Every finding on record at South Mountain HC

Based on observation, interviews and review of pertinent facility documents, it was determined that the facility failed to ensure the development and implementation of menus to consistently provide adequate portions of milk and bread to residents in accordance with the facility's diet manual, policy and national nutritional standards for a four-week cycle menu. This deficient practice was evidenced by the following:On 8/18/25 at 8:59 AM, during entrance conference it was determined that the facility was licensed for a capacity of 195 beds and had a current census of 189 beds.On 8/18/25 at 10:13 AM, the surveyor toured the kitchen with the Food Service Director (FSD) in the presence of a second surveyor. At the end of the tour, the surveyor requested a copy of the facility's four-week cycle menus (reflects the regular diet) and the extensions (a breakdown of what all the therapeutic and mechanically altered diets received).On 8/19/25 at 12:15 PM, the surveyor observed lunch meal service in the first-floor main dining area. There was no milk on the beverage cart and creamers were offered for coffee. In addition, the main meal did not have a bread indicated on the menu. The alternate meal had serving of garlic bread indicated on the menu.A review of the four-week cycle menus and extensions provided by the facility between 8/18/25 and 8/22/25 reflected four ounces of milk was served at lunch and dinner (instead of required eight ounces). It also reflected that each lunch and dinner had two options on the menu, therefore, of 112 meals developed on the menus, 28 included a bread serving.In addition, the menus provided indicated that 26 of 28 dinner meals crackers would be served; however, this was not indicated on the extensions and therefore also not on residents' dinner meal tickets (this translates to what food service staff place on the resident's tray).A review of a three-week cycle menu provided to the surveyor on 8/25/25 by Registered Dietitian (RD) #2, who stated she approved these menus for nutritional adequacy dated 4/9/25, were not the same as the active menus. Of 84 lunch and dinner meal selections, 61 were different from the active menus provided.on 8/21/25 at 10:06 AM, the surveyor interviewed RD #1, in the presence of a second surveyor. She stated that corporate provided the menus and could not speak to who reviewed and approved the menus for nutritional adequacy.On 8/21/25 at 10:37 AM, the Corporate RD (CRD) and the FSD joined the interview. The CRD stated the menus were seasonal and were planned in advance (spring/summer and fall/winter). She also stated that corporate developed the menus; however, she reviewed the choices with the facility RD's and FSD to ensure they would be acceptable to the resident population. The facility preferences were then relayed back to corporate. The CRD could not speak to who reviewed and approved the menus for nutritional adequacy and stated they were based on the Diet Manual. The FSD also stated that she was unaware as to who reviewed and approved the menus for nutritional adequacy. On 8/22/2025 at 12:51 PM, the surveyor interviewed the CRD, FSD, and RD #1, in the presence of the survey team related to menu development and approval. The CRD stated that four ounces of milk was served at lunch and dinner since there was a lot of waste and that resident's were not drinking it. The FSD stated that many trays were returned to the kitchen with unopened milk. The CRD and the FSD could not speak to whether or not they investigated the reason for the unopened milk (dislike verse staff not opening for residents that needed assistance). The CRD acknowledged that the Diet Manual reflected eight ounces of milk should be served at each meal but stated it gets wasted. She stated that bread was not served consistently on the menu to avoid serving heavy carbohydrate meals. She acknowledged that the Diet Manual has recommended meal patterns which is not consistently reflected on the facility menus. She also acknowledged that the facility provided a therapeutic Consistent Carbohydrate Diet (CCD, a carbohydrate-controlled diet) for residents that were diabetic. The CRD could not speak to why she was applying that across the board to the entire facility. She added her concern if a resident on a CCD diet was in a room with a resident on a Regular diet, then the CCD diet resident would also ask for bread which would cause a problem for the RD. She could not speak to why that situation would not require individual education verse enforcing the elimination of a carbohydrate portion (bread) for the entire building. During this interview, the CRD stated the facility RD's approved the menus for nutritional adequacy (which contradicted a previous interview). RD #1 stated that she had not done that and the CRD stated that RD #2 approved the menus, however RD #2 was on vacation. The CRD would not state whether or not the menus were based on the Diet Manual. She stated the menus were based on the needs of the facility; I mean the needs of the residents. The CRD and RD #1 were unable to provide the surveyor with the signed menus approved by RD #2.On 8/22/25 at 2:35 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional and the [NAME] President (VP) of Clinical Services. The LNHA acknowledged that the menus were developed by corporate. On 8/25/25 at 10:47 AM, the survey team met with the LNHA. He stated RD #2 had returned from vacation and could not speak to why the signed approved facility menus were not readily available.On 8/25/25 at 11:02 AM, the surveyor interviewed RD #2, in the presence of the survey team. She stated that menu development was a team effort between the RD's, the CRD and the FSD but I am the final word. I sign the menus attesting to nutritional adequacy. She stated the menus were based on the Diet Manual, including portions sizes and the amount of servings required for each food group. She acknowledged a bread was not reflected for every lunch and dinner meal because we count carbs for the day and bread just seemed extra. RD #2 provided the surveyor with the menus she signed and attested to have approved for nutritional adequacy. We reviewed the two meals for lunch and dinner offered on cycle week one, day one (Sunday) for the Regular diet. She could not speak to why the main lunch meal did not account for bread yet the lunch alternate meal and both choices for dinner included bread. RD #2 acknowledged that four ounces of milk were served instead of eight ounces per the Diet Manual at lunch and dinner. She further stated that a lot of residents did not want milk, and it was a corporate decision to serve four ounces of milk to avoid waste. RD #2 acknowledged that the menus did not reflect the portions for milk and bread in accordance with the Diet Manual.On 8/25/25 at 12:04 PM, RD #2 provided the surveyor a list of residents who disliked whole milk and a list of residents who disliked skim milk. The list did not include substitution's and did not account for size (fluid ounce) preferences or those who required lactose free milk. The lists provided accounted for 23 residents that disliked both skim and whole milk, 23 out of 189 residents (12.2% of the population).A review of the Diet Manual the facility follows Diet Manual of Dietetics in Health Care Communities of New Jersey; 8th Edition dated 2023 and reviewed by the facility on 1/9/25, reflected that the Regular diet provided a variety of foods to meet the needs of individuals and is nutritionally adequate in all nutrient's when planned according to Dietary Reference Intakes (DRIs) established by Food and Nutrition Board; Institute of Medicine, USDA Dietary Guidelines for Americans 2020-2025. The Sample Menu for Regular Diet included one cup serving of low-fat milk at each meal as well as a slice of bread.A review of the facility policy Menu Development dated October 2024, reflected that a RD would ensure the menus meet current Dietary Standards and that the diet manual should be used as a reference in menu development. It also reflected the menus would be reviewed by the facility team and a copy will be kept on file. Menus would be approved by the facility RD prior to implementation, including any menu changes. In addition, it reflected copies of the current and previous menus would be kept for one year.A review of an undated job description Clinical Nutrition Director, reflected assistance in menu development, implementation and approval was part of the position's responsibilities and duties. NJAC 8:39 - 17.1(b);17.2(a,b);17.4(a(3))

Based on observations, interviews, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous foods in a safe and sanitary environment to prevent the development of food borne illness.This deficient practice was observed during two kitchen tours and was evidenced by the following:On 8/18/25 at 10:13 AM, the surveyor toured the kitchen with the Food Service Director (FSD), in presence of a second surveyor and observed the following:To the left of the handwashing sink, and to the right of the walk-in freezer, there was a damaged wall with a penetration, which the FSD stated had been that way since she started in May 2025 and the Director of Maintenance (DOM) was aware. The FSD stated that there was no formal communication with the DOM, it was all verbal either one on one, via phone or at morning meeting. She stated there was no logbook and she did not send emails since the DOM did not read his emails. She stated the Licensed Nursing Home Administrator (LNHA) was aware she had outstanding maintenance concerns.In the middle walk-in refrigerator, there was a wood square propped under the metal rack to the left, due to a missing rack leg. The FSD acknowledged the wood was not able to be cleaned and sanitized and stated that the DOM was aware.In the same walk-in refrigerator, there was a black milk crate stored on the metal rack which had a mix of beverages (four-ounce milks, health shakes, and other fluids mixed together). The FSD stated they were left from the tray line meal service and that the staff put the leftovers back in the refrigerator for next use. She acknowledged that this practice could lead to an outdated item if the beverages were not sorted through and use by dates checked one by one before the next meal.Both of the kitchen walk-in refrigerators did not have gaskets on the doors. The FSD stated the DOM was aware.In the dry storage area, there was a hard plastic shelving unit that was flush to the ground without a six inch space between the shelf and the floor.The hoods over the cooking equipment had six lights on each side, which did not work, the FSD stated the DOM was aware.There were double stacked convection ovens that did not work. The FSD stated the DOM was aware.There was a single convection oven that had a heavy buildup of black debris on the bottom and the glass doors had a heavy baked on brown and reddish colored debris. The FSD acknowledged the same and stated it was cleaned once a month.There was a double stacked steamer. Both unit gaskets were in disrepair. The FSD stated the DOM was aware. The top unit had a buildup of black debris on bottom. The FSD acknowledged the same.There was a three-door reach in refrigerator that had been out of service since 8/14/25. The FSD stated the DOM was aware.There were two warming boxes (units that keep cooked food hot), both of which gaskets were in disrepair. The warming box to the right had a buildup of food debris on the bottom which the FSD acknowledged.The handwashing sink in this area had a leaking faucet. The FSD stated the DOM was aware.There were also two food preparation sinks in this area which shared a faucet. The faucet was leaking and the FSD stated that it only provided scalding hot water and that the DOM was aware.There was a top reach in beverage/milk refrigerator that had not been working since the previous Friday. The FSD stated that the DOM was aware.There was a ceiling vent over the ice cream freezer that had fuzzy greyish brown debris hanging down over the freezer and racks of clean inverted coffee mugs. The FSD acknowledged the debris and stated it needed to be cleaned.The dish machine room had multiple missing and cracked floor tiles with still nesting water. There was also a wood block propped under the dish machine table. There were walls to either side of the dish machine in disrepair with penetrations and a build up of back debris on the wall to the right of the dish machine. The FSD stated the DOM was aware of what the surveyor observed.On 8/19/25 at 10:53 AM, a third surveyor interviewed Resident #10, who stated they received expired milk yesterday dated 8/17/25.On 8/22/25 at 9:11 AM, the surveyor interviewed the DOM, in presence of the survey team. He stated that there was no formal communication between himself and the FSD related to maintenance concerns. He stated that the nursing units had logbooks but there was not one for the kitchen. When the surveyor inquired why there was no logbook for the kitchen he stated, 'it's been like that for 14 yrs. He stated that when there was something in the kitchen that required maintenance attention, he would fix it on the spot or would order parts if need be. The DOM stated he had no written or formal way of keeping track of any issues brought to his attention from the kitchen or a way to track their resolve. In addition, he stated he was unaware of any maintenance issues in the kitchen prior to the beginning of survey. The DOM stated that he replaced 12 loose tiles in the dish machine area of the kitchen two days ago and was notified of that the night before. He also stated that one of the double stack convection ovens had not been working for over a year due to an electrical issue that was unable to be resolved.On 8/22/25 at 9:47 AM, the third surveyor interviewed Resident #10, who stated they received expired eight-ounce fat free milk at breakfast, dated 8/21/25. The resident stated the Certified Nursing Aide (CNA) confirmed the expiration date.On 8/22/25 at 9:55 AM, the third surveyor interviewed the CNA who verified that the date on the unopened milk carton was 8/21/25. She stated that the kitchen was responsible but that everyone should be checking the tray. In addition, she stated that if expired milk was consumed it could make a resident sick.On 8/22/25 at 2:35 PM, the survey team met with the LNHA, Director of Nursing (DON), Regional Nurse and the [NAME] President (VP) of Clinical Services. The LNHA confirmed that there was no formal way of communicating kitchen maintenance issues to the DOM. He stated concerns were addressed in morning meeting.On 8/25/25 at 10:47 AM, the survey team met with LNHA. He stated that the maintenance concerns identified in the kitchen during survey were addressed, thereby acknowledging there were maintenance concerns.On 8/25/25 at 11:02 AM, the surveyor interviewed the Registered Dietitian (RD) who has worked at the facility for 12 years (four days a week). She stated she conducted informal kitchen rounds every morning and communicated with the FSD related to any concerns she identified. The RD stated prior to a two-week vacation from which she had just returned she was only aware of a three-door reach in refrigerator not working. She stated that there was a logbook in the kitchen to record and track maintenance needs.On 8/25/2025 at 12:04 PM, the RD reapproached the surveyor in the presence of the survey team and stated she was mistaken, and that there was no logbook in the kitchen for maintenance concerns. The RD stated concerns were communicated verbally and at the morning meetings.A review of the facility policy Food Safety and Sanitation with a reviewed date of 2024, reflected the facility would provide safe, nutritious meals in compliance with federal, state and local regulations. It also reflected food would be clean, wholesome and free of spoilage and stock would be rotated using the first in, first out (FIFO) method.A review of an undated facility policy Kitchen Maintenance, reflected food preparation areas should be maintained in a clean, safe and sanitary condition, to prevent food borne illness, accidents and equipment failure. It also reflected the following: Daily Maintenance, included wash and sanitize kitchen equipment used during food preparation. It also included check expiration dates. Weekly Maintenance, included deep clean ovens. Monthly Maintenance, included inspect all kitchen equipment for proper function and safety; perform preventative maintenance on equipment as per manufacturer's instructions; and check sinks for leaks. Documentation, included to keep equipment maintenance records.A review of an undated facility job description for Maintenance Director, included the DOM was responsible for planning, organizing, implementing, and overseeing the total maintenance and repair program of the facility. This included the building, equipment, systems and grounds to ensure the health, safety, comfort and well-being of residents, staff and visitors. This also included routine inspections were completed, documented and corrected.NJAC 8:39-17.1(a);17.2(g);31.2(b,c,e)

Based on observations, interviews and review of pertinent facility documents, it was determined that the facility failed to implement an effective pest control program in the kitchen.This deficient practice was evidenced by the following:On 8/18/25 at 10:13 AM, the surveyor toured the kitchen with the Food Service Director (FSD), in presence of a second surveyor. The surveyors observed a live bug walking up a white tiled wall above a stainless-steel table which had food preparation equipment on it, uncovered.The FSD observed the bug as well and stated, we have a pest control problem here; it was like this when I got here; maintenance is aware; we have a company [name redacted] that comes every Tuesday.The surveyors then observed two live bugs walking on the floor, in the dry storeroom. There were also two glue traps of the floor of the storeroom filled with bugs.During the remainder of the kitchen tour, the surveyors observed damaged walls with penetrations as well as still nesting water where multiple floor tiles were missing in the dish machine area.On 8/22/25 at 9:11 AM, the surveyor interviewed the Director of Maintenance (DOM), in the presence of the survey team. He stated that he had no involvement with pest control and that the Director of Housekeeping (DOH) was responsible to oversee the pest control program. The DOM acknowledged there was pest control problem in the kitchen and added there was a logbook in the kitchen where staff were responsible to note pest sighting (date and location). He further stated that the exterminator would then check those books and treat the targeted areas. The DOM stated the exterminator scheduled a bombing (Bug bombs, also known as foggers or extermination bombs, are canisters of insecticide that disperse a large volume of insect-killing mist when activated. They are used to treat widespread infestations by filling an entire room or area with insecticide) for the kitchen Monday night.On 8/22/25 at 9:25 AM, the surveyor interviewed the DOH, in the presence of the survey team. She stated that she communicated with the exterminator on a regular basis to ensure areas throughout the building where pests were identified would be treated until irradicated. She acknowledged the kitchen had a pest control problem and added the exterminator treated every week. The DOH identified a pest management [name redacted] log sheet and acknowledged that the exterminator wrote no reports in the kitchen each week for June through 8/19/25. She stated that the kitchen staff should have been filling that out when they see a pest in the kitchen to identify the pest and location. She added the sheet is a form of communication to the exterminator, so they would know the areas to treat. The DOH stated about a year or two ago there was an infestation, and the exterminating company had to bomb the kitchen because the exterminator brought to the facility's attention that this larger scale treatment had to be done to contain the problem. She could not speak to why pest control in the kitchen was an ongoing problem; however, she did add that it was damp in the kitchen and roaches like moisture. On 8/22/25 at 2:19 PM, the surveyor interviewed the FSD, in presence of survey team and reviewed the original pest control form for the kitchen. She acknowledged that the kitchen staff were not utilizing the logbook to identify pest sightings for the exterminator. In addition, she could not speak to why the exterminator filled out the staff observations column as no reports.On 8/22/25 at 2:35 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Nurse, and the [NAME] President of Clinical Services. The surveyor presented the above concerns.On 8/25/25 at 10:47 AM, the LNHA met with the survey team. He stated that the kitchen would be bombed Tuesday night after the kitchen closed. The LNHA further stated that after the last exterminator visit on 8/19/25 (the day after survey started), the exterminator advised that they needed something stronger. He stated he was made aware of the pests in the kitchen a few months ago, but he thought it was taken care of.8/25/25 at 11:02 AM, the surveyor interviewed the Registered Dietitian (RD), in the presence of the survey team. The RD stated she worked four days a week and walked through the kitchen each morning and would report any concerns to the FSD. She stated that she was made aware of a pest control problem in the kitchen a few weeks ago. The RD further stated there was a pest control logbook in the kitchen to identify the date and location of pest sightings so the exterminator would know areas to treat.A review of the [name redacted] Pest Management logbook dated 6/2/25 through 8/19/25 (12 entries), reflected no reports of pest observations in the kitchen. A review of [name redacted] Pest Management Service Inspection Report's dated 6/1/25 through 8/19/25 (12 reports) included a report dated 6/1/25 which reflected, Treated the kitchen for roach activity, reports dated 7/29/25 and 8/5/25 did not include treatment for the kitchen. On 8/19/25, the report included Conducted heavy treatment in the kitchen.A review of an email sent from the [name redacted] Pest Control company to the LNHA dated 8/20/25 at 11:47 AM, reflected We would like to schedule an after-hours intensive cleanout for your kitchen.A review of the facility policy Pest Control dated as reviewed 2024, reflected if pests were seen in the kitchen, the food service manager or appropriate staff should be informed, describing where and when the pest was seen and documented in the log. Appropriate action will be taken to eliminate any reported pest situation in the department. It also reflected the contractor would complete preventative spray treatments and if the problem persisted, the exterminator would use a chemical bomb to destroy the pests. In addition, the policy reflected the extermination company must establish an ongoing preventative program to limit the possible return of such pests.NJAC 8:39 - 31.5(a)

Based on observation, interview, and a review of pertinent medical records, it was determined that the facility failed to minimize the potential spread of infection to residents during medication administration for 1of 4 nurses observed during medication pass on 1 of 4 nursing units.This deficient practice was evidenced by the following.On 08/19/25 at 8:34 AM, during medication administration observation the surveyor observed a Registered Nurse (RN#1) taking Resident #202's Blood Pressure (BP) with a blood pressure monitor. After taking Resident #202's BP the nurse was observed taking the BP monitor (without sanitizing) and placing it next to her medication cart. RN#1 was then observed preparing Resident #202's medications (no observation of performing hand hygiene) and was then observed entering the resident's room. The surveyor observed RN#1 lifting the resident's head of bed with a bed remote control, which was next to the resident's bed. RN#1 was then observed handling Resident #202's pillows and placing it behind the resident's back. After administering Resident #202's medications the surveyor observed RN#1 returning to her medication cart, without performing hand hygiene and signing off Resident #202's Electronic Medication Administration Record (e-MAR).After signing off the e-MAR for Resident #202's, the surveyor observed RN#1, without performing hand hygiene or disinfecting the BP monitor, take the BP monitor and enter Resident #74's room. The surveyor stopped RN#1 just before she was going to take Resident #74's BP. The surveyor asked RN#1 to step out of the resident's room with the BP monitor.At that time, the surveyor interviewed RN#1, who acknowledge that she did not perform hand hygiene or disinfect the BP monitor. RN#1 further stated that she should have disinfected the BP monitor after taking Resident 202's vitals and that she should have performed hand hygiene after administering Resident #202's medications.The surveyor then observed RN#1 wash her hands. RN#1 was observed putting on the faucet, wetting her hands, applying soap, and then scrubbing her hands for 5 seconds away from the stream of water and then rinsing her hands with the stream of water. At that time, the surveyor asked RN#1, how many seconds should she scrub her hands away from a stream of water, the RN#1 stated for 20 second. The surveyor then asked RN#1 if she scrubbed her hands away from a stream of water for 20 seconds, RN#1 stated No. On 8/19/25 at 1:00 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator and the Regional Director of Nursing.No further information was provided.A review of the facility's policy titled Medication Administration with a review date of 11/2024 and was provided by the Regional Director of Nursing revealed the following: Wash hands before and after resident contact. An alcohol-based commercial may be substituted. A review of the facility's policy titled Hand Washing/Hand Hygiene with a review date of 04/28/25 and was provided by the Regional Director of Nursing revealed the following: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-microbial) and water for the following situations:c. Before preparing or handling medications.Under Washing Hands: 1. Vigorously later hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under moderate stream of running water, at comfortable temperature. Hot water is unnecessarily rough on hands. A review of the facility's policy titled Cleaning and Disinfecting Equipment Between Residents. with a review date of 4/15/25 and was provided by the Regional Director of Nursing revealed the following: To provide maximum safety and prevent transmission of pathogenic microorganisms from one resident to another, this facility will ensure that measures are in place to clean and disinfect all equipment that come in contact with the resident prior to the use of another resident.NJAC 8:39-19.4 (a)(1), (m)

Based on observation, interview and review of facility documents, it was determined the facility failed to maintain a comfortable and homelike environment for the residents (Resident #131). This deficient practice was identified on 1of 5 nursing units reviewed for environment and was evidenced by the following:On 8/18/2025 at 11:29 AM, the surveyor observed Resident #131, in the day room. The surveyor observed the resident's room and noted the resident's dresser, with the 3rd drawer down broken. The surveyor observed nails sticking out of the inside of the drawer. On 8/19/2025 at 10:29 AM, the surveyor observed Resident # 131, in a reclining chair, next to their bed. The resident's eyes were closed. The surveyor again noted the dresser with the broken drawer. On 8/20/2025 at 8:50 AM, the surveyor observed Resident # 131, in a reclining chair, in front of the dresser. The resident did not respond to the surveyor's questions. The surveyor again noted the dresser with the broken drawer. The surveyor reviewed the electronic medical record for Resident #131. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Alzheimer's Disease with late onset (a brain disorder that slowly destroys memory and thinking skills) and Type 2 Diabetes Mellitus without complications (a condition in which the body has trouble controlling blood sugar). A review of the Minimum Data Set (MDS), an assessment tool dated 8/5/2025, revealed the resident had a Brief Interview for Mental Status of 00 out of 15, indicating the resident was severely cognitively impaired. Further review of the MDS, revealed the resident was dependent for all activities of daily living. On 8/21/2025 at 8:30 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who stated she was asked to come in today since the Unit Manager (UM) would not be in. She stated if something was in disrepair or needed to be fixed it would go into the maintenance logbook at the nurse's station. She walked with the surveyor to Resident # 131's room and observed the broken drawer. LPN #1 walked into the room and looked at the drawer. She asked the Certified Nursing Aide (CNA) #1, who was performing Resident #131's care in the room, about the drawer. CNA #1 stated he hadn't noticed it. She acknowledged that it should have been noticed and entered in the maintenance log. LPN # 1 showed the maintenance logbook to the surveyor, which was at the nurse's station. She reviewed, the book with the surveyor, from 6/20/25 and acknowledged that the drawer was not listed there. On 8/21/2025 at 8:45 AM, the surveyor interviewed the Maintenance Director (MD), who stated the first thing he did in the morning was to check all the maintenance log books on the units. He added he also checked with the supervisor to see if there were any issues that were not documented in the books. The MD stated if something was in the book, it would be addressed right then and there. The surveyor showed the MD the picture of Resident #131's broken drawer and he acknowledged the nails sticking out of the wood. He stated he would have expected to be called right away to come fix it. The MD stated he would have addressed it right away, but he had no idea that it was broken. He stated a broken drawer would be addressed right away by removing and replacing the dresser. On 8/21/2025 at 9:02 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated if they (staff) noticed it (something broken), it should be in the maintenance book. The surveyor showed the LNHA the picture of the broken drawer and he acknowledged it should have been noticed especially because the nails were sticking out. The LNHA stated, It should have been addressed right away. He stated the staff had already made him aware of the surveyor's findings. On 8/22/2025 at 2:35 PM in the presence of the survey team, the surveyor made the [NAME] President of Clinical, the LNHA, the Regional Nurse and the Director of Nursing aware of the above findings.NJAC 8:39-4.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that an air mattress (designed to prevent and treat pressure wounds) was accurately set in accordance with the resident's weight for one (1) of one (1) resident reviewed for pressure ulcers, Resident #172.This deficient practice was evidenced as follows:On 8/19/2025 at 10:39 AM, the surveyor interviewed Resident #172, who was in bed. The surveyor observed an air mattress pump at the foot of the resident's bed. The setting on the pump was set at approximately 360. The resident stated, All I know is the pump is for the air mattress because I have a wound. On 8/20/2025 at 8:45 AM, the surveyor observed the resident in bed with the air mattress pump set at approximately 360. The survey met with resident's nurse to attempt to do a wound care observation, but the nurse stated the wound care was done this morning by the wound care team.The surveyor reviewed the electronic medical record (EMR) for Resident #172.A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; chronic diastolic (congestive)heart failure (the left ventricle has become stiffer than usual, and the heart can't relax the way it should, which could cause shortness of breath) and adjustment disorder with depressed mood (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities). A review of the quarterly Minimum Data Set, an assessment tool dated 5/8/2025, revealed the resident had a Brief Interview for Mental Status of 15 out of 15, indicating the resident was cognitively intact. A review of the individual comprehensive care plan revealed a focus of has hx (history) of refusing incontinent care, refusing to go to bed at night. Date Initiated: 07/01/2024. Further review, revealed a focus of at risk for skin breakdown r/t fragile skin, PVD (peripheral vascular disease- a circulatory disorder that results from narrowed blood vessels, leading to reduced blood flow, primarily affecting the legs and feet), impaired mobility, incontinence, Hx: skin impairment, revision on: 12/20/2024 with an intervention that included utilize pressure relieving cushion to chair, LAL (low air loss) mattress to bed, revision on 3/21/2025. A review of the Order Summary Report revealed a physician's order (PO) for Air mattress on bed for pressure prevention every shift for Pressure Prevention Check setting and function on air mattress Start Date 3/28/2024 at 1500 (3PM). A review of the Treatment Administration Record (TAR) for August2025 revealed the above PO had been signed as completed for day shift on 8/19/2025 and 8/20/2025.On 8/22/2025 at 10:07 AM, the surveyor observed with Licensed Practical Nurse (LPN) #1, Registered Nurse (RN) #1, and Certified Nursing Assistant (CNA #1). At the beginning of the observation, LPN #1 had bumped the air mattress pump and knocked it off the bed. The nurse picked the pump up and placed it back on the bed. The surveyor observed the setting remained on approximately 360, the same setting as the prior observations. After the wound care observation was completed, the surveyor questioned the air mattress pump. Both RN #1 and LPN #1, confirmed the air mattress setting was at 360. On 8/22/2025 at 10:33 AM, the surveyor interviewed CNA #1, who stated the air mattress was set by resident's weight and the nurses checked it. On 8/22/2025 at 10:35 AM, the surveyor interviewed LPN#1, who stated she rounded with the wound care team. The surveyor asked about the air mattress setting of 360, LPN#1 stated it probably got messed up when the pump fell. The surveyor made her aware of the above observations and that the settings had been the same prior to the pump falling. She stated the pump should be set close to the resident's weight. She checked the electronic medical record in the presence of the surveyor and verified the resident's weight was 259 pounds. She stated the higher setting would make the mattress too hard. LPN #1 stated the reason it was important to have the settings set to the resident's weight was for wound prevention or healing, so it (the mattress) could adjust to the weight. On 8/22/2025 at 10:45 AM, the surveyor interviewed CNA #2, who stated, We check to make sure there is air in there if not, we call maintenance. On 8/22/2025 at 11:17 AM, the surveyor interviewed RN#1, who was Resident #127s assigned nurse. RN #1 stated she makes sure the air mattress was working but she was not checking the settings. RN #1 reviewed the TAR in the presence of the surveyor and acknowledged she had signed the above-mentioned PO as being completed but then confirmed she signed that it was working. On 8/22/2025 at 11:21 AM, the surveyor interviewed the Director of Nursing (DON), who stated the purpose of an air mattress was prevention of stage 3 and 4 pressure ulcers. She stated maintenance applied the air mattress and sets it. The DON stated maintenance would ask for the weights and set the pump. She added it was between the nurses and the unit managers to check that the weight setting was correct. On 8/22/2025 at 1:27 PM, the DON, in the presence of another surveyor, confirmed that the facility does not have a policy on the air mattress settings. She stated the setting should be adjusted to the resident's weight due to weight distribution and added we are in servicing all the nurses on checking the settings.On 8/22/2025 at 2:35 PM in the presence of the survey team, the surveyor made the [NAME] President of Clinical, the Licensed Nursing Home Administrator, the regional nurse and the DON were made aware of the above findings. A review of the facility's policy, Homelike Environment Policy revised 1/1/2025, revealed Policy: The facility is committed to creating and maintaining a homelike environment by: Ensuring the environment is free from odors, clutter, and hazards while maintaining a warm and inviting atmosphere. Procedures: 3. Maintenance Services: Maintenance staff will ensure all resident rooms and common areas are kept in good repair, with no hazards such as loose flooring, exposed wiring, or broken furniture. 6. Staff Training: Housekeeping and maintenance staff will be trained in infection prevention, safety.with emphasis on respecting resident preferences and maintaining a homelike environment. NJAC 8:39-25.2 (c), 27.1(e)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in one (1) of six (6) residents (Resident #202) observed during the medication observation pass.The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 8/19/25 at 8:54 AM, during the medication administration observation, the surveyor observed Registered Nurse (RN#1) enter the room of Resident #202. The surveyor observed RN#1 informing Resident #202 that she would be taking the resident's vitals and would then be administering the resident's medications. RN #1 was observed taking the resident's vitals which were blood pressure167/59, heart rate (HR) 67. On 08/19/25 at 8:57 AM, the surveyor observed RN#1 preparing to administer five (5) medications to Resident #202 which included Metoprolol Tartrate 50 mg tablet (medication for lowering blood pressure), Depakote 250 mg extended-release tablets (medication for seizures), Hydralazine 50 mg tablet (medication for lowering blood pressure), Buspar 5mg tablet (medication for anxiety), and Norvasc 5mg tablet (a medication for lowering blood pressure). After RN#1 finished preparing the resident's medication she was observed entering the resident's room and administering Resident #202's medications.After RN#1 finished administering Resident #202's medications, the surveyor observed RN#1 signing off the Electronic Medication Administration Record (e-MAR) but did not observe her entering the vitals for the Metoprolol Tartrate 50mg, Hydralazine 50 mg, or Norvasc 5 mg tablets. After completing medication administration observation, the surveyor did record review which revealed that the resident had parameter orders for Metoprolol, Hydralazine, and Norvasc which included a hold order if the Systolic Blood Pressure (SBP) (the pressure in the arteries when the heart contracts and pumps blood throughout the body) or the Heart Rate (HR) fell below a certain level. A review of the full medical record revealed no documentation of the resident's Blood Pressure which included the SBP. A review of the admission Record (an admission summary) reflected that Resident #16 was admitted to the facility with diagnoses that included but not limited to; hypertension (a condition in which the force of the blood against the artery walls is too high), hypertensive heart disease without heart failure(heart damage caused by long-term high blood pressure), and hypertensive urgency (a condition of a very high blood pressure reading (such as over 180/120) without any signs of acute organ damage like chest pain shortness of breath, or vision changes). A review of the August 2025 Order Summary Report (OSR) revealed the following PO's) dated 08/12/25:1.Hydralazine tablet 50 mg, give 1 tablet by mouth two times a day B/P (blood pressure) hold SBP less than 110 per policy. May cause dizziness/increase photosensitivity.2.Metoprolol Tartrate tablet 50 mg, give 1 tablet by mouth two times a day B/P hold SBP less than 90, and pulse hold HR less than 60 per policy. Take with or immediately after meals. May cause dizziness. May cause orthostatic hypotension.3.Norvasc tablet 5 mg (Amlodipine besylate), give 1 tablet by mouth two times a day B/P hold SBP less than 110 and pulse per policy. May cause dizziness/lightheadedness. Avoid grapefruit.A review of the August 2025 e-MAR revealed the following POs dated 8/12/25:1.Hydralazine tablet 50 mg, give 1 tablet by mouth two times a day B/P (blood pressure) hold SBP less than 110 per policy. May cause dizziness/increase photosensitivity with an administration time of 0900 (09:00 AM) and 1700 (5:00 PM). A further review of the e-MAR revealed that nurses were not plotting the B/P (which included the SBP) or HR.2.Metoprolol Tartrate tablet 50 mg, give 1 tablet by mouth two times a day B/P hold SBP less than 90, and pulse hold HR less than 60 per policy. Take with or immediately after meals. May cause dizziness. May cause orthostatic hypotension with an administration time of 0900 (9:00 AM) and 1700 (05:00 PM). A further review of the e-MAR revealed that nurses were not plotting the B/P or HR3.Norvasc tablet 5 mg (Amlodipine besylate), give 1 tablet by mouth two times a day B/P hold SBP less than 110 and pulse per policy. May cause dizziness/lightheadedness. Avoid grapefruit with an administration time of 0900 (9:00 AM) and 1700 (05:00 PM). A further review of the e-MAR revealed that nurses were not plotting the B/P or HR. On 8/19/25 at 11:00 AM, the surveyor interviewed RN#1, who stated that she would take the resident's vitals which included the BP and HR and will write it down on a piece of paper. RN#1 acknowledge that she does not enter the vitals into the electronic medical record. In the presence of the surveyor, RN#1 reviewed Resident #202's e-MAR and acknowledged that the resident had three medication that required parameters which included Hydralazine 50 mg, Metoprolol Tartrate 50 mg, and Norvasc 5 mg and that the e-MAR contained no place to document the resident's vitals. She further acknowledges that medications that have perimeters should contained a place to plot the BP and HR. She stated that all three medications did not contain a place to plot the BP and HR.On 08/19/25 at 1:00 PM, the surveyor discussed the above concerns with the facility administration team that consisted of the Licensed Nursing Home Administrator (LNHA) and the Regional Director of Nursing. There was no additional information provided.A review of the facility's policy for Medication Administration that was dated 11/2024 and was provided by the Regional Director of Nursing revealed the following:The policy does not mentioned perimeters but mentions to review the eMAR and notified the physician if something was questionable. If an order for a medication is unusual (such a large dose more than two tablets will be required), question the order. Check the physician order sheet (POS) against the eMAR. Compare the eMAR to the label on the drug container. Call the physician or pharmacist with any concerns.NJAC 8:39-11.2 (b), 29.2 (d)

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 8/19/25, the surveyor observed four (4) nurses administer medications to six (6) residents. There were 27 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.41%. The deficient practice was identified for two (2) of six (6) residents, (Resident #55 and #74), that were administered medications by two (2) of four (4) nurses that were observed.The deficient practices were evidenced by the following:1). On 8/19/25 at 8:32 AM, during the medication administration observation, the surveyor observed Licensed Practical Nurse (LPN#1) entered the room of Resident #55. The surveyor observed LPN#1 informing Resident #55 that she would be administering the resident's medications. The surveyor observed the resident who was in their bed and was observed eating breakfast.On 08/19/25 at 8:35 AM, the surveyor observed LPN#1 preparing to administer five (5) medications to Resident #16, which included 15 ml of Potassium Chloride 20 MEQ/15 ml solution (low potassium levels), one (1) tablet Carvedilol 3.125 mg (medication for lowering blood pressure), one (1) tablet of Torsemide 20 mg , three (3) tablets of Colace 100 mg (medication for constipation), and one (1) tablet of Norvasc 5 mg (medication for lowering blood pressure). While preparing the resident's medications the surveyor observed LPN#1 reviewing the resident's Electronic Medication Administration Record (e-MAR), the surveyor noticed that LPN#1 did not click and read the full directions for Potassium Chloride 20 MEQ/15 ml solution (ERROR #1). LPN#1 told the surveyor that the resident received their Potassium liquid whole, the surveyor then observed LPN #1 entered the resident's room and administered the resident's medication including Potassium Chloride 20 MEQ/15 ml solution. The resident was observed drinking approximately 60 ml of water after being administered their Potassium liquid.A review of the admission Record (an admission summary) reflected that Resident #55 was admitted to the facility with diagnoses that included but not limited to; hypertension (a condition in which the force of the blood against the artery walls is too high), hypokalemia (low potassium), and chronic diastolic (congestive) heart failure (occurs when the heart's lower left chamber (left ventricle) becomes stiff and doesn't fill with blood properly during heart relaxation rate. A review of the annual Minimum Data Set, an assessment tool used to facilitate the of care, dated 06/18/25, reflected that the resident's cognitive skills for daily decision-making score was 11 out of 15, which indicated that the resident's cognition was mildly impaired.A review of the August 2025 Order Summary Report (OSR) revealed a Physician's Order dated 06/30/25, for Potassium Chloride solution 20 MEQ/15 ml (10%), give 15 ml by mouth two times a day for hypokalemia. 15 ml=20 MEQ dilute every 15 ml with at least 90 ml (3 ounces) of fluid. Administer with or after meals.A review of the August 2025 e-MAR revealed a Physician's Order dated 06/30/25, for Potassium Chloride solution 20 MEQ/15 ml (10%), give 15 ml by mouth two times a day for hypokalemia. 15 ml=20 MEQ dilute every 15 ml with at least 90 ml (3 ounces) of fluid. Administer with or after meals with an administration time of 0900 (09:00 AM) and 1700 (05:00 PM).A review of the Manufacturer's Specifications for Potassium Chloride 20 MEQ/15ml solution revealed the following:-Dilute the solution: Pour the measured liquid dose into a glass with at least 4 ounces (1/2 cup) of water or juice. Cold liquid can also help mask the unpleasant taste. On 8/19/25 at 11:00 AM, the surveyor interviewed Resident #55 who acknowledge that they always received their Potassium in a little medicine cup and that it was never administered diluted in a cup of water. Resident #55 stated that they never experience any stomach or throat irritation taking the medication whole and undiluted. On 8/19/25 at 11:20 AM, the surveyor in the presence of LPN #1, reviewed Resident #55's e-MAR. LPN#1 reviewed the directions for Resident #55's Potassium Chloride Solution and acknowledged that there was an order to dilute the Potassium solution with 90 ml of water. LPN#1 further acknowledge that she should have diluted the medication prior to administering the medication. 2. On 8/19/25 at 09:16 AM, during the medication administration observation, the surveyor observed Registered Nurse (RN#1) entered the room of Resident #74. The surveyor observed RN#1 identify Resident #74 and then observed RN#1 taking the resident's vitals. RN#1 then informed Resident #74 that she would be administering the resident's medications. On 08/19/25 at 9:20 AM, the surveyor observed LPN#1 preparing to administer five (5) medications to Resident #74, which included one tablet of Carvedilol 12.5 mg (medication for lowering blood pressure), one tablet of Hydralazine 50 mg tablet (medication for lowering blood pressure), one tablet of Aspirin 81 mg chewable tablet (order was for Aspirin 81 mg enteric-coated tablet which is a special coating that allow the medication to be dissolve in the small intestine, which protects the stomach from experiencing discomfort)(coronary artery disease) ERROR #2, Norvasc 10 mg (medication for lowering blood pressure) and Apixaban 5 mg (coronary artery disease). The surveyor observed RN#1, after preparing the above medications, fill a cup with approximately 120 ml of water and was observed her walking into Resident #74's room. Once RN#1 entered the room, she was stopped by the surveyor, just prior to administering the resident's medications. The surveyor asked the nurse to leave the resident's room with the resident's medications. The surveyor, in the presence of RN#1, reviewed the resident's e-MAR. At that time, RN#1 acknowledge that the resident had an order for Aspirin enteric coated 81 mg tablets. She further acknowledges that she picked the wrong form of Aspirin. When the surveyor asked her why enteric coated Aspirin was different from regular chewable Aspirin, RN#1 was not able to tell the surveyor the difference between the two Aspirin's.A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; hypertension (a condition in which the force of the blood against the artery walls is too high), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete painful blockage).A review of the Annual Minimum Data Set, an assessment tool used to facilitate the management of care dated 07/14/25, reflected that the resident's cognitive skills for daily decision-making score was 11 out of 15, which indicated that the resident' had mild cognitive impairment.A review of the August 2025 OSR revealed a PO dated 07/08/25, for Aspirin EC low dose tablet delayed release 81 mg (Aspirin), give one tablet for CAD (coronary artery disease). Do not crush/chew. Give with plenty of water. Monitor for sign of bleeding, bruising, dark urine, and tarry stools.A review of the August 2025 e-MAR revealed a PO dated 07/08/25, for Aspirin EC low dose tablet delayed release 81 mg (Aspirin), give one tablet for CAD (coronary artery disease). Do not crush/chew. Give with plenty of water. Monitor for sign of bleeding, bruising, dark urine, and tarry stools with an administration time of 0900 (9:00 AM).On 8/19/25 at 1:10 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator (LNHA) and the Regional Director of Nursing.No further information was provided.A review of the facility's policy for Medication Administration that was dated 11/2024 and was provided by the Regional Director of Nursing revealed the following: Under Medication Pass: Read medication name, dosage, and timing. Read labels on all medications three times: before removing from cart/before pouring it/ and after pouring it. NJAC 8:39-11.2(b), 29.2(a)(d)

Based on observation, interview, and record review, it was determined that the facility failed to properly secure medications in one (1) of four (4) medication carts observed during Medication Administration Pass.This deficient practice was evidenced by the following: On 8/19/25 at 09:16 AM, during the medication administration observation, the surveyor observed Registered Nurse (RN#1) enter the room of Resident #74. The surveyor observed RN#1 identify Resident #74 and then observed RN#1 taking the resident's vitals. RN#1 then informed Resident #74 that she would be administering the resident's medications. On 08/19/25 at 9:20 AM, the surveyor observed LPN#1 preparing to administer five (5) medications to Resident #74, which included Carvedilol 12.5 mg (medication for lowering blood pressure), Hydralazine 50 mg tablet (medication for lowering blood pressure), Aspirin EC (enteric-coated tablet which is a special coating that allow the medication to be dissolve in the small intestine, which protects the stomach from experiencing discomfort) 81 mg (coronary artery disease), Norvasc 10 mg (medication for lowering blood pressure) and Apixaban 5 mg (coronary artery disease). The surveyor observed RN#1, after preparing the above medications, fill a cup with approximately 120 ml of water. The surveyor observed RN #1 walk into Resident #74's room without locking the medication cart. The surveyor observed no residents in the vicinity of the medication cart. Once RN#1 entered the room, the surveyor stopped her just prior to administering the resident's medications. The surveyor asked the nurse to leave the resident's room with the resident's medications. The surveyor stopped RN#1 because she was going to administer the wrong form of Aspirin (non-enteric coated). At that time, the surveyor asked RN#1 if her medication cart was locked, in which she replied no. RN#1 acknowledged that she should have locked the medication prior to leaving the medication cart and entering the resident's room. On 8/19/25 at 1:00 PM, the surveyor presented the above concerns to the Regional Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). No further information was provided. A review of the facility's policy for Medication Storage that was dated 12/2024 and was provided by the Regional DON indicated the following: A. with the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy.A review of the facility's policy for Medication Administration that was dated 11/2024 and was provided by the Regional DON indicated the following:Keep the med cart visible or locked at all times while passing medications.NJAC: 8:39-29.4 (a) (h) (d)

Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure: a) a consistent system for labeling and dating was implemented to ensure all potentially hazardous foods were labeled with a use by date, b) the kitchen environment, all equipment and dishware was maintained in a clean and sanitary manner and transported appropriately, and c) staff performed appropriate hand hygiene, to limit the potential for contamination, and the risk of potential foodborne illness. The deficient practice was evidenced by the following: On 05/08/24 at 9:26 AM through 10:40 AM, the surveyor conducted a tour of the kitchen with the Registered Dietitian (RD) and the Food Service Director (FSD) and observed the following: 1. The step garbage can next to hand washing sink did not open when the foot pedal was stepped on and this was confirmed by the RD. 2. The walk-in refrigeration unit contained the following: - A metal pan on the bottom shelf contained six cabbage heads with visible darkened areas/spots. The cabbage was not labeled and did not contain a use by date. The surveyor asked the RD if the cabbage was dated and she stated, I don't see one. - A plastic type bin of uncovered celery stalks, located on a bottom shelf, had a sticker affixed to the bin with 2/27/24. When asked about the date, the RD stated, they forgot to take the label off the bin and confirmed there was no use by date on the celery when she lifted the packages and was unable to locate a use by date. - A blue colored box that contained bags of red grapes had 4-26-24 written on the box. There was no use by date. - Two boxes of mushrooms, both uncovered, were also located on the shelf, one box was labeled Medium 10 lbs with a white sticker 4/18, and the second box was labeled 4/30. Neither box contained a use by date. -The grate covering the fan located in the refrigeration unit contained black spots and soiled areas and there was black splatter type debris on the ceiling, corner, and portions of the wall areas. 3. The walk-in refrigerator contained the following: - One ten-pound box of Fully Cooked Boneless, Skinless Chicken Meat, Diced Chicken was labeled in red handwriting, 4/30. The box was labeled, Keep Frozen, there was no indication when the product was defrosted or a use by date. - Three white boxes labeled ten pounds of Fully Cooked 1/2 Inch [NAME] Meat Chicken, two of the boxes had a date on the box 02/08/24 and there was no use by date, the third box had a handwritten date, 4/18/24 and did not contain a use by date. - A box that contained rolls of Turkey Bologna, that were not dated and the box was labeled Sell/Freeze by 11/24/23, Keep Refrigerated, another box of 19.76 pounds of Turkey Bologna rolls had a handwritten date of 11/29/23 with the same Sell/Freeze by 11/24/23 label. There was no use by dates on the items. Another Turkey Bologna roll had a printed label Date Received 1/23/24, partially over another label Sell/Freeze by 02/15/24, Keep Refrigerated. The surveyor asked the FSD what the product use by date should be. The FSD stated, seven days from the open date. The surveyor asked where the date was located on the boxes. The FSD stated, I don't see it. The surveyor asked if there should be a use by date on the products and the FSD stated, yes and he was unable to provide a use by date. -A package of opened parmesan cheese was wrapped and had a piece of paper with a handwritten date 11/28/24. There was no use by date, and the package was discarded by the FSD. -A five-pound opened container of Cottage Cheese had a sticker on it, Received 04/02/24, there was no use by date. The sell by sticker on the package indicated, 04/26/24. The surveyor asked about the use by date, the RD stated, I don't see a use by date. -Three cases of 4-ounce skim milk dated, May 7, 2024, and the surveyor asked the RD if the milk could be used and the RD stated, no. -14 cased of defrosted juices, STORE AT 0F printed on box in bold. The boxes did not contain use by dates 4. The walk-in freezer contained the folllowing: -The door gasket was ripped and pulling off door and the door curtain was ripped. -A box contained a plastic bag of breaded chicken patties which was not sealed and was open to air. The box was dated 04/16/24 and there was no use by date. -Three logs of frozen ground beef were stored on top of packages of various frozen meats. There were no use by dates. -There was a three pack of frozen turkey burgers and there was no use by date. 4. The dry storage room contained the following: a large, unsealed bin with stains on top of the bin. The bin had dark splatter type stains on the outside and in the inside of the bin. The top of the bin had Coconut Shredded, Open 05/01/24 written on the top of the lid. There was a white shredded product in the bin. The FSD confirmed that there was no use by date. -The floor in the dry storage room had debris in the corners of the room. The surveyor asked the FSD about a cleaning schedule for the kitchen and the FSD stated there was no schedule yet, as he was new to the facility and was working on it. -17 individual four-ounce containers of thickened cranberry juice cocktail were located on a shelf in the dry storage room. The juice had a best if used by date of 4/4/24. -Splatters of various colored debris were observed on the ceiling in the dry storage room. -A large fan inside the kitchen to the outside had a grate covered with dust like debris. -The can opener that was affixed to the metal table was very soiled with dark debris on the base and blade. The FSD confirmed as he observed that the base of the can opener was difficult to remove due to debris. On 05/10/24 at 8:52 AM, during a second kitchen observation conducted with the FSD, the surveyor observed the large slicer covered with plastic, which was identified as clean, and when the FSD removed the plastic there were several areas of food debris on the base and blade area. On 05/08/24 at 12:10 PM, during a lunch meal observation on the second floor, the surveyor observed the [NAME] transporting dishware and other supplies from the hallway into the dining room on a three tiered black cart. The bottom tier of the cart contained eight dishes, face up, that were uncovered during transit. 05/08/24 at 12:21 PM, during the same meal observation on the second floor, the [NAME] was observed using paper towels to wipe perspiration off of his head, then proceeded to place gloves on his hands without first performing hand hygiene, and proceeded to plate food on the uncovered dishes from the cart. The Handwashing/Hand Hygiene Policy, revised December 2023, revealed This facility considers hand hygiene the primary means to prevent the spread of infection. 6. Waterless alcohol products are preferred method for hand hygiene except for the following situations: a. When hands re visibly soiled . 8. Use an alcohol-based hand rub containing at least 62 % alcohol; or alternatively, soap and water for the following: . f. Before donning sterile gloves. The Storage Areas Policy, undated, revealed .Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate methods designed to prevent contamination or cross contamination. 4. All containers must be legible and accurately labeled and dated. 6. Schoops must be provided for bulk foods. Scoops are not to be stored in food or ice containers, but are kept covered in a protected area near the containers. 8. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. a. Old stock is always used first (first in-first out method). c. Food should be dated as it is placed on the shelves. Date marking top indicate the date or day by which a ready to eat, potentially hazardous food should be consumed, sold or discarded will be visible on all high risk food. 14. Refrigeratged Food Storage. a. All refrigerator units are kept clean and in good working condition at all times. f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. 15. Frozen Foods: d. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. NJAC 8:39-17.2 (g)

Based on observation, interviews and review of pertinent documentation, it was determined that the facility failed to a.) adhere to accepted standards of infection control practices for donning (put on) the required Personal Protective Equipment (PPE) prior to providing care to residents on isolation and Enhanced Barriers Precautions. (Resident #23 and #279) and b.) perform appropriate hand hygiene according to the Center for Disease Control (CDC) and the facility's policy. The deficient practice was evidenced by the following: 1. On 5/8/23 at 10:30 AM, during initial tour on unit 1 North, the surveyor observed a white signage posted at Resident #23's door. The door was closed and there was a PPE bin with yellow disposable gowns, outside the room. The surveyor observed the Contact Precautions signage which included but were not limited to; Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 5/9/23 at 12:34 PM, the surveyor observed a Certified Nursing Assistant (CNA) #1 take a lunch tray into Resident #23's room. CNA#1 did not don a yellow gown as the sign on the resident's door indicated before entering the room. Upon exiting Resident #23's room, The surveyor conducted an interview with the CNA. The CNA acknowledged that she did not have a gown on when entering the resident's room and she stated, I had gloves on and they didn't tell us to put a gown on before entering into this room when we are passing out trays. At 12:40 PM, the surveyor brought the Licensed Practical Nurse/Nurse Manager (LPN/UM) to the door of Resident #23 and asked what the Stop Contact Precautions signage meant. The LPN/UM stated that everything on the sign should be done before you enter the room. The LPN/UM stated that the resident was on contact isolation for Methicillin-resistant Staphyloccus Aureus (MRSA-a bacteria that causes infection) in the nares. She confirmed that CNA #1 should have donned a gown before entering the room. The LPN/UM stated that We need to gown up and put gloves on every time we go in this room because the staff is going to have contact with the patient the purpose of PPE was to prevent the spread of infection. The LPN/UM further explained to CNA #1, for contact isolation rooms, you need to put PPE for everything. The surveyor reviewed the medical records for Resident #23 which revealed the following: The Admission Record (AR) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Methicillin Resistant Staphylococcus Aureus infection as the cause of diseases classified elsewhere and Metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). A review of the Order Summary Report indicated a physician order, dated from 5/7/24 to 5/10/24 and from 5/10/24 to 5/13/24 for Maintain Contact Precautions for MRSA every shift until 5/13/2024 15:00 (3:00 PM). A review of the May 2024 Treatment Administration Record (TAR) under Maintain contact precautions for MRSA every shift revealed that nursing had signed the TAR as completed for the Day, Eveni (evening) and Night shifts. A review of Nursing Progress Notes (PN) dated 5/8/24 at 00:22 (12:22 AM) revealed, on isolation precautions for unspecified MRSA. On 5/15/24 at 12:10 PM, during an interview with the Infection preventionist nurse (IPN), the IPN stated, Anyone going into contact isolation room, must have PPE and expectations from the staff are to do what the posted sign says. On 05/15/24 at 12:41 PM, the Director of Nursing(DON) , The Licensed Nursing Home Administrator (LNHA) and the Regional Nurse were informed of the above concerns. 27193 2. On 05/08/24 at 10:25 AM, the surveyor toured the Subacute Extension Unit (SAE) and observed signage posted at the door for enhanced barrier precautions which included but were not limited to; Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing. The surveyor observed an isolation bin containing gowns, gloves and surgical mask in the hallway at the door entrance. On 05/08/24 at 10:30 AM, the surveyor entered the room and observed Resident #279 in bed. The head of the bed was elevated and the resident was resting with the eyes closed. The resident had a Foley Catheter (medical device that helps drain urine from the bladder) contained in a dignity bag and hung on the bedrail. On 05/08/24 at 11:37 AM, the surveyor observed 2 staff members in the room assisting Resident #279 with care. One staff was changing the bed linen and the other staff was assisting the resident with dressing. Both staff were observed with mask and no gown on. During an interview with staff #1 at 10:45 AM, she identified herself as a CNA (#2) and informed the surveyor that staff #2 was an orientee Nursing Assistant (NA). The CNA stated that Resident #279 had a Foley catheter, wore a leg bag during the day. On 05/10/24 at 10:30 AM, the surveyor knocked at the door, and the staff prompted the surveyor to enter the room. The curtain was drawn and the surveyor observed the NA at the beside assisting Resident #279 with care. The NA had a mask and gloves on. The NA did not have a gown on as required by the signage posted at the door. On 05/10/24 at 10:45 AM, the surveyor interviewed the Registered Nurse/Unit Manager regarding the above observation. The RN/UM revealed that the NAs should not be working alone. They just came in, they should be working with another CNA. The UM further stated that all staff should have on the required PPE while providing care. On 05/10/24 at 11:30 AM, review of the electronic medical record (EMR) reflected that Resident #279 was admitted to the facility with diagnoses which included, but were not limited to; muscle weakness and urinary tract infection, site not specified. A review of the Order Summary Report for May 2024, revealed the following orders for Resident #279: Foley Catheter Care every shift. Maintain Enhanced Barrier Precautions related to: Foley Catheter Use every shift for Disrupt potential spread of MDROs ( Multi-drug Resistant Organisms.) On 05/15/24 at 08:53 AM, the surveyor interviewed CNA #2 who was observed in the room with the Orientee and not wearing the required PPE. The CNA stated that she was not aware that she had to have a gown on while changing the linen and could not provide the rationale for not wearing the required PPE while at the bedside providing care. On 05/15/24 at 1:15 PM, the facility was informed of the above concerns and requested the policy for Enhanced Barrier Precautions (EBP). 41858 4. On 05/09/24 at 11:32 AM, the surveyors entered an unsampled resident's room with CNA# 1 and CNA #3 for an incontinence care check. In the presence of the surveyors, CNA#1 performed hand washing as follows: she turned on the water, wet her hands, applied soap, lathered, and rubbed hands together for a total of 12 seconds outside of the running water, she rinsed her hands under the water, obtained a paper towel and dried her hands. CNA #3 walked over to the sink with the running water and performed hand washing as follows: she wet her hands, applied soap, lathered and rubbed hands together for a total of 11 seconds outside of the running water, she rinsed her hands under the water, obtained a paper towel, dried her hands and used a clean paper towel to turn off the water. Both CNA's donned gloves and proceeded with the incontinence check. 05/09/24 at 11:35 AM, after CNA# 1 and CNA# 3 exited the resident's, the surveyors interviewed them regarding hand washing. CNA#3 stated she sings the Happy Birthday song once while lathering her hands and then sings it again while rinsing her hands. She stated, It (lathering hands with soap) should be done for at least 20 seconds. CNA #1 agreed. CNA #3 stated, she counted in her head for 20 seconds while lathering. On 05/09/24 at 11:44 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who stated hand hygiene should be done before and after care, before and after medication administration and in between residents. She stated you turn on the water, wet hands, lather hands with soap for 30 seconds before rinsing. LPN#1 further stated you sing happy birthday 2 times while rubbing hands with soap, then rinse them, dry hands with a paper towel and take another paper towel to turn off the water. On 05/14/24 at 11:07 AM, the surveyor interviewed the Infection Preventionist Nurse (IPN) regarding hand washing. She stated, hand hygiene should be done before any care, after eating, and after touching soiled things. The IPN stated hand washing was done with soap and water as follows: turn on the water, rub hands for 20 seconds with the soap, rinse hands, dry and use a clean paper towel to turn off the water. She stated staff could sing happy birthday a couple of times and sing it again while rinsing your hands. On 05/14/24 at 12:42 PM, during a meeting with the DON, the RNC and the LNHA, the surveyor presented the above concerns. The DON stated, you handwash every time you touch the patient, during care, in between patients and when hands are soiled. She stated, you turn on the water, wet hands, apply soap, lather and rub hands for 20 seconds, rinse hands, use a paper towel to dry and get another one to turn off the faucet. A review of the facility provided Employee In-Service Education dated 4/18/24, Objective: Infection Control-Isolation Precautions + Hand Washing . revealed that CNA #1, CNA #2 and CNA #3 attended. A review of the facility provided annual Hand Hygiene Competency revealed a Yes under Competent for Hand Hygiene with Soap & Water .4. Vigorously rubs hands for at least 20 seconds including palms, back sides of hands between fingers, thumbs, and wrists for CNA #1, dated 6/6/23 and CNA #2, dated 6/5/23. On 05/16/24 at 8:15 AM, the Director of Nursing (DON) provided the policy for Enhanced Barrier Precautions. The following were noted: Purpose To outline the implementation of Enhanced Barrier Precautions to disrupt the potential spread of multidrug-resistant organisms. Procedure: EBP is used in conjunction with standards precautions and expand the use of PPE to don a gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Examples of high- contact resident care activities requiring gown and gloves use for Enhanced Barrier Precautions include: Dressing Providing hygiene Changing Linens . Indwelling medical devices examples include central lines, urinary catheters, feeding tubes and tracheostomies. EBP should be used for any residents who met the above criteria, wherever they reside in the facility . The policy was not being followed. A review of the facility's policy Handwashing/Hand Hygiene dated December 2023 revealed: Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Procedure: Washing hands 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) . Applying and removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. A review of the facility's provided policy un-titled with revised date April 2024 revealed: Contact Precautions- are a type of Transmission-Based Precaution that is intended to prevent transmission of infectious agents, that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of a gown and gloves on every entry into a resident's room. The resident is given dedicated equipment and is placed into a private room as available, cohorted, or grouped together. The facility will post clear signage on the door or wall outside of the resident room indicating the type of precautions and required person protective equipment (PPE), e.g., gown and gloves, along with the high-contact resident care activities requiring PPE. NJAC 8:39-19.4 (a) (1) (2) (5)

Based on observation, interview and document review it was determined that the facility failed to serve hot and cold food items at appropriate and appetizing temperature for 3 of 5 resident units (1 South, 2 North and 2 South), for 1 of 1 resident reviewed for food (Resident #165) and for 3 of 5 residents who attended a resident council meeting. The deficient practice was evidenced by the following: On 05/08/24, at 11:12 AM, the surveyor interviewed Resident #165 who stated the main concern was that the hot food was cold, along with the coffee for all three meals. On 05/09/24 at 9:46 AM, during a follow up interview with Resident #165, the resident stated the temperatures were off and the hot food was not hot, and the cold food was not cold. On 05/10/24 at 10:39 AM, a surveyor conducted a resident council meeting and 3/5 residents stated the food was not hot enough and the coffee could be cold at times. Two of the five residents stated that they requested cold cereal for breakfast because they knew the hot food would be cold. Two of five residents stated the lunch and dinner were also not hot enough. A resident stated, when the food comes up, the food stays there for a few minutes and it's not going to get to you, and it will be cold when I get it. On 05/10/24 at 8:10 AM, surveyor #1 conducted a meal observation on 2-North and observed the following: -8:13 AM the meal cart was brought to the unit. -8:18 AM, 5 minutes after the cart was brought to the unit, one staff removed a tray and brought it to a resident room. -8:22 AM, the 2nd meal tray was removed from the cart. -8:36 AM, the Licensed Nursing Home Administrator (LNHA) joined Surveyor #1 for the the observation. -8:37 AM, (25 minutes after the meal truck was delivered) the surveyor and the LNHA both checked meal temperatures of the last meal tray (Resident #280) and using separate thermometers. -Vegetable Frittata surveyor LNHA 93 degrees Farenheight (F) 94 F Hot Farina surveyor LNHA 128 130 F Whole Milk surveyor LNHA 50 F 47.7 F Orange juice surveyor LNHA 52 F 51.6 F Coffee surveyor LNHA 123 F 122 F On 05/10/24 at 8:47 AM, Surveyor #1, reviewed temperature logs in the kitchen with the [NAME] and Food Service Director (FSD) which revealed: Vegetable Fritatta 191 F Juice 38 F Farina 200 F At that time, the surveyor interviewed the FSD regarding what the hot food temperatures should be when they reach the resident and the FSD stated, ideally hot should be 140 F or above, and cold food should be 41 F or below which revealed the food temperatures in the kitchen were acceptable. On 05/09/24 at 8:05 AM, Surveyor #2 observed the meal cart arrive on the 1 South Unit (low side) and observed the first tray was passed at 8:09 AM. At 8:27 AM, an open meal cart arrived with the meal trays for the high side of the unit. At 8:31 AM, the staff initiated passing the trays. At 8:44 AM, the last meal tray was passed and the surveyor tested Resident #60's tray in the presence of the Unit Manager Liscened Practical Nurse, which revealed: Puree Fruit: 115.3 F Milk: 56.8 F Cheese Sauce for Farina: 109.6 F On 05/10/24 at 8:30 AM, Surveyor #3 observed the 2 South Sub-Acute, meal delivery and the meal truck arrived on the unit at 8:40 AM. The last tray was passed at 8:54 AM and the meal temperatures of an unsampled resident's meal tray were checked by the surveyor in the presence of a Recreation Aide which revealed: Eggs: 111.0 F Farina: 120.3 F Hot water for Tea: 115.9 F A Test Tray form provided by the LNHA on 05/10/24 at 9:00 AM revealed Acceptable Temperatures: Soup/Hot Cereal- 140 F or above; Milk/ Juice- 40- 50 F; Coffee 135-180 F; Breakfast Entree- 120 F, or above; Entree- 130 F or above. NJAC 8:39-17.4 (a)2

Based on obervations, interviews, record review, and pertinent facility documents it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents a.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission and b.) were seen by the attending physician or Nurse Practitioner (NP) every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 8 of 8 residents (Resident #4, #11, #23, #33, #77, #130, #135 and #147) reviewed for physician visits. This deficient practice was evidenced by the following: 1. On 5/9/24 at 12:25 PM, the surveyor observed Resident #77 sitting in her chair who stated, I have been here for almost 2 years, and I saw the doctor only 2 or 3 times. A review of Resident #77 Admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but not limited to: Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified (nerve damage caused by diabetes that affects different parts of the body), Heart failure, unspecified (when the heart muscle doesn't pump blood as well as it should), Anemia in Chronic Kidney Disease (a gradual loss of kidney function), and Dependence on Renal dialysis (A blood purifying treatment given when kidney function is not optimum). A review of the progress notes in the Electronic Medical Records (EMR) revealed the attending physician saw the resident on 1/11/23, 2/3/23, 11/29/23, 1/2/24, and 3/28/24. Further review of the EMR revealed the NP saw the resident on 6/22/23, 8/29/23, 10/24/23, 12/22/23, 1/18/24, and 2/23/24. A review of the progress notes revealed that the resident was admitted to the facility in January 2023. Resident #77 was discharged and returned to the facility in December 2023 and January 2024. Further review of the progress notes, did not reveal that the physician saw the resident upon readmission in December 2023 or upon return in January 2024 or February 2024. A review of the EMR did not reveal a Progress Note (PN) from the attending physician or the attending NP in March 2023, April 2023, May 2023, July 2023, September 2023, and April 2024 or that the physician and NP were consistently alternating monthly visits. 2. A review of Resident #23s AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), Hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness caused by brain, spinal cord or nerve problems) following cerebral infarction (that occurs when blood flow to the brain is blocked or reduced) affecting left non-dominant side and Acute respiratory failure (when your lungs cannot deliver enough oxygen or remove enough carbon dioxide from your blood) with hypoxia (levels of oxygen in the blood are lower than normal). A review of the PN in the EMR revealed the attending physician saw the resident on 5/8/23, 9/29/23, 11/24/23, 1/29/24, 5/14/24. Further review of the EMR revealed the NP saw the resident on 1/11/23, 3/7/23, 4/4/23, 5/1/23, 6/16/23, 7/20/23, 10/18/23, 11/16/23, 12/20,23, 1/22/24, 2/8/24, 3/13/24, 4/1/24, and 5/8/24. A review of the PN revealed the resident was out of the facility in February 2024 and April 2024. Further review of the progress notes, did not reveal that the physician saw the resident upon readmission in February 2024, March 2024, or April 2024. A review of the EMR did not reveal a PN from the attending physician or the attending NP for February 2023 and August 2023 or that the physician and NP were consistently alternating monthly visits. 3. A review of Resident #33's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Paranoid Schizophrenia (kind of psychosis that makes you unreasonably suspicious of others), Major depression disorder, recurrent, unspecified, and Chronic obstructive pulmonary disease, unspecified (a common lung disease causing restricted airflow and breathing problems). A review of the PN in the EMR revealed the attending physician saw the resident on 1/23/23, 4/19/23, 7/13/23, 11/28/23, 2/5/24, and 4/4/24. Further review of the EMR revealed the NP saw the resident on 10/17/23, 1/3/24, 2/8/24, 3/22/24, and 4/10/24. A review of the PN revealed the resident was at the facility from January 2023. The resident was discharged and returned to the facility in December 2023. Further review of the progress notes, did not reveal that the physician saw the resident upon readmission in December 2023 and January 2024. A review of the EMR did not reveal a PN from the attending physician or the attending NP in February 2023, March 2023, May 2023, June 2023, August 2023, September 2023, or December 2023 or that the physician and NP were consistently alternating monthly visits. 4. A review of Resident #11's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Acute respiratory failure (when your lungs cannot deliver enough oxygen or remove enough carbon dioxide from your blood) with hypoxia (levels of oxygen in the blood are lower than normal), Chronic obstructive pulmonary disease, unspecified (a common lung disease causing restricted airflow and breathing problems), Pneumonia, unspecified organism (inflammation and fluid in your lungs caused by a bacterial, viral or fungal infection) and unspecified asthma, uncomplicated (a condition in which your airways narrow and swell and may produce extra mucus). A review of the PN in the EMR revealed the attending physician saw the resident on 3/10/24 and 5/5/24. Further review of the EMR revealed the NP saw the resident on 1/25/23, 3/13/23, 5/23/23, 7/19/23, 8/8/23, 9/15/23, 10/17/23, 11/8/23, 12/8/23, 1/3/24, 2/9/24, 4/23/24. A review of the PN revealed the resident was discharged and returned to the facility in August 2023. Further review of the progress notes, did not reveal that the physician saw the resident upon readmission in August 2023, September 2023 or October 2023. A review of the EMR did not reveal a PN from the attending physician or the attending NP for February 2023, April 2023, June 2023 or that the physician and NP were consistently alternating monthly visits. 5. A review of Resident #147's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Type 2 Diabetes mellitus without complications, Muscle weakness (generalized), Depression, and unspecified and pain in right knee. A review of the PN in the EMR revealed the resident was admitted to the facility in May 2023. A review of the PN in the EMR revealed the attending physician saw the resident on 5/26/23, 6/7/23, 7/7/23, 8/7/23, 11/29/23, 1/31/24, and 3/29/24. Further review of the EMR revealed the NP saw the resident on 9/21/23, 12/26/23, 2/22/24, and 4/25/24. A review of the EMR did not reveal a PN from the attending or the attending NP in October 2023. 41858 6. A review of Resident #130's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Unspecified Dementia (affects memory, thinking and interferes with daily life), unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety and Alzheimer's disease, unspecified (caused memory loss and other cognitive impairment). A review of the progress notes in the EMR revealed the attending physician saw the resident on 1/30/23, 5/28/23, 9/29/23, 11/24/23, 1/26/24, and 3/22/24. Further review of the EMR revealed the Nurse Practitioner saw the resident on 3/13/23, 3/30/23, 4/5/23, 4/17/23, 4/18/23. A review of the progress notes revealed the resident was readmitted to the facility in March of 2024. Further review of the progress notes, did not reveal that the physician saw the resident upon readmission in March 2024 or April 2024. A review of the EMR did not reveal a progress note from the attending physician or the attending nurse practitioner in February 2023, June 2023, July 2023, August 2023, October 2023, December 2023, February 2024 or that the physician and NP were consistently alternating monthly visits. 7. A review of Resident #135's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Polyosteoarthritis (having arthritis in five or more joints at the same time) and type 2 diabetes (results from insufficient production of insulin, causing high blood sugar). A review of the progress notes in the EMR revealed the attending physician saw the resident on 1/3/23, 2/28/23, 3/30/23, 5/23/23, 6/27/23, 8/29/23, 10/9/23, 11/16/23, 1/15/24, and 3/28/24. Further review of the EMR revealed the Nurse Practitioner saw the resident on 12/11/23. A review of the EMR did not reveal a progress note from the attending physician or the attending nurse practitioner in April 2023, July 2023, September 2023, February 2024 or April 2024. 37791 8. A review of Resident #4's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (a complex process that involves the intrusiveness of renal dialysis, which can sustain life but doesn't cure or heal. Dialysis is a treatment that helps the body remove waste products and extra fluid from the blood when kidneys are unable to do so), major depressive disorder (a condition with a persistently low and depressed mood) and hypertension (a condition in which the force of blood against the artery walls is too high). A review of the progress notes in the EMR revealed the attending physician saw the resident on 1/8/24. Further review of the EMR revealed the Nurse Practitioner saw the resident on 1/13/23, 2/2/23, 2/23/23, 3/3/23, 3/13/23, 4/17/23, 5/1/23, 5/4/23, 5/12/23, 6/21/23, 6/30/23, 7/14/23, 7/24/23, 8/9/23, 8/28/23, 9/8/23, 10/4/23, 10/16/23, 10/31/23, 11/1/23, 11/3/23, 12/1/23, 12/11/23 ,12/26/23, 1/9/24,1/10/24, 1/12/24, 1/15/24, 1/17/24, 1/19/24, 1/22/24, 1/24/24, 2/1/24, 2/28/24, 3/6/24, 3/18/24, 4/17/24, 5/6/24, and 5/9/24. Further review of the EMR did not reveal that the physician and NP were consistently alternating monthly visits. On 05/14/24 at 11:30 AM, the surveyor interviewed the Registered Nures/Unit Manager, who stated, we inform the DON if we notice the attending has not seen the resident. He was unable to speak to the frequency of physician visits. On 05/14/24 at 12:45 PM, during a meeting with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Regional Nurse Consultant (RNC), the DON stated the attending physican for long term care alternated every 60 days. They should do the initial on admission then monthly for first 90 days, then can be seen by MD every 60 days, NP can see in between. The surveyor verified attending physician and/or the NP must see resident at least every 30 days. The LNHA, the DON, and the RNC were all in agreement. On 5/14/24 at 1:16 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager regarding physician visits, who stated, They document in the EMR every time they see a resident. The attendings are supposed to see the resident every 30 days. They have their schedule. Whenever we call them to see the resident or if the resident requests, they (the physician) come see them. A review of the facility policy Physician Visits reviewed December 2023 revealed: Policy Statement: The Attending Physician must make visits in accordance with applicable state and federal regulations. Policy Interpretation and Implementation: 1.The Attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. 2.The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and the at least every sixty (60) days thereafter. 4.After the first ninety (90) days, if the attending Physician determines that a resident need not be seen by him/her every thirty (30) days, and alternate schedule may be established, but not to exceed every sixty (60) days. A Physician Assistant or Nurse Practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted law or regulation. NJAC 8:39-23.2 (b)(d)

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure reference checks were completed for Ten (10) of Ten (10) newly hired staff reviewed. This deficient practice was evidenced by the following: On 05/14/24, the surveyor reviewed Ten (10) randomly new employee files which revealed the following: Staff #1-a Certified Nursing Assistant (CNA), with a hire date of 09/22/22, did not have a previous employee reference on file. Two (2) undated typed personal reference letters were on file. Staff #2-a CNA, with a hire date of 04/12/24, did not have a previous employee reference on file. An emailed personal reference letter dated 05/09/24 and an undated typed personal reference was on file. Staff #3 - a Registered Nurse (RN), with a hire date of 02/27/23, did not have a previous employee reference or any personal references on file. Staff #4- a Dietary staff, with a hire date of 05/15/23, did not have a previous employee reference on file. There were two (2) undated typed personal reference letters on file. Staff #5- a Maintenance Staff, with a hire date of 11/22/22, had an undated and unsigned employer verification on file. Staff #6-a CNA, with a hire date of 04/18/24, had an emailed previous employee reference letter dated 05/08/24. Staff #7-a RN, with a hire date of 07/24/23, did not have a previous employee reference on file. Staff #8- a Dietary staff, with a hire date of 01/18/24, did not have a previous employee reference on file. One (1) undated typed personal reference letter was on file. Staff #9 -a Licensed Practical Nurse (LPN), with a hire date of 04/11/24, did not have a previous employee reference on file. One (1) undated typed personal reference letter was on file. Staff #10-a LPN, with a hire date of 03/21/24, had a typed previous employee reference on file dated 05/10/24. One (1) undated typed personal reference letter was on file. On 05/14/24 at 12:24 PM, the surveyor interviewed the Human Resource Director (HR) who stated that he requests 2 reference letters form the employee and they could be from a relative or co-worker. The HR stated that he does not get the reference letters prior to hiring and that he asked the employees to provide the reference letters. When asked if references should be done prior to working, the HR stated, We try to do it, it looks better. On 05/14/24 at 12:50 PM, the surveyor interviewed the Administrator (LNHA), the Director of Nursing (DON) and the Regional Registered Nurse (RRN) regarding the hiring process. The LNHA stated that prior to hiring, an application, a background check, license verification, a physical and references should be done. The RRN stated that contacting previous employers to verify employment should be done prior to hiring. On 05/15/24 at 10:29 AM, during a follow up interview with the LNHA, DON and RNN, the LNHA stated that the references could be personal or from previous employers. The RRN stated that the employee can provide a personal reference, but the facility should call and verify that reference prior to employment. The RRN further stated that the facility should attempt to contact previous employers to verify employment prior to hiring. A review of the facility's policy titled Abuse and Neglect Policy and Procedure, reviewed 11/13/23, revealed that all prospective employees will be carefully screened using the following process to identify potential risk of abuse/neglect of any resident:1. Reference Check, 2. License check and background check. NJAC 8:39-9.3(b)

Based on interview and review of other facility documentation, it was determined that the facility Quality Assessment and Performance Improvement (QAPI) committee, that identified quality concerns, failed to utilize the Facility Performance Improvement Plan to follow the facility process to measure and utilize data acquired for frequency of physician visits. This deficient practice was evidenced by the following: On 05/16/24 at 9:40 AM, the surveyor reviewed the facility provided QAPI Plan Primary physicians' documentations compliance Effective Date: February 26, 2024 which revealed Design and Scope: Statements and Guiding Principles: PMD's (primary medical doctor)/NP's (Nurse Practitioner) Federal documentations compliance. Other Services Provided: Nursing and medical record staff will monitor physician visits compliance and informing the upper management. Feedback, Data Systems and Monitoring: Monitoring Process: Audit physicians and their NP's progress notes every other month for compliance x 6 months. Conduct meetings with the physician and and their NP's every time there's issues to address. Goal is 100% compliance 3 months. At 10:32 AM, during a meeting with the surveyor, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) regarding the results of the above mentioned QAPI Plan, the DON stated she presented the QAPI Plan at the April QAPI meeting. She stated audits were done but she was unable to provide the surveyor with an audit tool or evidence that the audits were being done according to the Monitoring Process of auditing physician and NP's progress notes every other month for compliance since being self-identified on 2/26/24 or that the audit results were presented at the QAPI meeting. She was also unable to show the surveyor that the facility was progressing toward the Goal of 100% compliance in 3 months. The DON stated she sent an email or a text to the physicians that were identified. The LNHA stated, the purpose (of a QAPI plan) was to show improvement, identify issues, how we are going to work on them and if they are working. Regarding the purpose of audits, the RNC stated, so we can identify if it is working. We continue with what is working if not we come up with a plan to change it. The LNHA and the DON both confirmed that they were unable to quantify the audits that were completed. Therefore, they were unable to show a monitoring system to show that their QAPI Plan was working. A review of the facility policy Performance Improvement-QA Committee last revised 1-2024, revealed: Policy: .The committee will implement quality assurance and performance improvement programs (PIP) for the facility . The committee .Any ongoing concerns will be discussed, and PIP will be started to rule out route cause. PIP will be revised and updated as schedule. Staff will be educated as needed. NJAC 8:39-33.1(a)(b)(c)(e)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) provide personal hygiene and provide timely assistance for 2 of 2 residents dependent on staff for incontinence care, Resident #21 and #147 and b.) provide nail care to Resident #280 who required assistance with ADL's care. This deficient practice was evidenced by the following: 1.) On 5/9/24 at 10:20 AM, the surveyor observed Resident #147 in bed, the head of the bed was elevated, and the resident was able to answer questions. Upon inquiry, the resident stated he/she had not been provided with incontinence care since last night. Resident #147 further stated that, I have asked the Certified Nursing Assistance (CNA) to change me in the morning, but they haven't. At 10:36 AM, the surveyor asked the Unit Manager (UM) to make incontinence rounds on this resident. Resident #147 was observed to have on 2 adult briefs with the inner brief saturated with urine and soiled with feces (stools). The UM closed the double briefs and told the resident, Let me call your CNA to provide you incontinence care. At 11:06 AM, the surveyor interviewed the Director of Nursing (DON) and UM, who stated, Incontinence rounds are done normally every 2 hours and the residents should not be double briefed. Due to the above observation, the surveyor and the UM continued incontinence care rounds which revealed the following: At 11:10 a.m., unsampled Resident #89 was wearing a brief and appeared to be wet. At 11:15 a.m., Resident #21 was wearing a double brief and was dry. At 11:21 a.m., unsampled Resident #65 was wearing a pull-up and was dry. At 11:25 a.m., unsampled Resident #123 was wearing a brief that did not appear to be wet but was soiled with feces. At 11:32 a.m., unsampled Resident #116 was wearing a brief and was dry. A review of the Admission Summary revealed that Resident #147 was admitted to the facility with diagnoses which included but were not limited to Type 2 Diabetes Mellitus without complications, Urinary Tract infection, site not specified, and Depression. The quarterly Minimum Data Set (MDS), an assessment tool, dated 2/27/2024, revealed that Resident # 147's Brief Interview for Mental Status (BIMS) was 3 out of 15 which indicated the resident was severely cognitively impaired. Section GG of the MDS which referred to Activities of Daily Living (ADLs) revealed that Resident #147 was totally dependent on staff for toileting hygiene. Section H of the MDS which referred to Bladder and Bowel revealed that Resident #147 was always incontinent of urine and bowel. Section M of the MDS revealed that the resident had one unhealed Stage 3 pressure ulcer. Review of the Care Plan for Resident #147 initiated on 5/10/23 with revision date of 5/23/23, revealed a focus for [name redacted] has impaired functional status r/t (related to) recent hospitalization , muscle weakness, pain, deconditioning, high fall risk, impaired mobility. The goal was for Resident #147 will show improvement in functional status evidenced by increased self-participation in ADL's. The interventions included: Toileting hygiene: Dependent X 1: Helper does ALL of the activity; resident does none of the effort to complete the activity. Further review of the Care Plan, initiated on 5/10/23 with a revision date of 4/25/24 revealed a focus for [name redacted] is at risk for skin breakdown r/t fragile skin, impaired mobility, incontinence, Hx (history): skin problems; MASD (Moisture-associated skin damage [an inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus.]) bilateral (b/l) [both] thighs resolved 11/1/23 Pressure 3 wound on Sacrum-extending to Left buttocks. A review of the form CNA Task under Toileting Hygiene (GG), Toilet transfer (GG), Bladder Incontinence and Bowel Incontinence, which revealed the last time the resident received care was on 5/8/24 at 19:08 (7:08 PM). There was no other documentation that the resident received incontinence care between 5/8/24 at 7:08 PM and the time of the above observation. On 5/15/2024 at 12:41 PM, the above concerns were presented to the DON, the Licensed Nursing Home Administrator, and the Regional Nurse. 2.) On 5/9/23 at 11:15 AM, the UM checked Resident #21 for incontinence care. The surveyor and the UM observed resident in bed, who was wearing 2 adult briefs, the resident was dry. The UM acknowledged that the residents should not be double briefed. A review of the Admission Summary revealed that Resident #21 was admitted to the facility with diagnoses which included but were not limited to Cerebral infarction, unspecified (a type of ischemic stroke that results from a blockage in the blood vessels supplying blood to the brain), Pressure ulcer of sacral region, Stage 3 (a full thickness skin loss that has progressed beyond the layers of skin and into the fatty tissue below ), and muscle weakness (generalized). The Annual MDS dated [DATE], revealed that Resident #21's BIMS was 14 out of 15, indicating the resident was cognitively intact. Section GG of the MDS which referred to ADLs revealed that Resident #21 was totally dependent on staff for toileting hygiene. Section H of the MDS which referred to Bladder and Bowel revealed that Resident #147 was always incontinent of urine and bowel. At 11:32 AM, the surveyors interviewed CNA #1 and CNA #2. They both acknowledged that they make incontinence rounds twice a shift, they check their residents in the morning and if the residents are dry then check them after breakfast. They further stated, if the resident asks them to change them, they will change the resident. CNA #1 and CNA #2 also stated that they put only one brief on the resident and would tell the nurse if they saw a resident in double briefs. On 5/15/2024 at 12:41 PM, the above concerns were presented to the DON, the Licensed Nursing Home Administrator, and the Regional Nurse. 27193 3. Observation on 05/08/24 at 11:22 AM, revealed Resident #280 in bed, with nails long, jagged with a black coated substances underneath the fingernails. Observation on 05/09/24 at 08:41 AM, revealed the resident eating breakfast, the fingernails were long and jagged with black coated substance underneath the fingernails. Observation on 05/10/24 at 10:10 AM, after AM care had been provided, revealed the resident in bed, The nails were still long and jagged with black coated substances underneath the fingernails. When inquired regarding nails care, Resident #280 stated that she was visually impaired. Resident #280 stated that he/she was assisted with morning care but nail care was not done. She stated that she would like the nails to be trimmed and cleaned. On 05/10/24 at 10:13 AM, during an interview with CNA #3 who cared for Resident #280, she confirmed that Resident #280 was a total care. she further stated, I have to do everything for the resident. When inquired about nails care, CNA#3 stated that nail care was part of AM care. On 05/10/24 at 10:22 AM, the surveyor escorted the Registered Nurse (RN) to the room and we both observed the fingernails long and jagged with the coated black substance underneath the fingernails. The nurse stated, Oh yes the fingernails needed to be cleaned. The resident stated, If I could do it I will clean it, but I am visually impaired. In the presence of CNA #3, Resident #280 stated, I do not want them to be cut all way down but I want them to be cleaned. On 5/10/24 at 11:30 AM, during a second interview with the RN assigned to the resident's care, she stated that Resident #280 refused the nails to be cleaned. However, the surveyor returned to the room with CNA #3 and the resident stated in the presence of the CNA #3, I do not want the nails to be cut all way down but I want them to be cleaned. The RN could not provide a care plan or documentation of Resident #280's refusal of care. On 5/10/24 at 12:15 PM, the surveyor reviewed the Electronic Medical Record (EMR) which revealed that Resident #280 had diagnosis which included Alzheimer's disease, impaired vision related to glaucoma, and anxiety disorder. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/24 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating R# 280 had moderate cognitive impairment. Further review of the MDS revealed R# 280 required substantial maximum for hygiene. Review of the care plan had a focus for impaired functional status related to muscle weakness and recent hospitalization . The goal was for Resident #280 to show improvement by increased self-participation in Activities of Daily Living (ADL's). Interventions included: Assist as needed. Encourage self participation in ADL's as tolerated. Review of the facility policy titled, Activities of Daily Living Supporting, with revised date of 03/24, indicated, Residents will be provided with care and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's) The policy further stated that Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Under Policy Interpretation and Implementations: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: c. elimination (toileting). A review of the facility document titled, Job Description with Position: Certified Nursing Assistant, revealed Basic Function: To provide services that support the care delivered to patients/residents requiring long term or rehabilitative care. Under Duties and Responsibilities: 1.e.) Assistance is given with patient care, such as, bathing, dressing, positioning, monitoring temperature, feeding, making up beds, and toileting. k.) Familiar and able to perform all of the basic CNA skills. NJAC 8:39-27.1 (a), 27.2(d, g, h, j)

Based on observation, interview, and record review it was determined that the facility failed to consistently assess a resident's dialysis access site when returning from the dialysis clinic. The deficient practice was identified for 1 of 2 residents, Resident #4, reviewed for dialysis care and services and is evidenced by the following. On 5/9/24 at 10:15 AM, the surveyor observed the resident seated in a wheelchair in their room eating breakfast. The resident was alert but refused an interview. The resident told the surveyor that they had dialysis the previous day. The surveyor reviewed the medical record for Resident #4. The Admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis(a complex process that involves the intrusiveness of renal dialysis, which can sustain life but doesn't cure or heal. Dialysis is a treatment that helps the body remove waste products and extra fluid from the blood when kidneys are unable to do so), major depressive disorder (a condition with a persistently low and depressed mood) and hypertension (a condition in which the force of blood against the artery walls is too high). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/19/24, reflected that the resident had a brief interview for mental status (BIMS) score of 9 out of 15, indicating that the resident was cognitively, moderately impaired. A review of the Dialysis Communication Sheets from 4/1/24 until 5/10/24 revealed that the resident's AV Fistula (Arterialvenous fistula; how patients are connected to a dialysis machine) was located on the resident's left arm and that the facility was checking the bruit/thrill (a thrill is a vibration felt when palpating a blood vessel. While a bruit is the auscultated equivalent of the thrill) pre-dialysis and at the dialysis center. The Dialysis Communication Sheets had no information showing that the bruit and thrill were being checked post-dialysis by the facility. The surveyor reviewed the facility progress notes from 4/1/24 through 5/10/24 which revealed no post-dialysis documentation. A review of the comprehensive care plan revealed a focus area of ESRD (end stage renal disease), receiving dialysis, potential for complications. A review of the interventions revealed the following interventions Monitor dialysis shunt for thrill & bruit every shift. Monitor site for s/s (sign and symptoms of) infection. If thrill or bruit not present or s/s infection are observed, notify MD (medical doctor) for prompt intervention. Monitor bleeding at site, if present, apply direct pressure with sterile gauze and notified MD. A review of the May 2024 Order Summary Report (OSR) revealed the following physician's order (PO) dated 3/12/24 to check blood pressure and pulse prior to leaving for dialysis and on return from dialysis. No BP (blood pressure) on left arm every shift Monday, Wednesday and Friday Pre and Post dialysis. A further review of the May 2024 OSR revealed no PO to check the AV fistula access site (bruit and thrill). A review of the April and May 2024 electronic medication administration record (EMAR) revealed no documentation showing that the AV fistula access site (bruit and thrill) was being checked every shift. On 5/13/24 at 11:40 AM, the surveyor interviewed the 2 South Registered Nurse/Unit Manager (RN/UM) who stated that a dialysis resident who had an AV access site,that it (bruit and thrill) should be checked every shift including post-dialysis. In the presence of the surveyor, the RN/UM reviewed Resident #4's medical record. The RN/UM reviewed the Dialysis Communication Sheets and acknowledge that the resident had an AV fistula on their left arm and that the bruit and thrill should be checked on every shift. The RN/UM acknowledge that they were no post-dialysis notes written on the Dialysis Communication Sheets and this documentation would have included the resident's vitals and that the resident's AV fistula access site (bruit and thrill) was checked. The RN/UM also reviewed the resident's progress notes, PO and EMAR and acknowledge that there was no documentation that showed that the resident's AV fistula site (bruit and thrill) was checked post-dialysis. The RN/UM then reviewed the resident's care plan and acknowledged that the resident's AV fistula access site (bruit/thrill) should be checked every shift. The RN/UM told the surveyor that he will try to find any additional information to show that the facility was checking the access site post-dialysis. On 5/14/24 at 11:30 AM, the surveyor interviewed the RN/UM, who had no additional information. The RN/UM stated that the resident should have had an order to check the AV fistula access site (bruit and thrill) every shift and he further stated that there was no documentation that he could provide which showed that the facility was checking the resident's bruit and thrill post-dialysis. On 5/14/24 at 12:35 PM, the surveyor presented the above concern to the administration team which included the License Nursing Home Administrator, Director of Nursing (DON) and the Regional Clinical Nurse (RCN). The RCN acknowledge that it was important to check the bruit and thrill to assure the wasn't any clotting. There was no additional information provided. A review of the facility's policy for Care of a Resident Receiving Dialysis revised on 1/5/2024, and was provided by the DON revealed the following: If a resident has an AV fistula (access site), nursing will access and palpate for thrill and auscultate for bruit every shift by a license nurse. This will be documented in the EHR (electronic health record). NJAC 8:39-27.1(a); 2.9

Complaint #: NJ00170376 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a resident received as needed (prn) narcotic (a controlled drug that produces pain relief) medication in accordance with the prescriber's orders and accepted professional standards. The deficient practice was identified for 1 of 6 residents (Resident #227) reviewed for medication management. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. A review of a closed medical record revealed a Progress Note (PN) dated 04/11/23 at 1409 (2:09 PM), identified that Resident #227 complained of getting both Oxycodone and Vicodin 10 minutes apart. The note revealed that both the Director of Nursing (DON) and Unit manager was made aware of the complaint. The surveyor reviewed the closed medical record for Resident #227. The Admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (a complex process that involves the intrusiveness of renal dialysis, which can sustain life but doesn't cure or heal. Dialysis is a treatment that helps the body remove waste products and extra fluid from the blood when kidneys are unable to do so), encounter for orthopedic aftercare following surgical amputation, and hypertension (a condition in which the force of blood against the artery walls is too high). A review of the admission Minimum Data Set (MDS), an assessment tool, used to facilitate the management of care, dated 4/04/24, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident was cognitively intact. A review of the April 2023 Order Summary Report (OSR) revealed the following physician's order (PO) dated 4/4/23 for Oxycodone (pain) tablet 5 mg (milligrams) give 2 tablets by mouth every 6 hours as needed for moderate pain. 2 tablets (5MG) =10 MG. May cause drowsiness/dizziness. Avoid alcohol. A further review revealed a PO dated 4/4/23 for Vicodin (hydrocodone/acetaminophen) 5/300 mg give 1 tablet by mouth every 6 hours as needed for severe pain. A review of the April 2023 electronic medication administration record (EMAR) revealed that on 4/11/23 at 0455 (4:55AM), 2 tablets of Oxycodone 5 mg was documented as being administered to Resident #227 with a pain scale of 6 (moderate pain). The April 2023 EMAR also revealed that on 4/11/23 at 0456 (4:56AM) that 1 tablet of Vicodin 5/300 was documented as being administered with a documented pain scale of 7 (severe pain). A review of a facility Medication Error Report form dated 4/11/23, revealed the following: Under description of error the facility wrote that the resident was assess having a pain level of 6 and that the nurse should have administered per the physician's order 2 tablets of Oxycodone 5 mg tablets. The nurse should have waited a hour to assess the resident. Under reason for error the facility wrote the following: Failure to read order before administering medication. Pain management therapy should have been evaluated before considering a different medication. On 5/13/24 at 1:00PM, the surveyor attempted to interview the Registered Nurse (RN) but was informed by the Director of Nursing (DON) that the nurse no longer worked at the facility. On 5/14/24 at 12:35 PM, the surveyor presented the above concern to the administration team which included the License Nursing Home Administrator, Director of Nursing (DON) and the Regional Clinical Nurse (RCN). There was no additional information provided. A review of the facility's policy for Medication Preparation for Dispensing revised on 1/31/2024, and was provided by the DON revealed the following: G. Prior to Medication Administration: 1. Verify each medication preparation that the medication is the RIGHT DRUG, at the RIGHT DOSE, the RIGHT ROUTE, at the RIGHT RATE, at the RIGHT TIME, for the RIGHT CUSTOMER. 2. Verify that the MAR reflects the most recent medication order. 3. Check expiration date on medication label. J. Medication Administration: 3. Medications are administered in a timely fashion as specified by policy. 4. As specified by federal and state regulations, controlled substances are documented as given at the time of administration. K. After Medication Administration: 1. Document necessary medication administration/treatment information (e.g., when medications are administered, medication injection site, refused medications and reason, prn medications, etc.) on appropriate forms. NJAC 8:39-11.2(b), 29.2 (a)(d) ,

Based on interview and review of pertinent facility documentation, the facility failed to ensure the required committee members, the Infection Preventionist (IP), was present for four of six Quality Assurance and Performance Improvement (QAPI) meetings and was evidenced by the following: On 05/16/24 at 9:53 AM, the surveyor reviewed the facility provided QAPI book, that included the quarterly sign in sheets for the QAPI meetings, which revealed: - Employee In-Service Education; Date: Jan (January) 2023; Subject: QAPI the IP did not sign in as being in attendance. - Daily Department Head Meeting; Date: 7/26/23; Subject: QAPI 2nd Quarter April-June 2023 the IP did not sign in as being in attendance. - Employee In-Service Education; Date: 10/17/23; Subject: QAPI the IP did not sign in as being in attendance. - Daily Department Head Meeting; Date: 1/31/24; Subject: QAPI 4th Quarter 2023 the IP did not sign in as being in attendance. On 05/16/24 at 10:08 AM, during a meeting with the surveyor, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Regional Nurse Consultant (RNC), the LNHA stated that the required members that should attend the QAPI meeting included but were not limited to; the Administrator, the DON, the medical director, department heads, and the Infection Preventionist. At 10:17 AM, in the presence of the surveyor, the LNHA, the DON, and the RNC reviewed the signatures on the January 2023 sign in sheet and were unable to determine who the IP was at that time or that the IP had attended the meeting. The LNHA reviewed the sign in sheets for July 2023, October 2023, and January 2024 and was unable to verify that the IP was in attendance. The LNHA stated, the purpose of the sign in sheets was to keep a record of who was there at that time. The RNC stated, the purpose of the IP attending was to review infection control, identify any trends or outbreaks we are having. A review of the facility policy Performance Improvement-QA Committee last revised 1-2024, revealed: Procedure: The Performance Improvement Committee shall be composed of, but not necessarily limited to the following personnel: -Administrator -Medical Director -Director of Nursing -Infection Preventionist NJAC 8:39-33.1(a)(b)

Based on observation, interview, and review of medical records, it was determined that the facility failed to act upon the Wound Doctor (WD) treatment recommendations according to professional standards of clinical practice for 2 of 2 residents reviewed for pressure ulcers, Resident #15 and #85. The deficient practice was evidenced by the following: 1. On 4/8/22 at 11:00 AM, the surveyor interviewed Resident #15 who stated, I have bedsore in my buttock area. The resident was receiving wound treatment daily. The surveyor reviewed Resident #15's hybrid (paper and electronic) medical records that revealed the following: According to the Admission Record, Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) an assessment tool dated 1/6/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that cognition was intact. The MDS also reflected that the resident was at risk for pressure ulcer. The resident currently had a stage two pressure ulcer to the sacral area. The WD's Visit Reports dated 3/1/22, 3/8/22, 3/15/22, 3/22/22, and 4/6/22 indicated a wound treatment recommendation to cleanse the wound with saline, apply Xeroform (a non-adhering protective dressing), foam dressing BID (twice daily). The March and April 2022 Order Summary Report (OSR), reflected an order to cleanse the stage two pressure injury to the sacrum with NSS (normal saline), pat dry then apply Xeroform dressing to the wound bed, and cover with dry dressing every day. The WD Visit Report recommendations and the 3/29/22 Wound Description form indicated to perform the wound treatment BID, However, the treatment recommendation was not transcribed to the Electronic Medical Record (EMR) and the electronic Treatment Administration Record (eTAR). On 4/8/22 at 1:25 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that she was unaware of the wound treatment order of BID by the WD because the Licensed Practical Nurse/Wound Nurse (LPN/WN) would enter and update the treatment orders. The RN/UM acknowledged that the WD's treatment recommendation should have been transcribed in the eTAR. On 4/11/22 at 9:45 AM, the surveyor conducted a phone interview with the LPN/WN in the presence of the RN/UM. The LPN/WN stated that he made wound rounds with the WD weekly, and the WD would communicate the wound treatment order to him during rounds and email the report afterward. He would then transcribe the new wound treatment order into the EMR and transcribed it to the eTAR. At that time, the surveyor asked the LPN/WN to explain why the March and April 2022 OSR reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN/WN stated that he was not aware of the wound treatment order and the WD recommendation discrepancy until the surveyor's inquiry. The LPN/WN further stated to the surveyor that he should have clarified the wound treatment order to the doctor. 2. On 4/7/22 at 10:40 AM, the surveyor observed Resident #85 in bed lying on an mattress. The surveyor reviewed the medical record for Resident #85 which revealed the following: According to the physician's progress notes dated 3/23/22, Resident #85 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Status Assessment MDS (SCSA/MDS) dated [DATE], indicated a BIMS score of 8, which reflected that the resident's cognition was moderately impaired. The SCSA/MDS indicated that the resident was determined to be at risk for developing pressure ulcers/injuries and had a stage three pressure ulcer to the sacral area. The WD Visit Report dated 3/15/22 indicated its wound treatment recommendation to cleanse the sacral wound with saline, apply Xeroform (used to cover and protect low to non-exudating wounds), and dry dressing daily. The WD visited the resident on 3/22/22 and updated the recommendation on the Visit Report to discontinue the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The WD Visit Report dated 3/29/22 and 4/6/22 indicated a recommendation to continue to cleanse the sacral wound with saline, apply skin prep every shift and leave it open to the air. The April 2022 OSR reflected physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/11/22 at 1:00 PM, the License Practical Nurse Unit Manager (LPN/UM) informed the surveyor that the facility LPN/WN assisted the WD to do weekly wound assessments on residents. The LPN/UM stated that the LPN/WN would receive wound reports from the WD, which included wound treatment recommendations. She further stated that the LPN/WN would transcribe the wound treatment recommendations into the eTAR. The LPN/UM acknowledged to the surveyor that the WD treatment recommendation on 4/6/22 was not transcribed to the EMR and the eTAR. On 4/13/22 at 10:25 AM, the surveyor interviewed the LPN/WN concerning the 4/6/22 WD's Visit Report recommendations. The LPN/WN informed the surveyor that he assisted the WD to wound rounds every Wednesday. The LPN/WN stated that the WD would later provide him with written reports that included wound treatment recommendations. He further stated that the resident's Medical Doctor (MD) told him to follow the WD recommendations. The surveyor further asked the LPN/WN if the WD recommendations were all followed, and he stated no, it should have been followed. On 4/13/22 at 2:11 PM, the Administrator and Director of Nursing met with the survey team. No further information was provided. A review of policy titled Physician Services revised 2022, did not indicate how the consultant's recommendations should be executed by the nursing staff. NJAC 8:39-11.2 (b)

Based on observation, interview and record review, it was determined that the facility failed to implement the Comprehensive Care Plan (CP) intervention for 1 of 8 residents (Resident #84) reviewed for falls. The deficient practice was evidenced by the following: On 1/14/19 at 12:01 PM, the surveyor observed Resident #84 in bed with eyes open with the television on. The resident did not verbally respond to the surveyor. The surveyor reviewed Resident #84's medical record on 01/23/19. According to the admission sheet, Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed the facility's investigation from the Incident Report dated 1/17/19 that revealed Resident #84 had an unwitnessed fall from the bed. The resident was found on the left side of the bed by the Certified Nursing Assistant (CNA). Resident #84 had no apparent injuries and was unable to state what happened. A care plan intervention was initiated on 1/18/19 which included that Resident #84 should not be left unattended. The surveyor reviewed the facility's investigation from the Incident Report dated 1/21/19 that revealed Resident #84 was in their room seated in a wheelchair and was being supervised by a Registered Nurse (RN). The report indicated that the RN asked the CNA to watch the resident because she needed to get something from the nursing station. According to the Incident Report investigation, the CNA remained outside the resident's room not directly visualizing the resident. The CNA documented in the Incident Report that she checked on the resident three times and then she heard a loud noise and found the resident laying on the floor. The Incident Report investigation also revealed that resident had a bump and laceration on the back of the resident's head and dressing was applied. The surveyor reviewed Resident #84's care plan dated 11/26/18 which indicated under the focus area; risk for falls related to impaired mobility, cognitive impairment, on [CONDITION(S)] medications and a history of falls. The intervention included do not leave resident unattended and was dated 1/18/19. On 1/24/19 at 9:50 AM, the surveyor interviewed the CNA who was assigned to care for Resident #84 on the day of the incident. She stated that on 1/21/19 she was entering notes in the Kiosk (an electronic record for CNAs to use when documenting care of their residents) that was located outside of Resident #84's room. The CNA stated that the RN was sitting near that door way and approached her and asked her if she could keep an eye on the resident while she gets something from the nursing station. The CNA further stated that she checked on the resident three times while she entered her notes in the Kiosk and after the third time she schecked she heard a crashing sound and found the resident laying on the floor. The CNA also stated that at the time of the fall, she was aware of the intervention not to leave the resident unattended. On 1/24/19 at 10:55 AM, the surveyor interviewed the RN who stated that on 1/21/19 she was monitoring Resident #84. The RN stated that she needed to get something from the nursing station and asked the CNA who was standing at a Kiosk next to the resident's room to watch Resident #84. The RN stated that she didn't wait for the CNA to enter the room and left the resident unattended. The RN also stated at the time of the fall, she was aware of the intervention not to leave the resident unattended. On 1/25/19 at 10:30 AM, the surveyor discussed the above concern with the Administrator and Director of Nursing. No additional information was provided. Refer to F689 NJAC 8:39-27.1 (a)

Based on observation, interview and record review of documentation provided by the facility, it was determined that the facility failed to ensure resident safety and supervision for a resident identified as a high risk for falls. Resident #84 was identified by the facility as a high risk for falls, was left unattended, fell and sustained a laceration on the head that required hospital evaluation and treatment including staples to the laceration. The deficient practice was identified for 1 of 8 residents, Resident #84, reviewed for falls and was evidenced by the following: On 01/14/19 at 12:01 PM, the surveyor observed Resident #84 in bed with eyes open with the television on. The resident did not verbally respond to the surveyor. The surveyor reviewed the resident's medical record on 01/23/19. According to the admission sheet, Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses which included Fracture to the Left Tibia, [CONDITION(S)] and Muscle Weakness. A review of Resident #84's Admission Minimum Data Set, an assessment tool dated 11/30/18, indicated Resident #84 was severely impaired cognition, because the facility assessed the resident as rarely or never made themselves understood and rarely or never understands. The resident required extensive assistance of one staff member for bed mobility and transfers. The surveyor reviewed Resident #84's Fall Risk assessment dated [DATE], that revealed the resident had a total score of 19, which indicated a score of 10 or above was a high risk for falls. A review of the Progress Notes dated 01/17/19 and 01/21/19 revealed Resident #84 had two falls. The surveyor reviewed the Incident Report investigation dated 01/17/19 that revealed Resident #84 had an unwitnessed fall from the bed. The resident was found on the left side of the bed by the Certified Nursing Assistant (CNA). Resident #84 had no apparent injuries and was unable to state what happened. A care plan intervention was initiated on 01/18/19 that included Resident #84 should not be left unattended. The surveyor reviewed the facility's investigation from the Incident Report dated 01/21/19 that revealed Resident #84 was in their room seated in a wheelchair and was being supervised by a Registered Nurse (RN). The report indicated that the RN asked the CNA to watch the resident because she needed to get something from the nursing station. According to the Incident Report investigation, the CNA remained outside the resident's room not directly visualizing the resident. It was further documented in the Incident Report that the CNA reported she checked on the resident three times and then she heard a loud noise and found the resident laying on the floor. The Incident Report investigation also revealed that resident had a bump and laceration on the back of the resident's head and a dressing was applied. Resident #84 was sent to the Emergency Department for evaluation. The surveyor reviewed the Progress Notes under nursing daily notes dated 1/21/19 at 4:11 PM, which revealed that Staff called and noted resident on the floor alert and able no SOB (shortness of breath), upon assessment noted blood stain in the floor and laceration noted on back of the head. Pressure dressing applied. Further review of the Progress Notes under nursing daily notes dated 1/21/19 at 9:52 PM, the RN documented that Resident #84 returned from the emergency room at 6:45 PM and was alert, confused, breathing non-labored. Vital signs were checked and neurochecks were continued. The RN documented that a CT scan (Computed Tomography scan) was done and the results were negative. The RN further documented that staples were applied to the laceration on the back of the resident's head. The surveyor reviewed Resident #84's care plan dated 11/26/18 which indicated under the focus area; risk for falls related to impaired mobility, cognitive impairment, on [CONDITION(S)] medications and a history of falls. The interventions included do not leave resident unattended and was dated 1/18/19. On 01/23/19 at 11:00 AM, the surveyor observed Resident #84 seated in the wheelchair by the nurse's station, awake and alert. The surveyor greeted the resident and the resident responded with a smile. On 01/24/19 at 9:50 AM, the surveyor interviewed the CNA who stated that on 01/21/19 she was entering notes in the Kiosk (an electronic record for CNAs to use when documenting care of their residents) that was located outside of Resident #84's room. The CNA stated that the RN was sitting near the door way and approached her and ask her if she could keep an eye on the resident while she gets something from the nursing station. The CNA stated that she checked on the resident three times while she entered her notes in the Kiosk and after the third time she checked she heard a crashing sound and found the resident laying on the floor. The CNA also stated that at the time of the fall, she was aware of the intervention not to leave the resident unattended. On 1/24/19 at 10:55 AM, the surveyor interviewed the RN who stated that on 1/21/19 she was monitoring Resident #84. The RN stated that she needed to get something from the nursing station and she asked the CNA who was standing at a Kiosk next the resident's room to watch Resident #84. The RN stated that she didn't wait for the CNA to enter the room and left the resident unattended. The RN also stated at the time of the fall, she was aware of the intervention not to leave the resident unattended. On 01/25/19 at 10:30 AM, the surveyor discussed the above concern with the Administrator and Director of Nursing. No additional information was provided. NJAC 8:39-27.1