A 32oz container of Portobello Mushroom Soup with no open date. The FSD removed and threw away the item. Reach in Freezer: 1. Upon opening the right freezer door, ice and frost was observed around the left side of the door. When asked if this should occur, the FSD stated no because it could imply that the door is not closing properly. Walk in Refrigerator: 1. The Refrigerator/Freezer Temperature Log the 3/6/2025 PM section was filled out identifying the temperature as 36 degrees for the refrigerator and 0 degrees for the freezer. The FSD confirmed that the log should not be pre-filled for the PM section. 2. In the rear of the refrigerator, along the back wall, the surveyor noted brown liquid residue. When asked how often the refrigerator is cleaned, the FSD stated that it was just done but will have it mopped again. Walk in Freezer: 1. The Refrigerator/Freezer Temperature Log the 3/6/2025 PM section was filled out identifying the temperature as 36 degrees for the refrigerator and 0 degrees for the freezer. The FSD confirmed that the log should not be pre-filled for the PM section. 2. One sprinkler head completely encased in ice with a consistent frozen water stream that reached from the sprinkler to the floor with approximately 1 inch ice build up on the floor and freezer shelves. Dry Storage Area: 1. The Storeroom Temp Log the 3/6/2025 PM section was filled out identifying the temperature as 72 degrees. Dishwasher: 1. The surveyor questioned the FSD if the facility had a low temperature or high temperature dishwasher. The FSD responded that it was a low temperature dishwasher. The surveyor observed that the dishwasher was in operation and the staff were in the process of cleaning the breakfast dishes. The surveyor observed the following sign on the front of the dishwasher: Check Temps!!!!!! Before AND During dishmachine process Wash Temp falls below 160 Rinse Temp falls below 180 STOP dishwashing and notifying a supervisor immediately. The surveyor again questioned if the dishwasher is a low or high temperature. The FSD again continued to state it was a low temperature dishwasher. The surveyor and the FSD reviewed the temperatures while the dishwasher was processing dishes. The following temperatures were noted: Rinse: 155; Wash 140; Pre-Wash: 130. The surveyor asked if the temperatures were reaching proper temperatures to ensure that there is no potential bacterial growth and the potential for food borne illness. The FSD stated that she will have to check. The surveyor reviewed the Dish Machine Warewashing Log and observed that the morning temperatures were not completed. The Licensed Nursing Home Administrator was made aware and confirmed that the temperature was not meeting proper temperatures and it will be converted to a low temperature dishwasher with chemicals until the mechanic can come to address the issues. Across from the dishwasher, a slicer was observed uncovered and exposed to the environment. The FSD confirmed that it should be covered when not in use. On 3/10/2025 at 09:56 AM to 10:28, the surveyor completed a follow up inspection of the kitchen with Regional Food Service Director (RFSD) and observed the following: 1. Missing self-closing waste receptacle next to the handwashing station. When asked if a waste receptacle was required next to the hand washing sink, the RFSD confirmed that there should be one next to the sink and one has been ordered. 2. The Refrigerator/Freezer Temperature Log the PM section was not filled out for the dates of 3/6/2025; 3/7/2025; 3/8/2025; and 3/9/2025. The RFSD confirmed that it should have been filled out. When asked approximately what time the PM section should be completed, the RFSD stated around 4-5pm. 3. In the walk-in freezer, the ceiling to floor icicle was removed; however, ice blocks and shards were observed throughout the area. On the left hand side of the freezer, spilled frozen carrots were observed under the shelving. 4. The RFSD confirmed that the dishwasher has been operating as a low temperature machine since surveyors identification of the temperatures during entrance on 3/6/2025. Upon review of the Dish Machine Warewashing Log, the following was observed for morning temperatures: 3/7/2025 Wash Temp-165 Final Rinse- 120; 3/8/2025 Wash Temp- 165 Final Rinse- Unable to be identified; 3/9/2025 Wash Temp-165 Final Rinse- unable to be identified; 3/10/2025- Wash Temp-165 Final Rinse- unable to be identified. The Noon and Evening Sections were not completed for the above dates. 5. The slicer was observed uncovered and exposed to the environment. The RFSD confirmed that it should be covered when not in use. A review of the facility's Food Storage policy, last reviewed December 2024, included under Policy Interpretation and Implementation: 1. Food services, or other designated staff, will maintain clean food storage areas at all times [ .] 10. The Food Services Manager, or his/her designee, will check refrigerators and freezers daily for proper temperatures. The Food Services Director will maintain records of such information. A review of the facility's Food Safety and Sanitation policy, last reviewed December 2024, included under Procedure: 1. B. The food and nutrition services department will follow regulations as outlined by other official health agencies and organizations with jurisdiction over the facility. A review of the facility's undated Dishmachine Use policy included under Policy Interpretation and Implementation: 3. Dishmachine hot water sanitation rinse temperatures [ .] 180 degrees F for all other machines. The facility could not provide a policy regarding the storage of kitchen wares when not in use. The facility could not provide a policy regarding the identification of an open date. NJAC 8:39-17.2(g)

Complaint: NJ174453 Based on observations, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to use appropriate infection control practices, specifically by A.) failing to contain and date respiratory equipment, B.) failing to wear a gown while performing care in a room requiring personal protective equipment and C.) failing to offer hand hygiene to residents prior to eating. The deficient practice was identified for 3 of 5 residents (Residents # 75, 101, 477) reviewed for Respiratory Care, 1 of 1 resident (Resident # 84) reviewed for Tracheostomy Care, and 1 of 3 Units observed during the Dining Task. The deficient practice was evidenced by the following: 1. On 03/06/2025 at 11:26 AM during the initial tour, Surveyor # 1 observed Resident # 101 in bed. At that time, Surveyor # 1 observed a Bilevel Positive Airway Pressure (BiPAP) mask not in a bag, exposed to air. On 03/10/2025 11:26 AM, Surveyor # 1 observed Resident # 101 in bed. At that time, Surveyor # 1 observed the BiPAP mask and nasal cannula not in a bag, exposed to air. At that time, Resident # 101 said the staff used to put them in a bag all the time but haven't in months. He/She further stated that it was nice when they [facility] put them in a bag. A review of Resident # 101's Electronic Medical Record (EMR) revealed a diagnoses of but not limited to Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. On 03/12/2025 at 9:36 AM during an interview with Surveyor # 1, the Unit Manager Nurse (UMN) replied, They should be in a plastic bag and cleaned daily. Nasal cannulas should be in a bag and changed weekly when Surveyor #1 asked how are respiratory supplies such as cannulas to be stored when not in use. On the same date at 10:36 AM during an interview with Surveyor # 1, the Infection Preventionist (IP) said masks and nasal cannulas should be in bags and they should be changed weekly. When Surveyor #1 asked why that is important, the IP replied it is exposed to germs in the air. On 03/10/2025 at 11:40 AM, Surveyor # 1 observed Resident # 84 in bed in their room. At that time, Certified Nurses Aide (CNA) # 1 was observed in the room providing care to the resident. CNA # 1 was wearing a face mask and gloves but not a gown. At that time, Surveyor # 1 retrieved the Unit Manager who confirmed that CNA # 1 should be wearing a gown in the room. A review of Resident # 84's Quarterly Minimum Data Set (an assessment tool) dated 12/15/2024 revealed that he/she received tracheostomy care, including oxygen and suctioning. A review of Resident # 84's Care Plan located in the Electronic Medical Record, revealed a focus for Enhance Barrier Precautions (an infection control strategy, involving gown and glove use during high-contact resident care activities, to reduce the transmission of multidrug-resistant organisms in nursing homes, particularly for residents with wounds or indwelling medical devices). A review of the facility-provided policy titled Enhanced Barrier Precaution Policy updated in December of 2024 revealed under Table 1: Implementing Contact verses Enhanced Barrier Precautions that use of Enhanced Barrier Precautions applied to resident that Has a wound or indwelling medical device, and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO [Multidrug Resistant Organism]. The facility could not provide a policy detailing how oxygen supplies are to be stored when not in use. 43936 2. On 03/06/2025 at 11:07 AM during the initial tour, Surveyor # 2 observed Resident # 75 in bed in their room. At that time, Surveyor # 2 observed a nebulizer face mask (Mask used to deliver aerosolized medication through the nose and mouth) on top of the nebulizer machine. The mask was not covered and exposed to the air. On 03/11/2025 at 11:09 AM, Surveyor # 2 observed Resident # 75 in bed in their room. At that time, Surveyor # 2 observed the nebulizer face mask on top of the nebulizer machine. The mask was not covered and exposed to the air. A review of Resident # 75's Electronic Medical Record (EMR) revealed under Order Summary that he/she had an order to Change neb [nebulizer] tubing weekly, sign and date. On 03/11/2025 during an interview with Surveyor # 2, the Director of Nursing (DON) confirmed that nebulizers should be in covered in a bag. She further stated that it is important for infection control. 51232 3. Upon initial tour of the facility on 03/06/2025 at 10:32 AM, Surveyor #3 observed that Resident #447 was receiving oxygen (O2) through a nasal cannula (NC), which was used to deliver supplemental oxygen, connected to an oxygen concentrator that provides extra oxygen to those who have difficulty breathing. However, the oxygen tubing was not labeled and dated. On 03/10/2025 at 12:15 PM, Surveyor #3 reviewed the electronic medical records for Resident #447 as follows: According to the Admission Record Resident #447 was admitted to the facility with various diagnoses, including but not limited to Chronic Obstructive Pulmonary Disease (COPD), a progressive lung condition that leads to breathing difficulties due to airflow obstruction. A review of Resident #447's Order Summary Report indicated the following: start date 03/05/2025; the resident was to receive O2 at 3 liters per minute via NC continuously every shift for shortness of breath related to COPD. During an interview with Surveyor #3 on 03/12/2025 at 10:37 AM, the Infection Preventionist said that oxygen tubing should be changed and labeled weekly. If the oxygen tubing is not dated or signed out in the EMR, it is assumed that the task has not been completed. A review of the facility undated provided policy, titled, Oxygen Administration did not address labeling and dating. 49712 4. During a dining observation on 03/10/2025 at 12:47 PM surveyor #4 observed 11 residents and 2 staff in the dining room. Residents were all sitting at tables waiting for lunch to arrive. No hand hygiene was offered to residents. The First tray arrived at 12:51 PM, staff went to cart to retrieve trays and serve residents no hand hygiene was observed for staff. During an interview on 03/11/2025 at 1:13 PM with surveyor #4, The Director of Nursing replied, Yes. When asked if hand hygiene should be performed by staff and residents prior to meals. During an interview on 03/12/2025 at 10:36 AM with surveyor #4 the Infection Preventionist (IP) said residents should be offered hand sanitizer wipes before meals from the staff. The IP also said staff should be performing hand hygiene before and after providing care, before serving meals, and when visible soiled. A review of a facility provided job description for Certified Nursing Assistants revealed under Food Service Functions to, Prepare residents for meals (i.e., take to bathroom, wash hands ) A review of an undated facility provided policy titled Handwashing/Hand Hygiene revealed to wash hands, before and after eating, and before and after all resident care activities. N.J.A.C. 8:39-19.8(m), 19.4(a)

Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 3 of 4 floors (2nd, 3rd, and 4th floors). This deficient practice was evidenced by the following: 1. On 03/10/2025 at 12:25 PM, Surveyor #1 observed Shower Room B on the 4th floor: the door was missing a section of the panel facing into the shower room, the white shower curtain for a stall was ripped, there were white debris on a blue shower curtain in another stall, the tiles surrounding the toilet were cracked, brown debris was present in a shower stall, and the drain contained brown matter. During an interview with Surveyor #1 on 03/11/2025 at 10:21 AM, the Housekeeping Director (HD) said that the shower rooms were cleaned twice daily. Certified Nurse Aides (CNAs) were responsible for removing any fecal matter from the showers and notifying housekeeping for necessary disinfection. Housekeeping was also tasked with reporting any broken items to nursing or maintenance, which were logged into an electronic system. Additionally, he conducts rounds throughout the facility twice a day to ensure that standards are upheld. During an interview with Surveyor #1 on 03/11/2025 at 10:31 AM, the Maintenance Director (MD) said that he conducts rounds throughout the facility three to four times a day to inspect for any broken or non-functional items, as well as to assess the overall condition of the building. He emphasized the importance of keeping an appealing environment for the residents, specifically noting that the shower room door on the 4th floor should be intact and that there should be no cracked tiles in that area. A review of the undated facility policy, titled, Homelike Environment, revealed, The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Those characteristics includes a.) clean, sanitary, and orderly environment. 45209 2. During the initial tour of the building on 03/06/2025 at 11:09 AM, surveyor # 2 observed Resident #66's bathroom in room [ROOM NUMBER]-1. The surveyor observed that both of the toilet safety rails attached to the wall with exposed 2x4 wood planks. The wood planks were not painted along with the wall around the project that had numerous spackling areas. On the same date at 11:19 AM, surveyor #2 observed Resident #101's room which presented with missing drawer fronts (approximately 3), resulting in exposed personal property which were viewable to the public, and drawers (approximately 3) that were not able to be closed completely. During an interview with the surveyor on 03/11/2025 at 10:23 AM, the Housekeeping Director (HD) stated that housekeeping should notify the nursing department of any broken items in resident rooms and they will put it the computer system for maintenance to follow up on. During an interview with the surveyor on 03/11/2025 at 10:31 AM, the Maintenance Director (MD) reported that all projects should look complete in the end. The MD confirmed that there should not be any exposed wood, unpainted, or raw spackled areas. When asked about broken drawers, the MD stated that the maintenance department can either fabricate or order replacement drawers. When showed pictures of Resident #66's bathroom and Resident #101's broken drawers, the MD confirmed that the bathroom should have been painted and presented in better fashion and that resident rooms should not have numerous broken drawers. During an interview with the surveyors on 03/7/2025 at 10:23 AM, the Director of Nursing, in the presence of the Regional Director of Nursing and the Licensed Nursing Home Administrator, the resident environment was acknowledged. 43936 3. On 03/06/2025 at 10:40 AM, Surveyor # 3 observed Resident # 183 in their room. At that time, Surveyor # 3 observed two, clear plastic bags filled with linen left on the floor under the sink in the room. On 03/07/2025 at 11:14 AM, Surveyor # 3 observed the bathroom in room [ROOM NUMBER]. At that time, Surveyor # 3 observed water stains on the ceiling tile, a used, green incontinence brief in the trash can, stains on the wall near the doorway of the room. The Surveyor also observed an opened hand sanitizer wall-dispenser. There was no hand sanitizer located within. A review of the undated facility policy titled, Cleaning and Disinfection of Environmental Surfaces revealed that, 11. Walls, blinds and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. 49712 4. During initial tour on 03/06/2025 at 10:02 AM Surveyor #4 observed the following: peeling and missing wallpaper at the end of Hallway A on the fourth floor; a broken window blind in room [ROOM NUMBER]; an orange substance smeared on the floor in room [ROOM NUMBER], the wall next to bed had scratches on it and a dirty tray table; in the B side shower room, there was a dirty wound dressing on the radiator. During an observation on 03/11/2025 at 09:59 AM of the A side shower room surveyor #4 observed the following: a pair of pants on a chair; discarded clothes on a shelving unit and floor in front of the shelving unit; a tied plastic bag with what appeared to be linen in the corner; a tied plastic bag with toilet paper, and boxes of supplies in another corner with a plastic cup on the floor. During an interview on 03/11/2025 at 10:20 AM with surveyor #4, The Housekeeping Director (HD) said that the shower rooms were cleaned twice a day. The HD said that certified nursing assistants (CNA) were responsible for removing any clothes or linens from the shower room, however if housekeeping saw them in there, they would remove them. The HD also stated that rooms should be cleaned every day, the cleaning consist of dusting, taking out trash, restocking paper products, cleaning windows and mopping floors. The HD said the rooms and shower rooms should look good and clean, and if anything is broken it should be reported to the maintenance department. During an interview on 03/11/2025 AM with surveyor #4, the Maintenance Director (MD) said they round on the building 3 times a day and if anything is broken or non-function it is repaired. The MD also said that walls and wallpaper is monitored and tended to monthly. The MD also said that window blinds are an ongoing project, they are trying to keep up with it. The MD agreed that the walls, and blinds should be kept in good repair. During a dining observation on 03/10/2025 at 12:47 PM surveyor #4 observed 11 residents and 2 staff in the dining room. The resident tables were bare. The first resident was served at 12:51 PM on the tray. The last resident was served at 01:09 PM. All residents in the dining room were served on trays. During an interview with surveyor #4 the Director of Nursing (DON) said that the 4th floor dining room was used every day for meals. The DON also said the meals should be taken off the trays and served to the resident on the table. A review of an undated facility provided policy tilted Dining Policies revealed, The goal is to serve meals in a more home like setting. The staff will appropriately set up each resident's table setting individualized per the president's choice N.J.A.C. 8:39-31.4(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure palatable temperature of food for 1 of 1 lunch meal. This deficient practice was evidenced by the following: On 3/11/25 at 11:08 AM, surveyors conducted a meeting with the Resident Council which included nine residents. All nine residents reported that food not served at proper temperatures. On 3/11/25 at 11:16 AM, the surveyor observed the Regional Food Service Director (RFSD) who calibrated (process to make sure the instrument is taking an accurate temperature reading) before he proceeded to obtain food temperatures from the steam table. The RFSD confirmed that cold items should be below 41 degrees and hot items should be above 160 degrees. During this time, items were removed and reheated to proper temperatures from the steam table. The RFSD asked the kitchen staff if the items were temperature checked prior to placing on the steam table, in which it was discovered that temperature checks were not conducted. On the same date at 3/11/25 at 1:28 PM, a temperature testing tray was completed by the RFSD and Food Service Director (FSD) on the 4th floor after all trays were passed on the floor. The surveyor noted the following temperatures: Coleslaw: 52 degrees Fahrenheit Potato Salad: 52 degrees Fahrenheit Juice: 46 degrees Fahrenheit Milk: 47 degrees Fahrenheit At this time, both the RFSD and FSD confirmed that cold items temperature should be between 36 to 41 degrees. Both RFSD and FSD stated that they have been experiencing difficulty in keeping the temperature cold items. A review of the undated facility's Food Temperature policy, included: all cold items must be maintained and served at a temperature of 41 Fahrenheit or below. NJAC 8:39-17.4(a)(2)

Based on interview and record review, it was determined that the facility failed to accurately transmit the Minimum Data Set (MDS) for 2 of 3 residents reviewed for Resident Assessment, Residents #46 and #21, and was evidenced by the following: The MDS is a comprehensive federal mandated process for clinical assessment of all residents that should be completed and submitted to the Quality Measure System. The facility must electronically transmit the MDS no later than 14 days after assessment being completed. After transmitting of the MDS, it will generate a quality measure to enable a facility to monitor the residents decline and progress. The following residents were identified that the MDS were not transmitted timely: 1. Resident # 46: the discharge return not anticipated MDS dated [DATE] was completed 11/9/2024 and was due to be transmitted no later than 11/23/2024. It was transmitted on 3/10/25. 2. Resident #21: the discharge return not anticipated MDS dated [DATE] was completed on 11/6/24 and due to be transmitted on 11/20/24. It was transmitted on 3/10/25. On 03/11/25 at 09:55 AM, during an interview with the surveyor, the MDS Coordinator stated that MDS's should be transmitted within 2 weeks of completion. She stated she prefers to transmit the MDSs within a week. The MDS Coordinator acknowledged that Resident #46 and Resident #21 discharge return not anticipated MDSs were transmitted late. The facility provided policy titled, Electronic Transmission of the MDS, reflected All MDS assessments will be transmitted to the State database in accordance with current Omnibus Budget Reconciliation Act regulations governing the transmission of MDS data. NJAC 8:39 - 11.1

Based on observation, interview, and review of pertinent facility documents, the facility failed to ensure that food brought in from visitors was stored in a safe and sanitary condition by failing to document temperatures on a temperature log for personal refrigerators. The deficient practice was identified for 2 of 2 Residents who had personal refrigerators in their room. The deficient practice was evidenced by the following: On 03/07/2025 at 12:15 PM, the surveyor observed Resident # 70 in bed in their room. At that time, the surveyor observed a black, small refrigerator in their room. At that time, the surveyor observed paper on the side of the fridge titled, Temperature Log indicating the month of March. The log did not have any temperatures recording on it including the current date. On 03/09/2025 at 12:18 PM, the surveyor observed Resident # 49 in bed in their room. At that time, the surveyor observed a small, black refrigerator in the room. The refrigerator did not have a temperature log at all. On 03/11/2025 at 12:02 PM, during an interview with the surveyor, the Director of Nursing (DON) said that the temperature log is filled out on the night shift by the nurses. She replied, We don't want anything to be spoiled when the surveyor asked why would it be important to check the temperatures. On 03/12/2025 at 9:26 AM, during an interview with the surveyor, Licensed Practical Nurse (LPN) # 1 said we check the temperatures. She explained that there is a log on the refrigerator and that mostly the nurses do attempt. A review of the facility policy titled, Outside Food Policy with a review date of December, 2024 revealed that, 7. If a resident has an in-room personal refrigerator, designated staff (housekeeping?) will monitor these units for temperature control, food or beverage disposal, and sanitation, using the guidelines in this policy. N.J.A.C. S 8:39-17.4 (a)2

Based on observation, interview, and record review it was determined that the facility failed to accurately assess the status of a resident in the Minimum Data Set (MDS), an assessment tool used to facilitate care. This deficient practice was identified for 1 of 36 residents (Resident #100) reviewed for MDS accuracy and was evidenced by the following: The surveyor reviewed the medical record for Resident #100. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Parkinsonism, Major Depressive Disorder, and Schizoaffective Disorder, BiPolar Type. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/10/2025 included the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident's cognition was moderately impaired. Section A, Question A1500, of the MDS did not identify Resident #100 as having a postitive 2 PreAdmission Screening and Resident Review (PASRR) Level 2, which indicated a serious mental illness. A review of Resident #100 Electronic Medical Record (EMR) included identification of positive PASRR Level 2 Determination Notification dated 8/24/23. During an interview with the surveyor on 3/7/2025 at 10:23 AM, the Social Worker (SW) identified the positive PASRR level 2 and stated that once a resident has a positive level 2 they will always be considered positive. When asked if the most recent comprehensive MDS should identify a positive PASRR 2, the SW stated yes. During an interview with the surveyor on 3/11/2025 at 9:54 AM, the MDS Coordinator stated they will follow up to see if an MDS modification needed to be completed to identify the PASRR Level 2. During an interview with the surveyor on 3/7/2025 at 10:23 AM, the Director of Nursing, in the presence of the Regional Director of Nursing and the Licenced Nursing Home Administrator, confirmed that Resident #100 should have been coded yes for question having a state level 2 PASRR and a modification of the MDS was completed. A review of the facility's undated Electronic Transmission of the MDS policy included the following under Policy Interpretation and Implementation: 1. Specific staff members responsible for completion of the MDS receive training on the assessment process, in accordance with the MSDS 3.0 RAI instruction manual before being permitted to use the MDS computer system. NJAC 8:39-11.1

Based on observation, interview, and record review it was determined that the facility failed implement the recommendations into the resident's assessment and care planning from a resident's Pre-Admission Screening and Resident Review (PASARR) level 2 determination. This deficient practice was identified for 1 of 1 residents (Resident #100) reviewed for PASARR and was evidenced by the following: . A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Parkinsonism, Major Depressive Disorder, and Schizoaffective Disorder, BiPolar Type. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/10/2025 included the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident's cognition was moderately impaired. Section A, Question A1500, of the MDS did not identify Resident #100 as having a state level 2 Preadmission Screening and Resident Review (PASRR) process to have serious mental illness. A review of the resident's individual comprehensive care plan (ICCP) did not identify Resident #100 positive PASRR Level 2 along with the state identified recommendations. A review of the PASARR Level II Determination Notification letter by the New Jersey Department of Human Services Division of Mental Health and Addiction Services dated 8/24/2023 revealed that Resident #100 had mental health treatment needs that could be met in a nursing facility. According to the notification, the recommendations made for the resident included the following: 1. Psychiatric consult upon admission to the nursing facility. 2. Routine follow up visits with the Primary Care Physician and Psychiatrist. 3. Medication Monitoring 4. Supportive Counseling 5. Routine Laboratory Testing 6. Formulate and implement a behavioral modification plan to address any behavioral disturbances. 7. Provide education to the client and family on mental illness and medication. 8. Develop a Crisis Intervention/Safety Plan with the client. During an interview with the surveyor on 3/7/2025 at 10:23 AM, the Social Worker (SW) explained that a positive PASRR 2 meant that the resident had a major mental health illness. When asked what was done with that information, the SW stated that the state recommendations on the Level 2 would be shared with the entire clinical team, including the psychiatrist, and the resident care plan would be based on those specific recommendations. The surveyor inquired if the PASRR 2 is a permanent status or if that changes based on admissions. The SW confirmed that it is a permanent status. When asked if the SW was familiar with Resident #100, the SW agreed that they are on his floor. When asked to review the resident's care plan, the SW could not identify a focus area for the positive Level 2 that included state recommendations. The surveyor inquired who would be responsible for implementing a Level 2 care plan and the SW confirmed that social work and nursing. During an interview with the surveyor on 3/12/25 at 9:36 AM, Licensed Practical Nurse Unit Manager (LPNUM) explained that a PASRR level 2 should be identified on a care plan to ensure that they are safe and properly cared for in a nursing facility. When asked if the PASRR level 2 should be on the care plan, the LPNUM confirmed and stated that it should also include all the recommended interventions. During an interview with the surveyors on 3/7/2025 at 10:23 AM, the Regional Director of Nursing, in the presence of the Director of Nursing and the Licensed Nursing Home Administrator, acknowleged that the PASRR Level 2, along with its recommendations, should be identified on a resident care plan. A review of the facility's undated Preadmission Screening and Resident Review (PASRR) Policy does not address implementation of state recommendation. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to keep medications stored and labeled properly specifically by having unpackaged medications in the drawers and not labeling a medication with an opened date. The deficient practice was identified for 3 of 4 medication carts reviewed under the Medication Task. The deficient practice was evidenced by the following: On 03/07/2025 at 11:01 AM while on the second floor, the surveyor inspected the 2-C Cart. At that time while observing the top drawer of the cart, the surveyor observed an opened insulin injection pen (insulin medication needle delivery device) without a date it was opened. In the second and third drawer of the cart, the surveyor discovered ten, loose tablets and capsules. At that time of the inspection, the surveyor interviewed Licensed Practical Nurse (LPN) # 1. LPN # 1 said that the night shift is supposed to clean the cart. She also said that the nurse on each shift is responsible for the cart. Lastly, LPN # 1 said that the insulin pen should have an opened date. On the same date at 11:20 AM, while on the third floor, the surveyor inspected the medication cart on the B side unit. At that time, the surveyor observed one unidentified, loose tablet in the second drawer. On the same date at 11:29 AM, while on the fourth floor, the surveyor inspected the medication cart on the A side unit. At that time, the surveyor observed one unidentified, loose tablet in the second drawer. On 03/11/2025 at 1:13 PM during an interview with the surveyor, the Director of Nursing (DON) replied, Yes after the surveyor asked if insulin pens be dated once they are opened. The DON also said that medication carts should be checked everyday and that they are cleaned monthly. A review of the facility policy titled, Storage of Medications revealed under, Policy Interpretation and Implementation that, 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. and that, 9. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. N.J.A.C. S 8:39-29.4 (b)

Complaint: NJ00183795, NJ00173600, NJ00174453 Based on observation, interview and review of facility meal tickets it was determined that the facility failed to ensure the preferences on the meal tickets were followed for 2 of 2 residents observed for food concerns. (Resident #89 and Resident #101 This deficient practice was evidenced by the following: According to the Admission Record, Resident #89 was admitted to the facility with diagnoses including but not limited to; Morbid (severe) Obesity due to excess calories, and Type 2 Diabetes Mellites with Hyperglycemia (high blood sugar). According to the Minimum Data Set, an assessment tool used to manage care dated 12/26/2024, revealed that Resident # 89 had intact cognition. During a dining observation on 03/11/2925 at 12:23 PM, the surveyor inspected Resident #89's lunch tray and ticket for accuracy. The following items were missing from the tray coffee creamers, vegetarian vegetable soup, chef salad, and green vegetables. According to the Admission Record, Resident #101 was admitted to the facility diagnoses including but not limited to: Morbid (severe) Obesity due to excess calories, and Type 2 Diabetes Mellites with Hyperglycemia (high blood sugar). According to the Minimum Data Set, an assessment tool used to manage care dated 12/21/2024, revealed that Resident # 101 had intact cognition. During a dining observation on 03/11/2025 at 12:16 PM, the surveyor inspected Resident #101's lunch tray and ticket for accuracy. The following items were missing, a fruit plate and 1/2 cup of grapes. During an interview on 03/11/2025 at 12:29 PM with the surveyor, the Regional Dietary Director (RDD) said the dietary aide last on the food line was responsible to assure tray accuracy before sending the trays out. The RDD also said the All-Available menu is being revamped as some items were not available. The RDD said they usually make the chef salads in the morning and that was overlooked today, and the creamers, and soup should have been on Resident # 89's tray. The RDD also said the fruit plate for Resident #101 was not available today. A review of an updated facility provided policy titled Resident Food Preferences revealed under, Policy Interpretation and Implementation that, 6. The Food service Department will offer a limited number of food substitutes for individuals who do not want to eat the primary meal. NJAC 8:39 -17.4(a)(3)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) properly store medications, b.) maintain clean and sanitary medication storage areas, and c.) properly label opened multidose medications. This deficient practice was observed in 2 of 2 medication storage rooms and 3 of 3 medication carts and was evidenced by the following: On [DATE] at 11:05 AM, in the presence of the Unit Manager Registered Nurse (UM/RN), the surveyor observed the two main (2M) medication storage room door unsecured and slightly opened. The UM/RN confirmed that the door to the medication storage room should have been closed and secured. The surveyor and the UM/RN entered the 2M medication storage room and observed the following: Three (3) sterile auto guard intravenous (IV) 24-gauge (24GA) catheters expired on [DATE]. One (1) sterile auto guard 22GA catheter expired on [DATE]. One (1) sterile auto guard 20GA catheter expired on [DATE]. One (1) sterile blood collection set expired on [DATE]. Six (6) 5 milliliter (ml) sterile Heparin Lock flush solution (an anticlotting injectable medication) 50USP units/5ml (10usp units/ml) prefilled syringe flushes expired on [DATE]. One (1) 5ml sterile Heparin Lock flush solution 50USP units/5ml (10usp units/ml) prefilled syringe flush expired on [DATE]. One (1) 12ml sterile Heparin Lock flush solution 50USP units/5ml (10usp units/ml) in 0.9% sodium chloride syringe expired ,d+[DATE]. One (1) opened multidose vial of tuberculin purified protein derivative Aplisol 5 TU/0.1ml (5 tuberculin units/0.1 milliliters) (an injectable medication used to test for tuberculosis) undated and unlabeled. The UM/RN at this point informed the surveyor that any nurse that opens a multidose medication should label and date the medication because each medication has a different expiration time after being opened. Two (2) sterile IV start kit packages, opened, and stored in a drawer with unopened kits. At that time, the UM/RN stated, they are not supposed to be kept once opened since they are sterile packages, and once opened they should be thrown out. One (1) fresh mint fluoride toothpaste opened, used, and stored in the cabinet. To this the UM/RN stated, it is not supposed to be stored there and possibly a staff member used it and put it back. On [DATE] at 12:28 PM, the surveyor interviewed the Pharmacy Consultant (PC) who stated that multidose medications should be dated and labeled appropriately once opened to comply with expiration times and once opened, the effectiveness of the medication cannot be guaranteed past expiration. On [DATE] at 12:43 PM, in the presence of the Unit Manager Licensed Practical Nurse (UM/LPN), the surveyor observed the three main (3M) medication storage room. The following was observed: One (1) multidose 10ml vial of insulin lispro (an injectable medication used to treat diabetes) opened and undated. Two (2) plastic containers containing food in the medication refrigerator stored next to medications and one (1) 5.3-ounce (oz) container of yogurt in the medication refrigerator freezer. At that time, the UM/LPN informed the surveyor that she kept her lunch in this refrigerator because she did not trust keeping her lunch in another refrigerator on the unit. The UM/LPN confirmed that food should not be stored in the medication refrigerator. On [DATE] at 1:00 PM, the PC confirmed to the surveyor that nothing, including food should be stored in the medication refrigerator. On [DATE] at 8:32 AM, while observing medication administration on 2M nursing unit, the surveyor observed Licensed Practical Nurse #1 (LPN #1) enter a resident's room and did not lock the medication cart while it was left unattended in the hallway. On [DATE] at 8:50 AM, during medication administration on nursing unit 2M, in the presence of LPN #1, the surveyor identified that two different unsampled residents' pre-filled insulin pens were stored together in one plastic bag labeled for one resident in the medication cart. LPN #1 stated at this time, that the second pen must have been placed into the wrong bag. On [DATE] at 9:40 AM, while observing medication administration on 3M nursing unit, the surveyor observed LPN #2 enter a resident's room and did not lock the medication cart while it was left unattended in the hallway. On [DATE] at 1:02 PM, the surveyor interviewed the Director of Nursing (DON) who stated that medication should be locked behind a locked door in the medication room, and the medication cart should be locked when unattended by the nurse. The DON also confirmed that only medication and a thermometer to monitor the refrigerator temperature should be stored in medication refrigerators, and food should never be stored in the medication refrigerator. The DON stated that any multidose medication that had been opened should always be properly labeled and dated. Furthermore, the DON stated that medication labeled for one resident should not be kept in a bag labeled for a different resident which could potentially lead to the wrong medication to be given to the wrong person. On [DATE] at 11:02 AM, in the presence of LPN #3, the surveyor observed nursing unit four main (4M) A side medication cart which had a total of 24 loose medication pills of various colors and sizes in the bottom of the drawers. At this time, LPN #3 informed the surveyor that there should not be loose pills in the medication carts. On [DATE] at 11:28 AM, in the presence of LPN #2, the surveyor observed nursing unit 3M A side medication cart which had a total of 59 loose medication pills of various colors and sizes in the bottom of the drawers. On [DATE] at 12:07 PM, in the presence of LPN #1, the surveyor observed nursing unit 2C medication cart which had a total of six (6) loose medication pills of various colors and sizes in the bottom of the drawers. On [DATE] at 1:21 PM, in the presence of the Licensed Nursing Home Administrator (LNHA), the DON informed the surveyor that there should not be loose medication in the medication carts and that the medication carts should be checked by each nurse to make sure it is not messy. A review of the facility's undated Storage of Medications policy included: 1. drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received . 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . 4 .shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing system. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secure location. Medications must be stored separately from food and must be labeled accordingly. 10. Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. A review of the facility's undated Administering Medications policy included: 7. Check the expiration date on the medication label. When opening a multi-dose container, place the date on the container . 9. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide . N.J.A.C. 8:,d+[DATE].4

Based on observation, interview 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 and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 01/03/2023 at 9:45 AM, the surveyor toured the kitchen, in the presence of the Food Service Director (FSD) and observed the following: In the dry storage room, there was a red food coloring bottle with the date written on it of October 2020. The FSD discarded the bottle and confirmed that the item should have been thrown away. The surveyor selected random cans from the non-dented shelf and observed 2 dented cans on the non-dented can shelf. The FSD removed the 2 dented cans, placed them on the dented can's shelf and confirmed the cans should not have been there. On the clean dry rack, the surveyor observed a personal disposable cup with a straw sticking out of it. The FSD confirmed the cup should not be placed on the clean dry rack with the clean dishes and immediately discarded it. The surveyor further observed on the clean dry rack, 3 plastic plate covers that had food particles on the plate covers and observed 2 coffee pots, along with a large metal flat pan on the clean dry rack that were visibly dirty. The FSD confirmed that the 3 plastic covers, the 2 coffee pots, and the large flat metal pan were all visibly dirty on the clean dry rack. Review of the facility's policy CCS Dating and Labeling policy dated 11/05/2022, revealed the kitchen will assure food safety by maintaining proper dates and labels for all ready to eat products. 2. all food items will be labeled with a recived date .and 5. discard all foods that expire immediately. Review of the facility's Dented Can policy dated 07/06/2022, revealed kitchen will receive quality acceptable canned goods. Uacceptable, dented canned goods will be reported and returned/discarded in a timely manner. 2. upon discovery, place dented can in the designated Dented Can area. Review of the facility's General kitchen cleaning policy undated, revealed the staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. NJAC 8:39- 17.2

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris. This deficient practice was evidenced by the following: On 01/03/2023 at 10:30 AM, the surveyor accompanied by the Food Service Director (FSD) took an exterior tour of the designated facility's garbage area. In the area, was a trash compactor and a dumpster. The surveyor and FSD observed the area around the facility's trash compactor and dumpster were littered with trash, which included plastic wrappers, cardboard boxes, empty containers, paper, and other unidentifiable objects. There were also two cardboard boxes laid across two holes that were filled with water from the rain. On the same date and time, in an interview, the FSD confirmed that the area was dirty and should remain clean at all times and confirmed the cardboard boxes over the holes in the ground that were filled with rainwater. The FSD removed the cardboards and threw them away. The facility's policy revealed To maintain at all times the dumpster area is clean and organized. 3. If any trash blows out of the trash can or you drop any trash on the ground or around the dumpster, you are responsible to pick it up (tie up the bags first). If you make a mess by the dumpster when throwing out garbage, you must clean it up. NJAC 8:38-19.3(c)

Based on observation, interview, and record review, it was determined that the facility failed to provide pressure relief to prevent the worsening of a pressure sore for Resident #12. This resulted in the deterioration of the pressure sore from a Stage II superficial wound to a Stage IV full-thickness pressure sore that became infected, requiring treatment with an antibiotic. In addition, the facility failed to provide pressure relief for Resident #18 who had a history of [REDACTED].#12 and #18, 2 of 9 residents reviewed for care provided to prevent pressure sores and to facilitate healing and was evidenced by the following: 1. During the initial facility tour on 2/27/13 at 10:30 a.m., the Registered Nurse (RN) told the surveyor that Resident #12 had a facility-acquired "Stage II sacral pressure sore." At 11 a.m., the surveyor observed 2 Certified Nursing Assistants (CNA1 and CNA2) in the resident's room. Resident #12 was out of bed in a recliner "geri-chair." There was no pressure relieving cushion in the recliner. The resident was moaning and calling out repetitively. Both CNAs confirmed that the resident usually gets out of bed "around this time." On 3/4/13 at 8:50 a.m., the surveyor observed Resident #12 lying in bed asleep. At 10:25 a.m., the surveyor observed the resident sitting in the geri-chair in the hall across from the nursing station. The surveyor observed that the resident exhibited facial grimacing and was calling out "Oh" repetitively. There was no pressure relief cushion observed in the geri-chair. The surveyor reviewed the medical record on 3/5/13. A physician order [REDACTED]." The location of the blister was not identified, however the corresponding Comprehensive Care Plan (CCP) initiated "1/13" indicated that the blister was on the resident's buttocks. The CCP was updated on 1/25/13 to reflect that the wound was now an "open blister." The interventions in place included a "pressure relief chair pad." A Physician order [REDACTED]. Documentation in the medical record included weekly evaluations and treatment from a visiting wound care company. The Patient Visit Record (PVR) dated 1/30/13 indicated that Resident #12 had a Stage II, "partial-thickness ulceration of the right gluteus, 1.2 x 1.0 cm (centimeters)" which was determined to be caused by pressure to the area. Interventions included "off-load pressure on area" and "w/c cushion." A PO dated 3/1/12 indicated the "Use of regular wheelchair with elevated leg rests and gel cushion." An Occupational Therapy Discharge Summary dated 1/25/13 indicated that Resident #12 had poor balance control and safety awareness and needed to use a "geri-chair" when out of bed. In addition, the resident was to use the geri-chair "as tolerated." The wound evaluation PVR dated 2/6/13 indicated that in 1 week, the resident's wound deteriorated to a Stage III, full-thickness pressure ulcer that increased in size to 1.5 x 1.5 cm. At that time, the treatment was changed to Santyl, a [MEDICATION NAME] agent, and recommendations for pressure relief remained in place. The PVR dated 2/27/13 indicated that an "abscess" had developed in the "full-thickness ulceration of the right gluteus" that now measured 1 x 1.5cm with a 1cm depth. The treatment was changed at that time to "[MEDICATION NAME]" (medicated gauze strip) packing daily and when necessary. A PO dated 2/27/13 for a "wound culture" was ordered and the results received on 3/1/13 reflected an active infection. As a result, Resident #12 was started on the antibiotic [MEDICATION NAME] 250mg daily for 7 days. On 3/5/13 at 9:35 a.m., the surveyor observed the wound treatment in the presence of a Licensed Practical Nurse (LPN), a Registered Nurse (RN) and CNA1. The surveyor observed that when the resident was positioned to the left side, the cover gauze was not in place over the soiled packing. The exposed packing was 100% soiled with drainage. The RN assessed the drainage as "moderate to large [MEDICAL CONDITION]." When the packing was removed, the surveyor observed a full-thickness Stage IV open wound. The wound was not measured at this time. At 10:45 a.m., the surveyor observed Resident #12 in the hallway positioned in the geri-chair moaning "Oh, Oh" repetitively. There was no pressure-relieving cushion in the chair. During an interview at this time, CNA3 told the surveyor that Resident #12 used to be in a regular w/c with a cushion, but has been using the geri-chair without a cushion for "about 2-3 months." On 3/5/13 at 11 a.m., the Unit Manager (UM) told the surveyor that the resident's chair was changed to a geri-chair on 1/31/13 because the resident "couldn't tolerate a regular w/c." The UM confirmed that a cushion should have been used for pressure relief in the geri-chair and it was not. During an interview on 3/6/13 at 8:45 a.m., CNA4 told the surveyor that she worked the 3-11 p.m. shift and Resident #12 was "always out of bed" when she started the shift. CNA4 stated "I'm the one who puts (the resident) back to bed." CNA4 told the surveyor that the resident was put back in bed "around 3 p.m." which would indicate that Resident #12 had been out of bed in a geri-chair for approximately 4 hours daily without pressure relief since 1/31/13. On 3/6/13 at 10:25 a.m., the surveyor reviewed the Treatment Administration Record for that day which indicated that the wound was assessed as a Stage IV with an increased size of 2 x 1.5 x 1cm. The treatment was changed to cleanse with 1/4 strength Dakin's Solution prior to packing with the [MEDICATION NAME] gauze strip. During an interview at 10:40 a.m., the Nurse Practitioner (NP) told the surveyor that the wound was now being called "an abscess" although until that time it was assessed as a pressure sore. The treatment was changed because the drainage from the wound was maloderous. The NP confirmed that the wound was infected and the resident was being treated with an antibiotic. The NP further stated being unaware that Resident #12 sat in a geri-chair daily with no pressure-relieving cushion and that the resident "absolutely should have had a gel-cushion in the chair to relieve pressure" and to prevent further deterioration. Refer to F281 2. During the initial tour on 2/27/13 at 10 a.m., the Charge Nurse told the surveyor that Resident #18 was confused and had an open wound on the left great toe and was currently being treated with antibiotics. The surveyor observed the resident seated in a wheelchair with pressure relief heel boots on both feet. The surveyor reviewed Resdient #18's medical record on 3/4. The resident was admitted to the facility on [DATE] and according to the initial nursing assessment the resident had redness to both heels. The resident was hospitalized on ,[DATE] and readmitted to the facility on [DATE]. Upon readmission the resident had a 1 cm. by 0.5 cm. dry scab on the right heel and a 0.5 cm. by 0.5 cm. dry scab on the left heel. A physician order [REDACTED]. According to the Wound Care notes, on 2/20/13 the right heel had a "partial thickness" wound measuring 0.2 cm. by 0.3 cm. and the left heel had a "dry callous." The note included to "off load pressure on area" and apply "heel boots." The surveyor observed Resident #18 on 3/5 at 10 a.m. seated at the bedside in a wheelchair. The resident was wearing socks and both feet were on the bilateral plastic footrests. The surveyor observed the resident again at 12:25 p.m. seated in the wheelchair wearing socks and both feet were directly on the plastic footrests. At both times the surveyor observed foam heel boots across the room on top of the wall-mounted heating unit. The surveyor observed the resident in bed on 3/6 at 8:45 a.m. Both of the resident's heels were directly on the mattress. They were not "off loaded." The surveyor returned to the room at 9:05 a.m. to observe the nurse provide treatment to the resident's great toes and heels. At that time both feet were lifted off the bed surface with a blue foam lift cushion. The surveyor observed the nurse apply skin prep to both heels which were healed. The nurse then treated the great toes on both feet and wrapped them in gauze. The surveyor returned to the resident's room at 12:05 and observed the resident in the wheelchair. The resident had nothing on the right foot except for the gauze wrap and had a foam heel boot on top of her right great toe. The skin on both heels was exposed and the resident's heels were directly on the plastic footrests. There was no pressure relief in place. The surveyor returned to the resident's room at 12:15 p.m. with a nurse. The nurse confirmed that the resident should have pressure relief to both feet while seated in the wheelchair. NJAC 8:39-27.1(a)