Every finding on record at Lions Gate

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.This deficient practice was observed and evidenced by the following:On 6/4/26 at 9:36 AM, the surveyor conducted an interview with the Chief Executive Chef (CEC) prior to the initial tour of the kitchen. The CEC stated that the kitchen was Kosher which included separate kitchens, refrigerators, freezers, and dish machines for meat and dairy. On 6/4/26 at 9:48 AM, the surveyor in the presence of the CEC and the Food Service Director (FSD) toured the kitchen and observed the following:1. On the chef's preparatory table, there was a can opener with a black sticky residue. The CEC stated the can opener should be cleaned daily.2. In the hallway outside the dishwasher area, there were three (3) white plastic buckets and four (4) white cardboard boxes stored directly on the floor underneath a 4-tiered metal rack containing chemicals. The CEC stated that the buckets contained chemicals for the dishwasher, the boxes contained soap, and that they should not have been stored directly on the floor. On 6/4/26 at 10:30 AM, in the presence of the FSD, the Assistant FSD (AFSD) and the Operation Manager for Dining (OM),the surveyor toured the Rehab 1 Unit satellite kitchen.The surveyor observed the two (2) dish machines labeled dairy and meat. The dish machines were not being used at the time. The surveyor reviewed the Dish/Pot Machine Temperature Log sheet hanging on the wall. The FSD stated that the dish machines were low temperature machines, and the wash cycle should be at 130 degrees Fahrenheit (F), and the rinse cycle should be at 165F. At that time the surveyor reviewed the following temperatures documented on the June 2026 Dish/Pot Machine Temperature Log: 6/1/26 Breakfast Wash(W)- 140 Rinse(R) 116 diary dish machine6/1/26 Lunch W 154, R 138 meat dish machine6/1/26 Dinner W 139 R 115 meat 6/2/26 Breakfast W 139 R 115 dairy 6/2/26 Lunch W 153 R 137 meat 6/2/26 Dinner W 122 R 107 meat6/3/26 Dinner W 137 R 118 meat6/4/26 Breakfast W 155 R 136 dairy At that time, the AFSD stated that if the dish machines did not meet the appropriate temperatures, the staff should let the managers know so the dish machines could be serviced. The AFSD further stated that the dishes would be sent to the main kitchen to be washed until the dish machine was fixed. On 6/5/26 at 12:05 PM, during the follow up tour of the Rehab 1 Unit Kitchen, the AFSD stated that the dish machines were actually high temperature dish machines and that the wash cycle should be at 160 F and the rinse cycle should be at 180 F. On 6/8/26 at 8:40 AM, the facility provided a copy of the May 2026 Dish/Pot Machine Temperature Log for Rehab 1 Unit kitchen which revealed the following documented temperatures:5/10/26 Breakfast W -137 dairy machine6/11/26 Breakfast W-135 dairy6/13/26 Breakfast W- 149 dairy6/22/26 Dinner W 143 dairy6/23/26 Breakfast W- 116 R 139 dairy 6/24/26 Breakfast W 114 R 136 dairy6/24/26 Breakfast W 114 R 149 dairy6/25/26 Breakfast W 127 R 139 dairy6/27/26 Breakfast W 115 R 130 dairy6/28/26 Breakfast W 135 R 129 dairy6/28/26 Lunch W 153 R 173 meat6/30/26 Breakfast W 124 dairy On 6/8/26 at 12:39 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) in the presence of the survey team. The LNHA stated that the high temperature dish machines should have a wash cycle of 160 F and a rinse cycle of 180 F. The LNHA further stated that when the temperatures were out of range, the staff should have notified the FSD or a supervisor and the dish machines should have been serviced. The LNHA added that it was important that the dish machines were at the correct temperatures to properly clean the dishes, that chemicals should not be stored directly on the floor and should be stored in a designated area, and that it was important to clean the can opener after each use for sanitary reasons. A review of the facility's Equipment sanitation policy undated, revealed that all food service equipment shall be cleaned and sanitized after each use in accordance with manufacture specifications and established sanitation procedures. A review of the facility's Chemical Storage policy undated, revealed all chemicals will be stored in a safe manner and items will be stored 6 inches from the floor. A review of the facility's Dish and Pot Machine Temperature Monitoring policy undated, included dish machine and pot machine operating temperatures shall be monitored and documented to ensure equipment is functioning and providing effective cleaning and sanitation. NJAC 8:39-17.2(g)

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) discharge tracking record in accordance with federal guidelines. This deficient practice was identified for 1 of 1 resident reviewed for resident assessment (Resident #77). This deficient practice was evidenced by:ReferenceA MDS is a comprehensive tool that is a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. On 6/4/26 at 1:10 PM, the surveyor reviewed Resident #77's electronic medical record. The record included that the resident was discharged home on 2/15/26, but that there was no discharge tracking record completed for the resident's discharge date . On 6/5/26 at 9:04 AM, the surveyor interviewed the MDS Coordinator. The MDS Coordinator confirmed that the discharge tracking record was not completed or transmitted for Resident #77. She stated it should have been completed and transmitted within 14 days of the resident's discharge. On 6/8/26 at 9:14 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) in the presence of the survey team. The LNHA stated that the discharge MDS should be completed within 14 days of discharge. The DON stated that it was important that the Discharge MDS was completed in a timely manner because it was a requirement for reimbursement and quality measures. A review of the facility's MDS Assessment policy dated October 2025, revealed that the MDS clinical assessment was completed on all residents at the appropriate intervals as required by the federal government. Assessments were completed upon admission, readmission, discharge, quarterly, annually and when a resident experienced a significant change in condition. NJAC 8:39-11.2

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to develop a comprehensive care plan for 1 of 2 residents (Resident #11) reviewed for limited range of motion. This deficient practice was evidenced by the following:On 6/04/26 at 10:15 AM, the surveyor observed Resident #11 lying in bed. The resident's left hand was contracted without a splint device in place. On 6/05/26 at 12:46 PM, the surveyor observed Resident #11 lying in bed. The resident's left hand was contracted without a splint device in place. The surveyor reviewed the electronic medical record (EMR) for Resident #11. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, Hemiplegia (the partial or total paralysis of one side of the body) and hemiparesis (weakness or partial paralysis affecting only one side of the body) following cerebral infarction (the medical term for a stroke) affecting left dominant side, and contracture (the permanent or prolonged shortening and tightening of muscles, tendons, skin, or other soft tissues) of muscle, unspecified upper arm. A review of the Order Summary Report, dated as of 4/15/26, included a physician's order for a splint device to be applied to the left hand every morning and be removed every night at bedtime with an order date of 4/15/26. A review of Nursing Progress Notes, dated 4/15/26, indicated that nursing staff were aware that an order had been placed for a splint device to be applied to the left hand every morning and removed every night at bedtime. A review of the Occupational Therapy Discharge summary, dated [DATE], included the recommendation that a splint device should have been worn throughout the day and been removed at night, or worn for whatever duration would have been tolerated by Resident #11. A review of the June 2026 Treatment Administration Record (TAR) indicated that Resident #11 had frequently refused to wear their splint device. A review of the individual comprehensive care plan did not include resident-specific instructions for the use of a physician ordered splint device to the resident's left hand. On 6/08/26 at 9:44 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that it was the responsibility of nursing staff to ensure that splint devices were applied to residents as they were ordered. On 6/08/26 at 9:48 AM, the surveyor interviewed Registered Nurse (RN) #1 who stated that Resident #11 had an order for a splint device. RN #1 also stated that Resident #11 had often refused to wear their splint device. On 6/08/26 at 9:52 AM, the surveyor interviewed the Director of Nursing (DON) who stated that a resident-specific care plan for the use of a physician's ordered splint device should have been completed by either therapy staff, nursing staff, or nursing leadership. A review of the facility's Orthopedic Devices policy revised October 2025, included the following: Orthopedic devices would be utilized, monitored, and maintained in accordance with physician's orders, therapy recommendations, and resident-specific care plans to ensure safe and effective use. Resident care plans and physician orders would specify (a.) the purpose of the device, (b.) duration of use, (c.) frequency of application and removal, (d.) required comfort checks, (e.) skin assessment requirements, and (f.) any adjustments, modifications, or re-evaluations as needed. NJAC 8:39 - 27.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] at 9:50 AM, the surveyor conducted an interview with the Director of Culinary (DC) prior to the initial tour of the kitchen. The DC stated that items stored in the refrigerators and freezers should be labeled and dated with the received date, the opened dated, and the use-by date. The DC further stated that dishware should be inverted and air dried after washing. On [DATE] at 10:18 AM, the surveyor, accompanied by the DC, observed the following in the kitchen: In the Meat Refrigerator: 1. A shallow two-inch hotel pan of tilapia which was sealed with plastic wrap. The pan was not labeled to identify the food item or dated with a use-by date. At that time, the DC discarded the tilapia. In the Dairy Refrigerator: 2. Asiago cheese which was re-sealed with plastic wrap with a use-by date of [DATE]. The DC discarded the cheese. 3. A pan of marinara which was sealed with plastic wrap with a use-by date of [DATE]. The DC discarded the marinara. 4. A one-gallon container of creamed herring which was previously opened. The container was not labeled or dated with an opened or use-by date. The DC discarded the container of creamed herring. 5. A 16-ounce jar of capers which was re-sealed with plastic wrap. The jar was not labeled or dated with an opened or use-by date. The DC discarded the jar of capers. In the Dairy dish drying area: 6. Seven sixth pans stacked on the drying rack which were wet nested. The surveyor lifted the top pan which revealed liquid between the pans. 7. Three third pans stacked on the drying rack which were wet nested. The surveyor lifted the top pan which revealed liquid between the pans. In the Meat dish drying area: 8. Two stacks of hotel pans on the drying rack which were wet nested. The surveyor lifted the top pans of each stack which revealed liquid between the pans. On [DATE] at 9:33 AM, the surveyor, accompanied by Dietary Service Aide (DSA) #1, observed the following in the freezer portion of the refrigerator located in the Rehab 1 dining room: 9. A three-gallon tub of vanilla ice cream. The lid of ice cream tub was lifted and not properly sealed. The container was not labeled with an opened or use-by date. 10. A three-gallon tub of strawberry ice cream. The lid of the ice cream tub was lifted and not properly sealed. The container was not labeled with an opened or use-by date. 11. Four small, disposable cups covered with lids. The DSA identified the cups as ice cream which was previously portioned out and prepared. The containers were not labeled with a use-by date. At that time, DSA #1 discarded the ice creams. On [DATE] at 9:44 AM, the surveyor, accompanied by DSA #2, observed the following in the refrigerator located in the Skilled 2 dining room: 12. A 46-ounce container of nectar thick water which was labeled with a use-by date of [DATE]. 13. A 46-ounce container of nectar thick lemon-flavored water which was labeled with a use-by date of [DATE]. At that time, DSA #2 discarded the containers and stated that the DSAs and dietary supervisors were responsible for maintaining the refrigerators in the dining rooms. On [DATE] at 9:52 AM, the surveyor, accompanied by DSA #3, observed the following in the refrigerator located in the Rehab 2 dining room: 14. Three 46-ounce containers of nectar thick lemon-flavored water which had an expiration date of [DATE]. 15. A 46-ounce container of nectar thick water which had an expiration date of [DATE]. At that time, DSA #3 discarded the containers and stated the DSAs and dietary supervisors were responsible for checking the refrigerators in the dining rooms. On [DATE] at 10:30 AM, the surveyor interviewed the DC who stated the DSAs were responsible for maintaining the refrigerators in the nursing unit dining rooms. The DC further stated that the DSAs should check the refrigerators to ensure opened items are labeled with the opened date and use-by date. The DC also stated that the DSAs should discard items that are expired or past the use-by date. On [DATE] at 1:08 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated she expected food items to be labeled and dated appropriately, food items to be discarded upon expiration, and pans to be dried according to regulation. The LNHA further stated the dietary staff were responsible for maintaining the dining room refrigerators and should label and date food items appropriately and discard expired food items. A review of the facility's Operational Standards Refrigerator policy, revised ,d+[DATE], included, Food is properly stored in appropriate containers labeled with product name, date prepared/opened, use-by date and employee initials. A review of the facility's Refrigerators and Freezers policy, undated, included, All food is appropriately dated to ensure proper rotation by expiration dates, and Expiration dates on unopened food are observed and 'use-by' dates are indicated once food is opened. Further review of the policy included, Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past 'use-by' or expiration dates. A review of the facility's Pots, Pans, Utensils Washing and Air Drying policy, revised ,d+[DATE], included, All sanitized items must be air dried and cooled completely before stacking and storing. NJAC 8:,d+[DATE].2(g)

Based on observation, interviews and review of pertinent facility records, the facility failed to develop and implement an individualized comprehensive care plan for a resident that was requiring an anti-anxirty and anti-psychotic medication. This deficient practice was identified for 1 of 5 residents (Resident #29) reviewed for medication regimen. On 2/10/25 at 10:00 AM, during the initial tour, the surveyor observed Resident #29 awake, and alert, fully dressed, sitting in a wheelchar in their room. The survyeor reviewed the medical record for Resident #29. A review of the Admission Record, an admission summary, revealed that the resident had the diagnosis which included, Systemic Lupus Erythematous (an autoimmune disease where the body's immune system mistakenly attacks the body's healthy tissues), major depressive disorder (a depression characterized by persistent sadness, loss of interest, fatigue, feelings of worthlessness), protein calorie malnutrition (when the body does not get enough protein or calories.) and primary insomnia (difficulty sleeping not related to medical or psychological conditions. A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment, dated 12/24/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident's cognition was intact. Further reveiew in Section M of the MDS indicated that the resident was receiving antipsychotic and antianxiety, and antidepressant medication. A review of the active Order Summary Report (OSR) for February 2025, included the following physician orders: A PO, dated 10/13/24, for Xanax 0.5 milligrams (mg), give 1 tablet by mouth as needed for major depressive disorder related to major depressive disorder. A PO, dated 10/14/24, for Abilify 2 mg by mouth. A review of the February 2025 Medication Administration Record (MAR) revealed that Resident #29 was receiving Abilify 2 milligrams (mg) by mouth daily and Xanax 0.5 mg by mouth at bedtime. A review of individualized comprehensive care plan (ICCP) did not include a care plan including interventions for an antipsychotic or antianxiety medication. On 2/10/25 at 11:00 AM, the surveyor requested from the Director of Nursing (DON) a copy of Resident #29's ICCP. Futher review of the ICCP, included a focus area for the use of Abilify and Xanax initiated on 2/10/25 after surveyor inquiry. On 2/11/25 at 10:40 AM, the surveyor conducted an interview with the Registered Nurse (RN #3) who stated that when a resident had any suicidal ideation or behavior issues the Unit Manager (UM) should initiate a care plan immediately. She then stated that she could initiate the care plan as well. On 2/11/25 at 10:56 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #8) who stated that a resident with suicidal ideation or behavior should be care planned. She then stated that she would have to look at the policy. On 2/12/25 at 1:23 PM, the surveyor interviewed the DON who stated that when she was making copies of the care plans for surveyor, she noted the anti-psychotic medications were not on the care plan. The DON then stated that she could not provide copies of the ICCP without updating the care plan. The DON stated that the care plan should have been initiated within a short period of time. and that the Unit Manager, MDS coordinator or anyone could have initiated the care plan. A review of facility's Behavioral Management policy dated May 2024, included, that all residents receive care and services to assist him or her to reach their highest level of mental and psychosocial functioning through interdisciplinary evaluation and assessments. Procedure Guidelines 7. the RAI [Resident Assessment Instrument] care plan process resident behavior management plan, interventions and effectiveness will be reviewed. NJAC 8:39-11.1

Complaint #NJ179408 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a.) that the wound treatment cart was locked when not in use b.) accountability for the completion of the narcotic shift-to-shift count logs in accordance with the facility policy b.) an accurate account of the administration and documentation of controlled medications c.) properly dispose of medications at the time of resident refusal and d.) that expired medical supplies were not available for use in resident care in the medication storage room and in the emergency crash cart. This deficient practice was identified during the medication storage task for 1 of 2 medication carts on 1 of 4 nursing units (Rehab 1 Nursing Unit), 1 of 2 medication rooms (Rehab 2 Nursing Unit Medication Room), and the Rehab 1 Nursing Unit Emergency Treatment Cart and was evidenced by the following: 1. On [DATE] at 10:36 AM, the surveyor, in the presence of Licensed Practical Nurse (LPN) #5, observed that the wound treatment cart was not locked. When interviewed, LPN #5 stated that she had just completed a wound treatment and had forgotten to lock the cart. LPN #5 stated that it was important to lock the Wound Treatment Cart when finished to ensure that no one accessed it. 2. On [DATE] at 10:37 AM, in the top drawer of the medication cart, the surveyor observed a Lidocaine Patch (a topical pain relief patch) that was previously opened and was dated ,d+[DATE]. When interviewed, LPN #5 stated that the Lidocaine Patch was endorsed by the ,d+[DATE] nurse because the resident did not want it at the time it was last scheduled. LPN #5 was unable to state which resident the Lidocaine Patch was ordered for. 3. On [DATE] at 10:45 AM, the surveyor, in the presence of Licensed Practical Nurse (LPN) #5, reviewed the shift-to-shift Controlled Drugs-Count Record and the surveyor observed that on [DATE] at 7:00 PM, the Nurse on Signature (oncoming nurse) was blank and the Nurse Off Signature (outgoing nurse) was signed by LPN #5. There was no further documentation on the form to indicate that the shift-to-shift narcotic count was performed on [DATE]. LPN #5 stated that when she came in the outgoing nurse reviewed the Controlled Drug-Count Record and the oncoming nurse reviewed the narcotic count. LPN #5 stated that on [DATE], she was the oncoming nurse and LPN #6 was the outgoing nurse who had forgotten to sign. LPN #5 stated that today both she and LPN #6 had completed the shift-to-shift narcotic count, but they had both forgotten to sign. LPN #5 further stated that there were no reported discrepancies identified in the narcotic count. Further review of the Controlled Drugs-Count Record revealed that on [DATE], at 7:00 AM, the Nurse on Signature was blank, and a signature was noted in the space allotted for the Nurse Off Signature. On [DATE] at 7:00 AM, the Nurse on Signature was blank, and a signature was noted in the space allotted for the Nurse Off Signature. On [DATE] at 7:00 PM, a signature was noted in the space allotted for the Nurse on Signature and the Nurse Off was blank. LPN #5 stated that it looks like they forgot to sign. LPN #5 stated that both nurses should sign the Controlled Drugs-Count Record when they are finished counting. 4. At that time, in the presence of LPN #5, the surveyor reviewed the controlled substance logs for the Rehab 1 Nursing Unit medication cart and noted the following: Resident #201's prescription card (BINGO card, medication packaged in a blister package with cardboard backing) containing Tramadol HCL 50 MG (Half Tab=25 MG) tablets (opioid pain reliever) contained 20 tablets, but the declining inventory log indicated that there were 21 tablets remaining. LPN #5 stated that she must have gotten distracted and had forgotten to sign it out. LPN #5 stated that it was important to sign the medication out on the declining inventory sheet at the time of administration to ensure that the narcotic count was correct. LPN #5 stated that she did sign the medication out as administered on the resident's Medication Administration Record (MAR). Resident #201's prescription card containing Pregabalin 75 MG Capsule (used to treat nerve pain) contained 23 capsules, but the declining inventory log indicated that there were 24 capsules remaining. LPN #5 stated that she must have gotten distracted and had also forgotten to sign the dosages out. On [DATE] at 12:01 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that the oncoming nurse should count the narcotics, and the outgoing nurse should review the Controlled Drugs-Count Record Book to make sure that the narcotic count is right, and the medications are not compromised. LPN/UM #1 stated that the nurses were required to sign the book when they come in and when they go out. LPN/UM #1 stated that the Consultant Pharmacist came into the facility monthly and audited the narcotic book. LPN/UM #1 stated that the narcotic count has always been correct. LPN/UM # 1 stated that she would think that the nurses had not counted if they had not signed the Controlled Drugs-Count Record and narcotics could be missing. At that time, LPN/UM #1 further stated that narcotics should be signed for when they were removed from the medication cart. LPN/UM #1 stated that it was good practice because the narcotic count may be off if the nurse did not sign the book and only signed the Medication Administration Record (MAR). At that time, LPN/UM #1 further stated that the wound treatment cart should be locked at all times so that patients or families can not take anything out of it. On [DATE] at 1:52 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses should count their controlled drug in the medication cart at the end of the shift for accuracy of narcotics. The DON further stated that the Unit Manager was responsible to review the narcotic book weekly for signatures being captured and to ensure accuracy of the documentation. At that time, the DON further stated that narcotic medication should be signed out upon removing it from the medication cart in the book. The DON stated that it was not sufficient to just sign the medication out on the Medication Administration Record (MAR) because you are required to sign the medication out when it is removed. The DON stated that the mismanagement of narcotics or missing dosages were a concern if narcotics were not signed out from the cart at the time of removal. On [DATE] at 11:53 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that she was at the facility last week and reviewed three random medication carts for the narcotic count. The CP stated that she checked the signature logs at the back of the book and sometimes there was one missed signature here and there. The CP stated that she had not performed medication pass observations at the facility as it was not part of their contract, but will going forward, as it was just initiated after surveyor inquiry. On [DATE] at 11:30 AM, the DON provided the surveyor with a Medication Pass Observation dated form dated [DATE], which revealed that LPN #5 had not received a medication pass observation on that date because the former CP indicated that LPN #5 had finished passing medications early due to a low census, and instead received a medication pass in-service with LPN #5 and reviewed administration of all types of meds. The facility failed to provide the surveyor with documented evidence that LPN #5 had received a medication pass observation when requested. On [DATE] at 2:41 PM, the DON stated that she was not aware that the CP was not doing medication pass observations at the facility and that they needed to be requested. At that time, the DON further stated that she was responsible to ensure that LPN/UM #1 completed the narcotic record review and had not informed the LPN/UM #1 that it was her responsibility to do so. The DON further stated that she was not aware of the frequency that the CP performed narcotic record review. 45589 5.) On [DATE] at 10:03 AM, during a tour of the Rehab 2 Nursing Unit Medication Room, in the presence of LPN/UM #1, the surveyor observed the following expired supplies in the second drawer adjacent to the sink: culture swabs with an expiration date of [DATE]; and greater than 25, disposable sampling swabs with an expiration date of [DATE]. On [DATE] at 10:23 AM, during a tour of the Rehab 1 Nursing Unit in the presence of LPN/UM #1, the surveyor observed the following expired items in the emergency crash cart: three suction connection tubing with an expiration date of [DATE]; one ChloraPrep swab with an expiration date of ,d+[DATE]; one dial-a-flow tubing (a medical device used to control the flow of fluid via an intravenous line) dated [DATE]; one box of size medium disposable examination gloves with an expiration date of ,d+[DATE]; one box of size large nitrile disposable examination gloves with an expiration date of ,d+[DATE]. On [DATE] at 10:28 AM, the surveyor interviewed LPN/UM #1 who stated that supplies should be within date to ensure proper function. LPN/UM #1 also stated that the night shift 11:00 PM to 7:00 AM nurse was responsible to the check the crash carts and that a staff member from Central Supply checked the carts monthly for expired items. On [DATE] at 12:15 PM, during tour of the first floor common area, inside of an emergency crash cart the following expired items were observed: two boxes of disposable examination gloves with an expiration date of ,d+[DATE]. A review of the facility's undated Administering Medications policy included: Medications should be administered in a safe and timely, manner, and as prescribed. .The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions . .During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide . A review of the facility's undated Narcotic Count Policy included: Purpose: To establish guidelines for the accurate and secure shift-to-shift counting of narcotics. .The facility (name redacted) shall ensure the secure and accurate counting of narcotics at each shift change to prevent discrepancies and ensure resident safety . Narcotic Count at Shift Change: At the beginning and end of each shift, the oncoming and outgoing licensed nurses shall conduct a joint count of all controlled substances. Both nurses shall verify the count against the narcotic record. Documenting and Record-Keeping: .All narcotic administration shall be documented in the resident's medication administration record . A review of the facility's undated Receipt, Usage, Disposition, and Reconciliation of Controlled Medications Policy included: .Each administration must be recorded in the Medication Administration Record (MAR) and the narcotic record. .A shift-to-shift controlled medication count shall be conducted and documented by outgoing and incoming licensed nurses. Monthly audits shall be performed to ensure compliance and identify any discrepancies. Any discrepancies must be reported immediately to the Nurse Manager or Nursing Supervisor and DON or Facility Administrator . A review of the facility's undated Crash Cart Policy policy included, 5. Routine Inspections: To ensure readiness .Weekly Checks: Review expiration dates and replace as necessary. A review of the facility's undated Emergency Cart Inspection and Inventory policy included, Procedures 2. Routine Inspections .Any missing, damaged, or expired items shall be replaced immediately. NJAC 8:,d+[DATE].7 ( c ); 29.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure food served to residents was palatable. This deficient practice was identified for 5 out of 5 residents (Resident # 29, #31, #37, #74 and #75) who attended the Resident Council meeting conducted by the survey team on 2/10/25 and confirmed during the lunchtime meal service on 2/11/25 for 1 of 4 nursing units (Skilled 1) tested for food palatability. This deficient practice was evidenced by the following: On 2/7/25 at 10:00 AM, during the initial tour of the Skilled 1 nursing unit, Resident #29 stated that the food was the worst and the meat was tough. At 10:13 AM, Resident #37 stated that the food was cold, and the meat was tough and inedible. At 10:34 AM, Resident # 31 stated that the food was inedible, cold, and the meat was tough. On 2/10/25 at 10:37 AM, the surveyor conducted a resident council meeting with five alert and oriented residents (Resident # 29, #31, #37, #74 and #75). All five residents stated the food was not good and the meat was tough. All five residents further stated that they had previously complained about the food at the monthly resident council meetings, but nothing had improved. Resident #29 stated that the chicken is served in a hard lump and cannot cut the chicken. Resident #75 added that the food stinks. On 2/11/25 at 12:00 PM, the Director of Culinary (DC) provided the survey team with two meal trays from the Skilled 1 nursing unit satellite kitchen - a regular consistency tray and a pureed consistency tray. Three surveyors tasted the food and observed the following: Regular Sloppy [NAME] - no concerns with palatability Regular Cauliflower - tasted bland and mushy Regular Peas/Carrots - tasted bland and the peas were hard Pureed Sloppy [NAME] - tasted pasty and the flavor did not match the regular texture sloppy joe Pureed Peas/Carrots - tasted bland Mashed Potatoes - tasted bland and floury On 2/11/25 at 1:08 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), of the above findings. The LNHA stated that everyone's taste is different, but would prefer the residents to enjoy their meals. Review of the facility's Food Presentation policy, undated, included, Policy: to ensure that food is served in a visually appealing, safe, and consistent manner; to have the food taste and look good. NJAC 8:39-17.4(a)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices to ensure a.) staff performed appropriate hand hygiene during meal service for 1 of 4 dining rooms observed (First floor Skilled Nursing Unit ), b.) an ice scooper was used to obtain ice from the ice machine during dining observation of 1 of 4 dining rooms observed (First floor skilled nursing unit), c.) ensure respiratory equipment was stored in an appropriate way to prevent the spread of infection for 1 of 4 residents reviewed for use of respiratory equipment (Resident # 18) and d.) enhanced barrier precautions (EBP) was initiated for 1 of 4 residents (Resident #31) reviewed for infection control. This deficient practice was evidenced by the following: 1.) On 2/10/25 at 12:31 PM, the surveyor observed the lunch meal service in the first-floor skilled nursing unit dining room. The surveyor observed the Dietary Service Aide (DSA#5) had removed dirty plates from an unsampled resident at Table #5, scraped the food form the plate into the trash, then proceeded to go into the refrigerator, removed a bottle of juice, poured the juice into a cup and served this juice to another unsampled resident without performing hand hygiene (HH). On 2/11/25 at 8:12 AM, the surveyor observed the following during the breakfast meal service in the first-floor skilled nursing unit dining room. 1. DSA #5 cleaned a blue plastic tray with a rag, then poured coffee for Resident # 74, added cream and sweetener and placed a lid on the coffee cup without performing HH. 2. DSA #5 removed dirty dishes from another table and placed in the cart with the dirty dishes without performing HH. 3.DSA #5 served eggs and toast and jelly to Resident #55 without performing HH. 4. DSA #5 served oatmeal to Resident #29 without performing HH. 5.DSA #5 went to the refrigerator, removed a carton of milk, poured the milk into Resident #54's oatmeal bowl, without performing HH. 6. DSA #5 served the oatmeal to Resident #54, without performing HH. 7. DSA #5 walked to the refrigerator, removed a carton of honey thickened milk, and walked into the satellite kitchen area, poured the thickened milk into the oatmeal, added in sugar and stirred the oatmeal then served Resident #34 the oatmeal with performing HH 8. DSA #5 served oatmeal to Resident #71 without performing HH. 9. DSA #5 poured juice for Resident #34, then served an omelet and toast to Resident #74 without performing HH. 10. DSA #5 served pancakes to Resident #51 without performing HH. 11. Resident #74 requested his/her toast be buttered, DSA #5 then donned (put on) gloves to both hands, buttered the toast, then removed the gloves without performing HH. 12. DSA #5 served an omelet to an unsampled resident without performing HH. 13. DSA#5 served Resident #51 pancakes without performing HH. 14. DSA#5 served Resident #29 pancakes without performing HH On 2/11/25 at 8:55 AM, the surveyor interviewed DSA #5 who stated that hand hygiene should be completed between serving residents. DSA #5 further stated that she washed her hands with soap and water in the sink in the satellite kitchen. On 2/11/25 at 10:03 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that hand hygiene should be performed in the dining room in between serving the residents their meals. On 2/11/25 at 10:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated that hand hygiene should be completed in between serving residents their meals. The DON further stated that it was important to use hand hygiene between serving residents to prevent infection or contamination. On 2/11/25 at 12:15 PM, the surveyor observed the following during the lunch meal in the first-floor skilled unit dining room: 1. DSA #5 served the lunch meal to an unsampled resident without performing HH. 2. At 12:18 PM, DSA #5 assisted Resident #31 put on his/her sweater then served soup to several unsampled residents without performing HH. 3. At 12:25 PM, DSA #5 scraped dirty dishes into the trash, placed the dirty dish into the dishpan then served Resident #37 their lunch meal without performing HH. 4. At 12:27 PM, DSA #5 scraped dirty dishes into the trash, placed the dirty dishes into a dishpan then served Resident #29 their meal without performing HH. A review of facility's Handwashing/Hand Hygiene policy, reviewed December 2024 included, Indications for hand hygiene included: a. immediately before touching a resident, .c. after touching a resident, after touching a resident's environment, and .g, immediately after glove removal. A review of facility's Culinary Services Hand Washing Procedure revised May 024, included each employee will wash their hands frequently to eliminate visible dirt and to reduce bacterial load and cross contamination Before: .b. beginning a new task .and After O. removing or changing gloves, P. scraping trays, Q. physical contact with a residents, . and U. touching equipment such as, refrigerator doors or utensils that have not been cleaned or sanitized. 2.) On 02/10/25 at 12:20 PM, the surveyor observed the following during the lunch meal service in the first-floor skilled nursing unit dining room. The surveyor observed DSA #4 used a plastic drinking cup and with her bare hand, reached into the ice machine and scooped the ice into the plastic cup. At 12:29 PM, the surveyor observed DSA #4 again used a plastic drinking cup with her bare hand, reached into the ice machine and scooped the ice into the plastic cup. On 2/11/25 at 9:24 AM, the surveyor interviewed DSA #4 who stated that an ice scooper should be used to dispense ice form the ice machine. DSA #4 further stated that a plastic cup should never be used in the ice machine to obtain the ice. On 2/11/25 at 12:22PM, the surveyor observed DSA #5 during the breakfast meal service in the first-floor skilled nursing unit dining room. The surveyor observed DSA #5 used a resident plastic drinking cup with her bare hand, reached into the ice machine and scooped the ice into the plastic cup. On 2/11/25 at 10:55 AM, the surveyor interviewed the DON who stated that an ice scooper should be used when getting ice from the ice machine. The DON further stated that it was important to use an ice scooper to remove ice from the ice machine to prevent the spread of infection or contamination. On 1/13/25, the facility provide the surveyor an in-service titled Ice Scoop Training which included that ice scoops are to be used in all ice machines for safety .2. Ice scoops are the only tool to use when getting ice from the ice machine, 3. DO NOT use- glasses, cups, spoons, plastic cups or anything that is NOT an ice scoop. A review of the facility's Infection Prevention and Control policy revised December 2024, included S. Infection prevention and control program (IPCP) refers to a program (including surveillance, investigation, prevention, control and reporting) that provides a safe, sanitary and comfortable environment to help prevent the development and transmission of infection. 45589 3.) On 2/7/25 at 10:37 AM, during the initial tour of the first-floor skilled nursing unit, the surveyor observed Resident #18 awake and alert sitting in his/her wheelchair in their room. The surveyor observed a nebulizer mask (a device that fits over the nose and mouth to deliver medication to the lungs) lying directly on the bedside table, not stored in a plastic bag. On 2/11/2025 at 10:09 AM, the surveyor observed Resident #18 sitting in his/her wheelchair in his/her room with their eyes closed. The surveyor observed a nebulizer mask lying directly on the bedside table, not stored in a plastic bag On 2/11/2025 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #3) who stated Resident #18 used the nebulizer as needed and would ask for it if needed. LPN #3 also stated that after using the nebulizer mask, the mask should be cleaned and then stored in a plastic bag. LPN #3 confirmed that the nebulizer mask in Resident #18's room was not stored in a plastic bag. LPN #3 further stated that it was important to store the nebulizer mask, when not in use, in a plastic bag for infection control. On 2/11//2025 at 1:40 PM, the surveyor reviewed the medical record for Resident #18. A review of the admission record, an admission summary, revealed the resident had diagnosis which included, congestive heart failure, dementia, and anxiety. A review of the quarterly Minimum data Set (MDS), an assessment tool, dated 1/21/25, included the resident had a Brief Interview for mental status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of the the physician's orders (PO) for Resident #18, which included the following: A PO, dated 1/30/2025, for Albuterol Sulfate Inhalation Nebulization Solution 1.25 Milligram (MG)/3 milliliters (Albuterol Sulfate)-1 vial inhale orally via nebulizer every 6 hours as needed for wheezing. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 11/9/2023, that the resident had Congestive Heart Failure. Interventions included: to give medications (meds) as ordered. On 2/12/2025 at 12:15 PM, the surveyor interviewed the DON who stated that after use, the nebulizer should be cleaned, dry at room air, then stored and maintained in a plastic bag. The DON also stated that this was important to store the nebulizer mask in a plastic bag when not in use to prevent contamination from the environment. A review of the facility's undated Nebulizer Therapy Policy included, Procedures .3. Equipment Maintenance and Safety .Nebulizer mask and tubing shall be stored in a plastic bag when not in use and replaced weekly. 41072 4.) On 02/07/25 at 10:34 AM, the surveyor observed Resident #31 awake and alert, sitting in a wheelchair in their room. The surveyor observed an Intravenous (IV) pole located in the resident's room. Resident #31 stated that he/she had an IV inserted in his/her right upper arm about four (4) days ago for a Urinary Tract Infection (UTI). No Enhanced Barrier Precautions (EBP) signage was observed posted inside or outside the resident's room. On 2/10/25 at 12:22 PM, the surveyor observed Resident #31 not in his/her room. At that time, the surveyor observed an empty bag of IV antibiotic medication hanging from the IV pole in the resident's room. No EBP signage was observed posted inside or outside the resident's room. The surveyor reviewed the medical record for Resident #31. A review of the Admission Record, an admission summary, revealed the resident had diagnosis which included, Multiple Sclerosis (a chronic, autoimmune disease that affects the central nervous system) and urinary tract infection. A review of the resident's quarterly MDS, dated [DATE], included the resident had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident was always incontinent of urine. A review of the ICCP included a focus area, dated 1/31/2025, that the resident had an infection of the urinary tract infection. Interventions included: administer antibiotic as per medical doctor (MD) orders. The care plan did not include EBP. A review of the Order Summary Report (OSR), dated as of 2/11/25, included the following physician's orders (PO): A PO, dated 2/4/25, for midline placement. A PO, dated 2/4/25, to check midline site every shift for signs and symptoms of infection every shift A PO, dated 2/3/25, to start on 2/4/25 for Aztreonam Injection Solution Reconstituted 1 Gram (an antibiotic). Use 1 gram intravenously two times a day related to UTI for 7 days, with end date of 2/11/25. A PO, dated 2/11/25, to remove Midline. A review of the Midline Insertion Documentation form from an outside company, dated 2/4/25, indicated the midline was placed to the right upper arm. On 2/11/2025 at 10:03 AM, surveyor interviewed the Infection Preventionist (IP) who stated that a resident who had a Midline catheter for IV antibiotics should be on EBP. The IP stated that Resident # 31 was not on EBP because she thought the resident had a peripheral IV site not a midline IV catheter. On 2/12/2025 at 12:15 PM, the surveyor interviewed the DON who stated that a resident who had a midline IV catheter should be on EBP. Reference: Center for Disease Control and Prevention, Long-Term Care Facilities, document titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes dated June 28, 2024, states, .22. What is the definition of indwelling medical device? An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally inserted central catheters (PICCs)) . Although the data are limited, CDC does not currently consider peripheral I.V.s (except for midline catheters) . as indications for Enhanced Barrier Precautions . A review of the facility's Enhanced Barrier Precautions (EBP) policy, reviewed December 2024, included, EBP are required for patients with any of the following: 2. Indwelling medical devices: Midlines, PICC lines, Central lines. NJAC 8:39-19.4(n)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that residents were served their meals in a manner that promotes respect and dignity for 2 residents (Resident #32 and #42) observed during a lunch meal service on 1 of 4 units (Skilled 2). This deficient practice was evidenced by the following: 1.) On 2/10/25 at 12:00 PM, the surveyor observed the lunch meal service in the Skilled 2 nursing unit dining room. Resident #32 was seated in a geriatric (geri) chair (a reclining chair) at a table with two other residents. At 12:38 PM, the surveyor observed Licensed Practical Nurse (LPN) #1 standing over Resident #32 while feeding the resident tomato soup and sips of his/her beverage. At 12:47 PM, LPN #1 stopped feeding Resident #32 as the resident had finished his/her soup. The LPN then walked away from the resident. At 12:55 PM, the Resident #32 was served an entree of pureed fettuccine and pureed broccoli. LPN #1 was now seated at a different table feeding another resident. There were no staff feeding Resident #32 his/her entree. At 1:03 PM, Certified Nursing Assistant (CNA) #1 walked over to Resident #32 and started to feed the resident his/her entree while standing over the resident. The CNA then left to feed another resident at a different table. Resident #32 was not finished eating the entree. At 1:12 PM, the CNA #2 walked over to Resident #32 and started to feed the resident his/her entree while standing over the resident. The CNA then left the resident to feed another resident seated at the same table. Resident #32 was not finished eating the entree. At 1:19 PM, LPN #2 walked over to Resident #32 and gave the resident sips of his/her beverage while standing over the resident. At that time, the resident was served a pureed dessert. The LPN fed the resident his/her dessert while standing over the resident. The resident ate 100% of the dessert. LPN #2 never offered the resident the rest of his/her entree and staff assisted the resident out of the dining room. At 1:27 PM, the surveyor interviewed LPN #1 who stated there were usually five CNAs who each had a resident on their assignments who required assistance with feeding. The LPN further stated that staff assisting residents with feeding should sit down in a chair side by side with the resident in order to monitor the resident during the meal. When asked about Resident #32, the LPN stated she fed the resident his/her soup and juice, but that she should have been seated next to the resident. The LPN further stated that residents should be fed within 10 minutes of their food being served. At 1:31 PM, the surveyor interviewed CNA #1 who stated staff should be eye level with the resident while assisting with feeding. When asked about Resident #32, the CNA stated she should have been eye level with the resident when assisting with feeding. The CNA further stated that residents should be fed within a minute or so to prevent the food from getting cold. At 1:35 PM, the surveyor interviewed CNA #2 who stated staff assisting residents with feeding should be sitting next to the resident. When asked about Resident #32, the CNA stated she could not sit next to the resident because there was not enough room, but that staff should be ensuring residents are positioned in a way that staff can be seated while feeding. The CNA further stated that staff should feed residents immediately when the food is served to prevent the food from getting cold. At 1:40 PM, the surveyor interviewed LPN #2 who stated staff assisting residents with feeding should probably be sitting next to the resident to maintain eye contact. When asked about Resident #32, the LPN stated she should have been seated while feeding the resident. The LPN further stated that staff should assist residents with feeding right away while the food is hot. The surveyor reviewed the medical record for Resident #32. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, dementia and muscle weakness. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/19/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident was dependent on staff for eating. On 2/11/25 at 1:08 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA), who stated staff should sit next to the resident while assisting with feeding to maintain eye contact and to conversate with the resident. The DON further stated that resident should be fed immediately after the food is served so that the resident is not watching other residents eat, and so the food is warm and more pleasurable. A review of the facility's Assistance with Meals policy, undated, included Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. A review of the facility's Food Presentation Policy, undated, included, Timing and Freshness: Dishes should be prepared and served immediately after plating to maintain the freshness of the food and preserve its appearance. 37547 2.) On 2/10/25 at 12:11 PM, the surveyor observed a menu posted outside of the Second Floor Skilled Nursing Unit Dining Room which featured tomato soup, grilled cheese, or fettuccine alfredo with broccoli and a soft cookie. Further review of the Menu indicated that lunch was scheduled from 12:00 PM to 1:00 PM. At 12:22 PM, a rolling cart was brought into the dining room with three meal trays on it which were passed out to the residents. Meal choices were given to the residents prior to meal service and alternatives were offered. At 12:30 PM, the surveyor observed Resident #42 seated in a wheel chair at the dining room table awaiting meal delivery. The resident's meal ticket was on the table and indicated that the resident was ordered a mechanical soft diet with thin liquids. The resident called out, I am very hungry. At 12:32 PM, Dietary Service Aide (DSA) #2 reviewed Resident #42's meal ticket and took the resident's meal order. The resident refused fettuccini alfredo with broccoli and instead requested a peanut butter and jelly sandwich. DSA #2 then offered Resident #42 mashed potatoes and broccoli and the resident stated yes to both. Resident #42 informed DSA #2 that he/she was, very hungry. At 12:43 PM, Certified Nursing Assistant (CNA) #3 was observed feeding tomato soup to an unsampled resident who was seated at the same table as Resident #42 . CNA #3 then proceeded to request soup for both Resident #42 and a second unsampled resident who was seated at the same table. At 12:45 PM, the second unsampled resident was served tomato soup while Resident #42 watched the two residents seated at the table eating their soup. Resident #42 had only been served a cold beverage at that point and stated, I am very hungry. At 12:47 PM, Resident #42 was served a peanut butter and jelly sandwich that was cut into four small pieces with the crust removed and had not received the mashed potatoes and broccoli that were ordered. The resident then proceeded to eat the sandwich independently. At 12:56 PM, the CNA #3 requested food for the table and DSA #2 stated, I have to serve the food table by table. At that time, Resident #42 stated, I like soup. Resident #42 then requested chicken noodle soup. CNA #3 stated that the facility only had tomato soup, to which Resident #42 did not respond. At 1:13 PM, the two unsampled resident's at Resident #42's table were served dessert. Resident #42 had finished his/her peanut butter and jelly sandwich and was not offered any dessert. At 1:17 PM, a Certified Nursing Assistant (CNA) asked Resident #42 if he/she were finished with their meal and failed to offer the resident dessert before they proceeded to remove the resident from the dining room. At 1:18 PM, the surveyor interviewed DSA #2 and asked her why Resident #42 had not received their mashed potatoes, broccoli, soup and dessert and she stated that there had been a mishap due to the staff not communicating. DSA #2 further stated that the resident did not like soup and would have wasted it if it were served. At 1:21 PM, the surveyor interviewed CNA #3 who stated that Resident #42 would not have eaten mashed potatoes and broccoli if they had brought it. CNA #3 stated that the resident only wanted chicken noodle soup, not tomato. CNA #3 stated that the resident liked to eat cake and would have eaten dessert if it would have been served. On 2/11/25 at 2:25 PM, the surveyor interviewed the Director of Nursing (DON) who stated that everyone should have been served at the same time for dignity. The DON stated that everyone should have been offered everything on the menu and should have been given a choice of every appetizer, entree and dessert on the menu. The DON further stated, The resident should be given a choice every single time. A review of the facility's undated Dignity policy included: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. A review of the facility's undated Assistance with Meals policy included: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. NJAC 8:39-4.1(a) 12

Complaint #NJ179408 Based on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of narcotic drug diversion to the New Jersey Department of Health and the Office of the Ombudsman for the Institutionalized Elderly in a timely manner in accordance with state and federal requirements. This deficient practice was identified for 1 of 1 Nurse (Licensed Practical Nurse (LPN) #4 and 3 of 3 residents (Resident #197, #198, and #199) reviewed for pain medication administration on 1 of 4 nursing units (Rehabilitation Unit #1) and was evidenced by the following: Refer to F755 On 2/11/25 at 8:48 AM, the surveyor reviewed the medical record of Resident #197. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, displaced fracture of base of neck of right femur (the bone of the thigh, between the knee and the hip), subsequent encounter for closed fracture with routine healing, and repeated falls. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool, dated 9/23/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident had experienced occasional pain that was described as moderate that occasionally interfered with therapy activities and day to day activities and that had rarely or had not affected the resident's ability to sleep. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 9/24/24, that the resident had acute/potential pain related to (r/t) immobility/fracture. Interventions included: Be alert to verbal/non-verbal signs and symptoms (s/s) of pain. Notify Nurse as needed if resident complains of (c/o) or shows s/s of pain. A review of the Order Summary Report (OSR) included the following physician's orders (PO): -A PO, dated 9/19/24, for Tramadol HCL oral tablet 50 milligrams (MG) give one (1) tablet every six (6) hours as needed for moderate pain for 14 days pain management. -A PO, dated 9/20/24, for Oxycodone HCL oral tablet five (5) MG give one (1) tablet by mouth every four (4) hours as needed for severe pain related to displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing for 14 days. On 2/11/25 at 8:48 AM, the surveyor reviewed the medical record of Resident #198. A review of the Admission Record revealed the resident had diagnoses which included, displaced trimalleolar (ankle) fracture of right lower leg, subsequent encounter for closed fracture with routine healing and unsteadiness on feet. A review of the most recent comprehensive MDS, dated [DATE], included the resident had a BIMS score of 15 out of 15, which indicated the resident's cognition was fully intact. Further review of the MDS revealed the resident had not experienced pain or hurting at any time in the past five days during a pain assessment interview. A review of the ICCP included a focus area, dated 9/25/24, that the resident had a trimalleolar fracture right lower extremity (RLE) related to fall. Interventions included: Observed for verbal/nonverbal s/s of pain. Notify nurse as needed. A review of the OSR included the following PO: -A PO, dated 9/24/24, for Oxycodone HCL Tablet 5 MG give 1 tablet by mouth every 4 hours as needed for moderate pain (4-7) for 14 days. -A PO, dated 9/24/24, for Oxycodone HCL Tablet 5 MG give two (2) tablets by mouth every 4 hours as needed for severe pain (8-10). On 2/11/25 at 8:48 AM, the surveyor reviewed the medical record of Resident #199. A review of the Admission Record revealed the resident had diagnoses which included, acute kidney failure, unspecified, chronic gout (a complex form of arthritis), low back pain, unspecified, and wedge compression fracture of first lumear vertebra (a type of spinal fracture), subsequent encounter for fracture with routine healing. A review of the most recent comprehensive Minimum Data Set (MDS) dated [DATE], included the resident had a BIMS score of 15 out of 15, which indicated the resident's cognition was fully intact. Further review of the MDS revealed the resident had experienced occasional pain that was described as moderate that had rarely or had not affected the resident's therapy activities, day to day activities or the resident's ability to sleep. A review of the ICCP included a focus area, dated 8/30/24, that the resident had a risk of pain related to deconditioning and gout. Interventions included: Administer meds as ordered. Monitor effectiveness and for any adverse side effects and Assess need for pain meds prior to activities of daily living (ADLs)/and or therapy. A review of the OSR included the following PO: -A PO, dated 9/16/24, for Oxycodone HCL oral tablet 5 MG Give 1 tablet by mouth every 4 hours as needed for moderate (mod.) pain for 14 days. -A PO, dated 9/16/24, for Oxycodone HCL oral tablet 5 MG Give 2 tablets by mouth every 4 hours as needed for severe pain for 14 days. On 2/11/25 at 12:01 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated the oncoming nurse, and the outgoing nurse should both count the narcotics and sign the book to ensure that the narcotic count was right, and the medications had not been compromised. LPN/UM #1 further stated that there was a recent problem with an agency nurse who signed out narcotics, but it was questionable whether the residents had received them. LPN/UM #1 stated that the incident was reported and was investigated by the Director of Nursing (DON). On 2/11/25 at 1:36 PM, the surveyor requested and received a copy of a Long-Term Care Reportable Event Survey that was reported to the New Jersey Department of Health on 10/4/24, for an event that occurred on 9/28/24 at 7:00 PM, six (6) days after the event, and detailed that there was a loss or theft of narcotics on the Rehab 1 Nursing Unit. A review of a narrative report detailed that on 9/28/24, it was noted that three (3) residents had narcotics removed and signed off from their narcotic inventory record, and none of the doses were signed off on their medication administration record (MAR). Two of the residents denied being medicated for pain and stated they were not medicated for pain by the nurse on this day. It was also noted that on 9/23/24, three doses of medication were removed from the inventory, however, were not signed off as administered and the resident stated that he/she has not taken anything for pain since 9/22/24. It was suspected that the same nurse removed these doses from inventory and changed the date and forged someone else's signature. The nurse was placed on the do not return list and it was reported to her agency. Further review of the Long-Term Care Reportable Event Survey revealed the Office of the Ombudsman for the Institutionalized Elderly was notified of the event on 10/4/24 at 4:45 PM, six days after the event occurred. Further review of the investigation included a Report of Theft or Loss of Controlled Substances (Drug Enforcement Agency (DEA) Form 106) which detailed that there were fourteen Oxycodone HCL immediate release (IR) 5 MG tablets reported stolen and one Tramadol HCL 50 MG tablet was reported stolen. On 2/11/25 at 2:06 PM, the surveyor interviewed the DON who stated that LPN #5 and LPN #6 reported odd behavior from LPN #4 (an agency nurse) which included hyperactivity to the supervisor. The DON stated that LPN #4, was observed down the hall passing medication past the shift change and had the narcotic inventory book opened, as she looked in the computer for a long time. The DON stated that the narcotic inventory was accurate when LPN #6 and LPN #4 counted at 7 PM. The DON stated that LPN #5 noted that narcotic medications were signed out on the time that she worked that were not her signature and she stated the forged signature raised a suspicion. The DON stated that the first instance was obvious for Resident #199, because the resident denied receipt of the medication and a review of the MAR did not reflect receipt. The DON stated that the resident stated that their last dose was on 9/22/25. At that time, the DON reviewed Resident #199's Individual Narcotic Record (INR) for Oxycodone IR 5 MG tablets which indicated that on 9/23/24 at 7 AM, on 9/23/24 at 11:30 AM, and on 9/23/24 at 4:00 PM, two tablets were signed out by someone other than LPN #5 who was assigned to the resident on this date, and the signature did not belong to LPN #5, or anyone who worked on that date. The DON further stated that LPN #4 was assigned to Resident #199 on 9/28/24 and signed out two tablets of Oxycodone IR 5 MG to the resident at both 12:20 PM and at 6:12 PM, for a total of ten tablets. At that time, the DON stated that Resident #197 was unable to tell us if he/she was medicated for pain or not, but two tablets of Oxycodone and one Tramadol tablet were signed out on the INR and were not signed out on the MAR and there was an established pattern. At that time, the DON reviewed Resident #198's INR with the surveyor which indicated that on 9/28/24 at 9:30 AM and 6:40 PM, LPN #4 signed out two tablets of Oxycodone IR 5 MG tablets which had not been signed out on the MAR. On 2/12/25 at 2:26 PM, in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team, the DON stated that she did not know when she was required to notify the NJDOH and the Office of the Ombudsman for the Institutionalized Elderly of a suspected and alleged drug diversion. The DON stated that it was not reported right away because of a delayed response on behalf LPN #4. The DON stated that she was unable to immediately confirm diversion and wanted to interview LPN #4 because she was not sure if it were actual diversion, and did not want to create a false report. The LNHA stated that she was not sure of what the required reporting timeframe was for notifying both the NJDOH and the Office of the Ombudsman for the Institutionalized Elderly of an alleged or suspected drug diversion. The DON further stated that the day that she reported, was the day she decided that she was going to treat it as drug diversion when LPN #4 failed to comply with a face-to-face interview. The DON further stated that she had not provided a summary and conclusion to the NJDOH yet because they had not requested it. A review of the facility's undated Reportable Event Policy included: Mandatory reporting of incidents that can affect the health, safety, or well-being of residents is required. .Reporting Procedure: .External Reporting: The Director of Nursing or Healthcare Administrator will determine the appropriate bodies that need to be informed such as the NJDOH, Ombudsman, Policy, Physician, local health department, and family. A review of the facility's undated Drug Diversion and Prevention Policy included: .Reports of confirmed drug diversion will be submitted to the NJDOH, law enforcement, and licensing boards as required . NJAC 8:39-9.4(f)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to obtain a re-weight according to the facility's policy for a resident with a history of significant weight loss. This deficient practice was identified for 1 of 1 resident (Resident #51) reviewed for nutrition and evidenced by the following: On 2/10/25 at 1:01 PM, the surveyor observed Resident #51 in the first-floor skilled nursing unit dining room being served breakfast. The resident received pancakes cut into bite sized portions. The resident complained that the pancakes were cold and did not eat the pancakes. On 2/11/25 at 8:20 AM, the surveyor observed Resident #51 in the first-floor skilled nursing unit dining room being served breakfast. The resident received pancakes cut into bite sized portions. The resident ate about 50% of their meal. The surveyor reviewed the medical record for Resident #51. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, vascular dementia, gastro-esophageal reflux disease (GERD) and dysphagia (difficulty swallowing). A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 1/28/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident had a weight loss of 5% or more in the last month, or 10% or more in the last six months, while not on a physician-prescribed weight loss regimen. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 5/29/24, that the resident had nutritional problem related to dementia, anxiety, depression, diabetes, dysphagia, and mechanical altered diet. Interventions included: 5/29/24, monitor weight as ordered. Notify Registered Dietician (RD)/ Medical Director (M)D as needed of weight gain/loss. A review of the Order Summary Report (OSR), dated as of 2/11/25, included the following physicians' orders: A PO, dated 12/9/24, for carbohydrate, controlled diet. Mechanical soft- ground meat texture, thin liquids consistency. A PO, dated 1/27/25, for a supplement two times a day for weight loss. A PO, dated, 1/24/25, for weekly weights times 4 weeks one time a day every Wednesday for 4 weeks. A review of the Dietician Note (DN), dated 1/27/24, included the resident had a significant weight loss in one month with multiple weight fluctuations in the past few months. Intake remains good, consuming 50% of meals. Further review of the DN included recommendations to monitor intake, weight trends and increased the supplement to twice a day. A review of the Weights and Vitals Summary, as of 2/10/25 included the following weights: On 12/1/24, the resident weighed 127 lbs.(wheelchair) On 1/1/25, the resident weighed 135 lbs. (wheelchair)- with incorrect documentation added by RD On 1/8/25, the resident weighed 121.3 lbs. (wheelchair)- with incorrect documentation added by the RD On 1/29/25, the resident weighed 133 lbs.(wheelchair) On 2/1/25 the resident weighed 121. lbs.(wheelchair) On 2/6/25, the resident weighed 107.9 lbs. (sitting) On 2/10/25, the resident weighed 110.4 lbs. (standing) A PO, dated 2/10/25, included an order to reweigh one time. A review of the February 2025 Medication Administration Record (MAR) revealed that a weight of 121 lbs. was documented in the MAR on 2/20/25 at 3:28 PM. A review of the Progress Notes (PN), dated 1/18/25 through 2/10/25, did not include evidence that a re-weight was attempted after the documented weight loss of more than five pounds, or that the RD or physician was notified of the significant weight loss on 2/1/25 and 2/6/25. On 2/11/25 at 9:52 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #4) who stated the nurse scheduled the weights that the CNAs needed to obtain weekly. The CNA further stated that she reports the weights to the nurse but does not look at the resident's weight history for comparison. CNA #4 explained that if a resident needed to be re-weighed, the nurse would instruct the CNA to obtain the weight at that time. CNA #4 stated that the nurse would put the weights in the electronic medical record (EMR). On 2/11/25 at 9:56 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #3) who she was the nurse for Resident #51 that day. LPN #3 stated that the nurse would put the residents who needed weights on the daily schedule, the CNA would obtain the weight, and the nurse would enter the weight into the EMR. If there was a significant weight change from the last weight, the nurse should reweigh the resident and if the weight was verified, then the nurse should contact the RD and the doctor. LPN #3 reviewed the documented weights with the surveyor and confirmed that the resident should have been reweighed and the RD and doctor should have been notified on 2/1/25 and 2/6/25. On 2/11/25 at 10:46 AM, the surveyor interviewed the RD who stated that the CNAs would obtain the weights, and the nurse would document the weights in the EMR. The RD explained that if a resident had a weight change since the last weight, a re-weight should be obtained immediately to confirm if the weight was accurate. The RD further stated that for true significant weight losses, the nurse would notify the RD and the doctor. The RD stated she was unaware of the weight obtained on 2/1/25, 2/6/25 and 2/10/25. The RD stated that on 1/27/25 she had increased the residents supplement to 2 times a day and had placed the resident on weekly weights and to monitor the resident's intake. On 2/11/25 at 11:33 AM, LPN #3 stated that she and CNA#4 reweighed the resident in the wheelchair and the weight obtained was 117.8 lbs. The RD and the doctor was made aware of the weight change. A review of the Dietician Note (DN), dated 2/12/25, the RD questioned the accuracy of the above weights. The note reflected that the weight loss likely due to a decline in intake and limited acceptance of prior supplement. The resident continued with fair appetite, consuming 25-50% of meals. The RD will honor preferences to encourage intake, will continue to monitor intake, weight trends and labs as available. On 2/12/25 at 12:15 PM, the surveyor interviewed the Director of Nursing (DON) who stated that when there was a discrepancy in Resident #51's weight obtained on 2/1/25, 2/6/25 and 2/10/25, the nurse should have reweighed the resident to confirm the weight loss, then notified the RD and the doctor. A review of the facility's Weight Policy, undated, included that any weight change of 5% or more since the last weight assessment is retaken for confirmation. If the weight is verified, nursing will immediately notify the dietician. NJAC 8:39 - 27.2 (a)

Based on observations, interviews, facility document review, and facility policy review, it was determined that the facility failed to follow the planned menu and serve foods to residents in the amount indicated on the diet spreadsheet for 2 of 2 meals observed. This had the potential to affect 71 residents who received meals from the kitchen, as identified by the facility. Findings included: Review of a facility policy titled, Menu Extensions/Diet Spreadsheets, dated 01/2016, revealed, Policy: Menu extensions are to be available, referred to, and followed with each meal that is prepared and served. 1. Each employee is responsible for following the prepared menu extensions. 3. When serving, the employee refers to the menu extension to ensure that the proper portion sizes and diet needs are being met. Review of the facility policy titled, Diets and Menus Portion Control, dated 03/2017, specified, Policy: Standardized portions of food will be planned and served for all menu items to ensure standards for nutritional content and food cost are met. 1. Portion sizes will be indicated on menu extensions and production sheets. 3. The correct type and size of utensils will be used for each menu item. The policy further indicated a #8 scoop held 4 ounces (oz.), a #10 scoop held 3 1/4 oz., a #12 scoop held 2.67 oz., and a #16 scoop held 2 oz. 1. A review of the Diet Extensions Week #3 Monday Lunch specified a regular diet included: - 6 ounces (oz.) of navy bean soup, - 1/2 cup (c.) of sliced pears, - 2 oz. of turkey with two slices of bread and 1 oz. of cranberry sauce, - 1/2 c. of green beans, - 1/2 c. of mashed potatoes, and - one oatmeal cranberry cookie. Alternates for the regular diet included 3 oz. of roast beef on one slice of bread, and 4 oz. of tomato corn salad. A mechanical soft-chopped meats diet included: - 6 oz. of navy bean soup, - 1/2 c. of sliced pears, - 2 oz. of chopped turkey on white bread with no crust and 1 oz. of cranberry sauce, - 1/2 c. of green beans, - 1/2 c. of mashed potatoes, and - one oatmeal cranberry cookie. Alternates for the mechanical soft-chopped meats diet included 3 oz. of chopped beef on one slice of white bread with no crust, and 4 oz. of V-8 juice. A mechanical soft-ground meats diet included: - 6 oz. of navy bean soup, - 1/2 c. of sliced pears, - 2 oz. of ground turkey on white bread with no crust and 1 oz of cranberry sauce, - 1/2 c. of green beans, - 1/2 c. of mashed potatoes, and - one oatmeal cranberry cookie. Alternates for the mechanical soft-ground meats diet included 3 oz. of ground beef on 1 slice of bread with no crust, and 4 oz. of V-8 juice. A full ground diet included: - 6 oz. of pureed navy bean soup, - #8 scoop (4 oz.) pureed pears, - 2 oz. of ground turkey on #12 scoop (2.67 oz.) pureed bread with 1 oz. of cranberry sauce, - #8 scoop (4 oz.) of pureed green beans, - 1/2 c. of mashed potatoes, and - #12 scoop (2.67 oz.) of pureed oatmeal cranberry cookie. Alternates for the full ground diet included 3 oz. of ground beef with #16 scoop (2 oz.) of bread, and 4 oz. of V-8 juice. On 02/06/2023 (Monday) from 12:30 PM to 1:07 PM, Dining Room Service Aide (DRSA) #1 was observed plating the first floor skilled lunch menu items for the resident lunch meal trays. For regular diets, DRSA #1 was observed using a 4 oz. ladle to plate navy bean soup, using a tong to plate turkey, and a #12 scoop to plate mashed potatoes. For the regular alternates diets, DRSA #1 was observed using a tong to plate roast beef, and a 3 oz. ladle to plate tomato corn salad. For a mechanical soft-chopped meat diet, DRSA #1 was observed using a 4 oz. ladle to plate navy bean soup, a tong to plate chopped turkey, and a #12 scoop to plate mashed potatoes. For mechanical soft-chopped meat diet alternates, DRSA #1 was observed using a #16 scoop of chopped beef. No V-8 juice was served. For a mechanical soft-ground meat diet, DRSA #1 was observed using a 4 oz. ladle to plate navy bean soup, using a tong to plate ground turkey, and a #12 scoop to plate mashed potatoes. For mechanical soft-ground meat diet alternatives, DRSA #1 was observed using a #16 scoop of ground beef. No V-8 juice was served. During an interview on 02/06/2023 at 1:09 PM, DRSA #1 revealed that she used a 4 oz. ladle to serve navy bean soup, 4 oz. ladle to serve gravy, #12 scoop for mashed potatoes, #16 scoop for ground roast beef, a tong to serve regular and chopped turkey, and 3 oz. ladle to plate tomato corn salad. She indicated the menu with serving sizes was not present during the meal service and she sometimes looked at the menu when it was brought to her from the main kitchen. DRSA #1 stated she expected the menu, including serving sizes, to be followed. 2. Review of the Diet Extensions Week #3 Tuesday Lunch specified a regular diet included: - 6 oz. of split pea soup, - 1/2 c. of mandarin oranges, - one slice of Havarti and tomato frittata, - 1/2 c. of sweet potato wedges, - 1/2 c. of spinach salad, and - one slice of cherry pie. Alternates for the regular diet included a #10 scoop (3.25 oz.) of tuna melt with cheese on sliced bread, and 8 oz. of milk. A mechanical soft-chopped meat diet included: - 6 oz. of split pea soup, - 1/2 c. of mandarin oranges, - one slice of Havarti and tomato frittata, - 1/2 c. of sweet potato wedges with no skin, - 4 oz. of tomato juice, and - one slice of cherry pie. Alternates of the mechanical soft-chopped meat diet included #10 scoop (3.25 oz.) of tuna melt with cheese on sliced bread without crust, and 8 oz. of milk. A mechanical soft-ground meat diet included: - 6 oz. of split pea soup, - 1/2 c. of mandarin oranges, - one slice of Havarti and tomato frittata, - 1/2 c. of sweet potato wedges with no skin, - 4 oz. of tomato juice, and - one slice of cherry pie. Alternates for the mechanical soft-ground meat diet included a #10 scoop (3.25 oz.) of tuna melt with cheese on sliced bread without crust, and 8 oz. of milk. A full ground diet included: - 6 oz. pureed split pea soup, - #8 scoop (4 oz.) of pureed mandarin oranges, - 3 oz. of ground frittata, - #10 scoop (3.25 oz.) of mashed sweet potato, - 4 oz. of tomato juice, and - #12 scoop (2.67 oz.) of pureed cherry pie. Alternates for the full ground diet included #10 scoop (3.25 oz.) of tuna salad and #12 scoop (2.67 oz.) of pureed bread, and 8 oz. of milk. A puree diet included: - 6 oz. pureed split pea soup, - #8 scoop (4 oz.) of pureed mandarin oranges, - 3 oz. of pureed frittata, - #10 scoop (3.25 oz.) of mashed sweet potato, - 4 oz. of tomato juice, and - #12 scoop (2.67 oz.) of pureed cherry pie. Alternates for the puree diet included a #10 scoop (3.25 oz.) of tuna salad and #12 scoop (2.67 oz.) of pureed bread, and 8 oz. of milk. On 02/07/2023 (Tuesday) from 12:10 PM to 12:52 PM, DRSA #2 was observed plating the second-floor skilled lunch menu items for the resident lunch meal trays. For regular diets, DRSA #2 was observed using a 3 oz. ladle to plate mandarin oranges and a tong to plate spinach salad. For mechanical soft-chopped meat and mechanical soft-ground meat diets, DRSA #2 was observed using a 3 oz. ladle to plate mandarin oranges and a tong to plate spinach salad. For full ground diets, DRSA #2 was observed using a #12 scoop to plate pureed oranges, #12 scoop to plate ground frittata, #16 scoop to plate pureed sweat potato, and #16 scoop to plate tuna melt. For pureed diets, DRSA # 2 was observed using a #12 scoop to plate pureed oranges, #16 scoop to plate pureed frittata, #16 scoop to plate pureed sweet potatoes, and #16 scoop to plate tuna melt. On 02/07/2023 at 12:53 PM, DRSA #2 stated she used a #16 scoop to plate puree tuna, #16 scoop for pureed sweet potatoes, #16 scoop for puree frittata, #12 scoop for pureed oranges, #12 scoop to plate ground frittata, and a tong to serve salad. She stated that when using a tong, you do not know how much the resident was getting served. DRSA #2 stated the main kitchen sent the serving utensils to the kitchenettes and was supposed to send the correct serving sizes for the meals. She stated she normally looked at the menu but did not get a menu to look at for that meal and could not ask for a menu because her radio, to call the main kitchen, was not working. She stated she expected the menu to be followed. On 02/08/2023 at 11:25 AM, Registered Dietician (RD) #10 stated the menu and serving sizes should be followed. She stated she completed audits for textures but not for staff using the correct serving sizes according to the menu. She indicated potential negative outcomes of not serving the correct portions included residents not getting enough calories and protein which could lead to weight loss. RD #10 stated she expected serving sizes and the menu to be followed. On 02/08/2023 at 11:56 AM, DRSA #1 stated she trusted the main kitchen to send the correct serving utensils. She indicated she did not have a menu to look at on Monday (02/06/2023) to look at the serving sizes indicated on the menu. She stated she expected the serving sizes and menus to be followed. She stated she did not receive training on checking the menu serving sizes. On 02/08/2023 at 12:11 PM, General Manager for Dining Services (GMDS) #16 revealed DRSAs were trained to follow the menu and serving sizes. He stated DRSA #1 had been employed by the facility for a couple of years but the other DRSAs were fairly new. He indicated the kitchen managers were responsible for ensuring the menu was followed. He stated the potential negative outcome of residents not getting the correct portion sizes was weight loss. GMDS #16 stated he would ensure the correct serving utensils were provided to the kitchenettes on each floor and expected the menu and serving sizes to be followed. On 02/09/2023 at 7:39 AM, the Administrator stated she expected the menu and serving sizes to be followed. She stated the kitchen managers were responsible for ensuring the staff serving in the kitchenettes had the correct serving utensil sizes needed to serve the meal. The Administrator stated she did not monitor serving sizes used during meals, but the dietician and kitchen managers were responsible for monitoring such practices. She stated tongs could not measure portions. She stated the potential negative outcome of residents not getting the correct portion sizes was undernourishment. On 02/09/2023 at 8:33 AM, the Director of Nursing (DON) stated the serving sizes, based on the menu/diet spreadsheet, should be followed. She stated the kitchen managers and dietician were responsible for checking that the correct serving sizes were being used according to the menu. She stated she never watched meal service to ensure the serving sizes being used matched the menu but would start monitoring. She expected the menu and serving sizes to be followed to maintain the nutritional adequacy of the residents' meals. New Jersey Administrative Code S 8:39-17.4(a)(3)

Based on observations, record review, and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's dental status for 1 (Resident #161) of 1 sampled resident reviewed for dental services. A review of Resident #161's Admission Record revealed the resident had diagnoses that included type 2 diabetes mellitus with unspecified complications and need for assistance with personal care. An admission Minimum Data Set (MDS), dated [DATE], revealed Resident #161 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS indicated the resident did not have any tooth fragments or broken natural teeth. A review of Resident #161's Nursing Admission/Readmit Screening/History, dated 01/25/2023, indicated the resident did not have any broken teeth. A review of Resident #161's Nutrition Risk Assessment for Short-Term Stay - Initial, dated 01/30/2023, revealed the resident did not have any missing/broken teeth. On 02/06/2023 at 3:26 PM, Resident #161 was observed sitting in a chair in their room watching television. The resident had teeth missing and broken teeth visible on the top and bottom gums. During an interview on 02/07/2023 at 11:46 AM, Resident #161 denied having trouble eating or having pain in their mouth, teeth, or gums. During an interview on 02/07/2023 at 3:45 PM, the Director of Nursing (DON) stated there had not been a dental consult completed for Resident #161, since the resident had not complained of pain or trouble eating, nor had they lost any weight. She confirmed the missing and broken teeth should have been reflected on the admission MDS. During an interview on 02/08/2023 at 11:06 AM, the MDS Coordinator confirmed she completed the oral and dental section for Resident #161. She stated she had derived the information from the Nursing Admission/Readmit Screening/History. During an interview on 02/08/2923 at 11:16 AM, Licensed Practical Nurse (LPN) #9 indicated she completed the nursing admission assessment for Resident #161. She stated she noted that the resident had missing and broken teeth on the top and bottom but did not document this on the assessment. She indicated the resident denied having dentures or pain. She stated she did not have a reason for not documenting the resident's missing and broken teeth and indicated she should have. During an interview on 02/08/2023 at 11:26 AM, the Registered Dietitian (RD) stated she generally did not document broken or missing teeth on the Nutritional Risk Assessment unless there was an issue with chewing, swallowing, or pain. During a follow-up interview on 02/08/2023 at 2:55 PM, the DON indicated the MDS and Nutritional Risk Assessment should accurately reflect Resident #161's broken and missing teeth. She confirmed that with both assessments not being completed correctly there was an issue with accurate assessments. During an interview on 02/08/2023 at 3:04 PM, the Administrator stated Resident #161's MDS and Nutritional Risk Assessment should be accurately completed to ensure the resident received all the necessary care and services. A review of a facility policy titled, Nutrition Care Nutrition Assessment/Progress Notes, dated March 2017, revealed, Policy: All residents will receive a comprehensive nutrition assessment by a registered dietitian or authorized designee. Assessment and documentation of nutritional concerns is recorded in a timely manner in the medical record. The nutrition assessment is an in-depth evaluation of both objective and subjective data related to an individual's food and nutrient intake, lifestyle, and medical history. New Jersey Administrative Code 8:39-11.1

Based on interviews, facility policy review, and record review, it was determined the facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASRR) was conducted for 1 (Resident #61) of 3 sampled residents reviewed for PASRR. Specifically, the facility failed to refer Resident #61 for a Level II PASRR when the resident was newly diagnosed with a mental illness. Findings included: A review of an undated facility policy titled, PASRR, revealed the policy did not address the need to refer residents with a newly identified mental illness for a Level II PASRR screening. A review of an Admission Record revealed the facility admitted Resident #61 on 11/05/2020 with diagnoses including post-traumatic stress disorder (PTSD), anxiety disorder, major depressive disorder, nightmare disorder, and unspecified psychosis. The record indicated the diagnosis of unspecified psychosis was added on 02/22/2021. A quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident had an active diagnosis of psychotic disorder. A review of a Pre-Admission Screening and Resident Review (PASRR) Level I Screen with a current assessment/authorization date of 11/05/2020, revealed Resident #61 did not have a diagnosis or evidence of a major mental illness limited to the following disorders: schizophrenia, schizoaffective, mood (bipolar and major depressive type), paranoid or delusional, panic or other severe anxiety disorder, somatoform or paranoid disorder; personally disorder; atypical psychosis or other psychotic disorder (not otherwise specified); or, another mental disorder that may lead to chronic disability. The screening was negative, which indicated the resident did not require a Level II PASRR completed. A review of a Medication Management Assessment, dated as completed 01/26/2021, revealed Resident #61 received Abilify (an antipsychotic medication) for psychosis. The assessment indicated a gradual dose reduction was not recommended for the medication due to the resident having a chronic mental illness with possible relapse risk. A review of a Progress Note, dated 02/22/2021, revealed the pharmacist consultant's recommendation to update the diagnosis for the administration of Abilify to psychosis per psych [psychiatric] consult. During an interview on 02/07/2023 at 3:42 PM, Certified Social Worker (CSW) #7 stated she was responsible for ensuring PASRRs were completed and indicated Resident #61's Level 1 PASRR was completed on 11/05/2020. She acknowledged the resident had a diagnosis of psychosis added to their diagnosis list on 02/22/2021 and stated she did not refer the resident for a Level II PASRR because she was not trained to do this when a resident received a new mental illness diagnosis. She stated she was last trained approximately three years ago on how and when to complete PASRRs. During an interview on 02/08/2023 at 11:55 AM, Minimum Data Set (MDS) Coordinator #6 stated Resident #61 was given the diagnosis of psychosis from the Nurse Practitioner (NP) due to the resident receiving Abilify. During an interview on 02/08/2023 at 12:26 PM, Registered Nurse (RN) #5 and MDS Coordinator #6 both stated Resident #61 received the psychosis diagnosis due to the resident's symptoms and behaviors. MDS Coordinator #6 stated a PASRR Level I should be completed upon admission and indicated she did not know what the Resident Assessment Instrument (RAI) Manual stated regarding when or if a PASRR Level II should be completed. MDS Coordinator #6 stated she was not aware of any other PASRR screening that should be completed for the resident. During an interview on 02/08/2023 at 12:40 PM, Medical Doctor (MD) #4 stated Resident #61 had been seen by psychiatry during the resident's stay at the facility, and the psychiatry staff gave the resident the diagnosis of psychosis due to the behaviors of crying, mood issues, refusing care, hallucinations, and paranoia. MD #4 stated she did not know about PASRRs or when they needed to be completed. During an interview on 02/08/2023 at 3:18 PM, the Director of Nursing (DON) and Administrator stated a PASRR Level I should be completed prior to admission to the facility. The DON stated she was not aware a PASRR Level II should have been completed for Resident #61 after the diagnosis of psychosis was added. She stated PASRRs were completed by the referring hospital or the social worker. The Administrator stated she did not believe the facility had to complete a Level II PASRR for the resident after the diagnosis of psychosis was added. The Administrator stated CSW #7 was responsible for completing PASRRs, and CSW #7 had received training online on PASRRs. The Administrator stated she expected staff to have proper training and be up to date with training on PASRRs. During a follow-up interview on 02/08/2023 at 3:57 PM, the Administrator stated CSW #7's last training was completed by the New Jersey Department of Human Services in 2015 via a webinar. New Jersey Administrative Code 8:39-5.1(a).

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure a care planned intervention for daily inspections of a resident's feet was implemented for 1 (Resident #161) of 3 residents reviewed for diabetes management. A review of an Admission Record indicated the facility admitted Resident #161with diagnoses that included type 2 diabetes mellitus with unspecified complications and need for assistance with personal care. An admission Minimum Data Set (MDS), dated [DATE], revealed Resident #161 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. The MDS indicated Resident #161 required supervision with personal hygiene and did not have any ulcers, wounds, or skin problems. A review of Resident #161's Care Plan, revised 01/26/2023, revealed the resident had a diagnosis of diabetes mellitus. Interventions included that staff were to check the resident's body for breaks in skin and treat promptly as ordered by the doctor and inspect the resident's feet daily for open areas, sores, pressure areas, blisters, edema, or redness. A review of Resident #161's Progress Note, dated 01/25/2023 at 10:56 PM, revealed the admission summary was completed at 7:00 PM and noted the resident's skin was intact and their toenails were long. A review of Resident #161's January 2023 Treatment Administration Record (TAR) revealed a skin assessment was completed on 01/28/2023. The daily inspections of the resident's feet were not addressed on the January and February 2023 TARs. A review of Resident #161's Skilled Nursing Care Notes, dated 02/03/2023 at 1:51 PM, revealed Resident #161's toenails were thick and in need of a podiatry consult. A review of Resident #161's Skilled Nursing Care Notes, dated 02/06/2023 at 4:46 AM, revealed the resident was noted to have thick toenails in need of a podiatry consult. A review of Resident #161's Skin Observation task dated from 01/25/2023 through 02/09/2023 revealed skin assessments were done daily without any scratches, reddened areas, discoloration, skin tears, or open areas noted. During an interview on 02/09/2023 at 10:30 AM, Certified Nurse Assistant (CNA) #15 stated the nurses did the weekly skin assessments on shower days, which were Saturdays. The CNAs looked daily at the residents' back, legs, arms, and back side for scratches, skin tears, bruises, et cetera, and if they saw anything they told the nurse. The nurses also looked at the feet for residents diagnosed with diabetes. CNA #15 stated she knew about Resident #161's feet because the resident was complaining about the condition of their feet upon admission and wanting to see a podiatrist. The CNA indicated she informed the nurse but did not recall which nurse. During an interview on 02/09/2023 at 10:45 AM, Registered Nurse (RN) #11 stated the nurses checked the feet of diabetic residents daily when the task showed up on the TAR. She indicated the nurses did not use the care plan, so if the task was not addressed on the TAR, the nurses did not know to do it. She reviewed Resident #161's TAR and confirmed the daily foot inspections were not addressed. She stated the first time she saw Resident #161's feet was the other day when the surveyor brought this to her attention. During an interview on 02/09/2023 at 10:56 AM, the Director of Nursing (DON) stated developing the care plan was a collaborative effort that started with the admission nurse. She reviewed Resident #161's care plan and stated RN #14 had completed the portion regarding the daily foot inspections. During an interview on 02/09/2023 at 11:08 AM, RN #14 confirmed she was the one who developed the portion of Resident #161's care plan that addressed the daily foot inspections due to the resident's diagnosis of diabetes. She indicated she was also the person responsible to input that task on the TAR so the nurses would know to complete the task. She stated she forgot to include the foot inspections on Resident #161's TAR. During a follow-up interview on 02/09/2023 at 3:01 PM, the DON stated the facility had recently changed its process regarding weekly skin assessments and daily foot assessments for diabetics to an evaluation and this was where the assessments should be documented. She indicated she did not know why the assessments were not documented for Resident #161 and stated not following the care plan put Resident #161 at risk for unidentified skin and foot issues. She also stated all assessments should be accurately documented and the care plan should be followed. During an interview on 02/09/2023 at 3:23 PM, the Administrator indicated daily foot assessments and weekly skin assessments should have been done for Resident #161 to identify actual or potential issues with their feet. She also indicated not doing so could put the resident at risk for developing avoidable issues and delaying necessary treatment to the resident's feet. A review of an undated facility policy titled, Care Plans-Comprehensive, revealed, Policy: A comprehensive care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. New Jersey Administrative Code 8:39-11.1

Based on observations, record review, interviews, and facility document and policy review, it was determined the facility failed to provide foot care and services to prevent potential diabetes complications for 1 (Resident #161) of 3 sampled residents reviewed for diabetes management. A review of Resident #161's Admission Record revealed the resident had diagnoses that included type 2 diabetes mellitus with unspecified complications and need for assistance with personal care. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #161 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS indicated the resident had no ulcers, wounds, or skin problems. A review of Resident #161's Care Plan, revised 01/26/2023, indicated the resident had diabetes mellitus and goals that included being free from signs/symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) and having no complications related to diabetes through the review date. Interventions included that staff were to check the resident's body for breaks in skin and treat promptly as ordered by the doctor and to inspect the resident's feet daily for open areas, sores, pressure areas, blisters, edema, or redness. A review of Resident #161's Admission Assessment, dated 01/25/2023, revealed no documentation regarding any foot issues. A review of Resident #161's Progress Note, dated 01/25/2023 at 10:56 PM, revealed Resident #161's admission summary was completed at 7:00 PM and noted the resident's skin was intact and their toenails were long. A review of Resident #161's January 2023 Treatment Administration Record (TAR) revealed a skin assessment was completed on 01/28/2023. A review of Resident #161's Skilled Nursing Care Notes, dated 02/03/2023 at 1:51 PM, revealed the resident's toenails were thick and in need of a podiatry consult. A review of Resident #161's Skilled Nursing Care Notes, dated 02/06/2023 at 4:46 AM, revealed the resident was noted to have thick toenails in need of a podiatry consult. On 02/06/2023 at 11:05 AM, Resident #161 was observed sitting in a chair in their room watching television. During an interview at this time, the resident indicated their only concern was that the facility was not addressing their feet. Resident #161 removed their right sock to show the condition of their foot and said the other foot was much worse. The exposed foot was swollen and had dry, flaky skin with redness noted between the great toe and second toe. The toenails were extremely thick, chalky white in color, and long and jagged, protruding past the tips of the toes approximately 1/8 to 1/4 inch. Resident #161 stated facility staff had told the resident they could not do anything about it and would have the foot doctor come and take care of them on three different days. The resident indicated the foot doctor had not come on any days the facility told them they would be there. The resident also indicated that no one had checked their feet daily. On 02/07/2023 at 11:42 AM, Resident #161 was observed sitting in a chair in their room wearing nonskid socks. Resident #161's feet were not elevated. During an interview at this time, Resident #161 stated they still had not received any foot or nail care. The resident indicated they felt that if their feet and toenails were not in such bad shape, they would get more out of therapy. During an interview on 02/07/2023 at 11:57 AM, Registered Nurse (RN) #11 stated the podiatrist would have to take care of Resident #161's feet, and she would tell the unit clerk. RN #11 indicated she had been told the resident had been informed that a podiatrist would come and see them on three different occasions, but no one had shown up. RN #11 stated she would check on this right away. She left briefly, then returned and entered the resident's room. She told the resident she would be right back to check their feet and denied having any knowledge of the condition of the resident's feet. On 02/07/2023 at 12:00 PM, RN #11 was observed to reenter Resident #161's room. The RN removed the sock from the resident's right foot. The foot and ankle were swollen, with chalky white, scaly skin that was flaking off. There was a reddened area between the resident's great toe and second toe, and the resident's toenails were long and jagged. RN #11 left the room and returned with Nurse Practitioner (NP) #12. On 02/07/2023 at 12:18 PM, NP #12 was observed entering Resident #161's room to assess the resident's feet. After assessing the resident's feet, the NP provided orders for ammonium lactate cream to both feet and to get an appointment right away with podiatry. He then left the room and reentered at 12:23 PM and told Resident #161 that podiatry would see them that day and to elevate their legs as much as possible to help with the swelling in their lower legs. On 02/07/2023 at 2:00 PM, the Director of Nursing (DON) provided a copy of Resident #161's January 2023 Treatment Administration Record (TAR). A review of the document revealed Licensed Practical Nurse (LPN) #13 documented he had completed a weekly skin assessment on 01/28/2022. There was no documentation of any specific findings from the assessment. During a phone interview on 02/07/2023 at 2:18 PM, LPN #9 stated she had done Resident #161's Admission Assessment the evening they were admitted . She indicated she had done a head-to-toe assessment and had noted Resident #161 had thick, long toenails and white padded dressings to their right heel, which, when the dressings were removed, appeared reddened yet blanchable. LPN #9 also indicated she had documented all of this on the admission assessment under skin condition. She stated she had reported the assessment to the oncoming nurse. On 02/08/2023 at 9:59 AM during a telephone interview, LPN #13 stated he remembered doing the skin assessment on Saturday, 01/28/2023, which was Resident #161's shower day. He stated he noted the resident's long, thick toenails during the assessment that day. He indicated he had also looked at the resident's feet the night before due to Resident #161 telling him about the condition of their feet and indicated that was when he faxed a referral to podiatry. LPN #13 stated he did not know why he did not document either assessment but indicated he should have. He stated he had only checked Resident #161's feet on 01/27/2023 and 01/28/2023. During an interview on 02/08/2023 at 3:01 PM, the Director of Nursing (DON) indicated the facility had recently changed its process regarding weekly skin assessments and daily foot assessments for diabetics to an evaluation, where the assessments should be documented. She stated she did not know why the assessments were not documented for Resident #161. She indicated not following the care plan put Resident #161 at risk for unidentified skin and foot issues. She stated all assessments should be accurately documented and the care plan should be followed. During an interview on 02/08/2023 at 3:23 PM, the Administrator indicated daily foot assessments and weekly skin assessments should have been done for Resident #161 to identify actual or potential issues with their feet. She also indicated that not doing so could put the resident at risk for developing avoidable issues and delaying the necessary treatment to the resident's feet. As of the survey exit on 02/09/2023, the facility had been unable to provide documentation of daily foot assessments, as care planned for Resident #161. A review of an undated facility policy titled, Diabetes - Clinical Protocol, revealed, Policy: To provide appropriate care and attention to residents who are diabetic. The Skin and Foot Care section of the policy included, 3. Report any changes of skin condition immediately. 4. Consult Podiatry for all foot/toenail routine and as needed. New Jersey Administrative Code 8:39-11.1

Complaint Intake NJ 1 Based on interviews, record reviews, and facility policy and hospice contract review, the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, and that each resident received adequate supervision and assistive devices to prevent accidents or injury for one resident (Resident #1) out of four residents reviewed for falls. Specifically, the facility failed to ensure that Resident #1 who was identified by the facility as a fall risk had his/her fall intervention which included to have bed in lowest position and fall mats in place whenever the resident was in bed and was in place before nursing staff exited the resident's room. It was determined that the facility's failed practice resulted in a fall with head injury (intraparenchymal hemorrhage of brain) for Resident #1. Findings included: 1. Resident #1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease with late onset, hypertensive heart disease with heart failure, encounter for palliative care, generalized anxiety disorder, major depressive disorder, age-related [CONDITION(S)], and unilateral primary [CONDITION(S)], unspecified knee. The 04/15/2021 quarterly Minimum Data Set (MDS) revealed the resident had severe cognitive impairment. The resident was totally dependent on staff for all activities of daily living (ADLs). The resident required two-person physical assistance with transfers. The facility submitted an AAS-45 (Facility Reportable Event) report to the New Jersey Department of Health on 06/27/2021. The report indicated on 06/26/2021, after a hospice aide provided care to Resident #1, the aide asked the nurse to get the resident out of bed. The hospice aide was not transferring residents due to the aide's pregnancy. The hospice aide proceeded to the next resident's care. When the nurse arrived to the resident ' s room, the resident was discovered on the floor. Resident #1 had fallen out of bed and sustained a knot on the head and a nosebleed. The resident was transferred to the hospital and diagnoses with a intraparenchymal hemorrhage (a bleed that occurs in the functional part of the brain). The report indicated fall mats were not in place at the time of the fall. The facility's incident report dated 06/26/2021 indicated under the predisposing situation factor that contributed to Resident #1's fall as, Resistive/combative with hands on care. The report noted under the other information portion of the report that Resident #1 was noted to be very impulsive and at times could become resistive with care. It indicated the resident's fall was unwitnessed. It was further reported that Resident #1 was found lying on the floor in his/her bedroom. The resident was reported to have been found on the floor with observable blood. The facility identified that Hospice Aide (HA)#1 who was the last to provide care to the resident had raised the resident's bed and removed the floor mat which was in place for the resident's fall while rendering care and failed to return the resident's bed back to the lowest position and likewise failed to replace the resident's fall mat before she exited the resident's room to get the facility's staff's assistant with transferring the resident from bed to geriatric chair per hospice care plan. It was noted that Resident #1 who was only oriented to self, attempted to get out of bed unassisted with the bed raised and without the fall mat in placed then fell in the process. The report indicated that Resident #1 was transported to the hospital at 9:40 AM and returned to the facility at 2 PM with diagnosis of intraparenchymal hemorrhage of the brain. The report concluded that Resident #1's care plan was updated to reflect that, After providing care to resident, if staying in bed, lower bed back to lowest position and replace bilateral floor mats and hospice staff will stay with resident until staff is available to assist with transfer. Resident #1's care plan related to falls indicated under the focus portion of the care plan that the resident was at high risk for falls related to confusion, gait, and balance problems. The intervention portion of the plan indicated that after providing care to the resident, if the resident was staying in bed, staff should lower the bed back to lowest position and replace bilateral floor mats. It indicated that Resident #1 had had a witnessed fall to the floor mat on 05/13/2021 and an unwitnessed fall on 06/26/2021. Interviews with the facility's Director of Nursing (DON) and the Director of Quality (DOQ) of hospice on 08/26/2021 at 9:56 AM and on 08/26/2021 at 10:15 AM, respectively, revealed the hospice care plan related to Resident #1's fall mirrored that of the facility. The DON also clarified that the hospice record was not kept as part of Resident #1's medical record at the facility. The surveyor requested a copy of hospice care plan for Resident #1. The DOQ said she would see if she could get it but did not get back to the surveyor on this. The progress note on 06/26/2021 at 10:00 AM by Licensed Practical Nurse (LPN) #1 revealed Certified Nurse Aide (CNA) #1 made LPN #1 aware that Resident #1 had been found on the floor in the resident's room. The record indicated the resident was seen lying on the resident's right side in a fetal position, face down in blood. Resident #1 was noted to be confused and unable to make needs known at the time. Resident #1's vital signs (VS) were taken, and they recorded the following: blood pressure (BP) 186/86; heart rate (HR) 77; oxygen (O2) saturation 100%; and temperature (T) 98.2 F. The assessment revealed Resident #1 had limited range of motion (ROM) in all extremities and that Resident #1 sustained an injury to the right side of the resident's forehead, with a knot present. The resident was observed to have a nosebleed. The facility received orders to send the resident to the hospital. A review of the 06/26/2021 hospital record revealed a computerized tomography (CT) scan of Resident #1's head indicated that Resident #1 sustained an intraparenchymal hemorrhage (a bleed that occurs in the functional part of the brain). In the progress note of 06/26/2021 at 12:15 PM, LPN #1 indicated the facility received a call from the emergency department (ED) doctor at about 11:30 AM that Resident #1 was being sent back to the facility with a diagnosis of intraparenchymal hemorrhage of the brain. The note indicated that hospice services were to be continued with the resident. The note indicated that the resident's status was reported by the ED doctor to have declined rapidly, with the recommendation for the resident to return to the facility and to continue comfort care. The medical record revealed Resident #1 returned to the facility on [DATE] at 2:00 PM via Emergency Medical Transport (EMT). Resident #1 was only oriented to person upon return to the facility. On 06/27/2021 at 7:00 AM, the record indicated that Resident #1 was found with no pulse or cardiac activity. A review of Resident #1's death certificate revealed the immediate cause of death was ruled as subarachnoid hemorrhage. The interval between onset and death was indicated as one day. On 08/26/2021 at 10:43 AM, CNA #2 was interviewed and recalled Resident #1 had dementia and was totally dependent on staff for all care. CNA #2 said Resident #1 moved around a lot in bed, so the resident's bed always had to be in the lowest position, and the floor mat always had to be in place. She said she was not present on the day of the incident with the resident. She said she was in-serviced after Resident #1's death and knew to never leave a resident's bed in a high position with the resident in bed when she left the room. On 08/26/2021 at 10:48 AM, LPN #1 said Resident #1 was demented with confusion. She said the resident had no behaviors and was able to make needs known at times. She said Resident #1 was a fall risk and was totally dependent on staff for care. She said she was in-serviced after the incident and a resident was never to be left alone while in bed without putting the bed in the lowest position and the fall mats in place if ordered/needed. She said that on the day of the incident, she (LPN #1) did her rounds in the morning, went into Resident #1's room and observed the resident was in bed with the bed in low position and a floor mat on each side the bed. She said that at approximately 8:55 AM, CNA #1 came to her and informed her that Resident #1 was found on the floor. She said when she went into Resident #1's room, she found the resident lying on the floor on the right side in a fetal position. She said Resident #1 was bleeding from the nose. The LPN said the bed was not at the highest or lowest position. She approximated that the bed top of the mattress was about 2 feet above the floor when she entered Resident #1's room. She stated neither of the two floor mats were on the floor beside the bed at the time of the observation. The facility got an order to transfer the resident to the hospital for evaluation. LPN #1 said that Resident #1 was sent back to the facility after a short stay at the ED with the diagnosis of intraparenchymal hemorrhage. On 08/26/2021 at 11:27, Hospice Aide (HA) #2 was interviewed. She said the first time working at the facility was back in December 2020. She said she shadowed another hospice aide for four days then started working by herself. She said she had been a home health aide for approximately [AGE] years prior to joining [company name omitted]. She said she took some computer-based training which included safe resident handling, transfers, how to give proper bed baths, emergency related trainings, etc. She said she did not take any training or competency tests at the facility related to safe resident handling and transfers since she started working at the facility. She clarified that although she was working at the facility when the incident with Resident #1 occurred, she had not received any training following the incident. She said that when she needed help with transferring a resident, she walked out in the hallway to get help. On 08/26/2021 at 12:15 PM, HA #1 (the hospice aide alleged to have left Resident #1 alone when the resident fell ) was interviewed via telephone. She was no longer employed by the hospice company. She acknowledged she was the aide who provided care to Resident #1 before the resident was found on the floor. HA #1 stated that Resident #1 was totally dependent on staff for care which included bed mobility. She said Resident #1 was unable to roll turn in bed, so she required help with repositioning the resident. HA #1 explained the procedure she followed when she cared for Resident #1. She said she took the fall mats off the floor in the resident's room as they posed a fall risk for staff during care. She recalled she washed and changed the resident. HA #1 said Resident #1 was asleep throughout the time she cared for the resident. She said that due to being heavily pregnant at the time, she relied on the facility staff to transfer Resident #1 to the resident's geriatric (geri) chair, as that was the final component of hospice care with the resident. She said she left the resident's room with the resident's bed in low position. However, she acknowledged that she did not replace the fall mats. HA #1 said CNA #1 was within viewing distance from Resident #1's room when she (HA #1) stepped out to inform her (CNA #1) that she (HA #1) was finished providing for Resident #1 and the resident was ready to be transferred. HA #1 said that CNA #1 immediately left in the direction of Resident #1's room. HA #1 said although Resident #1 was a two-persons transfer, she stated that CNA #1 approached Resident #1's room alone. HA #1 stated that she was approximately five minutes into caring for another resident when CNA #1 informed her that Resident #1 was found on the floor bleeding. On 08/26/2021 at 1:21 PM, CNA #1 (agency CNA) was interviewed via telephone. She said she recalled the incident with Resident #1. She said HA #1 was finished providing care to the resident and had approached her to state that she (HA #1) needed Resident #1 to be transferred to the geri chair. CNA #1 said that she immediately went in Resident #1's room to transfer the resident. CNA #1 acknowledged that she went in the resident's room without calling for other staff assistance and with the intent to transfer the resident alone. She acknowledged that she knew the resident needed assistance of two staff with transfer. She said when she entered the room, the resident was on the floor with blood on the floor. CNA #1 said the resident did not fall due to her attempt to transfer the resident by herself. On 08/26/2021 at 3:27 PM, CNA #3 said that when hospice aides arrived at the facility, they informed her that they would be needing her help with a resident's care at some point. She said hospice aides typically needed help with transferring residents. She said when it was time to help the hospice aide, the aide sometimes came to find her, or she checked in with the aide to know if her help was needed. On 08/26/2021 at 3:42 PM, CNA #4 said that when hospice aides arrived at the facility, they asked about care needs of the residents they were assigned and clarified if there was any noted event with the resident. He said that hospice CNAs had access to the care plans of the residents, just as the facility staff did. He concluded that hospice aides came to the nursing station to request help, or they sometimes approached him in the hallway. On 08/26/2021 at 4:25 PM, a follow-up interview was conducted with the DON and the Nursing Home Administrator (NHA) present. The DON said that the facility's investigation determined the cause of Resident #1's fall/injury was from HA #1 leaving the room to get assistance instead of using the call bell, not making sure the resident's bed was in the lowest position and not putting the floor mats back beside the bed. The DON acknowledged that the facility did not probe into CNA #1's intent to transfer Resident #1 alone. The DON said the facility was not responsible for training agency or contract staff. She said the contractual agreement the facility had with hospice and agency staff was that they trained their staff before the staff were sent to work at the facility. A review of the Hospice-Nursing Facility Services Agreement (The Hospice responsibility portion of the agreement) did not specifically delineate the type of training the facility wanted the hospice staff to have. The DON provided copies of the in-services the facility did with nursing staff as well as the one provided by the hospice company. The NHA and the DON reviewed the hospice training with the surveyor and were unable to provide additional documentation showing the facility ensured hospice/agency providers had trained their staff on the identified causes that contributed to Resident #1's fall. The NHA and the DON acknowledged that the facility was responsible for resident care whether it was from facility staff or outside provider's staff to ensure resident safety. Attempts made to interview the facility's medical director and Resident #1's attending physician were unsuccessful due to not returning the surveyor's call. The facility's fall policy provided by the NHA on 08/26/2021 at 12:16 PM read in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . The fall-risk factors portion of the policy listed incorrect bed height or width as environmental factors which contributed to the risk of falls. The policy also listed [CONDITION(S)] and other cognitive impairment as resident conditions that may contribute to the risk of falls. New Jersey Administrative Code § 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to disinfect a blood pressure cuff between each resident use to minimize the potential spread of infection. This deficient practice was identified for 4 of 4 residents (Residents #83, #63, #82 and #1) on 1 of 4 units (Rehab 2) observed for infection control practices and was evidenced by the following: On 02/05/21 at 9:38 AM, the surveyor observed a Licensed Practical Nurse (LPN) obtain Resident #82's blood pressure, while in the resident's room. The LPN used a reusable blood pressure cuff that was attached to a vital signs machine. After obtaining the blood pressure reading, the LPN exited the room and, without cleaning the blood pressure cuff and vital signs machine, entered Resident #63's room with the vital signs machine. The surveyor observed that there was a container of disinfectant wipes attached to the vital signs machine and that there was a Contact Precaution sign outside of the resident' room. The Contact Precautions sign revealed that Providers and Staff Must Also: Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Without cleaning the blood pressure cuff first, the surveyor observed the LPN obtain Resident #63's blood pressure using the same blood pressure cuff that was used on Resident #82. After obtaining the resident's blood pressure, the LPN exited the room. The surveyor observed that the LPN did not clean and disinfect the blood pressure cuff before or after its use and observed a Contact Precaution sign outside of Resident #63's room. At 10:11 AM, the surveyor observed the LPN obtain Resident #83's blood pressure, while in the resident's room. The LPN used the same blood pressure cuff that was previously used on Resident #63. The surveyor observed the LPN exit Resident #83's room with the blood pressure cuff and vital signs machine. The LPN did not clean and disinfect the blood pressure cuff before or after its use and observed a Contact Precaution sign outside of Resident #83's room. At 10:22 AM, the surveyor observed the LPN obtain Resident #1's blood pressure, while in the resident's room. The LPN used the same blood pressure cuff that was previously used on Resident #83. The surveyor observed the LPN exit Resident #1's room with the blood pressure and vital signs machine. The LPN did not clean and disinfect the blood pressure cuff before or after its use and observed a Contact Precaution sign outside of Resident #1's room. During an interview with the surveyor at 10:29 AM, the LPN stated that he forgot to clean and disinfect the blood pressure cuff. During an interview with the surveyor at 10:42 AM, the Charge Nurse said the vital signs machine was to be wiped down before and after each room. She added, The wipes are on the machine. Review of the facility's Isolation - Categories of Transmission-Based Precautions policy with a review date of 3/2/2020, revealed under Policy Interpretation and Implementation number 7, When transmission-based precautions are in effect, non-critical resident-care equipment items such as a stethoscope, sphygmomanometer (blood pressure), or digital thermometer will be disinfected between residents. A. If re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident. NJAC 8:39-19.4

Based on interviews and review of Medical Records (MR), and other pertinent facility documentation on 6/9/2020, it was determined that the facility failed to follow their policy to maintain complete communication notes between the facility and the [MEDICAL TREATMENT] center for 1 of 3 sampled residents (Resident #2). This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 7/9/19, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating no cognitive deficits. The MDS also indicated the resident required staff assistance for Activities of Daily Living (ADLs). Review of the Care Plan (CP) for Resident #2, with an initiated date of 8/31/17 revealed the resident was scheduled for [MEDICAL TREATMENT] appointments on MWF. Send HD ([MEDICAL TREATMENT]) communication book with resident for HD appointments. During an interview on 6/9/2020 at 12:02 p.m., Registered Nurse #1 (RN #1), stated for [MEDICAL TREATMENT] residents, a communication book goes with them on [MEDICAL TREATMENT] days with any new medications or changes. During an interview on 6/9/2020 at 2:30 p.m., the Director of Nursing (DON), stated the nurse did not attach the medication order to the [MEDICAL TREATMENT] Communication Book and should have. The nurse was not following the policy. Review of the Order Summary Report revealed an order dated 5/9/2020 [MEDICATION NAME] Tablet Give 1000mg by mouth every 8 hours for shingles for 7 days. Review of the Medication Administration Record [REDACTED]. Review of Resident #2's, [MEDICAL TREATMENT] Treatment Communication Form dated 5/11/2020, revealed no documentation or copy of doctor's order dated 5/9/2020 for [MEDICATION NAME] Tablet 1000mg was attached. On 6/9/2020 at 1:30 p.m., the surveyor reviewed the facility, End Stage [MEDICAL CONDITION], Care of a Resident with (undated) which revealed Resident will travel to and from [MEDICAL TREATMENT] center with communication book in order to facilitate communication between the parties. Staff will address any concerns upon return from [MEDICAL TREATMENT]. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 8:09 AM to 9:28 AM, the surveyor, accompanied by the Executive Chef (EC) and Dining General Manager (DGM), observed the following in the kitchen: 1. On a middle shelf in the Meat Walk-In Refrigerator, a catering bowl contained Dijonaise mustard and was covered with plastic wrap. The dijonaise mustard was dated prep ,[DATE] and use by ,[DATE]. The EC on interview stated I'm gonna throw it in the trash. On an upper shelf, a third pan contained sliced peaches. The peaches were labeled prep date [DATE] and use by [DATE]. The EC stated, they're expired. The EC threw the peaches in the trash. 2. On a middle shelf in the Meat Walk-In Refrigerator, an opened cardboard box contained 2 clear plastic bags of defrosted veal, per the EC. The surveyor observed that the veal was grayish in color. The cardboard box had no prep/pull/use by dates and the EC was unable to determine the date the veal had been defrosted. On interview the EC stated, I can't tell you how long that has been in here defrosting. I will need to set up a labeling system. Actually, it's been in here for 8 days per the received date sticker of ,[DATE]. We put the veal in the refrigerator when we received it. Our guidelines state that it is good for ,[DATE] days in the refrigerator. I'm throwing it out. The EC threw the veal in the trash. 3. On an upper shelf in the Walk-In Produce Refrigerator a hotel pan contained raw sliced onions. The onions were labeled with a prep date of [DATE] and a use by date of [DATE]. The EC stated, they're trash. The EC threw the pan of sliced onions in the trash. On interview the EC stated, Our receiver is responsible for monitoring the dates of food products in the refrigerated units. The sous chef is also responsible for following up. On an upper shelf a five pound container of peeled garlic was opened. The container had no open or use by dates. When interviewed, the EC stated, I'm gonna throw it in the trash, I can't tell how long it has been in the refrigerator. 4. On a middle shelf of the Meat Walk-In Freezer a hotel pan contained cooked diced potatoes. The pan had no cover and the potatoes were exposed. The pan had no label or dates. When interviewed, the EC stated They're going in the trash. The EC threw the potatoes in the trash. On an upper shelf, a plastic container contained Bavaka. The plastic container was opened and the Bavaka was exposed. On interview the EC stated, that's been exposed. The EC threw the container of Bavaka in the trash. 5. On the opened spice and condiment shelf a sixth pan contained Dry Active Yeast. The pan was covered with plastic wrap and was labeled opened on ,[DATE] and use by ,[DATE]. When interviewed, the EC stated that's trash. The yeast was thrown in the trash. 6. The surveyor observed a cleaned and sanitized meat slicer in the meat side serving area. The meat slicer was covered with a plastic bag. Upon removal of the plastic bag the base of the meat slicer was wet with a clear and watery substance. Further observation revealed that the entire meat slicer was wet with a clear, watery substance. On interview the EC stated, The slicer should have been allowed to air dry before covering it. I'm gonna have it recleaned, sanitized and air dried. When it is dry, they can re-cover it. 7. On an upper shelf in the Take-Out Shelf Area a stack of aluminum pans were uncovered and not inverted. The pans were exposed. The Dining General Manager (DGM) on interview stated, they should be in paper storage and stored inverted. On [DATE] from 10:37 AM to 11:11 AM the surveyor, accompanied by the DGM, observed the following in the kitchen: 1. In the catering/dry storage rack area the surveyor observed 5 creamer containers that were cleaned and sanitized and were to be used during resident meals. The containers were not inverted, had no lids, and were exposed. The DGM removed the containers from storage and instructed staff to rewash and sanitize and store/dry in the inverted position to prevent contamination. The surveyor reviewed the facility policy titled, SANITATION AND INFECTION CONTROL FOOD SAFETY-SS-1006, Sodexo Senior Service Policy and Procedure Manual, Revised ,[DATE]. The policy revealed the following under the Procedure section: 9. All foods prepared in operation must be covered and labeled as to the contents and date of preparation prior to storage in refrigerators and freezers. Labels for potentially hazardous foods also must include time of storage. The surveyor reviewed the facility policy titled, Sanitation and Infection Control Cleanliness & Sanitation -SS-1013, Sodexo Senior Service Policy and Procedure Manual, revised ,[DATE]. The policy revealed the following under the Procedure section: Slicer Machine: Blade, blade guard, carriage, machine surface and adjustment knobs should be smooth and dry to the touch and free of debris and grease. The surveyor reviewed the Sodexo Food Product Shelf-Life Guideline, Document #: 2.1.9, Rev. Date: [DATE]. The guideline revealed the following under Product section: Frozen Solid Muscle Meat (Beef, Veal,[NAME] Pork) Refrigerator Storage (40F/4C or below) 3 to 4 days. The Comments section revealed the following: Applies to steaks, chops and roasts. Must be thawed under refrigeration. NJAC 8:,[DATE].2(g)