Every finding on record at Continuing Care at Seabrook

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to have a process in place to ensure that consistent communication between the facility and the hospice provider occurred for the coordination of resident care. This deficient practice was identified for one 1 of 1 resident reviewed for hospice care (Resident #35) and the deficient practice was evidenced by the following:On 3/4/26 at 10:09 AM, the surveyor observed Resident #35 seated in a recliner and was non-verbal. The surveyor then reviewed the electronic and paper medical record for Resident #35. According to the Face sheet, an admission summary, Resident #35 was admitted to the facility with diagnoses which included but were not limited to; Parkinson's Disease (a movement disorder of the nervous system that worsens over time), unspecified dementia (decline of cognitive function), and chronic kidney disease (progressive damage and loss of kidney function). A review of the quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care and was dated 2/4/26, reflected a Brief Interview for Mental Status (BIMS) was not conducted since the resident was rarely/never understood. Additionally, the qMDS revealed the resident was dependent for all activities of daily living such as eating, dressing, shower/bathing, oral, personal and toileting hygiene. Further review of the qMDS reflected the resident was always incontinent for bladder and bowel functions with risk of developing pressure ulcer/injuries. Section O0110 indicated Resident # 35 received Hospice care. A review of the 2/4/26 Holistic Care Plan included that Hospice was responsible for the oversight of the resident's medication management. A review of the medical record reflected that on 3/24/25 at 10:30 AM, Resident #35 was admitted to hospice services. Further review of the hospice communication record revealed the last skilled nursing visit note was on 1/29/26. On 3/5/26 at 10:47AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the Hospice nurse documented notes under the Hospice tab of the physical chart (chart) for the residents they assessed. At that time, the surveyor and the LPN reviewed the chart together. The LPN confirmed that the most recent hospice note located in the medical record was dated 1/29/26, and the LPN could not located a more recent note. On 3/5/26 at 11:01 AM, the surveyor interviewed the Assistant Director of Nursing (ADON)/Unit Manager (UM) who stated that she did not know the Hospice nurses scheduled visit times with Resident #35. When asked who was the facility's designated interdisciplinary team (IDT) member that communicated with Hospice, the ADON/UM stated the nurses communicated with the Hospice nurse and the Hospice nurse was expected to place Resident #35's progress notes into the medical record. The ADON/ UM also stated that after each visit the Hospice communication note should be reviewed by the nurses, in addition to any verbal report that was received from the Hospice nurse. The ADON/UM informed the surveyor that the IDT team met with the Hospice nurse quarterly. On 3/6/26 at 11:08 AM, during an interview with the surveyor, the Hospice Nurse (HN) stated that during her visits she conducted a nursing assessment of the residents on hospice weekly unless a change of condition occurred. When asked why the progress notes from 1/30/26 to 3/5/26 were not in the medical record, the HN stated that there is no guidelines for the communication, and there is no time frames and therefore is not required to have them placed in the medical record. On 3/6/24 at 2:02 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), the Administrator in Training (AIT) and the Director of Nursing (DON), the surveyor discussed the concern regarding the inconsistent documented coordination of communication between Hospice and the facility to ensure that the needs of the resident were addressed and met 24 hours per day . Resident #35's hospice progress notes that included recommendations, the Hospice plan of care and assessment results were not readily available for the entire IDT members to review. Additionally, the surveyor discussed the concern that the IDT members did not identify that the hospice notes were missing from 1/30/26 to 3/5/26. On 3/9/26 at 9:19 AM, during an interview with the surveyor, the Social Worker (SW) stated that Hospice communicated psychosocial recommendations by writing in a piece of paper, any changes and the resident's status. The SW also stated that she had communication with the HN and the family on 2/16/26 for the quarterly meeting without the physician present. The surveyor asked the SW, if not having the Hospice progress notes from 1/30/26 to 3/5/26 readily available for the IDT member an acceptable standard of practice. The SW stated that it was not an acceptable process, and the documents should be readily available for the IDT. On 3/9/26 at 11:16 AM, in the presence of the survey team, the LNHA, and the AIT, the DON stated that she reviewed the facility policy which indicated that a documentation after a visit and without a time frame. At that time, the DON stated that there were at least three (3) weeks of notes that were not provided to the facility and had not been reviewed by the facility staff. A review of the facility provided policy titled, Hospice Program, dated 5/2021, under Section 7 indicated: After each hospice visit, hospice staff will provide the clinical/care team [with] a copy of visit notes which is placed in resident's paper medical record. Under Auditing/Monitoring, included that any variances related to non-compliance with this policy will be identified and reported to the department head. A review of the Hospice and Nursing Facility Services Agreement signed and dated 1/26/22, included under section 12.3 Compliance Program that Hospice acknowledged that the Facility has provided Hospice with information regarding Facility's corporate compliance program. NJAC 8:39-27.1(a)

Based on interviews and review of pertinent facility documents, it was determined that the facility failed to investigate an allegation of potential resident to resident abuse by a resident who displayed aggressive behaviors toward staff and other residents, when on 8/2/25 Resident #5 threw a shoe at another resident who was sitting in the living room of the facility. This deficient practice was identified for 1 of 3 residents reviewed for incident/accidents and was evidenced by the following: On 3/4/26 at 9:20 AM, the surveyor observed Resident #5 independently ambulating and was exiting another resident's room. Resident #5 was also observed holding multiple stuffed animals and dolls in their hands. On 3/5/26 at 10:30 AM, the surveyor reviewed Resident #5's medical record at that time, which revealed a Face Sheet (admission Summary) that revealed diagnoses included, but were not limited to, Alzheimer's Disease, Post -Traumatic Stress Disorder (PTSD), and Behavioral Disturbances. A Physician Note, dated 8/25/25 revealed ongoing behavior issues and was being closely followed by psychiatry .many episodes of aggressive behavior in the last few weeks and was sent to crisis evaluation . very confused and disorientate .The Assessments section revealed: Dementia with behavioral disturbance; Alzheimer's disease; Paranoia; Aggressive behavior; Generalized anxiety disorder and PTSD. The Care Plan which revealed that Resident #5 had behavior of being confused and agitated, disruptive and aggressive toward staff and other residents.On 3/5/26 at 11:15 AM, the surveyor reviewed a progress note dated 8/2/25, with the Registered Nurse Clinical Manager (RNCM). The notes revealed the following: Around 3:00 AM, Resident #5 wandered the hallways yelling, banging on the walls and threw a shoe at another resident in the living room. Resident #5 charged at staff with closed fists when being approached. Redirection was not effective. Supervision provided at a safe distance. Actions (referring to the behaviors) continued until 7:00 AM.On 3/5/26 at 12:05 PM, the surveyor interviewed the RNCM and requested any investigation or any incident report regarding the resident throwing a shoe at another resident, and any supporting documentation, including any statements taken. The RNCM informed the surveyor that there was no incident report for the above concerns, and the facility did not collect statements from any witnesses.On 3/5/26 at 12:45 PM, the surveyor requested from the DON any investigations for Resident #5. The DON provided 2 fall incidents. The documented incident of 8/2/25 was not provided. On 3/6/26 at 1:15 PM, the surveyor further reviewed the electronic medical record (EMR) for Resident #5. The Quarterly Minimum Data Set (MDS) dated [DATE], reflected that Resident #5 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of severe cognitive impairment. A review of the resident undated Care Pan provided by the facility reflected a focus under medications, I am taking antipsychotics medications. These are the following Actions/ Expressions I exhibit/exhibited to support use of antipsychotic medications: combative with staff, easily agitated toward peers. I got overwhelmed easily.On 3/6/26 at 12:30 PM, the surveyor interviewed the Director of Nursing and requested again any incident for 8/2/25. The DON stated that she did not have any incident reports for any incident dated 8/2/25. On 3/6/25 at 1:29 PM, the surveyor conducted an interview with the Licensed Practical Nurse (LPN) assigned to the Unit. The LPN could not comment on the incident; she was not the author of the clinical notes dated 8/2/25. The LPN confirmed that Resident #5 displayed aggressive behaviors toward staff and other residents.On 3/9/25 at 10:15 AM, no documentation/ investigation was provided by the facility.On 3/9/26 at 11:30 AM the surveyor reviewed the facility's policy titled, Abuse Reporting and Investigation with the Director of Nursing and the Licensed Nursing Home Administrator (LNHA) and inquired if the incident of 8/2/25 had been investigated and reported. The LNHA stated that she was not at the facility when the incident had occurred. The DON stated that the concern should have been investigated and reported to the Department of Health. The surveyor asked the DON if throwing a shoe at another resident could be considered abuse? The DON stated yes, and she would look for the investigation.On 3/6/25 at 12:15 PM, in the presence of the survey team the DON stated that there was no investigation for the incident of 8/2/25. The DON stated that this incident should have been investigated and reported to the Department of Health (DOH). The surveyor then asked if the other resident was assessed and what was then done to protect other residents, the facility did not have any documentation to provide. The DON confirmed there was nothing to provide regarding the incident. A review of the facility's Abuse, Reporting and Investigation last revised 5/2021, revealed the following:The community referring to the facility will investigate all suspected or alleged incidents of resident abuse, mistreatment, neglect, exploitation, involuntary seclusion, including injuries of unknown source and misappropriation of property. All incidents which met the definition of a reportable event as contained in this document will be recorded on an Incident Reporting form and reported as indicated. The Administrator, for the Health Services business line, the Practice Manager and the Health and Wellness Nurse Practitioner have ultimate responsibility for the incident reporting and investigation process.If a resident is alleged to have abused another, the residents involved are separated and contact between them is limited and monitored. Contact between the alleged resident abuser and other residents are monitored closely.When an incident, adverse event or near miss occurs, the staff knowing of the event must immediately notify the Practice Manager. The Practice Manager is responsible for completing the Support Services Incident Report within 24 hours of the event. It is essential that each section of the incident report be completed in full to prevent loss of valuable information. NJAC 8:39-27.1(a)

Based on interview and document review, it was determined that the facility failed to ensure they reported to the Department of Health (DOH) as required, an allegation of resident- to- resident abuse. Resident #5 had behavior of being aggressive toward staff and other residents. According to the clinical notes dated 8/2/25, Resident #5 threw a shoe at another resident who was sitting in the living room of the facility. The other resident was not identified and the incident was not reported. This deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #5) and was evidenced by the following:On 3/4/26 at 9:20 AM, the surveyor observed the resident exited a room with multiple stuffed animals and dolls in their hands. At 10:30 AM, that same day, a Certified Nursing Aide (CAN) identified the resident as Resident #5. On 3/5/26 at 10:30 AM a brief review of the electronic medical record revealed that Resident #5 displayed aggressive behavior toward staff and other residents. A clinical note dated 8/2/25 created by a Licensed Practical Nurse (LPN) on 08/02/25 at 7:35 AM, revealed that around 3:00 AM, on 8/2/25 Resident #5 was yelling, banging on the wall and threw a shoe at another resident who was sitting in the living room of the facility.On 3/5/26 at 11:20 AM, the surveyor reviewed the Clinical Notes with the Registered Nurse Clinical Manager (RNCM) and requested the investigation for review. The RNCM informed the surveyor that it was not an incident that required an investigation. The surveyor then asked for any statement that was collected regarding the incident. The RNCM stated that the facility does not collect statements from witnesses. The nurse would speak to the staff who had knowledge of the incident and documented the incident in the clinical notes.On 3/5/26 at 1:15 PM, the surveyor reviewed Resident #5 medical record. The admission Face Sheet, an admission summary reflected That Resident #5 was admitted to the facility with diagnoses which included but were not limited to; dementia with behavioral disturbances, anxiety, depression and Post Traumatic Stress Syndrome (PTSD).The Quarterly Minimum Data Set (MDS) dated [DATE], reflected that Resident #5 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of severe cognitive impairment. A review of the resident undated care plan provided by the facility reflected a focus under medications, I am taking antipsychotics medications. These are the following Actions/ Expressions I exhibit/exhibited to support use of antipsychotic medications: combative with staff, easily agitated toward peers. I got overwhelmed easily.The interventions included: before administering medications, redirecting me to a quiet area, offer 1:1 support. On 03/05/25 at 11:30 AM, the surveyor asked the RNCM if the above concerns was reported to the Director of Nursing (DON). The RNCM stated that the incident was discussed in the morning meeting, and the DON was aware. The surveyor then asked the RNCM if the other resident was assessed, the RNCM could not comment on the incident or any follow-up that was done. On 3/6/25 at 1:29 PM, the surveyor conducted an interview with the Licensed Practical Nurse (LPN) assigned to the Unit. The LPN could not comment on the incident; she was not the author of the clinical notes dated 8/2/25. The LPN confirmed that Resident #5 displayed aggressive behaviors toward staff and other residents.On 3/6/26 at 2:15 PM, the above concerns were discussed with the DON and the Licensed Nursing Home Administrator. The team then inquired if the incident was reported to the DOH. The DON confirmed that the incident was not reported to the DOH.On 3/9/26 at 10:30 AM, the Team Coordinator asked the facility administrative staff if the incident was reported to the DOH. The LNHA stated that she was on a leave of absence at that time and could not comment further on the incident. The DON stated that the incident should have been investigated and reported to the DOH. The DON added that she would look further. On 3/9/26 at 12:20 PM, a surveyor interviewed the LPN who wrote the clinical notes on 8/2/25. The LPN stated that she could not remember the incident nor identified the other resident.On 3/9/26 during the pre-exit conference, the facility was unable to provide documentation that the incident was reported to the DOH. A review of the facility's policy titled, Abuse Reporting and Investigation last revised, 5/2021, revealed the following under ReportingEach staff member must report any actual/known, suspected or alleged incident of physical abuse, neglect, financial abuse to the community leader. This includes incidents/actions that the staff member observes, suspects or is informed of by a resident. Under the Elder Justice Act, staff in nursing homes have an additional responsibility to report incidents to the state survey agency and law enforcement.The supervisor along with the Executive Director/Associate will initiate an investigation and will report the alleged abuse to the proper state agencies immediately or as soon as possible within 24 hours per the laws or regulations for service line involved.NJAC 8:39-5.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that all eligible residents were educated and offered the pneumococcal vaccination (vaccine) to prevent incidence of pneumonia. The deficient practice was identified for 2 of 5 residents reviewed for immunizations (Resident #23 and Resident #40), and was evidenced by the following: 1. On 9/8/24 at 10:44 AM, during initial tour of the facility, the surveyor observed Resident #40 in the activity room sleeping upright in their wheelchair. On 9/9/24 at 10:27 AM, the surveyor reviewed the medical record for Resident #40. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses included but not limited to; dementia, major depressive disorder, and generalized weakness. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 8/30/24, reflected that the resident had a brief interview for mental status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition. A review the electronic Medical Record (eMR) did not include documentation that the resident received or declined the pneumococcal vaccination. On 9/10/24 at 11:19 AM, the surveyor with the Unit Manager/Registered Nurse (UM/RN #1) reviewed Resident #40's eMR, and UM/RN #1 confirmed there was no documentation that the resident received or declined the pneumococcal vaccination. UM/RN #1 stated that she would follow-up with the Infection Preventionist (IP) to see if they had any further information. When asked who was responsible for obtaining the vaccination consent or declination and maintaining the vaccine records, UM/RN #1 stated the IP and the facility was responsible. On 9/10/24 at 12:15 PM, the surveyor in the presence of UM/RN #1 and the survey team interviewed the IP, who stated that Resident #40's family refused the pneumococcal vaccination, but the facility was still working on the long-term care process for declinations. When asked if there was any documentation of the refusal, the IP responded that she was working on that now to get it. The IP confirmed that the declination should have been obtained prior to surveyor inquiry and that the responsibility of maintaining the vaccine records was a collective between herself and the clinical team. On 9/12/24 at 11:22 AM, the Director of Nursing (DON) in the presence of the Administrator in Training (AIT #1), AIT #2, and survey team, acknowledged that the resident's declination for the pneumococcal vaccination should have been obtained prior to surveyor inquiry. 49094 2. On 9/8/24 at 10:08 AM, during initial tour of the facility, the surveyor observed Resident #23 in their bedroom lying in bed watching television. On 9/9/24 at 12:26 PM, the surveyor reviewed the medical record for Resident #23. A review of the Admission Record face sheet reflected that the resident was admitted to the facility with diagnoses including but not limited to; chronic obstructive pulmonary disease, hypertension (high blood pressure), congestive heart failure (heart muscle does not pump blood as well as it should), and hypertensive chronic kidney disease (elevated blood pressure caused by kidney disease). A review of the most recent quarterly MDS dated [DATE], reflected the resident had a BIMS score of 10 of out of 15, indicating a moderately impaired cognition. A review of Section O0300 indicated Resident #23's pneumococcal vaccine was up to date. A review of the Vaccine Administration Record revealed that the pneumococcal vaccine was administered on 8/29/16. A review of the (eMR) did not include documentation that the resident was offered and declined the vaccination upon admission. On 9/10/24, the surveyor requested the Pneumococcal Vaccine Consent Form declination form from the IP. On 9/10/24 at 12:33 PM, the surveyor interviewed the IP who stated that the pneumococcal vaccine administered on 8/29/16, was the most up to date vaccine for Resident #23. The IP stated that the facility was putting a system into place for the long-term care residents to offer vaccines to the residents upon admission. The IP confirmed that the resident was eligible for the pneumococcal vaccine, but was not offered. The IP was unable to provide any declination documentation. On 9/12/24 at 11:22 AM, the DON in the presence of AIT #1, AIT #2, and the survey team, provided the surveyor with a Pneumococcal Vaccine Consent Form declination for Resident #23 dated 9/10/24. The DON confirmed that the declination should have been obtained prior to surveyor inquiry. On 9/12/24 at 11:45 AM, the surveyor in the presence of the DON, AIT #1, AIT #2, and survey team, interviewed the Medical Director, who confirmed that Resident #23 should have been offered pneumococcal vaccine. A review of the facility's Infection Prevention and Control Preventing Transmission of Infectious Agents Process: Screening and Vaccinations policy dated June 2021, included .4. vaccines will be offered to residents and staff when available unless the immunization is medically contraindicated or the resident/staff has already been immunized . 6. the resident, resident representative, or staff member will have the opportunity to accept or refuse a vaccine and may change their decision at any time .documentation of refusal will be completed in the resident's EMR or the employee's health record .8. the resident's medical record and the employee's health record will include documentation that indicates [ .] if the resident did not receive the vaccine that this was due to medical contraindications or refusal . NJAC 8:39-19.4(i)

Based on observation, interview, record review and review of facility policy, it was determined that the facility failed to ensure the facility policy was followed to identify and adequately monitor target behaviors for residents receiving psychoactive drug therapy for 2 of 2 residents (Residents #27 and #33) reviewed for use of psychoactive medication use. The deficient practice was evidenced by the following: 1. On 08/22/23 at 10:05 AM during the initial tour, the surveyor observed Resident #27 sitting in the room and a visitor was at the bedside. The surveyor knocked on the door and was prompted by the visitor to enter the room. The surveyor explained the purpose of the visit to both the resident and the visitor. The visitor identified himself as the resident's representative and agreed to engage in a conversation with the surveyor at a later time. On 08/23/23 at 9:15 AM, the surveyor observed Resident #27 in the dining room area eating breakfast. On 08/25/23 at 7:45 AM, the surveyor observed Resident #27 asleep in bed. The resident representative was observed in the room. The surveyor observed two landing pads on each side of the bed. An interview with the representative revealed that Resident #27 could be aggressive at times with care givers. He stated that Resident #27 was recently hospitalized for Pneumonia (lung inflammation caused by bacteria or viral infection) and the visitor further stated that they were looking forward to taking the resident home. On 08/25/23 at 10:15 AM, the surveyor reviewed Resident #27 medical record. The Admission Face Sheet (an admission summary) reflected that Resident #27 was admitted to the facility with diagnoses which included, but were not limited to, pneumonia due to other specified infectious organisms, Alzheimer's Disease, unspecified dementia in other disease classified elsewhere, chronic obstructive pulmonary disease with lower respiratory infection, and acute respiratory failure with hypoxia. The admission Minimum Data Set (MDS) with an assessment reference date of 07/18/23, revealed that Resident #27 scored 02 out of 15 on the Brief Interview for Mental Status (BIMS) which was indicative of a severely impaired cognition. The Comprehensive Care Plan (CP) initiated 07/14/23 indicated under Cognitive Patterns, Mood, and Expressions #13 Goal(s) the following: I would like to have 6-8 hours of sleep throughout the night. Staff will be able to assist me to decrease the episodes of negative outbursts and or expressions throughout my stay. I become anxious when I am unable to remember things. This is how I exhibit or express anxiety, upset and agitated. The CP for Resident #27 did not address all behaviors exhibited by the resident. Resident #27 had physician's orders for the following psychoactive medications: Seroquel (Antipsychotic used to treat schizophrenia, bipolar disorder and depression) 25 milligrams (mg) tablet daily for mood disorder. 1(tab) Tablet Oral every day for mood disorder. Depakote Sprinkles (anticonvulsant used to treat bipolar disorder) 125 mg capsule, delayed release (2 caps) Capsule every twelve hours. Xanax (sedative used to treat anxiety and panic disorder) 0.25 mg tablet 1 tablet as needed every 8 hours as needed for anxiety. The psychiatry Progress Note dated 08/16/23, indicated the following: Patient reevaluated for Dementia, Mood Disorder, Anxiety. Nursing staff continue to report increased in agitation, yelling, hitting, difficulty to redirect during episodes, spits out oral anti-anxiety medications. On examination, patient [referring to Resident #27] was confused. Thought process is impoverished. Patient is likely to benefit from topical anti-anxiety medication as oral medication is sometimes not effective (spitting out). Plan: 1. Always consider supportive and individualized non-pharmacological interventions. Treat medical issues. Encourage participation in activities, social engagement as tolerated and as possible for psychosocial well-being. 1. Add Ativan gel 1 mg /ml (milliliter) topical every 12 hours as needed for anxiety. Continue will all current treatments, Benefit greater than risks. Resident #27 had diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was recently admitted with hypoxia and the oxygen saturation would drop at times and causing him/her to be anxious. On 08/29/23 at 8:57 AM, during an interview with the Clinical Coordinator Registered Nurse (CC/RN), she stated that Resident #27 had episodes of disruptive behavior, kicking, cursing and yelling. The psychotropic medication was prescribed during the resident hospitalization for agitation and altered mental status. The CC/RN further stated on 08/29/23 at 10:30 AM, that if the resident displayed target behaviors, they would be included in the nurses notes and then summarized monthly. The surveyor requested the monthly summary notes regarding the psychoactive medications and behaviors, and the facility was unable to provide. On 08/29/23 at 11:37 AM, during an interview with the the CC/RN and the Assistant Director of Nursing (ADON) both revealed that resident documentation was completed by exception. The ADON stated that the Certified Nursing Assistant (CNA) would ask questions from the Action and Expression Touch Screen, then document their answers and then report the information to the nurse. The nurse would then enter their documentation in the monthly summary. The surveyor requested the Action and Expressions Form for review. The surveyor reviewed the medical record and the following behaviors were entered in the progress notes for Resident #27: 07/13 07:05 AM, disrobing. 07/20/23 3:49 PM, agitated during lunch, shout[ing] at other residents, cursing. Agitated the other residents. 07/22/23 06:19 AM, agitation. 08/04/23 04:39 PM, agitation, restless, arguing with staff and residents. Continued to display Actions and Expressions. Swing arms at staff and residents. 08/11/23 2:35 PM, yelling, resistant with staff. 08/16/23 7:50 PM, spitting using foul language. On 08/30/23 at 12:27 PM, during a pre-exit conference with the administrative staff, the Director of Nursing (DON) stated that target behaviors for psychoactive medications were documented on the Activities of Daily Living Flow Sheet (ADLs) Form Action and Expression Touch Screen and she would provide the documentation in the morning. On 08/31/23 at 8:27 AM, the ADON in the presence of the survey team, stated that the CNA's failed to document the behavior on the ADLs Touch Screen Action and Expression. The ADON provided the CNA's documentation for the resident which documented, No behavior. On 08/31/23 at 9:30 AM, when the nurses notes were reviewed, along with the documentation from the Actions and Expressions Touch Screen provided by the facility for the corresponding time periods (07/13/23-08/29/23), the CNAs documentation did not include any behavior entries for the number of behavior incidents reportedly displayed and were documented in the medical record. 2. Resident #33 was admitted to the facility with diagnoses which included, but was not limited to Bipolar Disorder, major depressive disorder and anxiety. On 08/22/23 at 10:30 AM, the surveyor observed Resident #33 in the room and the resident was awake and alert and able to maintain a conversation. On 08/24/23 at 11:30 AM, the surveyor reviewed the medical record which revealed that Resident #33 was prescribed the following psychoactive medications: Seroquel 350 mg at bedtime for Bipolar disorder Seroquel 25 mg every one day for Bipolar Disorder. Depakote 250 mg tablet, 1 tablet twice daily for Bipolar Disorder. Bupropion Hydrochloride (medication used to treat anxiety) (100 mg) daily for bipolar Disorder current episode mixed. moderate. Ativan (medication used to treat anxiety) 0.5 mg as needed at bedtime for anxiety disorder. On 08/28/23 at 11:30 AM, the surveyor interviewed the resident regarding the prescribed medications. Resident #33 informed the surveyor that he/she could not recall all the medications prescribed, however he/she had been diagnosed with mental illness a long time ago. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #33 was able to make his/her needs known. Resident #33 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of an intact cognition. The Comprehensive Care Plan (CP) dated 08/10/23 which did not include a focus area for behavior. On 08/28/23 at 11:30 AM, the surveyor interviewed the CC/RN regarding the above medications and the target behavior that was identified and what was being monitored. The CC/RN could not identify the target behaviors for the above medications. When inquired regarding if the resident's behavior had been monitored and documented, the CC/RN stated that the behaviors were documented on the monthly summary. On 08/29/23 at 11:30 AM, the surveyor then requested the monthly summaries for review. The CC/RN could not provide the monthly summaries. A review of the nurses notes failed to identify the target behaviors that were being monitored. A review of the psychiatry consultation dated 05/01/23 indicated the following: Client was referred to [name redacted- crisis response program for the elderly ] due to become paranoid and anxious in response to being informed by staff that he/she is being transferred to a new psychiatric Nurse Practitioner. Progress notes were reviewed and there was no documentation regarding the resident exhibiting paranoid behavior. The following recommendations were suggested on the psychiatry consultation from [name redacted- crisis response program for the elderly]. 1. Have client participate in a behavioral Contract and Token Economy as a means of helping to decrease inappropriate behavior and providing positive reinforcement to encourage appropriate behavior, [name redacted- crisis response program for the elderly] recommend staff training on: ABC Tracking-Monitoring and Identifying Potential Triggers to behaviors (Assessment tool used to gather information that should evolve into a behavior implementation plan). The same recommendations were again documented on 06/13/23. When interviewed on 08/29/23 at 11:00 AM, the CC/RN confirmed that monthly summaries to monitor behaviors for Resident #33 were not being completed. The target behaviors were not identified or documented. The Patient Care associate [CNA] could not comment on the behavior. Upon inquiry the staff that were assigned to Resident #33 stated that the resident was attention seeking and would lower him/herself on the floor to get staff into the room. The staff did not state that the resident had been aggressive toward staff. The behavior was not captured on the ADL's Touch Screen Action and Expression. The CNA's indicated in their documentation that the resident did not exhibit any behaviors. On 08/30/23 at 12:33 PM, the DON stated that the CNA's documented the behavior on the computer, reported the behaviors to nursing and then the nurse would complete the monthly summary. On 08/31/23 at 8:27 AM, the ADON in the presence of the survey team, stated that the CNA's failed to document the behavior on the ADLs Touch Screen Action and Expression for both residents Resident #27 and #33. The ADON provided the CNA's documentation which revealed all documented, No behavior. On 08/31/23 at 9:30 AM, during a pre-exit conference held with the administrator and the DON, the DON confirmed that target behaviors were not identified or documented. A review of the facility policy titled, Psychoactive Medications dated 05/2003 last updated 06/2021, revealed the following : Psychoactive medication therapy shall be used only when it is necessary to achieve specific treatment goals. Once treatment goals have been achieved, residents on psychoactive medications will receive gradual dose reductions and behavioral interventions, as clinically indicated, in an effort to discontinue these medications. Procedure: All psychoactive medication orders will contain supporting documentation to define specific goals of treatment. The minimum documentation required includes a specific diagnosis or condition, if known, or a specific target behavior. Any medication used to manage the behavior will include provider documentation of target symptoms or behaviors in the clinical record and the documentation will be sufficient to demonstrate that said behaviors are : a. Violent or dangerous to self or others. b. Extremely disturbing to the resident or other staff. c. Interfere significantly with care delivery causing adverse outcomes. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and document review it was determined that the facility failed to follow their Handwashing/Hand Hygiene policy and perform hand hygiene during a lunch meal observation. This deficient practice was observed on 1 of 2 resident units and was evidenced by the following: On 08/22/23 at 11:55 AM, during the observation of the lunch meal in the main dining area on the fourth-floor unit, a Certified Nurse Aide (CNA) #1 was observed without performing hand hygiene as follows: 11:55 AM before and after delivering a lunch tray to Resident #1. 11:59 AM before and after delivering a lunch tray to Resident #2. 12:04 PM before delivering a lunch tray to Resident #3, and then required a second tray and was taken away. 12:07 PM CNA # 1 reached into her scrub top pocket, answered her cell phone, put the phone back into her pocket and then delivered a tray to Resident #3. 12:09 PM CNA #1 dropped a pen out of her pocket and then picked it up off of the ground. CNA #1 then delivered a lunch tray to Resident # 4. 12:11 PM before and after delivering lunch tray to Resident #5. 12:13 PM before and after delivering lunch tray to Resident #6. 12:14 PM before and after delivering a cup and drink to Resident #7. 12:16 PM before and after delivering lunch tray to Resident #8. 12:19 PM CNA #1 walked away from the dining area into another room to talk on her cell phone, and then returned to continue with meal delivery without first performing hand hygiene. 12:21 PM CNA #1 exited the dining room and then returned the cell phone into her pocket. On 08/22/23 at 12:23 PM, during an interview with the surveyor, CNA #1 stated she was supposed to use hand hygiene between passing each residents meal tray. You caught me, we were just hectic. CNA #1 also stated that the cell phone in her pocket was also dirty and hand hygiene needed to be performed after using her cell phone or reaching into her scrub pocket, which she acknowledged was a dirty environment. On 08/22/23 at 12:25 PM, during an interview with the surveyor, the Licensed Practical Nurse # 1 (LPN #1) explained her job duty was to oversee meals making sure the residents were safe and not choking. LPN #1 also stated that hand hygiene must be performed before and after delivering food to prevent the spread of germs. On 08/22/23 at 12:37 PM, the Director of Nursing (DON) stated the process for the lunch meal was that dietary and nursing were present for assisting, and the nursing staff would bring in hand wipes for the residents and also assist with feeding. The DON stated, staff should perform hand hygiene in between residents for infection control. She further stated that any items in scrub pockets were considered dirty and hand hygiene should be completed. A review of the facility provided, Handwashing/Hand Hygiene policy dated 5/2019 included but not limited to: Purpose to prevent the spread of potentially infectious organism to residents/patients, staff, and visitors. Definition hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel), or surgical hand antisepsis. When to perform some form of hand hygiene (at a minimum) -After touching a resident/patient's immediate environment -Hand washing is required anytime you are handling food -When handling food, hands must be washed. Alcohol based sanitizers can not be substituted. NJAC 8:39-19.4(a); 27.1(a)

Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag (drainage bag) was stored in a way to prevent the spread of infection. This deficient practice was identified for 1 of 3 residents reviewed for the use of indwelling urinary catheters (Resident #8) and was evidenced by the following: According to the Admission Record, Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/13/22, revealed the resident had a Brief Interview for Mental Status of 04, which indicated that the resident was severely cognitively impaired. Further review of the MDS revealed the resident was incontinent, had an urinary indwelling catheter, was impaired on one side of the body and required extensive assistance of two staff for toilet use. On 03/04/22 at 9:57 AM, the surveyor observed Resident #4's drainage bag and tubing was stored in a clear plastic bag that was tied to the handrail in the bathroom. The surveyor observed that the opening of the drainage bag was open and did not have a cap applied. On 03/08/22 at 12:29 PM, the surveyor observed Resident #4's drainage bag stored in a clear plastic bag that was tied to the handrail in the bathroom. The surveyor observed that the opening of the drainage bag was open and did not have a cap applied. The surveyor further observed a blue drainage bag cap (cap) stored inside a gray bin next to the drainage bag. During an interview with the surveyor on 03/08/22 at 12:47 PM, the Care Associate (CA) assigned to Resident #8, stated the resident was incontinent, had an indwelling urinary catheter and required total assist with care. The CA further stated the resident wore a leg bag when out of bed and that the drainage bag was reattached when the resident returned back to bed. The CA added that the drainage bag was cleansed, capped and stored in a plastic bag in the resident's bathroom when not in use. During an interview with the surveyor on 03/08/22 at 12:58 PM, the Clinical Manager (CM) stated Resident #8 required total assist with care and that staff were responsible for making sure the resident's urinary catheter was patent and intact. The CM further stated the resident changed into a leg bag when out of bed and that staff was supposed to rinse the drainage bag, apply a cap to the tip of the drainage bag opening and store it in a plastic bag in the resident's bathroom. At that time, the CM accompanied the surveyor to the resident's room to observe the resident's drainage bag storage. The CM confirmed the surveyor's findings and stated the resident's drainage bag was probably not capped because there was cap in the grey bin stored next to the drainage bag. The CM stated the resident's drainage bag should have been capped and that capping the opening of the drainage bag was important to prevent infection. During an interview with the surveyor on 03/09/22 at 10:59 AM, the Director of Nursing (DON) stated she expected staff to rinse the drainage bag, make sure it was capped securely and store it in a clean plastic bag. The DON added that it was important to securely cap the drainage bag to make sure bacteria was not introduced into the drainage bag that the resident would be using. A review of the facility's Urinary Catheters policy, dated 6/2021, indicated that proper infection control practices regarding catheter care, tubing and collection bag [drainage bag] would be followed at all times. NJAC 8:39 - 19.4 (a)(5)

Based on observation, interview, record review, and review of other facility documentation, it was determined that facility staff failed to administer medication in accordance with a physician's orders. This deficient practice was identified in 1 of 3 nurses, on 1 of 2 units (Fourth Floor Nursing Unit) observed during the medication pass. This deficient practice was evidenced by the following: On 03/04/22 at 8:47 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medication to a resident (Resident #43). At that time, the LPN advised the surveyor that he obtained a blood pressure reading for Resident #43 of 108/70. The surveyor observed the LPN prepare various medications for administration to the resident, including but not limited to one tablet of [MEDICATION(S)] 12.5 milligrams (mg) (a medication used to treat blood pressure) and one tablet Potassium Chloride Extended Release 20 milliequivalents (mEq) (a medication used to supplement potassium levels). The LPN then proceeded to the bedside of the resident, to administer medication to the resident. The surveyor asked the LPN to return to the cart, so that the two of them could review the medication regimen for Resident #43. The LPN stated that he should have prepared two tablets of Potassium Chloride for administration to the resident, as per the physician's order. In addition, the LPN stated that he should not have included the tablet of [MEDICATION(S)] for administration to the resident. He further stated that the resident's systolic blood pressure (SBP) (top number, indicating a measure of exertion when the heart beats) was 108 mm Hg (the unit of measure used for blood pressure) and the physician's order indicated that the medication should be held for a systolic blood pressure less than 110 mm Hg. During this time, the LPN acknowledged that two medication errors occurred. He added one tablet of Potassium Chloride to the resident's medication for administration and removed the tablet of [MEDICATION(S)] from the resident's medication for administration. A review of the admission Face Sheet for Resident #43 revealed a diagnosis that included but was not limited to hypertension (high blood pressure). A review of the Physician Order Form for March 2022 revealed orders that included but were not limited to the following for Resident #43: Potassium Chloride ER 20 mEq tablet, two tablets orally for [CONDITION(S)] (low potassium) and [MEDICATION(S)] 12.5 mg, one tablet orally for hypertension (high blood pressure), which included a note to hold for SBP less than 110. A review of the March 2022 Medication Administration Record (MAR) for Resident #43 revealed the LPN's initials on the referenced orders for the morning of 03/04/22. In addition, it was noted that the [MEDICATION(S)] was not administered to the resident, due to a vital sign (blood pressure) being out of range. During an interview with the surveyor, the survey team, and administrative staff on 03/04/2022 at 1:07 PM, the Director of Nursing (DON) stated that it would be her expectation for nursing staff to administer medication as ordered by the physician, including adherence with parameters and doses that comprised the order. The DON and Continuing Care Administrator (CCA) acknowledged the referenced errors, stated they understood the concerns of the survey team, and had no additional questions regarding the matters presented to them. A review of the facility's policy titled, Medication Administration, Receipt, Storage, & Disposal revealed an origination date of April 2005 and a version date of June 2021. Further review of the policy revealed that it was necessary for designated staff to administer medication correctly, including the right dose. The policy did not address administering medication in accordance with any parameters, a numerical or other measurable factor that provides a condition or guidance in which further action or inaction may occur. NJAC 8:39 - 29.2(d)

Based on interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, for 3 of 21 residents (Residents #5, #7 and #14) reviewed for resident assessments. This deficient practice was evidenced by the following: 1). The surveyor reviewed the MDS information for Resident #5, contained within the electronic medical record. Further review revealed that the most recent MDS record for the referenced resident was created on 01/11/22, with an Assessment Reference Date (ARD, the end date for the observation period) of 01/27/22. The surveyor observed the Quarterly MDS was not completed. 2). The surveyor reviewed the MDS information for Resident #7, contained within the electronic medical record. Further review revealed that the most recent MDS record for the referenced resident was created on 10/03/21, with an ARD of 10/26/21, and was signed on 11/21/21. 3). The surveyor reviewed the MDS information for Resident #14, contained within the electronic medical record. Further review revealed that the most recent MDS record for the referenced resident was created on 10/25/21, with an ARD date of 11/02/21, and was signed on 11/23/21. During an interview with the surveyor on 03/07/22 at 10:35 AM, the Continuing Care Administrator (CCA) stated that the MDS Coordinator (MDS-C) was on leave until April of 2022. The CCA further stated that an acting MDS-C was completing the MDS assessments in her absence. During an interview with the surveyor on 03/08/22 at 11:09 AM, the acting MDS-C stated that she was covering for an absent staff member, who ordinarily serves in the referenced capacity and has been doing so since 01/20/22. During the same date and time, the acting MDS-C stated that the most recent Quarterly MDS for Resident #7 was completed on 10/26/21 and acknowledged that an additional Quarterly MDS should have been completed in January of 2022. She also stated that the most recent Quarterly MDS for Resident #14 was dated 11/02/21 and acknowledged that an additional Quarterly MDS should have been completed in February 2022. During an interview with the surveyor on 03/08/22 at 12:20 PM, the Registered Nurse/Clinical Manager (RN/CM) stated the most recent Quarterly MDS for Resident #7 was completed around 10/26/21 and acknowledged that an additional Quarterly MDS should have been completed in January of 2022. She also stated that the most recent Quarterly MDS for Resident #14 was completed around 11/02/21 and acknowledged that an additional Quarterly MDS should have been completed in February of 2022. During an interview with the surveyor and team on 03/08/22 at 1:53 PM, the Director of Nursing (DON) stated that MDS assessments should be completed on resident admission, annually, at any time that a significant change in health or status occurs for a resident, and in the absence of such events, on a quarterly basis. The DON acknowledged that the MDS Quarterly assessments should have been completed for both Resident #7 and Resident #14 prior to March of 2022. During an interview with the survey team and administrative staff on 03/09/21 at 10:51 AM, the DON further acknowledged that an additional Quarterly MDS assessment was missed for Resident #5. The CCA stated that Resident #5 had been coded incorrectly in the MDS tracking system and the Quarterly MDS assessment should have been completed. The CCA reiterated that the Quarterly MDS assessments for Residents #7 and #14 should have both been completed prior to March of 2022. She further stated that the acting MDS-C scanned the wrong nursing unit (floor), causing some of the residents to be missed for timely MDS completion. Finally, she stated that it would be her expectation for assessments to be completed as they are due. During the same date and time, the DON stated it would be her expectation for MDS assessment tracking to occur more than once per month, so that potential issues such as those discovered are detected sooner. A review of the facility's policy titled, MDS Completion and Management revealed the policy had an origin date of April 2005 and a current version date of June 2021. The policy revealed a need for a quarterly MDS to be completed by the team on each resident within skilled nursing. In addition, it revealed that the MDS Coordinator or designee maintains the schedule for MDS completion within the electronic medical record and schedules subsequent assessments. NJAC 8.39 - 11.1

Complaint # NJ 4 Based on interviews, review of Medical Records (MR), and review of other pertinent facility documents on 8/20 and 9/2/20, it was determined that the facility staff failed to investigate an accident/incident when a resident had an unwitnessed fall with injury. The facility also failed to follow their policies titled Incident Report and Investigation Policy and Fall Management, for 1 of 5 residents (Resident #3) sampled for falls. This deficient practice was evidenced by the following: 1. According to the Face Sheet (FS), Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), an assessment tool dated 4/1/2020, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 11/15, indicating the resident had moderate cognitive impairment. The MDS also indicated that Resident #3 required extensive assistance with Activities of Daily Living (ADLs). Review of the Care Plan (CP) undated, revealed Resident #3 was Care Planned for falls, interventions included but were not limited to: Adequate lighting while in her room, proper footwear in place, remind resident to use the walker, and a low bed. Resident #3 was also CP for cognitive patterns, mood and expressions and was care planned for anxiety, depression and behaviors of [MEDICAL CONDITION] and had poor decision-making skills and needed cueing and supervision. Review of the progress notes dated 5/3/20 at 3:59 P.M., revealed documentation by the Licensed Practical Nurse (LPN#1) reporting that Resident #3 fell again throughout this shift and cut over right eye, pressure and ice applied to site. Resident placed in hallway with staff nurse, neuro (neurological) checks refused, residents' behavior uncontrollable. Review of the progress notes dated 5/3/20 at 10:32 p.m., revealed documentation by the Licensed Practical Nurse (LPN#2) reporting the following: S/P (status [REDACTED]. At 4:20 p.m., during checks noted resident sitting at the side of the bed, bleed for laceration to right eye due to S/P fall, noted with swelling and black and blue around the orbit of the right eye, assist into bed comfortable cleanse with NSS (normal saline) pat dry and apply clean dressing '' Review of the progress notes dated 5/4/2020 at 9:56 p.m., revealed the following documentation by the APN (Nurse Practitioner): .recent Covid 19 infection is seen today after a fall yesterday. He/she was found on the floor, sustained a large right orbital bruise & laceration to the right lateral eyebrow. During an interview on 8/20/20 at 1:56 p.m., the Unit Manager reported that Resident #3 had several falls while at the facility and interventions were put in place including a low bed, then placing the mattress on the floor. During an interview on 8/20/20 at 3:20 p.m., the Director of Nursing (DON) reported that Resident #3 fell again on 5/3/20 on day shift, however, she was unable to find an incident report. During an interview on 9/2/20 at 9:50 a.m., the Administrator (Admin) reported that the facility staff did a late entry on 8/20/20, for Resident #3's fall with injury on 5/3/20, since an incident report was never done. The Admin further stated; when a resident falls the charge nurse on the unit should complete an incident report, body assessment, and document in the progress notes the fall, resident's condition, vital signs, neuro checks if applicable and notify the doctor and the family member. During an interview on 9/2/20 at 11:25 a.m., the Licensed Practical Nurse reported, it was her responsibility to complete the incident report after Resident #3 fell on [DATE], and stated she was in-serviced on incident reports when hired October 2019, and again on August 21, 2020. During an interview on 9/2/2020 at 11:59 a.m., the DON reported she was the nursing supervisor on 5/3/20, when Resident #3 fell and completed the physical assessment, however, she was unable to locate the assessment for any documentation that she completed on 5/3/20. Review of the Facility's Policy titled policy's titled Fall Management dated 6/30/2013 and 2/2020, revealed the following under Policy: To minimize and/or decrease the risk of falls through an interdisciplinary review of guest/resident and to develop individualized care/service plan approaches. Under definitions: Any event resulting in the resident coming to rest unintentionally on the floor or other lower level but not as result of an overwhelming external force (e.g., resident pushes another resident) Under Procedure: section 6.e. Initiate and complete incident report and investigative protocols. Review of the Facility's Policy titled Incident Report and Investigation Policy dated 8/2004 and 9/2017, revealed the following under Policy: All incidents which meet the definition of a reportable event as contained in this document will be recorded on an Incident Reporting form and reported as indicated. Under Continuing Care section 1. When an incident, near miss or an adverse event (as defined herein) takes place, the licensed employee on the scene will complete the Resident incident Report Form (CareMedX) and electronically notify the individual responsible for performance improvement within 24 hours of the staff person having knowledge that this event occurred. N.J.A.C. 8:39- 13.4(c)(2)(iv)

Complaint # NJ 4 Based on observation, interviews, review of medical records and other pertinent facility documents on 8/20 and 9/2/20, it was determined that the facility failed to review, update, and revise the Care Plan (CP) to reflect changes in the residents condition for 1 of 5 residents (Resident #3) sampled for falls. The facility staff also failed to follow their policy titled Care/Service Plans. This deficient practice was evidenced by the following: 1. According to the Face Sheet (FS), Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), an assessment tool dated 4/1/2020, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 11/15, indicating the resident had moderate cognitive impairment. The MDS also indicated that Resident #3 required extensive assistance with Activities of Daily Living (ADLs). Review of the CP undated, revealed Resident #3 was Care Planned for falls with interventions which included but were not limited to: Adequate lighting while in her room, proper footwear in place, remind resident to use her walker, and a low bed. Resident #3 was also CP for cognitive patterns, mood and expressions and was care planned for anxiety, depression and behaviors of [MEDICAL CONDITION] and had poor decision-making skills and needed cueing and supervision. According to the progress notes dated 4/27/20, the APN (Nurse Practitioner) documented under Reason for visit, was Covid 19 positive. Under Assessments, was the [DIAGNOSES REDACTED]. Interventions included but were not limited to the following: [MEDICATION NAME], bloodwork and antibiotics were ordered. The CP failed to reflect these changes. Review of the medical records, progress notes revealed the following documentation by the APN (Nurse Practitioner) on 5/4/2020; .recent Covid 19 infection is seen today after a fall yesterday. He/she was found on the floor, sustained a large right orbital bruise & laceration to the right lateral eyebrow. During an interview on 9/2/20 at 11:59 a.m., the DON stated that the CP should be revised after a change of status, falls, or a [DIAGNOSES REDACTED].#3. Review of the CP failed to show any documentation or dates that the CP was reviewed, or revised post fall incidents, and after a Significant Change when the resident contacted Covid 19 and when placed on Hospice on 5/12/20. Review of the Facility's Policy titled Care/Service Plans dated 9/2012 and revised date of 4/2019, revealed the following under Policy; Each guest/resident will have an individualized care/service plan developed at time of admission/readmission. Each guest/resident individualized care/service plan will be revised to reflect any changes in condition and will be reviewed at designated internals at a minimum based on service line . NJAC 8:39-11.2 (3)(i)

Based on observation, interview and record review, it was determined that the facility failed to handle smallware (utensils, cups, straws) and serve food in a safe and sanitary manner to address the risk of development of food-borne illness. This deficient practice was evidenced by the following: During the lunch meal service on the Fifth floor on 11/08/19 at 11:40 AM, the surveyor observed the following: 1. The Dining Services staff offered paper menus to each resident. Some residents filled out their own menu selections, other residents required the assistance of the dining staff. 2. The General Manager of Dining Services (GM) with donned gloves, handled a resident's paper menu and then prepared a sandwich by touching the bread, lettuce and tomatoes with the same donned gloves. She then handled another resident's paper menu and prepared an egg salad sandwich by touching the bread, lettuce and tomatoes with the same donned gloves. The GM then handled another resident's paper menu and prepared a second egg salad sandwich by touching the bread, lettuce and tomatoes with the same donned gloves. She then removed her gloves and went into the kitchenette area. 3. The GM came out of the kitchenette area holding four-ounce clear plastic cups in her bare hands. The GM's fingers fingers touched the inside of the top cup. A dining staff member squeezed mustard into the top cup for a resident. 4. The GM with donned gloves, handled a resident's paper menu and then prepared a turkey and cheese sandwich by touching the bread, turkey, cheese, lettuce, and tomatoes with the same donned gloves. She then handled another resident's paper menu and prepared a tuna sandwich by touching the bread, lettuce and tomatoes with the same donned gloves. The GM then handled another resident's paper menu, fixed her blouse, removed her gloves and re-gloved without washing her hands in between. 5. The GM with donned gloves, handled a resident's paper menu and then prepared a turkey and cheese sandwich by touching the bread, turkey, cheese, lettuce and tomatoes with the same donned gloves. She then handled another resident's paper menu and prepared a sandwich by touching the bread, lettuce and tomatoes with the same donned gloves. The GM then handled another resident's paper menu and prepared another turkey sandwich by touching the bread, turkey, lettuce and tomatoes. 6. At 12:15 PM, the surveyor observed a Certified Nursing Assistant (CNA) #1 pick up a knife from the floor that a resident dropped. She placed the soiled knife in the soiled bin. She then took a clean knife from a clean bin and gave it to the resident without washing her hands in between. She then set up a tray and touched utensils and a cloth napkin without having washed her hands. The surveyor then observed a Care Associate pick up spoons that fell to the floor. She placed the soiled spoons in the soiled bin and then served two residents two bowls of ice cream without washing her hands in between. During the lunch meal service on the fourth floor on 11/12/19 at 11:55 AM, the surveyor observed the following: 1. A resident removed a straw from his/her drinking cup and placed it on the table. At that time, a Dining Services staff member walked over to the resident, picked up the straw with his bare hands and placed the straw back into the resident's cup. During the lunch meal service on the fifth floor on 11/13/19 at 11:51 AM, the surveyor observed the following: 1. The GM, with donned gloves, handled a resident's paper menu and then prepared a tuna sandwich by touching the bread, lettuce and tomatoes with the same donned gloves. She then cut a grilled cheese sandwich by holding the sandwich steady with her left hand, wearing the same donned gloves. 2. At 11:59 AM, while wearing the same donned gloves, the GM handed CNA #2 a pair of gloves. CNA #2 took the gloves. She then put one glove on the resident's table and then donned both gloves. She proceeded to touch and cut up a resident's sandwich into small pieces. During an interview with the surveyor on 11/13/19 at 2:06 PM, the Infection Control Registered Nurse #2 stated that if an employee was preparing food with gloves donned and then touched something else, the employee should have removed their gloves, washed their hands and then re-gloved before touching food again. She also stated that if an employee picked up soiled utensils from the floor, they should have washed their hands before moving to another task. During an interview with the surveyor on 11/14/19 at 9:06 AM, the Registered Dietitian/Director of Dining Services for the campus stated that if an employee was preparing food while wearing gloves and then touched a resident's menu, the employee should have removed their gloves, washed their hands and then re-gloved before touching food again. She also stated that if an employee picked up soiled utensils from the floor, they should have washed their hands before moving to another task. Review of the undated facility's Continuing Care Dining Services - Satisfaction Solutions document reflected that staff should use gloves when handling food without utensils and that gloves should be changed frequently between tasks. It also reflected that employees hands should be washed frequently throughout service and between soiled and clean functions. It further reflected that employees hands should be washed between handling clean and soiled dishes. Review of the facility's Food Handlers Employee Health policy, dated 05/2012, reflected that staff should wash their hands thoroughly with soap and warm water before handling exposed foods and food contact surfaces, as often as required to remove soil and contamination, as well as before and between glove use. Review of the facility's Hand Hygiene - Standard Operating Procedure, dated 05/2019, reflected that the purpose was to prevent the spread of potentially infectious organisms. It also reflected that hand hygiene should be performed after touching a resident and/or their belongings and after handling any contaminated item. In addition, it reflected that hands must be washed when handling food. Review of the facility's Preventing Illness Caused by Infectious Organisms, dated 05/10/18, reflected that infection prevention was the set of methods practiced to prevent and control the spread of disease. It also reflected that handwashing was required after contact with inanimate objects in the immediate vicinity of the resident; before, between and after all physical contact with a resident; as well as before putting gloves on and immediately after gloves are removed. The document indicated that the elderly were at a greater risk for severe complications from a food-borne illness, and so it was critical that Continuing Care staff remain alert to the risk factors for food-borne illness and take the proper steps to ensure the safe preparation and serving of foods. NJAC 8:39-17.2 (g)

Based on observation, interview, and record review, it was determined that the facility failed to 1.) perform adequate hand hygiene and maintain clean supplies for 1 of 1 Registered Nurse (RN) observed during the provision of wound care, and 2.) offer hand hygiene to residents prior to eating in 2 of 2 dining rooms. This deficient practice was evidenced by the following: 1. On 11/13/19 at 10:39 AM, the surveyors observed RN #1 perform handwashing prior to her providing wound care on a resident. RN #1 wetted her hands, applied soap and rubbed her hands together under the running water for 19 seconds. RN #1 then set up the wound care field. On 11/13/19 at 10:45 AM, the surveyors observed RN #1 perform handwashing. RN #1 wetted her hands, applied soap and rubbed her hands together under the running water for 21 seconds. RN #1 then removed the resident's sock and bandage. On 11/13/19 at 10:48 AM, the surveyors observed RN #1 perform handwashing. RN #1 wetted her hands, applied soap and rubbed her hands together under the running water for 17 seconds. On 11/13/19 at 10:49 AM, the surveyors observed RN #1 remove a pair of gloves from her right scrub top pocket, don the gloves and then complete the wound care of the resident's right foot. On 11/13/19 at 10:57 AM, the surveyors observed RN #1 wash her hands. RN #1 wetted her hands, applied soap and rubbed her hands together for 5 seconds before she placed her hands under the running water. During an interview with the surveyors on 11/13/19 at 11:01 AM, RN #1 stated the procedure for handwashing was to use a paper towel to turn the water on, wet hands, soap the hands and lather for 20 seconds, rinse the hands, and dry them completely. RN #1 stated it was important not to wash hands under the water because the soap runs off and it does not kill the germs. RN #1 stated gloves should not be kept in the scrub shirt pocket because they could become contaminated but that there were no gloves in the box in the resident's room. During an interview with the surveyors on 11/13/19 at 1:30 PM, the Infection Control RN (IC/RN) stated the process for washing hands was to wet the hands and wrists, apply soap being careful not to touch the inside of the sink, apply friction for at least 20 seconds, rinse the hands, and dry the hands. The IC/RN stated the friction was done outside of the water so the soap was not washed away because the soap was needed to clean the germs. During an interview with the surveyor on 11/13/19 at 1:50 PM, the Director of Nursing (DON) stated handwashing was done in the following steps: turn on the water, wet the hands, apply the soap, apply friction for at least 15 seconds, rinse the hands, and dry the hands. The DON stated that friction was done outside of the water because the water washes the soap off. The DON stated it was not a good practice to have patient care items in the nurses scrub pockets. 2. On 11/07/19 at 11:30 AM, the surveyor observed the lunch meal in the fourth floor unit dining room. At 11:43 AM, the surveyor observed four residents self propel their wheelchairs into the dining room. The residents were served their lunch meal upon arrival at their dining table. The residents were not offered hand hygiene prior to eating. On 11/08/19 at 8:52 AM, the surveyor observed the breakfast meal in the fourth floor unit dining room. The surveyor observed two residents self propel their wheelchairs into the dining room. The residents were served their lunch meal upon arrival at their dining table. The residents were not offered hand hygiene prior to eating. On 11/08/19 at 11:20 AM, the surveyor observed the lunch meal in the fourth floor unit dining room. The surveyor observed four residents self propel their wheelchairs into the dining room. The residents were served their lunch meal upon arrival at their dining table. The residents were not offered hand hygiene prior to eating. On 11/08/19 at 11:23 AM, the surveyors observed the lunch meal in the fifth floor unit dining room. The surveyors observed 16 residents at that time. Some resident were assisted to their dining table by staff and some self propelled themselves in their wheelchairs. Once seated at the table, the residents were not offered hand hygiene prior to eating. On 11/13/19 at 11:30 AM, the surveyors observed lunch in the fourth floor unit dining room. The surveyors observed 12 residents at that time. Some resident were assisted to their dining table by staff and some self propelled themselves in their wheelchairs. Once seated at the table, the residents were not offered hand hygiene prior to eating. On 11/13/19 at 11:34 AM, the surveyors observed lunch in the fifth floor unit dining room. The surveyor observed three residents self propel their wheelchairs into the dining room. The residents were served their lunch meal upon arrival at their dining table. The residents were not offered hand hygiene prior to eating. During an interview with a surveyor on 11/14/19 at 12:12 PM, the DON stated that residents should wash their hands before eating to prevent the spread of infection and for cleanliness. Review of the facility, Hand Hygiene Competency Checklist, dated 06/15, revealed step 4 to lather all surfaces of wrists, hands, and fingers producing friction for at least 20 seconds. Step 6 revealed to rinse all surfaces of wrists, hands and fingers. The facility provided Hand Hygiene Competencies dated 04/02/19 and 05/15/19 for RN #1 which revealed passed. Review of the facility, Hand Hygiene - Standard Operating Procedure, dated 07/19, revealed the purpose was to prevent the spread of potentially infectious organisms to residents, staff and visitors. Procedure 1 indicated that hand hygiene should be performed before and after eating and drinking. Procedure 5 revealed to wet hands first with water, apply product, rub hands together vigorously for at least 15 seconds, rinse hands and dry hands. Review of the facility, Hand Hygiene - Standard Operating Procedure, dated 05/19, indicated in Section 2. 'When to Use Alcohol Hand Sanitizer' to Ask residents/patients to use prior to eating. NJAC 8:39-19.4(a 1)(l)(m)(n)

Based on observation, interview, and record review, it was determined that the facility staff failed to ensure a resident received and consumed liquids in the appropriate consistency according to physician orders [REDACTED].#37) who was on nectar thickened liquids. This deficient practice was evidenced by the following: On 11/13/19 at 12:05 PM, the surveyor observed Resident #37 seated in a chair at a dining room table and eating half of a grilled cheese sandwich. The surveyor observed Dietary Aide (DA) #1 at the resident's side stirring a yellowish liquid in a tall clear glass with a spoon. At 12:10 PM, two surveyors observed Resident #37 drink the liquid and then cough slightly. The resident was able to clear his/her throat and no distress occurred. Upon a closer look, there was a powder-like substance in the glass and the liquid did not appear nectar thick. At that time, a Licensed Practical Nurse (LPN) #1, approached the resident, stirred the liquid, poured liquid from the spoon, and stated the liquid was thinner than a nectar consistency. LPN #1 removed the glass. The resident's meal ticket indicated the resident had a diet order for nectar thick liquids. Review of the Face Sheet reflected that Resident #37 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS), dated [DATE], reflected the resident had a Brief Interview of Mental Status (BIMS) of 7, which indicated the resident had an impaired cognition. The MDS also indicated that the resident had a [DIAGNOSES REDACTED]. Review of the Resident Medication Profile reflected that the resident had been on a Nectar Thick Liquid diet since 12/19/18 and a Mechanical Soft (chopped meats) diet since 01/29/19. Review of the resident's Holistic Care Plan, dated 10/14/19, reflected that the resident preferred to eat meals in the dining room and required Nectar Thick Liquids. Review of the Registered Dietitian's (RD) #1 clinical notes, dated 06/18/19, 06/20/19, 09/13/19, and 09/18/19 reflected that the resident required Nectar Thick Liquids. Review of a Speech Language and Pathology Evaluation and Plan of Care dated 05/16/19, reflected the resident had a [DIAGNOSES REDACTED]. It also reflected the resident required Nectar Thick Liquids. Review of a Nursing Clinical Note, dated 11/13/19 at 4:03 PM, reflected that the nurse observed the resident had coughed with liquids in the dining room at lunch time. The nurse assessed the resident who had no pain and no difficulty breathing at that time. The nurse took the resident's vital signs and indicated the resident was ok and would be monitored. Review of a Nursing Clinical Note dated 11/13/19 at 4:33 PM, reflected that resident was seen by the provider. Review of a physician's Progress Note, dated 11/13/19, reflected the resident was seen because he/she coughed in the dining room. The provider noted that the resident had been on Nectar Thick Liquids and should continue with that consistency. During an interview with two surveyors on 11/13/19 at 12:10 PM, LPN #1 stated that the meal ticket indicated the resident's diet and that a nurse oversees and checks the diets as well as the Registered Dietitian (RD). She further stated that she did not see that the resident's tray did not contain the pre-thickened liquid and that it was her mistake. LPN #1 also stated that the purpose of thickened liquids was to help prevent a resident from choking. During an interview with two surveyors on 11/13/19 at approximately 12:15 PM, DA #1 stated that she had been working in her capacity for approximately eight months and that she prepared apple juice for the resident. She stated she used a full glass of apple juice from the juice machine dispenser and added a packet of thickener and stirred it. DA #1 stated she thought that the liquid was at a nectar consistency. She was unaware of the directions on the back of the thickener packet that indicated that the packet contents had to be mixed with six-ounces of fluid. DA #1 stated that the glass she used was an eight-ounce glass. At that time, the Dining Supervisor (DS) stated that the glass used was a 10-ounce glass. The DS stated that thickened liquids were indicated for residents who have trouble swallowing. She further stated that they no longer had a measuring cup to portion the liquids. In addition, she stated that other employees train new employees in regard to dining service including how to thicken liquids and that they only thicken coffee and soda, as they have prepackaged thickened juices, milk, and water. During an interview with two surveyors on 11/13/19 at 12:21 PM, RD #1 stated that the team oversees the diets the residents were served at meal time to ensure they were accurate. She further stated that there were instructions on the back of the thickener packet and that anyone who was trained could prepare thickened liquids, which included dining services staff. During an interview with two surveyors on 11/13/19 at 12:25 PM, DA #2 stated that thickened liquids were served to residents who had swallowing problems. She further stated that she had trained DA #1 since she'd been working on the fifth floor. DA #2 also stated that they have prepackaged thickened juices. She further stated that she told DA #1 not to use the juice machine for thickened liquids especially because that juice was so cold that the powder did not mix or dissolve well. DA #2 stated that they only thicken coffee and soda and that they no longer have a measuring cup to portion liquid. The resident was provided with prepackaged nectar thick apple juice. During an interview with the surveyor on 11/13/19 at 12:32 PM, the General Manager of Dining Services (GM) stated that she provided a training about thickened liquids in (MONTH) 2019. She stated that she trained the staff and then there was further one-on-one training for new employees working alongside other staff. In addition, the GM stated that DA #1 attended the training last month and that she did not have competencies or return demonstrations for preparing thickened liquids for her staff. She stated that she would provide the surveyor with the training information. She further stated that the residents' diets were indicated on their meal tickets, dining services plated the food, and nursing oversees that the diets were correct. During an interview with the surveyor on 11/13/19 at 12:39 PM, the unit's Clinical Manager stated that the resident's diet was indicated on the meal slip and that it should be checked to the resident's name band. She further stated that a nurse oversees the dining room for all meals. In addition, she stated that CNAs and dining staff were also responsible to ensure the resident received the correct diet. During an interview with two surveyors on 11/13/19 at 1:34 PM, the Speech Therapist (ST) stated that thickened liquids were provided to residents that have swallowing problems. She also stated that nursing and the dining staff used the meal tickets, where the diet was indicated, to ensure the residents received the proper consistency. She further stated that anyone who was trained could prepare thickened liquids, and that the staff member who did not prepare the thickened liquid properly should be retrained. At 2:16 PM, the ST stated that dining services trained the kitchen staff how to prepare thickened liquids and that the Infection Control Registered Nurse (RN) #2 trained the nursing staff. During an interview with the surveyor on 11/13/19 at 2:06 PM, RN #2 stated that the nursing staff use only prepackaged thickened liquids and that the dining staff would have their own training and competency records. During an interview with the surveyor on 11/14/19 at 9:06 AM, the Director of Dining Services for the campus/RD #2 stated that the thickener packets should not have been on the units and that everyone should be trained how to thicken with powder in case it was necessary. RD #2 further stated that there should have been a measuring cup available to portion liquids. She also stated that she attended the training the GM stated she gave in (MONTH) for thickened liquids and clarified the training was about diets; in fact, not about thickened liquids or instructions on how to prepare thickened liquids. The surveyor reviewed the undated facility document that pertained to the content of the thickened liquid training, that was provided by the GM. The document revealed that there were three types of thickened liquids offered to residents (nectar, honey and pudding). The document did not reflect any content regarding preparation instructions for the thickened liquids. Review of an undated facility document titled, Thickened Liquids Local Review, reflected the following: 1. Thickened liquids would be provided when ordered. 2. Pre-thickened liquids would be used unless otherwise instructed. 3. Only Continuing Care staff deemed qualified by completing required training with return demonstration could assist with thickening liquids. 4. If a thickening agent was used, staff would follow the manufacturers guidelines on the thickening additive label to provide the consistency ordered. 5. Residents should be supervised when consuming any thickened liquid beverage in accordance with his/her plan of care. During a meeting with the surveyors, Director of Nursing, and Licensed Nursing Home Administrator (LNHA) on 11/14/19 at 11:00 AM, the LNHA stated that there were no routine competencies done for thickening liquids prior to the survey. NJAC 8:39-17.4(a)(1)

Based on observation, interview and record review, it was determined that the facility failed to monitor and address an unplanned, significant weight loss for 1 of 6 residents reviewed for nutritional concerns (Resident #56). The resident experienced a one month 18.6% significant weight loss. This deficient practice was evidenced by the following: On 11/18/18 at 12:00 PM, the surveyor observed Resident #56 in his/her room lying in bed. The resident appeared very thin. The resident stated to the surveyor that he/she had no appetite and had lost weight since being admitted . The resident stated it was not related to the food and stated that he/she had no other physical complaints. At that time, the surveyor observed a Certified Nursing Aide (CNA) who attempted to ascertain the resident's preferences for the lunch meal. The resident made a meal selection and requested very small portions. The resident stated that he/she consumed the most at the breakfast meal and that he/she was offered multiple food choices throughout the day. During an interview, the CNA confirmed that the resident's appetite was poor and that he/she typically requested very small portions. The surveyor reviewed the medical record for Resident #56 which revealed Resident #56 had been admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/22/18, reflected that the resident had an intact cognition, with no impairment of short or long term memory. A review of a Physician's Treatment Order dated 10/15/18 reflected an order to weigh the resident one time weekly for two weeks. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's weights in the Electronic Medical Record (EMR) reflected an admission weight on 10/15/18 of 110 pounds. There was no further evidence of the resident's weight status after admission. A review of the Registered Dietitian's (RD) nutrition note, included in the Holistic assessment dated [DATE], reflected an admission weight of 110 pounds. The nutrition noted further revealed that the resident reported that his/her appetite had been poor for approximately three weeks prior to admission and that he/she had already lost weight. The resident reported a usual body weight of 115 pounds. The RD further indicated that she would monitor the resident's intake and weight trends. The RD's Care Plan Goals, also dated 10/16/18, reflected that the resident would consume 50% of the entrees of each meal and maintain his/her current body weight. The RD's Care Plan Approaches reflected that the resident would maintain his/her weight without any significant changes and that the RD would monitor the resident's weights. There was no evidence that the care plan had been revised/updated after 10/16/18. A review of the CNA assignment sheets for 11/01/18 and 11/02/18 reflected that a weight for Resident #56 should have been taken. However, both days reflected no weight entry and there was no documented evidence as to why a weight was not obtained. On 11/20/18 at 09:47 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the resident had a very poor appetite. She stated that the staff made attempts all day long to get the resident to eat; however, there was no documented evidence of stated attempts. The LPN stated that the resident received a healthshake at 10:00 AM and that he/she had fairly good consumption; however, there was no documented evidence of the amounts of healthshakes or meals consumed. She also stated that the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/20/18 at 11:57 AM, the surveyor interviewed the RD, in the presence of the survey team, who stated that the resident had lost some weight; however, it was not significant. The RD acknowledged that the resident's appetite was poor and, when interviewed on admission, both the resident and his/her son stated that the resident had a poor appetite prior to admission. On 11/20/18 at 1:05 PM, the RD stated that the resident weighed 89.5 pounds as of today. This reflected a significant weight loss of 18.6% within one month of the resident's admission. The RD could not speak to why the weekly weight physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD could not speak to why another weight was not taken after admission when staff acknowledged the resident had a poor appetite. The RD stated that the facility process for monitoring weights would have been that she should have made sure weekly weights were done. The RD further stated that when the CNAs did not weigh the resident in accordance to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/20/18 at 1:32 PM, the surveyor and survey team met with the facility's administrative staff, including the Director of Nursing (DON), who acknowledged that weight monitoring should have been done for this resident and could not speak to why this was not done when there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/21/18 at 08:40 AM, the surveyor and survey team met with the Unit Clinical Manager, the DON, and the RD who acknowledged that there was no evidence of nutritional interventions to prevent weight loss from the resident's time of admission other than a healthshake once a day in spite of knowledge of resident's poor appetite. The DON stated that the resident would have been added to the facility's High Risk Rounds list, but they were unaware of the weight loss. On 11/21/18 at 09:30 AM, the RD stated that she was not aware of the facility's standards or professional standards of practice related to weight monitoring for newly admitted and readmitted residents. On 11/21/18 at 09:41 AM, the DON acknowledged there was no documented evidence as to why weekly weights were not recorded and no documented evidence that the resident had refused being weighed. A review of the facility's Weight Management policy version dated 04/25/18 reflected that when staff were unable to obtain a resident's weight related to a resident who had refused to be weighed, the licensed nurse would be notified and that would be documented in the medical record. There was no evidence of this in the medical record for Resident #56. The policy further reflected that a resident would be weighed on admission, readmission and typically seven days after admission/readmission. There was no evidence of this in the medical record for Resident #56. In addition, the policy is inconsistent with professional standards of practice which recommended a resident to be weighed on admission/readmission to establish a baseline and then weekly for four weeks thereafter to identify trends such as slow and progressive or significant weight loss. In addition, weight monitoring may also be pertinent if a resident had a decline in intake for more than a week. A review of the facility's Weight Management in CC algorithm reflected that a nurse was responsible to verify a weight was obtained. It further reflected that a resident should be weighed on admission and more frequently if concerned. In addition, the document identified loss of appetite as a leading cause of unintentional weight loss. The facility failed to provide evidence that they followed the guidelines indicated in this document. NJAC 8:39-17.1(c); 17.2 (d); 27.2 (e), (k)

Based on observation, interview and documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices and maintain dry storage in a safe and sanitary environment. This deficient practice was evidenced by the following: On 11/18/18 at 09:21 AM, in the presence of the Cook/Supervisor, the surveyor observed the following: 1. There was a build up of a reddish material on the ice machine baffle (a flow-directing panel inside the ice machine that restrains ice flow and regulates ice production). The Cook/Supervisor stated that it was dirt and that the machine was cleaned twice a month. 2. There were two air filters on the exterior of the ice machine with a heavy build up of grayish material. The Cook/Supervisor stated that it was dust. He could not speak to the last time it was cleaned or how often it should have been cleaned. 3. There was a table top mixer covered with a clear plastic bag. The Cook/Supervisor removed the bag and stated that if equipment was covered with a clear plastic bag, it indicated that it had been cleaned and sanitized. In his presence, the surveyor observed debris inside the mixing bowl and on the underside of the mixer. The Cook/Supervisor acknowledged that the debris on the underside of the mixer could become dislodged and fall into new product being processed. 4. There was a buffalo chopper (a food mixer used to cut food into pieces or for grinding) covered with a clear plastic bag. In the presence of the Cook/Supervisor, the surveyor observed debris in the bowl. The Cook/Supervisor stated that it was food particles. 5. There was an empty stand up mixer not covered with a clear plastic bag. In the presence of the Cook/Supervisor, the surveyor observed debris on the underside of the mixer and on the protective grill. The Cook/Supervisor stated that it was food particles. 6. There was a clear bin that held brown rice located in the dry storage room. The surveyor observed a clear scoop stored inside the container which directly touched the brown rice. The Cook/Supervisor stated that the scoop was not supposed to be stored inside the container. 7. The surveyor observed four ingredient bins stored under a stainless steel preparation table. They held flour, rice, thickener, and bread crumbs. The surveyor observed clear scoops stored in all four ingredient bins which directly touched the food products. 8. In the walk-in freezer, in the presence of the Cook/Supervisor, the surveyor observed three of five fan covers with a heavy build up of a grayish material. The Cook/Supervisor stated that it was dust. 9. There was a grill with a heavy build up of debris located in the main cooking area. 10. The surveyor observed 17 empty dish machine racks stored directly on the floor. The Assistant Dining Manager stated they should not have been stored that way and showed the surveyor dish rack caddies, which were used to stack and store dish machine racks off of the floor. 11. The surveyor observed three empty sheet pan air drying racks stored directly on the floor underneath a stainless steel cage that held chemicals. The Assistant Dining Manager and a Supervisor stated they should not have been stored that way. 12. In the presence of the Assistant Dining Manager and a Supervisor, the surveyor observed three dented cans stored amongst the emergency food supply (stewed tomatoes, light kidney beans and beets). The Supervisor stated that the dented cans should not be among the in-use products and removed them to a designated dented can area. On 11/21/18 at approximately 10:45 AM, the surveyor reviewed concerns from the kitchen tour with Administrative staff. On 11/21/18 at 10:53 AM, the surveyor reviewed the facility's Sanitation policy version dated 12/08/08, a Food Handling Sanitation policy version dated 09/01/07, as well as, an undated Daily Cleaning Checklist, Weekly Cleaning Checklist, Monthly Cleaning Checklist, and a Care Associate Cleaning Checklist. The documentation did not include guidelines/requirements related to proper storage of ingredient scoops, dented cans, proper storage of racks used for the cleaning and drying of dishware, or how to clean fan covers. NJAC 8:39-17.2 (g)

Based on observation, interview and record review, it was determined that the facility failed to ensure that a.) staff performed hand hygiene after medication administration. This deficient practice was identified for 1 of 2 Licensed Practical Nurse (LPN) observed during the medication administration pass, and b.) a blood pressure (BP) cuff was disinfected prior to use on a resident. This deficient practice was identified for 1 of 1 Physical Therapist observed taking a resident's BP and was evidenced by the following: 1. On 11/19/18 between 09:04 AM to 09:15 AM, the surveyor observed the LPN on the Fourth Floor unit during the medication pass. The surveyor observed that the LPN performed hand hygiene prior to administering seven medications to a resident. After administering the medications, the surveyor observed the LPN return to the medication cart, without having performed hand hygiene first. The LPN then left the medication cart to assist another resident to his/her room. On 11/19/18 between 09:18 AM to 09:38 AM, the surveyor observed the same LPN administer two medications to the next resident. The surveyor observed that the LPN performed hand hygiene prior to the medication administration. After administering the medications to the resident, the surveyor observed the LPN return to the medication cart without having performed hand hygiene first. The surveyor then observed the LPN prepare the medications for the next resident. After pouring five medications, the LPN performed hand hygiene prior to administering the medication to the resident. After administering the medication, the LPN did not perform hand hygiene prior to returning to the medication cart. On 11/19/18 at 09:39 AM, during an interview, the LPN stated that he/she should have performed hand hygiene after the medications were administered and before preparing the next resident's medications, in accordance with facility protocol. On 11/19/18 at 09:40 AM, the Director of Nursing (DON) stated that the LPN should have performed hand hygiene before and after medication administration. On 11/19/18 at 10:44 AM, the facility Registered Nurse Clinical Manager (RN/CM) stated the nurse should have performed hand hygiene prior to and after administering medications to a resident. On 11/19/18 at 11:54 AM, the Registered Nurse Staff Educator (RN/SE) provided the surveyor with the facility, Infection Control Annual Review dated 8/1/18 that revealed, During medication administration staff should wash hands upon entering the room, prior to having contact with the resident. Then after the medication has been given, prior to exiting the room. On 11/19/18 at 11:54 AM, the RN/SE provided the surveyor with the LPN's in-service for the Infection Control Annual Review dated 8/1/18 that revealed the LPN had been in-serviced accordingly. The RN/SE staff educator provided the surveyor with the LPN's, Hand Hygiene Competency Checklist dated 7/11/18 that revealed the LPN had knowledge of when to perform hand hygiene. 2. On 11/21/18 at 08:17 AM, the surveyor observed an LPN on the Fifth Floor as he/she walked down the hall while pulling a portable BP machine with the BP cuff dragging on the floor. At that time, the facility Registered Nurse/Clinic Manager (RN/CM) observed the BP cuff dragging on the floor and responded by hanging the BP cuff on the portable BP machine while it was in transit. The LPN placed the portable BP machine outside of room [ROOM NUMBER] and walked away. The surveyor then observed the Physical Therapist (PT) take the portable BP machine into room [ROOM NUMBER] where the PT was observed applying the BP cuff to the resident's left upper arm and obtaining a blood pressure. The PT did not disinfect the BP cuff prior to applying the cuff to the resident's arm. During an interview at that time, the PT stated that the BP cuff should have been cleaned before and after use on the resident. The PT acknowledged that she had not cleaned the BP cuff prior to use on the resident. On 11/21/18 at 09:11 AM, the facility RN/CM stated that the PT completed competencies to properly perform a BP and that the PT should have cleaned the blood pressure cuff prior to and after use on the resident. On 11/21/18 at 10:15 AM, the RN/SE provided the surveyor with the facility's, Infection Control Annual Review policy, dated 8/1/18, that revealed, Never use multi-use equipment for another resident until it is cleaned and completely disinfected. The RN/SE stated that the PT had been in-serviced on the annual infection control review. NJAC 8:39-19.4(a)(1-6) (l)

Based on observation and interview, it was determined that the facility failed to ensure that pharmacy return medications were secured appropriately to ensure the environment remains as free from accident hazards as is possible. This deficient practice was identified on the Fourth Floor unit and was evidenced by the following: On 11/19/18 at 11:45 AM, on the Fourth Floor hallway, by the elevator, the surveyor observed four sealed white plastic bags and one, unlabeled, red sealed plastic bag piled on top of a chair that was stationed just outside the Fourth Floor elevator doors. The white plastic bags each contained a label that was marked Return, along with the pharmacy company name. The surveyor also noted that there was a visitor waiting at the elevator doors and a facility employee seated in a chair that was directly located next to the pharmacy return bags. On 11/19/18 at 11:45 AM, the surveyor interviewed the facility employee seated in the chair next to the bags. The employee stated the bags were not with her and she was unaware of the contents of the bags. There were no residents present in the elevator hallway at the time. On 11/19/18 at 11:47 AM, the pharmacy courier and the Fourth Floor Clinical Care Manager Registered Nurse (CC/RN) came through the unit doors, with a rolling container. During an interview, the CC/RN stated that when she was getting off of the Fourth Floor elevator earlier she noticed that the pharmacy courier was waiting at the elevator with the pharmacy return bags. The CC/RN stated that she then stopped him at the elevator to go with her to get an additional pharmacy return container. The CC/RN confirmed that the bags contained medications and that she was preoccupied with making sure that the pharmacy courier left with all the pharmacy returns so she overlooked that the pharmacy return bags were left by the elevator unsupervised. Also, the CC/RN stated that she was not sure how long the pharmacy return bags had been unattended, as it had taken a little time to locate the keys to the medication room. The CC/RN stated that the pharmacy return bags should have been supervised while the the pharmacy courier accompanied her to the medication room. The pharmacy courier acknowledged that he had left the pharmacy return bags, containing medications, unsupervised on the chair to go get the additional pharmacy return container. He further stated that there was no company policy, that he was aware of, with regard to leaving pharmacy return bags unsupervised. On 11/19/18 at 11:51 AM, the Facility Administrator, Assistant Administrator and the Director of Nursing all stated that the pharmacy return bags should not have been left on the chair in the hallway unsupervised. On 11/21/18 at 08:45 AM, the surveyor interviewed the facility employee that was observed at the elevator on 11/19/18. She identified herself as a facility transporter. She stated that on 11/19/18, she had just transported a resident from therapy to the fourth floor unit dining room and then was seated in a chair waiting by the elevator. The facility transporter stated again that she was unaware what was in the bags on the the chair. On 11/21/18 at 09:36 AM, the Assistant Administrator stated that the pharmacy courier left the bags there unattended and that the Fourth Floor CC/RN was not aware that the driver had left the pharmacy return bags on the chair. The Assistant Administrator further stated that the pharmacy return bags should have gone with the courier when he went with the Fourth Floor CC/RN to get the additional pharmacy return container. NJAC: 8:39-29.4(g)

Based on interview, record review and documentation provided by the facility, it was determined that the facility failed to ensure an as needed (PRN) anti-psychotic medication had a 14 day, limited use period. This deficient practice was identified for Resident #19, 1 of 5 residents reviewed for unnecessary medication use, and was evidenced by the following: The surveyor reviewed the medical record for Resident #19 which revealed Resident #19 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In the medical record, Resident #19 had a Continuing Care Consult Form from the Psychiatrist dated 11/9/18 that revealed the recommendation to trial [MEDICATION NAME] (an anti-psychotic medication used to treat anxiety and panic disorders) for 3 months. Resident #19 had a physician's orders [REDACTED]. The medical record revealed that on 11/12/18, the nursing staff signed off on the order and entered the [MEDICATION NAME] into the electronic Medication Administration Record [REDACTED]. On 11/20/18 at 09:13 AM, the Registered Nurse Clinical Manager (RN/CM), on Resident #19's unit, stated that the nurse who transcribed the order should have questioned and clarified the [MEDICATION NAME] order duration. In addition, the RN/CM explained that the 11 PM to 7 AM nurse should have questioned and clarified the order when he/she conducted the daily chart check. The RN/CM further stated that she should have caught that the order was for 3 months and not 14 days. On 11/20/18 at 11:52 AM, the Director of Nursing (DON) stated that the 11 PM to 7 AM nurse explained that he thought the stop date was correct and did not realize it was for the 3 months. The DON confirmed that the nurse who transcribed the [MEDICATION NAME] order should have questioned the stop date; the Unit Manager should have reviewed and questioned the order; the 11 PM to 7 AM nurse should have questioned the order through the daily chart check process; and the pharmacist who filled the [MEDICATION NAME] order should have questioned the stop date as well. On 11/20/18 at 12:30 PM, the DON stated that the nurse practitioner (who had not been available for interview) had informed the DON that he intended to have the physician re-write the order for only 14 days but did not. The DON acknowledged that the nursing staff signed off on the 24-hour chart check but missed that the order duration should have been clarified. On 11/20/18 at 12:32 PM, the DON provided the surveyor with the facility, 24 Hour Order Transcription Verification policy dated 1/2015 that revealed charts with new orders will be checked every 24 hours by a licensed nurse or trained designee to verify that all orders are noted correctly. The licensed nurse or trained designee that transcribed the initial physician order [REDACTED]. The DON stated that the licensed nurse should have clarified the order. On 11/21/18 at 08:00 AM, the DON provided the surveyor with the facility, Standard Operating Procedure Psychoactive Drug Management policy, dated 3/2018, which revealed, residents with a PRN order will be limited to 14 days and cannot be renewed unless the medical provider evaluated the resident for the appropriateness of medication. NJAC 8:39-27.1(a); 29.3(a)(4)

Based on observation, interview and record review, it was determined that the facility failed to provide follow up care and monitoring of a cardiac pacemaker (a device placed in the chest to control abnormal heart rhythms). This deficient practice was identified for Resident #5, 1 of 1 residents reviewed for cardiac pacemakers and was evidenced by the following: On 8/7/17 at 9:50 a.m., during the initial tour, the surveyor observed Resident #5 lying in bed with his/her eyes closed. The unit Clinical Coordinator (CC) informed the surveyor that the resident had frequent re-admissions, was not oriented and had a history of [REDACTED]. On 8/8/17, the surveyor reviewed the record of Resident #5 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 had a Brief Interview for Mental Status (BIMS, an assessment of cognitive status) performed 8/1/17 with a score of 5, which indicated Resident #5 was severely cognitively impaired. On 8/8/17 at 12:25 p.m., the surveyor reviewed the resident's care plan. The care plan dated 10/11/16 revealed Resident #5 was admitted on [DATE] with a problem area identified as a pacemaker. The goals included ensure battery life is checked as per recommendation of Providers and Ensure follow up with cardiologist/device manufacturer representative. The Interventions included: routine follow up with MD office date: 10/11/16 and the name of Resident #5's cardiologist. Resident #5's care plan for the pacemaker had no additional updates. On 8/8/17 at 12:45 p.m., the CC informed the surveyor that Resident #5 had not seen the cardiologist and that the facility did not pick up on it until last week. The CC stated an appointment with cardiology was made for September 12, 2017. On 8/9/17 at 11:50 a.m., the surveyor reviewed the Nursing New Admit clinical note dated 10/8/16 that revealed the resident had a pacemaker. On 8/10/17, the facility provided a copy of a Nursing note dated 8/9/17 at 9:13 a.m. by the CC. The note indicated that the family member had canceled previous appointments because they thought that the resident was fine. The note further indicated that the CC educated the family member on the importance of routine pacemaker checks. The surveyor then reviewed the physician notes. A physician note dated 10/10/16 revealed the Reason for Appointment 1) I got a pacemaker. and Treatment 2) Pacemaker Clinical Notes: Cardio f/u 11/3/16 The physician's notes every month thereafter revealed that the physician documented status [REDACTED]. On 8/10/17 at 11:35 a.m., the Director of Nursing (DON) informed the survey team that the facility had no policy or procedure regarding pacemakers but the staff would be expected to follow all the doctors recommendations to monitor it. At 12:45 p.m., the DON had no additional documentation regarding pacemaker follow up appointments that were not performed for Resident #5. NJAC 8:39-27.1(a)