Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to revise a resident's comprehensive care plan (CCP) for one (1) of 19 residents reviewed (Resident #78). This deficient practice was identified by the following: On 02/15/24 at 10:55 AM, during the initial tour the surveyor observed Resident #78 lying in bed watching TV. Resident #78 stated that he/she was fine and had no concerns at that time. The surveyor reviewed the medical record for Resident #78. A review of the admission Record (AR) reflected that the resident was admitted to the facility with diagnoses that included, malignant neoplasm of prostate (prostate cancer), hypertension (high blood pressure, muscle weakness and dysphagia (difficulty swallowing). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 02/07/24, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. A review of the Order Summary Report (OSR) for February 2024 reflected a physician order Full Code (want resuscitation and all life saving measures during a medical emergency) discontinued 10/31/23 and Do Not Resuscitate and Do Not Intubate (DNR/DNI) active start date 11/1/23. A review of the individualized comprehensive care plan (ICCP) included a focus area for code status of Full Code. Interventions date initiated 10/26/23 included at any time, resident or legal representative may change the Full Code status. Upon this decision, the order will be changed and documented in the medical record. Ensure that code status is communicated to staff per facility protocol. On 02/16/24 at 11:44 AM, the surveyor interviewed Resident #78 who stated that he/she did not want anyone beating on their chest and confirmed their wishes were to be a DNR/DNI. On 02/21/24 at 12:05 PM, the surveyor interviewed the Registered Nurse (RN) who stated the resident's code status would be in the electronic medical record (EMR). She stated that it was a physician order (PO) as well as on the care plan (CP). The RN stated that all residents should have their code status on the CP and that the unit manager (UM) completed and updated the CP. She further stated that the nurses could update the CPs as well, but it was typically the UMs. On 02/21/24 at 12:10 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) for the long-term care unit. She stated that the code status was asked upon admission so they would know how to care for the resident in the event of an emergency. She further stated that the code status was also assessed quarterly. The LPN/UM stated that the code status was on the CP and that the UMs generally updated the CP but that each department head would also update their sections in the CP. The LPN/UM then clarified that the nurses or any licensed staff could update the CP. At 12:12, the LPN/UM stated to her knowledge the resident was a full code. She stated that in an emergency she would look in the EMR to confirm the resident's code status. At 12:16 PM, the surveyor and the LPN/UM reviewed the EMR together. At that time, the LPN/UM stated the resident had a PO for DNR/DNI and it was ordered on 11/01/23. She then reviewed the CP and stated that Resident #78 was a full code. The LPN/UM acknowledged the CP should have been updated and that she should have updated it. Upon further review, she stated that the 3 PM to 11 PM supervisor put the PO into the EMR but never updated the CP. At that time, in front of the surveyor the LPN/UM confirmed she was updating the CP in the EMR to reflect the resident's code status as DNR/DNI. A review of the updated ICCP after surveyor inquiry included a focus area for code status of DNR/DNI. Interventions date initiated 10/26/23 included at any time, resident or legal representative may change the DNR/DNI status. Upon this decision, the order will be changed and documented in the medical record. On 02/21/24 at 12:23 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses were responsible for updating the CP. At that time, the DON reviewed the EMR and stated that Resident #78 was a DNR/DNI. The DON then reviewed the CP for Resident #78 and stated that the focused area reflected DNR/DNI but was revised today 2/21/24. The DON stated that the CP should have been updated prior to surveyor inquiry. He then acknowledged that the CP should have been updated when the code status was changed. A review of the facility Care-Plans Comprehensive policy revised 06/2023, included, 7. Revisions a. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 8. Revising and Updating a. the Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: i. when there has been a significant change in the resident's condition; iv. At least quarterly. NJAC 8:39-11.2(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 4 of 6 residents (Residents #17, #35, #39, #63) observed for incontinence care on 1 of 4 units (B hall). This deficient practice was evidenced by the following: On 02/20/24 at 09:04 AM, the Long Term Care Unit Manager provided the surveyor with a list of incontinent residents in the facility. On 02/21/24 at 07:49 AM, the surveyor met with the Certified Nursing Assistant (CNA#1) on B hall to complete an incontinence tour. At that time, CNA#1 stated it was the previous CNA's responsibility to do incontinence rounds before they finished their shift. On 02/21/24 at 07:59 AM, the surveyor and CNA#1 greeted Resident #35 in their room and the resident was made aware of the incontinence rounds. Resident #35 was observed to have worn two diapers, with the inner diaper saturated with urine and the outer diaper dry. The resident was wearing a red tshirt with the back of the tshirt saturated from the neckline to the hem. The resident was lying on a dry quilted green pad, with a fitted sheet on the bed that had a large wet area. The resident was malodorous. CNA#1 acknowledged that the resident should not have been found wet with urine and stated that she did incontinence rounds on each resident every two hours. CNA#1 further stated that it was important to keep the residents dry for the prevention of urinary tract infections. A review of Resident #35's admission Record (AR) reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to chronic obstructive pulmonary disease (disease that cause air flow blockage in the lungs), diabetes, and supraventricular tachycardia (condition where your heart beats faster than normal). The quarterly Minimum Data Set (MDS), an assessment tool, dated 03/22/23, revealed Resident #35's Basic Interview for Mental Status (BIMS) was 11 out of 15 which meant the resident had moderate cognitive impairment. The MDS further assessed that the resident required extensive assistance from staff for personal hygiene and was frequently incontinent of bowel and bladder. On 02/21/24 at 08:12 AM, the surveyor met with CNA#2 on B hall to complete an incontinence tour. At that time, CNA#2 stated that incontinence rounds were done at morning rounds, after lunch and before the CNA left for the day. On 02/21/24 at 08:15 AM, the surveyor and CNA#2 greeted Resident #17 in their room and the resident was made aware of the incontinence rounds. Resident #17's diaper was observed to be soaked with urine. The resident was lying on a folded white blanket with a round tan stain, a dry quilted green pad, and a dry fitted sheet. CNA#2 acknowledged the stained blanket and stated that the urine soaked through and that it was important for the residents to be kept clean and dry to prevent sores. A review of Resident #17's AR reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to diabetes, chronic atrial fibrillation (irregular, rapid heart rate), and hypertension (high blood pressure). The significant change MDS, dated [DATE], revealed Resident #17's BIMS score was 3 out of 15 which meant the resident had severe cognitive difficulties. The MDS further assessed that the resident was dependent on staff for personal hygiene and was always incontinent of bowel and bladder. On 02/21/24 at 08:25 AM, the surveyor and CNA#2 greeted Resident #63 in their room and the resident was made aware of the incontinence rounds. Resident #63's diaper was observed to be soaked with urine. The resident was lying on a dry quilted green pad and a fitted sheet with a round tan stain. The resident was malodorous. CNA#2 stated that the urine had seeped through, and that the resident should not have been found that way. A review of Resident #63's AR reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to senile degeneration of the brain, hypertension, and functional urinary incontinence. The annual MDS, dated [DATE], revealed Resident #63's BIMS score was 14 out of 15 which meant the resident was cognitively intact. The MDS further assessed that the resident required assistance from staff for personal hygiene and was frequently incontinent of bowel and bladder. On 02/21/24 at 08:32 AM, the surveyor and CNA#2 greeted Resident #39 in their room and the resident was made aware of the incontinence rounds. Resident #39's diaper was observed to be soaked with urine. The resident's hospital gown was wet, the folded sheet under the resident was wet with a tan stain, and the fitted sheet was wet with a tan stain. The resident was malodorous. CNA#2 stated the resident should not have been found that way. A review of Resident #39's AR reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to traumatic subarachnoid hemorrhage (brain bleeding), pneumonitis (lung infection), and dementia. The annual MDS, dated [DATE], revealed Resident #39's cognitive skills for daily decision-making were severely impaired. The MDS further assessed that the resident required assistance from staff for personal hygiene and was always incontinent of bowel and bladder. On 02/21/24 at 08:39 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who stated that CNAs were responsible for incontinence care and that it should have been done every two hours, and in between if needed. LPN#1 was informed of the surveyor's incontinence rounds observations. LPN#1 acknowledged the residents should not have been found wet and stated that it was important that the residents were dry with clean linen for the prevention of skin breakdown. On 02/21/24 at 08:45 AM, the surveyor interviewed LPN#2 who stated that the CNAs were responsible for incontinence care and that the nurses would help. She stated that incontinence care was done in the morning, afternoon and at the end of the shift, adding, we check them every two hours. LPN#2 was informed of the surveyor's incontinence rounds observations. LPN#2 acknowledged that the residents should not have been found wet nor double diapered, stating, that is a big no no. LPN#2 stated that wet linens or tan stains meant that it was there previously and was not changed. LPN#2 stated it was important to keep the residents clean and dry for the prevention of bed sores and to prevent complications. On 02/21/24 at 08:54 AM, the surveyor interviewed the LPN Unit Manager (LPN/UM) who stated that the CNAs were responsible for incontinence care and that the residents should have been changed every two hours. The LPN/UM stated that her expectation for her staff that found a resident wet was to not find them soaked and then to correct it. The LPN/UM was informed of the surveyor's incontinence rounds observations. The LPN/UM acknowledged that the residents should not have been found wet and stated, it's very embarrassing. The LPN/UM stated it was important for the prevention of sores, skin irritations, and wounds, that the residents were found clean and dry with dry draw sheets and no double diapers ever. On 02/21/24 at 09:01 AM, the surveyor interviewed the Director of Nursing (DON) who stated it was the CNAs responsibility for incontinence care and that they were to do rounds every two hours. The DON stated that his expectation for his staff that found a resident wet was to change them. The DON was informed of the surveyor's incontinence rounds observations. The DON acknowledged that the residents should not have been found the way you described it. The DON stated it was important for the prevention of skin breakdown that the residents were found clean and dry. A review of the facility policy titled, Incontinent Care, reviewed 09/2023, revealed, Policy: It is the policy of this facility to promote resident comfort by keeping residents clean and dry to prevent skin breakdown. Procedures: 3. Remove all soiled items and place them in plastic bags. Soiled linen or briefs are to be properly disposed of in the waste bin. A review of the facility policy titled, ADL Care Policy, updated 09/2023, revealed, Policy: It is the policy and procedure of this facility for the CNA's to adequately provide ADL care to the residents. Procedure: 1. ADL care, including assisting residents with .toileting. A review of the facility document titled, Position Title: Certified Nurse Aide, revealed Responsibilities/Accountabilities: 17. Collects and bags soiled linen. NJAC 8:39-27.1 (a), 27.2 (d, h, j)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) ensure an indwelling urinary catheter drainage bag did not touch the floor or geriatric chair wheel, and b.) ensure the urinary catheter drainage bag was kept below the level of the bladder for 1 of 2 residents (Resident #75) reviewed for urinary catheter. This deficient practice was evidenced by the following: On 02/15/24 at 10:13 AM, the surveyor observed Resident #75 in a geriatric (Geri) chair (a padded, reclining wheelchair). The resident stated he/she had a urinary catheter (a tube placed in the body to empty urine) that was recently changed. The surveyor observed the resident's urinary catheter drainage bag was secured to the Geri chair without a privacy cover and the bottom of the drainage bag was touching the floor. On 02/16/24 at 12:39 PM, the surveyor observed Resident #75 in a Geri chair. The resident's urinary catheter drainage bag was secured to the Geri chair without a privacy cover and was touching the wheel of the Geri chair. On 02/21/24 at 9:00 AM, the surveyor observed Resident #75 in a Geri chair. The resident's urinary catheter drainage bag was on the resident's lap, above the level of the resident's bladder. According to the admission Record, Resident #75 had diagnoses which included, but were not limited to, acute kidney failure (sudden kidney damage), hemiplegia and hemiparesis (paralysis of one side of the body), chronic kidney disease stage 3, and benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/26/23, included the resident had a Brief Interview for Mental Status score of 13 which indicated the resident's cognition was intact. Further review of the MDS included the resident had an indwelling catheter. Review of the Order Summary Report, as of 02/21/24, included a physician's order to Change foley [urinary catheter] securement device and foley bag weekly, ordered 11/09/23. Review of the resident's Care Plan did not include the resident's indwelling urinary catheter. Review of the resident's Progress Notes, dated 02/01/24 through 02/21/24, did not include any resident behaviors. During an interview with the surveyor on 02/21/24 at 9:49 AM, the Certified Nursing Assistant (CNA) stated that the CNAs empty the urinary catheter drainage bags and ensure the drainage bags are positioned below the resident. The CNA further stated that the drainage bags should not be touching any dirty surfaces to prevent infection. During an interview with the surveyor on 02/21/24 at 9:58 AM, the Licensed Practical Nurse (LPN)/Unit Manager (UM) stated urinary catheter drainage bags should be secured below the level of the resident's bladder and not touching dirty surfaces to prevent infection. At that time, the LPN/UM accompanied the surveyor to Resident #75's room. The LPN/UM acknowledged that the drainage bag was in the resident's lap, above his/her bladder, and then secured the drainage bag to the Geri chair below the resident's bladder. During an interview with the surveyor on 02/22/24 at 12:46 PM, the Infection Preventionist (IP) stated urinary catheter drainage bags should be secured below the resident's bladder to prevent the urine backflowing into the resident. The IP further stated that the drainage bag should not be touching dirty surfaces to prevent infection. During an interview with the surveyor on 02/22/24 at 1:10 PM, the Director of Nursing (DON) stated that urinary catheter drainage bags should not be touching dirty surfaces because the catheter was a portal of entry for infectious organisms. The DON further stated that the drainage bag should be secured below the resident's bladder to prevent the backflow of urine which could cause discomfort or infection. Review of the facility's Urinary Catheter Care policy, dated 08/2023, included, It is the policy and procedure of this facility to minimize the risk of catheter-associated urinary tract infection and its related problems, minimize trauma to the urethra, and maintain cleanliness of the catheter and perineum. Further review of the policy did not include specifics on how the urinary catheter drainage bag should be secured to prevent infection. NJAC 8:39 - 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services for 1 of 1 resident (Resident #139) reviewed for respiratory care. The deficient practice was evidenced by the following: On 02/15/2024 at 10:04 AM, Surveyor #1 observed Resident #139 resting in bed, reading a book and was fully dressed for the day. Surveyor #1 observed that Resident #139 had oxygen (O2) being administered via (by way of) nasal cannula at three (3) liters/minute. The oxygen tubing was not labeled or dated. Resident #139 stated that he/she had pulmonary fibrosis (a condition in which the lungs are scarred, causing difficulty breathing) and required O2. Resident #139 further stated that he/she was not sure how often the staff changed the tubing. On 02/16/2024 at 12:34 PM and on 02/20/2024 at 10:24 AM, Surveyor #1 observed Resident #139 with O2 being administered via nasal cannula at 3 liters/minute and the oxygen tubing was not labeled or dated. On 02/22/2024 at 09:37 AM, Surveyor #2 conducted a review of the medical records which revealed that Resident #139 was admitted to the facility after hospitalization for influenza A (the flu). The resident's past medical history included but was not limited to pulmonary fibrosis. The admission Minimum Data Set (MDS), an assessment tool dated 01/11/2024 reflected a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated that the resident was cognitively intact. The MDS also indicated that the resident had continuous oxygen was in use on admission and while a resident at the facility. On 02/22/24 at 09:37 AM, Surveyor #2 reviewed the physician orders dated 01/04/2024, which included but were not limited to Oxygen at 3 liters/minute via nasal cannula continuously and change oxygen tubing weekly on Wednesdays 11 PM to 7 AM shift and PRN (as needed) (label with date). A review of the Treatment Administration Record (TAR) for February 2024 revealed the Oxygen tubing was changed on Wednesdays 11 PM to 7 AM shift on 02/7/2024, 02/14/2024, and 02/21/2024. On 02/22/2024 at 09:22 AM, Surveyor #2 interviewed the Licensed Practical Nurse (LPN) who stated the oxygen tubing was changed weekly on the night shift. The LPN also stated she thought the oxygen tubing was changed on Wednesday nights and the tubing should have been dated when changed. On 02/23/2024 at 10:16 AM, Surveyor #2 interviewed the Director of Nursing (DON) who stated the oxygen tubing should have been labeled and dated with each change. A review the facility policy Oxygen Administration indicated all oxygen tubing will be dated upon the first use and changed weekly. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility documents, it was determined that the facility failed to maintain medical records that were accurate and consistent for 2 of 19 medical records reviewed (Resident #17 and #24). This deficient practice was evidenced by the following: 1). The surveyor reviewed Resident #17's Electronic Medical Record (EMR) which revealed the following: According to the admission Record, Resident #17 had diagnoses which included, but were not limited to, Alzheimer's Disease. Review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 02/20/24, included the resident had a Brief Interview for Mental Status score of 03 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was receiving hospice care. Review of the Order Summary Report, as of 02/21/2024, included a physician's order for Do Not Resuscitate (DNR) dated 02/08/24. Review of the Care Plan, revised 02/06/24, included, [Resident #17] has a code status of DNR. Patient started on Hospice services 2/2/2024. Review of a progress note, dated 02/10/24, included, [Resident #17] is now on hospice services, and code status changed to DNR. Review of the miscellaneous tab in the EMR included a scanned copy of a Do Not Resuscitate form for Resident #17 which was signed by the resident's representative and the physician. The surveyor reviewed Resident #17's paper (physical) chart which revealed the following: Review of the first page in the resident's paper chart included a form which had FULL CODE (in the event a person's heart or breathing stopped, resuscitation would be provided) written in large letters and Resident #17's name and date of birth written below it. Further review of the paper chart did not include the resident's DNR code status. During an interview with the surveyor on 02/21/24 at 12:10 PM, Certified Nursing Assistant (CNA) #1 stated that if a resident was found unresponsive, the staff would look at the resident's EMR to find out the code status. During an interview with the surveyor on 02/21/24 at 12:17 PM, Licensed Practical Nurse (LPN) #1 stated that if a resident was found unresponsive, the staff could look in either the EMR or paper chart to find out the code status. The LPN further stated that it was important for the EMR and paper chart to match consistently because, if the resident is a DNR, you don't want to code the resident. During an interview with the surveyor on 02/21/24 at 12:25 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that if a resident was found unresponsive, the staff could look in either the EMR or paper chart to find out the code status. The LPN/UM further stated that it was important for the EMR and paper chart to match consistently, to ensure the resident's wishes are carried out. At that time, the LPN/UM reviewed Resident #17's EMR and paper chart in the presence of the surveyor and verified that the paper chart should not have included the resident was a full code. During an interview with the surveyor on 02/22/24 at 1:10 PM, the Director of Nursing (DON) stated that if a resident was found unresponsive, the staff could look in either the EMR or paper chart to find out the code status. The DON further stated that the EMR and paper chart should match consistently to prevent confusion in the event the staff needed to know the resident's code status. Review of the facility's Code Status policy, dated 10/2023, included, The resident's resuscitation status will be clearly indicated on his/her clinical record. 2). On 02/15/24 at 10:12 AM, the surveyor observed that Resident #24 was out of the facility that day. The surveyor interviewed LPN #2 who stated that the resident was out of the facility on Tuesdays, Thursdays, and Saturdays for dialysis (process that cleans blood by removing it from the body and passing it through a dialyzer, or artificial kidney). The LPN also explained that the resident had an arteriovenous (AV) graft (a direct connection of an artery to a vein) in the left upper arm where he/she received dialysis. On 02/16/24 at 12:35 PM, the surveyor observed the Resident #24 in his/her room eating lunch. The resident stated that he/she goes to dialysis three times a week and had an AV fistula in the left upper arm. He/she stated that the nurses check the fistula to make sure that it's working correctly. He/she further stated that he/she had no issues regarding the care that was provided. The surveyor reviewed Resident #24's medical record which revealed the following information: According to the admission Record, Resident #24 had diagnoses, which included but were not limited to, end stage renal failure and diabetes mellites. Review of the admission MDS dated [DATE], indicated that the resident was cognitively intact and received hemodialysis. Review of the Care Plan included an intervention that no blood pressures (BPs) or blood draws were to be done on the resident's left arm. Review of the Treatment Administration Record (TAR), dated 02/01/2024-2/29/2024, included a physician's order not to take blood pressures in Resident #24's left arm. Further review of the TAR revealed the nurses were signing that they were not taking BPs in the resident's left arm, however, the documentation in the Weights and Vital Signs Record of the EMR indicated nurses were documenting BPs in the left arm. The Weights and Vital Signs record for February indicated that following documentation: - On 02/19/24 at 05:44 AM, the BP was taken in the left arm. - On 02/18/24 at 21:06 (9:06 PM), the BP was taken in the left arm. - On 02/18/24 at 16:47 (4:47 PM), the BP was taken the left arm. - On 02/18/24 at 05:49 AM, the BP was taken in the left arm. - On 02/17/24 at 05:21 AM, the BP was taken in the left arm. - On 02/16/24 at 21:06 (9:06 PM), the BP was taken in the left arm. - On 02/16/24 at 18:48 (6:48 PM), the BP was taken in the left arm. - On 02/15/24 at 05:14 AM, the BP was taken in the left arm. - On 02/12/24 at 05:50 AM, the BP was taken in the left arm. - On 02/11/24 at 16:43 (4:43 PM), the BP was taken in the left arm. - On 02/11/24 at 05:53 AM, the BP was taken in the left arm. - On 02/10/24 at 23:10 (11:10 PM), the BP was taken in the left arm. - On 02/10/24 at 21:48 (9:48 PM), the BP was taken in the left arm. - On 02/10/24 at 20:23 (8:23 PM), the BP was taken in the left arm. - On 02/10/24 at 08:14 AM, the BP was taken in the left arm. - On 02/10/24 at 05:38 AM, the BP was taken in the left arm. - On 02/07/24 at 08:01 AM, the BP was taken in the left arm. - On 02/06/24 at 20:06 (8:06 AM), the BP was taken in the left arm. - On 02/04/24 at 05:47 AM, the BP was taken in the left arm. - On 02/03/24 at 05:41 AM, the BP was taken in the left arm. - On 02/02/24 at 21:04 (9:04 AM), the BP was taken in the left arm. - On 02/02/24 at 17:28 (05:28 PM), the BP was taken in the left arm. - On 02/02/24 at 06:00 AM, the BP was taken in the left arm. - On 02/01/24 at 05:20 AM, the BP was taken in the left arm. On 02/16/24 at 01:03 PM, the surveyor interviewed Resident #24 who stated that he/she knew that his/her left upper extremity had to be protected due to the AV fistula and that staff did not take and blood pressures or draw blood from the left arm. On 02/20/24 at 10:34 AM, the surveyor interviewed the CNA #2 who stated that Resident #24 required limited assistance with activities of daily living (ADLs). The CNA further stated that she thought that the resident had an AV fistula in the left upper arm, but she did not touch the AV site. She then added that she did not take vital signs in the facility and that the nurses were the only ones that could take resident vital signs. On 02/20/24 10:41 AM, the surveyor interviewed LPN #3 who explained that if a resident was admitted with an AV shunt, nurses would be responsible to check the AV site for functioning. She further stated the nurses would check the AV site for bruit and thrill every shift and would also monitor the site for infection, bleeding, bruising. She stated that the arm that had the AV shunt would have to be protected and the nurses should not take blood pressures or draw blood from the affected arm. At that time, the LPN reviewed Resident #24's vital sign record with the surveyor and confirmed that the nurses were documenting that they were taking the BP in the left arm. The LPN stated that she was not sure why some of the nurses were documenting on the VS record that they were taking the residents blood pressure in the left arm and that they documented in error. On 02/20/24 at 10:56 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who explained that if a resident was admitted to the facility with an AV shunt, the nurses were not to take BPs or perform blood draws on the affected arm. The RN/UM further stated that a physician's order would be obtained not to use that arm or take BPs in that arm. At that time, the RN/UM and the surveyor reviewed Resident #24's Vital Sign record and the RN/UM confirmed that the nurses were documenting that they were taking the residents blood pressure in the left arm. The RN/UM stated that the resident was alert and oriented and would notify the nurse not to use the left arm for blood pressures or blood draws. The RN/UM also confirmed that it was a multitude of different nurses that documented that they took the residents blood pressure in the left arm. On 02/20/24 at 11:21 AM, the surveyor interviewed the DON who confirmed that the nurses were documenting on the Vital Signs record that they took Resident #24's blood pressure in the left arm. The DON further stated that it was an error in documentation. The DON also stated that it could not be proven that they did not take the blood pressure in the affected arm because the nurses documented that they did. The DON added that the nurses should not be documenting that they took the residents blood pressure in the left arm, when they are also signing the physician's order in the TAR that they were not taking the resident's blood pressure in the left arm. The facility provided the surveyor with a signed, typed confirmation from Resident #24 on 02/22/24 that indicated that at no time did any nurse take his/her blood pressure in the left arm. Review of the facility's Medical Records and Confidentiality of Information and Personal Privacy policy, dated 08/2023, did not include any policy related to ensuring the medical record is accurate or consistent. NJAC 8:39-35.2 (d)

2.) On 02/16/24 at 12:15 PM, Surveyor #3 observed CNA #2 remove a food tray from the covered food cart and enter Resident #51's room. The CNA placed the tray on the bedside table (BST), moved the table closer to the resident, turned the light switch on, moved the BST over the resident, opened the cup lid, opened a sugar packet and poured it into the cup, handed the fork to the resident, opened the cardboard milk carton, removed the straw cover, and placed the straw into the milk carton. The CNA then moved some items on the tray, removed the plastic plate cover and exited the room where she then placed the plastic plate cover on top of the food cart in the hallway. The CNA then removed a meal tray from the covered food cart and entered Resident #44's room. The CNA placed the tray on the BST, moved the BST closer to the resident, touched the lotion container that on the BST, raised the BST, removed the plastic plate cover, used the bed control to adjust the head of the bed, moved the pillow, physically assisted the resident to move up in bed, used the bed control to adjust the head of the bed, and moved the BST over the resident. She then opened the cardboard milk carton, removed the straw cover, placed the straw into the milk carton, took the silverware out of the plastic bag, removed the plastic plate cover, and exited the room where she then placed the plastic plate cover on top of the food cart. The CNA then entered another room to speak with other staff members. No hand hygiene (HH) was observed during the meal tray pass. On 02/16/24 at 12:21 PM, Surveyor #3 interviewed CNA #2 who stated that the CNAs were responsible for delivering the meal trays and that HH was to be performed before touching the meal trays, and that once the tray pass was completed, she would have washed her hands with soap and water. The surveyor informed the CNA of the meal tray pass observation and that no HH was observed. The CNA acknowledged that she should have performed HH before touching the trays, in between trays, and that HH should have been done after touching resident belongings or adjusting the resident in the bed. The CNA stated she had been in-serviced on HH and that it was important to perform it correctly to prevent the transfer of bacteria. On 02/16/24 at 12:32 pm, Surveyor #3 interviewed LPN #2 who stated that it was the CNA's responsibility to pass the meal trays and that HH should have been done before and after giving each resident a tray. The surveyor informed the LPN of the meal tray pass observation and that no HH was observed. The LPN acknowledged that the CNA did not perform HH correctly and stated that it was important for infection control to perform HH before and after entering each resident's room. On 02/16/24 at 12:40 PM, Surveyor #3 interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that it was the CNA's responsibility to pass the meal trays out and that HH should have been done when they exit a resident room and before grabbing the next tray. The surveyor informed the RN/UM of the meal tray pass observation and that no HH was observed. The RN/UM acknowledged the CNA did not perform HH correctly and stated that HH should have been performed upon exiting a resident's room and upon touching anything else between residents. She added that it was important for infection control to perform HH correctly. On 02/16/24 at 12:52 PM, Surveyor #3 interviewed the Corporate RN Regional Infection Preventionist (CRN/RIP) who stated that HH should have been performed before removing a meal tray from the food cart and after delivering a tray to a resident. The surveyor informed the CRN/RIP of the meal tray pass observation and that no HH was observed. The CRN/RIP acknowledged that the CNA did not perform HH correctly and stated that HH was important to avoid contamination. On 02/16/24 at 12:59 PM, Surveyor #3 interviewed the DON who stated that it was the CNA's responsibility to pass out the meal trays and that he expected staff to perform HH before they started the tray pass and when they opened the resident's food items. The surveyor informed the DON of the meal tray pass observation and that no HH was observed. The DON acknowledged that the CNA did not perform HH correctly and stated that HH was important for infection control and prevention. A review of the facility policy, Handwashing/Hand Hygiene, dated 8/29/2023, revealed, Procedure: 4. In most situations, the preferred method is washing hands with soap and water. If hands are not visibly soiled, the use of an alcohol-based hand rub may be used for the following situations: a. Before and after direct contact with resident, f. After contact with a resident's intact skin, g. After contact with inanimate objects .,i. After contact with high touch surfaces . A review of the facility policy, Meal Pass Policy, reviewed 10/2023, revealed, Procedure: 2. Once the dietary staff member delivers the truck to the floor, staff will begin to pass out trays after performing appropriate hand hygiene. 3. Staff members will sanitize their hands in between each tray. A review of facility documentation titled, In-Service, Topic: Infection Control, 3. Handwashing, revealed the CNA's signature that she attended on 03/20/23. A review of facility documentation titled, Hand Hygiene Competency Validation, revealed the CNA's signature that she performed a return demonstration on 03/20/23 and on 11/29/23. NJAC 8:39-19.4 (m)(n), 27.1 (a) Based on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to a.) ensure the infection control practices for residents on transmission-based precautions (TBP) were followed to prevent the potential spread of infection by not utilizing droplet precautions in accordance with facility policy and accepted national standards for 1 (one) of 1 (one) resident (Resident #140) reviewed for TBP, and b.) follow appropriate infection control practices and perform hand hygiene as indicated during meal tray pass for 1 of 4 units (Cart 1 unit) observed. This deficient practice was evidenced by the following: 1.) On 02/15/24 at 10:09 AM, Surveyor #1 observed the outside of Resident #140's room and observed a sign posted on the resident's door that the resident was on Droplet Precautions [Infections transmittable through air droplets by coughing, sneezing, talking, and close contact with an infected patient's breathing. Droplets are about 30 to 50 micrometers in size]. The sign also indicated that the proper personal protective equipment (PPE) to be worn in the room was an isolation gown, gloves, protective eye shield, and an N95 mask (a mask designed to have a tight seal and provide efficient filtration of airborne particles). There was also an isolation cart containing the necessary PPE set up outside the resident's door. On 02/15/24 at 10:40 AM, Surveyor #1 was in the hall outside of Resident #140's room and observed the housekeeper cleaning Resident #140's room. The housekeeper was not wearing a protective gown, protective eyewear, or N95 face mask and Resident #140 was present in the room. The housekeeper was observed wearing a regular mask and gloves. The surveyor observed the housekeeper exit the resident's room to rewet the mop and again enter the resident's room without wearing the proper PPE of eye protection, isolation gown, or an N95 mask. At that time, Surveyor #1 observed Licensed Practical Nurse (LPN) #1 walk down the hall and the surveyor asked the LPN what type to PPE was required in Resident # 140's room. The LPN explained to the surveyor that Resident #140 had the diagnosis of COVID-19 and that full PPE, such as N95 mask, protective gown, gloves, and protective eyewear, had to be worn in the room and removed upon leaving the room. The surveyor informed the LPN that the housekeeper was in Resident #140's room and did not don the appropriate PPE. The LPN observed the housekeeper in Resident #140's room not wearing the appropriate PPE and called the housekeeper out of the room to educate the housekeeper on the importance of wearing the proper PPE when in a COVID-19 positive room. The surveyor interviewed the housekeeper at that time, and the housekeeper explained what type of PPE she should have worn in Resident #140's room. The housekeeper explained to the surveyor that she should have worn a protective gown, N95 mask, gloves, and eye protection. She then stated that she had been employed by the facility since 2009 and had been educated multiple times on the contagious disease COVID-19 and wearing the appropriate PPE in COVID-19 positive rooms. The housekeeper further stated, that was my fault and I should have put on the appropriate PPE. The housekeeper admitted to not wearing the protective eyewear, gown or N95 mask and explained to the surveyor where all the PPE was located. The housekeeper showed the surveyor the isolation bin outside the resident's room which contained N95 masks, gowns, and protective eye shields. The surveyor reviewed Resident #140's medical record which revealed the following information: According to the admission Record, Resident #140 was admitted to the facility with the diagnoses that included, but were not limited to, heart failure and major depression. The admission Minimum Data Set (MDS), an assessment that facilitates a resident's care, dated 12/27/23, indicated that Resident #140 was cognitively intact and was independent with self-care. The Physicians Order (PO) dated 02/13/24, indicated that Resident #140 was to remain on strict droplet isolation precautions until 02/21/24 for COVID-19. The Treatment Administration Record (TAR) dated 02/13/24 reflected the aforementioned physician's order for Resident #140 to be on strict droplet precautions every shift for the diagnosis of COVID-19 until 02/21/24. The Care Plan indicated that Resident #140 was to be on droplet/contact precautions due to diagnosis of COVID-19 until 02/21/24, with interventions that included: -Staff to wear proper PPE at all times when caring for the patient, initiated 02/15/2024. -Educate staff, therapy, family on the importance of maintaining single room isolation/contact precautions, initiated 02/15/2024. -Precaution signage on door of room and provide education to visitor and family member, initiated 02/15/2024 -Provide appropriate personal protective equipment for staff/visitor use. Infection Control Apron with PPE hanging on the door for easily access to facility staff/family On 02/21/24 at 09:49 AM, Surveyor #2 interviewed Certified Nursing Assistant (CNA) #1 who stated that when in a COVID-19 isolation room, the staff were required to wear gloves, gown, N95 mask, and a face shield. She further stated that the required PPE were located outside of the resident's room in bins and that it was important to wear the proper PPE to prevent the spread of infection. On 02/21/24 at 9:58 AM, Surveyor #2 interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated that when in COVID-19 isolation rooms, the required PPE to be worn were gown, goggles/face shield, N95 face mask, and gloves. She further stated that the required PPE was located outside of the resident's room and it was important to wear the correct PPE to prevent the spread of infection. On 02/22/24 at 10:50 AM, Surveyor #2 interviewed the Housekeeping Director (HD) who stated that if a housekeeper was assigned a certain hallway that had COVID positive rooms, then they were responsible to clean those rooms. The HD stated that when the housekeeper entered the COVID positive room, they were required to wear an isolation gown, N95 mask, face shield, and gloves. The HD confirmed that it was important to wear the appropriate PPE to protect yourself from whatever infection the resident had. On 02/22/24 at 12:46 PM, Surveyor #2 interviewed the Infection Preventionist (IP) who confirmed that staff were required to wear faces shields, N95 mask, isolation gowns, and gloves in COVID positive rooms to protect themselves from a contagious infection. On 02/22/24 at 01:10 PM, Surveyor #2 interviewed the Director of Nursing (DON) who confirmed that when staff were in a COVID isolation room, staff were required to wear N95 face mask, face shield, isolation gown, and gloves. He stated that the purpose for wearing the PPE was to protect the staff member and to prevent the spread of infection. A review of the facility policy titled, Infection Control General Practices, with a review date of 10/01/23, indicated that staff must use appropriate PPE according to the transmission-based precaution guidelines such as gloves, mask, gowns, and eye protection when providing care to residents with an infectious disease. A review of the facility policy titled, Transmission Based Precautions (TBP), with a revised date of 07/2023, indicated that TBP are designed for patients documented or suspected to be infected with a highly transmissible pathogen for which additional precautions beyond standard/universal precautions were needed to interrupt transmission. Three types of TBP were identified as airborne, droplet and contact precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to maintain a safe clean, comfortable, and homelike environment by a.) ensuring that the resident's wheelchairs were cleaned and repaired in a timely manner and b.) ensuring that each resident had their own waste receptacle (trash can) in their room. This deficient practice was observed for 8 out of 8 residents (Resident #2, #6, #25, #29, #44, #65, #72 and #78) and 3 out of 9 rooms (Rooms 106, 125 and 130) observed during environmental rounds. This deficient practice was evidenced by the following: 1.) On 02/16/24 at 09:14 AM, the surveyor observed Resident #65's wheelchair in the hallway folded but the bottom portion of the wheelchair where the footrest attached and to lock the wheelchair appeared to be dusty and have brown rust on it. On 02/16/24 at 09:16 AM, the surveyor observed Resident #72's wheelchair right arm rest was ripped, the bottom portion of the wheelchair where the footrest attached and to lock the wheelchair appeared to be dusty and have brown rust on it. On 02/16/24 at 11:52 AM, the surveyor observed Resident #44's wheelchair left arm rest was ripped and the bottom portion of the wheelchair where the footrest attached and to lock the wheelchair appeared to be dusty and have brown rust on it. On 02/20/24 at 11:20 AM, the surveyor observed Resident #6 sitting in their wheelchair in the dayroom area. At that time, the wheelchair appeared to be dusty. On 02/20/24 at 11:23 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that the housekeeping department was responsible for cleaning the wheelchair. She stated that the housekeepers had certain days that they took the wheelchair to be cleaned. She further stated that if the wheelchairs needed to be clean in between the housekeeping staff would. On 02/20/24 at 11:33 AM, the surveyor interviewed the Housekeeper (HK #1) who stated the housekeeping staff was responsible to clean the wheelchairs. She stated that she cleaned the wheelchair every one to two hours. HK #1 stated that while she was conducting her rounds she looked to see if any wheelchairs need cleaning. She explained she used disinfectant wipes to clean the wheelchairs. When asked if there was a cleaning log for the wheelchairs? HK #1 stated she was not sure if the housekeeping staff kept a log of cleaning the wheelchairs. On 02/20/24 at 11:42 AM, the surveyor interviewed the Registered Nurse (RN) who stated that the housekeeping department was responsible for cleaning the wheelchairs. She stated that the housekeeping department cleaned the wheelchairs periodically but was not sure of how often. The RN stated that the HK Director was very good with following thought with anything they needed. At that time, the surveyor and the RN observed a wheelchair in the hallway that appeared to have dust on the cushion. The RN lifted the seat cushion and observed debris underneath. The RN identified that the wheelchair belonged to Resident #78. She then stated that Resident #78 barely used the wheelchair. The RN explained that the housekeeping department would check the wheelchairs but that if nursing staff seen the wheelchair needed to be clean then they would notify housekeeping for the wheelchair to be cleaned. The RN stated she would expect the wheelchair to be cleaned. She then confirmed that the wheelchair was dusty and needed to be cleaned. She further stated that the wheelchair should be clean because of infection control and if the resident needed to use the wheelchair, they would want it to be cleaned. On 02/20/24 at 11:48 AM, the surveyor observed Resident #29's wheelchair and one (1) unidentified wheelchair in between rooms [ROOM NUMBERS] observed to have dust and debris on them. On 02/20/24 at 11:51 AM, the surveyor interviewed HK #2 who stated the CNAs were responsible for cleaning the wheelchair. She then stated that the CNAs cleaned them but that if it was an emergency and needed to be cleaned immediately then the housekeeping staff would clean them. On 02/20/24 at 11:53 AM, the surveyor interviewed CNA #2 who stated that the housekeeping staff was responsible for cleaning the wheelchairs. She stated she would let the housekeeping staff know that the wheelchairs needed to be cleaned. CNA #2 stated it was important for the wheelchairs to be cleaned for infection control. She explained because we do not want the residents to get sick from their wheelchairs being dirty as you never know what's on it. At that time, CNA #2 described the 2 wheelchairs in between rooms [ROOM NUMBERS] as rough and looked like they needed to be cleaned and disinfected. On 02/20/24 at 12:03 PM, the surveyor interviewed the Housekeeping Director (HKD) who stated that the housekeeping staff was responsible for cleaning the wheelchairs. She stated that the CNAs would also inform the housekeeping staff if a wheelchair needed to be cleaned. The HKD stated that she used to have a schedule for cleaning the wheelchairs, but it became a challenge because the residents were mainly in their chairs during the day. She explained that cleaning the wheelchairs was her hardest challenge because the wheelchairs have not been cleaned like they should be. The HKD stated that the evening shift 3 PM to 11 PM, there was only one HK staff that went around to clean the wheelchairs. She further stated that it became difficult because most of the residents were still in their wheelchairs during the evening shift. The HKD stated that she sometimes tried to clean the wheelchair while the resident was sitting in the wheelchair but only the handles. She then stated if they see the wheelchairs were ripped then they would report it to therapy. She indicated that she was working with therapy to see if they could replace them. The HKD emphasized about five to six months ago they had a really good system for cleaning the wheelchairs but that for the long-term care residents it became more difficult to keep a schedule for cleaning the wheelchairs. The HKD stated she had a schedule for staff to follow and explained the schedule was based off the room numbers and that a few were picked and cleaned that week. She again stated it has been months since they have been able to follow the schedule she created. On 02/20/24 at 12:13, the surveyor and the HKD conducted an environmental tour of all the wheelchairs in the hallway that the surveyor observed since 02/16/24 and revealed the following: At 12:13 PM, the HKD observed Resident #44's wheelchair and confirmed that the wheelchair needed to be cleaned. At 12:14 PM, the HKD observed Resident #72's wheelchair and stated that the resident was ambulatory. At the time, the HKD confirmed the wheelchair needed to be cleaned and the armrest needed to be replaced. At 12:15 PM, the HKD observed Resident #6's sitting in their wheelchair but confirmed the wheelchair needed to be cleaned. At 12:16 PM, the HKD observed Resident #78's wheelchair and confirmed it needed to be cleaned. At 12:17 PM, the HKD observed Resident #2's wheelchair and confirmed that it needed to be cleaned thoroughly and that the armrest needed to be replaced. She stated she would ask therapy to replace the seat cushion. At 12:18 PM, the HKD observed Resident #29's wheelchair and stated the resident was discharged . At that time, she confirmed that the wheelchair needed to be cleaned, the armrest needed to be replaced and then removed from the hallway since the resident was discharged . At 12:19 PM, the HKD stated she was not sure who the unidentified wheelchair was in the hallway but confirmed it needed to be clean, the arm rest needed to be replaced and then returned to therapy. At 12:21 PM, the HKD observed Resident #25's wheelchair and confirmed that it needed to be disinfected because it was dusty. On 02/20/24 at 12:22 PM, the HKD stated that it was important for the wheelchairs to be cleaned and disinfected because it was the resident's legs and their way of getting around. She further stated that the wheelchairs should be cleaned and disinfected to prevent infection control. On 02/20/24 at 01:25 PM, the surveyor and the Licensed Nursing Home Administrator (LNHA) observed Resident #65's wheelchair. At that time, the LNHA stated the wheelchair should have been cleaned and the arm rest needed to be changed. He then stated he was going to take the wheelchair right now to get cleaned. On 02/21/24 at 10:31 AM, the LHNA stated in the presence of the survey team that it was important to ensure the wheelchairs were cleaned and disinfected because of infection control. On 02/21/24 at 12:21 PM, the Director of Nursing (DON) stated the housekeeping staff was responsible for cleaning the wheelchairs and that they should be cleaned monthly. He further stated that it was important to ensure the wheelchairs were cleaned and disinfected because it was a dignity issue and infection control. The DON stated they did not want the resident sitting in a contaminated wheelchair and that the residents deserved to sit in a clean chair. A review of the facility policy Cleaning and Disinfection of Resident-Care Items and Equipment reviewed 12/2023, included, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] for disinfection. 2.) On 02/21/24 at 12:45 PM, the surveyor toured Rooms 106, 110, 125, 127, 130, 132, 137, 139 and 152 that were increased in sized to meet the required square footage for double occupancy and revealed the following: -room [ROOM NUMBER] (Residents #9 and #22) only had one trash can in the room. -room [ROOM NUMBER] (Residents #44 and #70) only had one trash can in the room. -room [ROOM NUMBER] (Residents #23 and #61) only had one trash can in the room. On 02/22/24 at 10:41 AM, the surveyor interviewed the DON who stated that each resident should have a trash can in their room. He further stated that each resident should have one, so they could put their trash in it and not on the floor. The DON concluded that residents in a double occupancy room were not expected to share a trash can. On 02/22/24 at 10:44 AM, the surveyor observed there was still one trash can in the room for both Resident #9 and #22. On 02/22/24 at 10:45 AM, the surveyor observed there was still one trash can in the room for both Resident #44 and #70. On 02/22/24 at 10:46 AM, the surveyor observed there was still one trash can in the room for both Resident #23 and #61. At that time, the surveyor observed Resident #23 lying in bed listening to music from their phone while the TV was playing. Resident #23 stated that he/she did not realize that there was only one trash can in the room but that it was fine. On 02/22/24 at 11:13 AM, the surveyor interviewed the LNHA who stated that each resident should have a trash can in their room unless the resident moved it. He stated that each resident should have a trash can in their room for infection control and for cleanliness. When asked were residents expected to share a trash can? The LNHA stated that he did not have an answer but then stated that every resident should have one. He concluded that it was not ideal to have only one trash in the room for two residents. A review of the facility policy Clean/Homelike Environment reviewed 09/2023, included, Residents are provided a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. 2. These characteristics include: d. personalized furniture and room arrangements. NJAC 8:39-27.1(a), 31.4(f), 31.8(c)(14)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to develop a person-centered comprehensive care plan to include a resident's indwelling urinary catheter for 1 of 2 residents (Resident #75) reviewed for urinary catheter. This deficient practice was evidenced by the following: On 02/15/24 at 10:13 AM, the surveyor observed Resident #75 in a geriatric (Geri) chair (a padded, reclining wheelchair). The resident stated he/she had a urinary catheter (a tube placed in the body to empty urine) that was recently changed. The surveyor observed the resident's urinary catheter drainage bag was secured to the Geri chair without a privacy cover and the bottom of the bag was touching the floor. According to the admission Record, Resident #75 had diagnoses which included, but were not limited to, acute kidney failure (sudden kidney damage), hemiplegia and hemiparesis (paralysis of one side of the body), chronic kidney disease stage 3, and benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/26/23, included the resident had a Brief Interview for Mental Status score of 13 which indicated the resident's cognition was intact. Further review of the MDS included the resident had an indwelling catheter. Review of the Order Summary Report, as of 02/21/24, included a physician's order to Change foley [urinary catheter] securement device and foley bag weekly, ordered 11/09/23. Review of the Medical Practitioner Note, dated 02/13/24, included, HOSPITALIZATIONS *10/20-10/30/2023: Patient sent to [hospital] for worsening kidney function . Foley catheter placed. Review of the resident's Care Plan did not include any focuses, goals, or interventions related to the resident's indwelling urinary catheter. During an interview with the surveyor on 02/21/24 at 9:49 AM, the Certified Nursing Assistant (CNA) stated that the CNAs empty the catheter bags and ensure the catheter drainage bags are positioned below the resident. The CNA further stated that the drainage bags should not be touching dirty surfaces to prevent infection. During an interview with the surveyor on 02/21/24 at 12:17 PM, the Licensed Practical Nurse (LPN) stated the Unit Manager (UM) was responsible for updating resident care plans. The LPN further stated that care plans should be updated as soon as there was a change in the resident's condition to promote the continuity of care. During an interview with the surveyor on 02/21/24 at 12:25 PM, the LPN/UM stated each department was responsible for updating the resident care plans. The LPN/UM further stated that care plans should be updated as soon as there was a change in the resident's condition to provide proper care for the resident. At that time, the LPN/UM reviewed Resident #75's care plan in the presence of the surveyor and acknowledged there was no care plan for the urinary catheter. The LPN/UM then stated that the urinary catheter should have been added to the care plan as soon as the resident had the catheter inserted. During an interview with the surveyor on 02/22/24 at 1:10 PM, the Director of Nursing (DON) stated that interventions for a urinary catheter included ensuring the drainage bag was secured below the bladder and not touching dirty surfaces. The DON further stated that the nurses were responsible for updating resident care plans and that they should be updated at the time the resident had any change in condition. Review of the facility's Care-Plans Comprehensive policy, dated 06/2023, included, Each resident's comprehensive care plan is designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; . Identify the interdisciplinary care team and professional services that are responsible for each element of care; . Reflect currently recognized standards of practice for problem areas and conditions. Further review of the policy included, The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: When there has been a significant change in the resident's condition; When the desired outcome is not met; When the resident has been readmitted to the facility from a hospital stay; and at least quarterly. NJAC8:39-11.2 (g)

Based on observation, interview, and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of foodborne illnesses, and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross-contamination. This deficient practice was observed and evidenced by the following: On 02/15/24 from 09:45 AM until 10:45 AM, the surveyor toured the kitchen in the presence of the Food Services Director (FSD) and observed the following: 1. At handwashing sink #1, there was a step lid trashcan that contained used paper towels, with no inner plastic bag. The FSD had no response when asked if the trashcan should have had a plastic bag to contain the trash. 2. In the walk-in refrigerator, there was one 2-inch half pan, that contained a ham sandwich, with clear plastic wrap partially covering the pan. The sandwich was visible and exposed to air. The FSD stated it was important that the pan should have been fully covered to prevent bacteria growth and threw the sandwich into the trash. 3. In the freezer there was one box marked Salisbury steaks, with a received sticker dated 2/7/24 and hand marked date 2/8/24, which the FSD stated was the date it was opened. The box contained an opened clear plastic bag with the steak patties exposed to air with visible ice crystals on the patties. The FSD acknowledged that the patties should not have been visible and exposed to air and stated that the bag should have been tied up and that ice crystals meant that the food was exposed to air. The FSD stated she would discard the patties and that if they were served that someone could have gotten sick. 4. There was one opened box marked chicken patties, with a received sticker dated 1/29/24, that contained one opened bag wrapped in clear plastic wrap with no open or use by date. The FSD acknowledged that the bag should have had an opened date and stated it was important to label the food correctly so staff would know how long a food item was stored. 5. There was one frozen eight-pound roast beef covered in ice crystals with no dates observed on the roast. The FSD acknowledged there was no label or date and stated that she usually put a received label on, but it must have come off. 6. On a table in the kitchen at the condiment section, there was one uncovered opened roll of foil that the FSD stated was used for food that went into the oven. The FSD acknowledged the roll of foil should have been covered so no food debris fell into the container. 7. There was a large free standing covered bin marked sugar, that was dated 1/10/24, with black specks observed. The FSD was unable to state what the black specks were and acknowledged that they should not have been there. The FSD stated that the sugar would be discarded, and the bin would be washed and sanitized. 8. On the pot/pan dry rack there was one large green cutting board with brown and black smudges and large gouges. There was one large yellow cutting board with large gouges. The FSD acknowledged the stains and gouges and stated that it was important for the prevention of bacteria that the cutting boards did not contain stains and gouges. 9. At the coffee station, there were large coffee filters, unbagged, resting on a shelf. The FSD acknowledged the coffee filters were stored incorrectly and stated that debris could have gotten on them or they could have fallen on the floor. 10. At handwashing sink #2, there was a step lid trashcan with a foot pedal that did not open the can. The FSD acknowledged it was important for the trashcan to open hands free so staff did not touch the can after washing their hands. On 02/15/24 at 12:37 PM, the FSD informed the surveyor that there was no cutting boards policy. On 02/16/24 at 10:02 AM, the surveyor toured the Nurse Station One locked pantry area with the Licensed Practical Nurse (LPN) who accessed the locked door. There was a refrigerator which the LPN stated was used for the resident's personal food items. The LPN stated that the nurse or certified nursing aide (CNA) would mark the items with the resident's name and date and that it was good for 2 to 3 days. The LPN stated that the staff would dispose of items if they were outdated. The surveyor observed a plastic bag that contained a disposable take out container. The bag was marked with a resident's name and room number; there were no dates on the bag. The LPN stated that she did not know how long the bag was in the refrigerator and that the bag should have had a date. She further stated that it was important to label and date all food items because spoiled food could have gotten a resident sick. On 02/20/24 at 10:45 AM, the surveyor interviewed the LPN Nurse Manager (LPN/NM) who stated the process when residents brought food into the facility was that the item was marked with the resident's name, date and room number and placed into the refrigerator in Nurse Station One, and that they were not left over 5 days. The LPN/NM stated that if there was no name or date noted that the food item would have been placed into the trash. The surveyor informed the LPN/NM of the undated personal food item that was observed on 02/16/24 and she stated that it was important to date the food correctly and that it should have been discarded. On 02/20/24 at 10:50 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the process when residents brought food into the facility was that the family or the nurse labeled the item with the resident's name and the date, and that it should be kept only a couple days. The surveyor informed the DON of the undated personal food item that was observed on 02/16/24 and he stated that it was important for the food item to have been dated so no one ate spoiled food. On 02/22/24 at 02:44 PM, the surveyors met with the administration team and made them aware of the kitchen concerns. A review of the facility's Labeling and Dating Policy, reviewed 07/2023, revealed, Policy: All food items must be labeled and dated. A review of the facility policy, Food from Outside Sources, updated 01/2024, revealed, Guidelines: 2. The food and beverages will be labeled with the resident's name, room number and date. A review of the undated facility policy, Proper Food Handling and Storage, revealed, Label food. (Name and discard date) A review of the facility policy, Solid Waste, updated 08/2023, revealed, Procedures: 1.and other solid wasted is stored in plastic bags which are sealed and placed in solidly constructed containers with plastic liners and tight fitting lids. NJAC 8:39-17.2(g)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to accurately utilize an infection assessment tool for 5 of 5 residents (Resident #12, #53, #66, #139, and #286) reviewed that were prescribed antibiotic medications in the facility. This deficient practice was evidenced by the following: Review of the facility's Antibiotic Stewardship line list for January and February 2024, revealed the following residents were prescribed antibiotics while at the facility: 1. Resident #12 was prescribed an antibiotic on 01/05/24 for five days for pneumonia. The line list further indicated that an infection assessment tool was completed with antibiotic use criteria met. 2. Resident #66 was prescribed an antibiotic on 01/09/24 for five days for an upper respiratory infection. The line list did not indicate whether an infection assessment tool was completed. 3. Resident #139 was prescribed an antibiotic on 01/10/24 for three days for a urinary tract infection (UTI). The line list further indicated that an infection assessment tool was completed with antibiotic use criteria met. 4. Resident #53 was prescribed an antibiotic on 02/15/24 for five days for a UTI. The line list further indicated that an infection assessment tool was completed, but the criteria for antibiotic use was not met. 5. Resident #286 was prescribed an antibiotic on 02/16/24 for seven days for a left thigh wound infection. The line list did not indicate whether an infection assessment tool was completed. Review of the facility's Monthly Antibiotic Stewardship Report binder for 2024 included suspected infection Situation Background Assessment Request (SBAR) forms, an infection assessment tool, for the following residents: 1. Review of Resident #12's Suspected LRI (Lower Respiratory Infection) SBAR, dated 01/06/24, revealed that the resident did not meet the criteria in any of the four Assessment Input situations provided on the form, however, the nurse checked off the box below the section which indicated, Nursing home protocol criteria are met. Further review of the SBAR included the resident was started on an antibiotic treatment. 2. Resident #66's SBAR was missing from the binder. 3. Review of Resident #139's Suspected UTI SBAR, dated 01/10/24, revealed the resident did not meet the criteria in either of the Assessment Input situations provided on the form and the nurse did not check off a box to indicate whether or not the nursing home protocol was met. Further review of the SBAR included the resident was started on an antibiotic treatment. 4. Review of Resident #53's Suspected UTI SBAR, dated 02/15/24, revealed the resident did not meet the criteria in either of the Assessment Input situations provided on the form and the nurse did not check off a box to indicate whether or not the nursing home protocol was met. Further review of the SBAR included the resident was started on an antibiotic treatment. 5. Resident #286's SBAR was missing from the binder. During an interview with the surveyor on 02/22/24 at 11:08 AM, the Infection Preventionist (IP) stated that the infection assessment tool utilized by the facility was the SBAR forms. The IP further stated that she educated the nurses that when a resident is started on an antibiotic, the nurse must complete the SBAR form and give it to the IP to review. When asked what happened if the resident did not meet the criteria on the SBAR, the IP stated that the nurse would notify the doctor to discuss discontinuing the antibiotic treatment. The IP also stated that once the SBAR is completed, the information is input into the Antibiotic Stewardship line list and filed into the Monthly Antibiotic Stewardship Report binder for that year. The IP clarified that once the SBAR was completed, it was the IP's responsibility to ensure the form was completed in its entirety. During the same interview, the IP reviewed the Antibiotic Stewardship Report binder for 2024, in the presence of the surveyor, and stated the following: 1. Resident #12's SBAR should have been completed accurately and the nurse should not have checked off that the criteria was met based on what was filled out on the SBAR form. 2. Resident #66's SBAR was missing from the binder and that the IP was still waiting for the nurse to complete the form. 3. Resident #139's SBAR should have been completed accurately and the nurse should have checked off whether or not the criteria was met. 4. Resident #53's SBAR indicated the criteria was not met and the nurse should have checked off that the criteria was not met. 5. Resident #286's SBAR was missing from the binder and that the IP was still waiting for the nurse to complete the form. The IP further stated that the residents whose SBAR forms were missing had already completed their antibiotic treatment, and that the forms should have been returned to the IP within 24 to 48 hours for review to determine if antibiotic treatment was needed. When asked about the importance of the Antibiotic Stewardship program, the IP stated it was to prevent antibiotic resistance. During an interview with the surveyor on 02/22/24 at 1:10 PM, the Director of Nursing (DON) stated that if a nurse suspected that a resident had an infection, the nurse should complete an SBAR form and notify the physician. The DON further stated that the nurses should be completing the SBAR forms accurately and in their entirety, and submit the forms to the IP within 24 to 48 hours. The DON also stated that the importance of the SBAR forms were to meet the criteria for the Antibiotic Stewardship program and to prevent multi-drug resistant organisms. Review of the facility's Antibiotic Stewardship Program policy, dated 10/01/23, included, Review infections and monitor antibiotic usage patterns on a regular basis. NJAC 8:39-19.4(d)

Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 9 of 10 days reviewed. This deficient practice was evidenced by the following: Review of the PBJ Staffing Data Report for Quarter 1 2023 (October 1 - December 31) revealed the facility had no RN hours for the following dates: -10/01/23 (Saturday) -10/02/23 (Sunday) -10/09/23 (Sunday) -10/15/23 (Saturday) -10/16/23 (Sunday) -10/29/23 (Saturday) -10/30/23 (Sunday) -11/12/23 (Saturday) -11/13/23 (Sunday) -12/24/23 (Saturday) Review of the Employee Daily Schedule By Shift, provided by the facility, for the aforementioned dates, verified that there was no RN scheduled to work 8 consecutive hours on the following days: -10/01/22 -10/02/22 -10/09/22 -10/15/22 -10/16/22 -10/29/22 -10/30/22 -11/12/22 -12/24/22 During an interview with the surveyor on 02/23/24 at 10:32 AM, the Staffing Coordinator (SC) stated that they were to have staffed one RN within 24 hours, for a total of eight hours, and that they usually had two RNs, not including the Director of Nursing (DON). She stated that on the weekends now, they always had 1 RN in the morning and 1 RN at night and that the 3 PM to 11 PM shift had Licensed Practical Nurses. The SC further stated that on the weekends in question that she noticed there was no RN coverage on most of the dates and that the rest of the days should have had an RN for at least 8 hours. During an interview with the surveyor on 02/23/24 at 10:43 AM, the DON stated that they were to have staffed at least one RN for 8 hours each day and that on the weekends that they had an RN scheduled for every weekend clarifying that two RNs alternated weekends. The DON stated that if they were out of an RN that the Unit Manager, or the DON would have covered the weekend and that they should have had an RN scheduled for 8 hours during the days that were requested. Review of the facility's policy, Staffing, reviewed 08/2023, revealed, Policy: It is the policy and procedure of this facility to adequately staff the facility in accordance with the recommended guidelines. NJAC 8:39-25.2(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and other facility documentation, it was determined that the facility failed to maintain a clean and sanitary environment on 1 of 2 Units, Unit 1. This deficient practice was evidenced by the following: a.) On 11/22/21 at 10:39 AM, during the initial tour of the facility, in Resident #58's room, the surveyor observed a dried, brown substance on the floor under a portable pole that had nutritional formula hanging from it. On the same date at 10:47 AM in Resident #75's room, the surveyor observed a dried, brown substance on the floor under a portable pole that had nutritional formula hanging from it. On 11/23/21 at 8:47 AM in Resident #58's room, the surveyor observed a disposable under-pad (highly absorbent bed pad) on the floor over the area where the brown substance was observed the previous day. The disposable pad had brown stains on it. At that time, the surveyor lifted the the corners of the disposable under-pad revealing the dried, brown substance observed the previous day. On the same date at 8:56 AM in Resident #75's room, the surveyor observed a disposable under-pad on the floor over the area where the brown substance was observed the previous day. The disposable pad had brown stains on it. At that time, the surveyor lifted the the corners of the disposable under-pad revealing the dried, brown substance observed the previous day. On 11/23/21 at 9:44 AM in Resident #75's room in the presence of the surveyor, the Director of Environmental Services lifted the disposable under-pad revealing the dried, brown substance on the floor. At this time, she said that someone will clean it immediately. She further explained that all resident rooms are mopped on a daily basis. b.) On 11/23/21 at 11:45 AM, the surveyor observed the shower room on Unit 1. The surveyor observed disposable razors, paper towels, incontinence briefs, disposable gloves, and opened containers of hygienic products on the floor and on the shower chairs. Also, the surveyor observed accumulated dust on the exhaust fan located in the ceiling. c.) On 11/23/21 at 11:52 AM in the hallway outside of room [ROOM NUMBER], the surveyor observed a geriatric recliner that had dried, brown stains on the left side of the chair. A review of an undated Daily Resident Room Cleaning document revealed after 5.; Damp mop floor: with germicide solution damp mop floor working from back corner to the door, use Wet Floor Sign when finished. Further, under Additional Information the document revealed, Every room to be cleaned is that resident home; treat it as such. Lastly, under Additional Information, the document revealed, Infection control is the goal on effective room cleaning technique. N.J.A.C. 8:39-31.3(a)

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to monitor and follow-up on comments/recommendations made by the Consultant Pharmacist (CP) regarding a medication error in accordance with its established policy. This was identified for 1 of 5 residents reviewed for unnecessary medications, (Resident #20). This deficient practice was evidenced by the following: 1. A review of the 9/18/2021 quarterly Minimum Data Set (MDS), an assessment tool revealed that Resident #20 had a Brief Interview for Mental Status score of 12, which indicated moderate cognitive impairment. According to section I Resident #20 had an active diagnosis of depression and section N revealed that Resident #20 received a daily antidepressant. 2. A review of a psychiatry evaluation, dated 7/1/2021 in the general progress notes revealed that the nurse practitioner (NP) made the following recommendation for Resident #20: Recommend increasing Zoloft (Sertraline HCl) from 50 milligrams (mg) to 75 mg QD (every day) for 5 days and then increase to 100 mg QD for depression. 3. A review of Resident #20's medical record (MR) revealed a physician's order had been written on 8/19/2020 for the resident to receive Sertraline HCL Tablet (a medication used to treat depression) 50 mg give 1 tablet by mouth at bedtime for depression. In addition, Resident #20 had an order dated 7/2/2021 for Sertraline HCl tablet 100 mg give 1 tablet by mouth at bedtime for depression. 4. According to the 7/1/2021-7/31/2021 Medication Administration Record (MAR) Resident #20 received Sertraline HCl tablet 25 mg 1 tablet by mouth at bedtime for depression for 5 days, starting on 7/2/2021 and received on 7/3, 7/4, 7/5, and 7/6/2021, as well as Sertraline HCl tablet 50 mg 1 tablet by mouth at bedtime for depression on 7/1/2021 to 7/31/2021, as ordered on 8/9/2020. In addition, starting on 7/8/2021 and continued to 7/30/2021 Resident #20 received Sertraline 100 mg tablet by mouth at bedtime for depression, as recommended and ordered by the NP on 7/1/2021 as well as Sertraline 50 mg 1 tablet by mouth at bedtime for depression. Resident #20 received a total of 150 mg of Sertraline HCl from 7/8/2021 thru 7/30/2021. 5. On 11/24/2021 at 12:07 PM the surveyor reviewed the Consultant Pharmacist's (CP) Monthly Report, with a printed date of 7/31/2021. The following suggestion dated 7/28/2021 indicated: A MEDICATION ERROR for Zoloft (Sertraline). There is a duplicate order for Zoloft. The dose suggested at psych eval (evaluation) was increased to 100 mg. The 50 mg dose is still active. The patient has been receiving 150 mg. Nurse (Licensed Practical Nurse) [LPN #2] notified at 11 am. A CP progress note in the MR, dated 7/28/2021 at 11:10 revealed the following: dup (duplicate) Zoloft and update documentation. According to the 7/1/2021-7/31/2021 MAR, on 7/31/2021 Sertraline 100 mg and Sertraline 50 mg were held and coded with 5. According to the Chart Codes/Follow Up Codes 5 = Hold/See Nurse Note. The surveyor reviewed the progress notes dated 7/31/2021 and was unable to find any documentation related to Sertraline being held. A review of the MAR for 8/1/2021 up to and including 11/29/2021 indicated that Resident #20 had continued to receive Sertraline HCl 50 mg 1 tablet at bedtime for depression and Sertraline HCL 100 mg 1 tablet at bedtime for depression for a total of 150 mg daily. There was no physician order to administer Sertraline 150 mg daily. Resident #20 had no documented adverse drug reaction to the 150 mg dose of Sertraline HCl. 6. According to the 9/9/2021 psychiatry progress note, the following recommendation was made: 3. Recommend to continue Zoloft 150 mg QHS (every bedtime) for depression & Melatonin 5 mg QHS for supplement; B>R. 7. During an interview with the surveyor on 11/24/21 at 1:46 PM, the facility Director of Nursing (DON) was asked why Resident #20 had continued to receive Sertraline at 150 mg HS (bedtime) daily after the CP had made the facility aware of the medication error, as documented on 7/28/2021 on the Consultant Pharmacist's Monthly Report and general progress notes. The DON responded, It was looked at at the end of July and should have been taken care of. I wasn't here that week, I was on vacation. They are getting 150 mg, right? The surveyor then asked the DON what was the expected timeframe for a medication error to be corrected once the facility was made aware by the CP. The DON responded, My expectation is that nurse (LPN #2) was informed of it on 7/28/2021 and the error should have been addressed at that time. The surveyor then questioned the DON who was responsible to ensure that CP recommendations/suggestions were addressed. The DON responded, The supervisor, the unit manager and ultimately me (DON) are responsible for ensuring that the CP recommendations are followed up on and completed. I'm working on finding out what happened when I became aware of this medication error yesterday. I thought the order was written for 100 mg and 50 mg, are they two separate orders? I have contacted the nurse practitioner and I am waiting for her to get back to me. 8. According to a hand written synopsis provided to the surveyor on 11/30/2021 by the facility DON, on 7/28/2021 the Consultant pharmacist called facility and spoke with LPN #2 related to Sertraline order. LPN #2 checked orders, seeing (1) order for 100 mg and (1) order for 50 mg. LPN #2 stated that there was not a duplicate order and Resident #20 was receiving 150 mg q HS (every night). The surveyor reviewed the facility provided policy with Subject: Pharmacy Consultant Reports, undated. The following was revealed under the heading Policy: Pharmacy consultant reports are reviewed monthly by the DON/ADON and given to the Unit Managers for distribution. Nursing recommendations will be completed by the Unit Managers/supervisors and physician recommendations will be placed on the physician clipboards for completion. Under the heading Procedure: Copies of the pharmacy consultant reports are copied monthly by the DON and given to the unit managers for review and handling. The recommendations to the MD will be placed on their individual clipboards for responses. Nursing recommendations will be completed by the unit managers/supervisors and returned to DON in a timely manner. The physicians have 30 days to review and answer the concerns in writing-either to accept recommendations and write orders or decline recommendations with a statement explaining their rationale. The physician will return recommendations to their respective clipboards or hand to the unit manager for further review. The unit manager will return completed pharmacy consultant recommendations to the DON when there (sic) are completed. N.J.A.C. 8:39-29.3(a)1.

FACILITY Kitchen Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 2 of 2 garbage dumpsters and 1 of 1 recycling dumpsters. This deficient practice was evidenced by the following: On 11/22/2021 between 9:09 to 10:04 AM, the surveyor, accompanied by the Food Service Director (FSD) observed the following during the initial kitchen tour: 1. During the observation of the garbage area located outside of the facility, the surveyor observed 3 garbage dumpsters. 2 dumpsters were designated as trash dumpsters and 1 dumpster was designated for cardboard recyclables, per the FSD. Dumpster #1 (trash dumpster) was observed to have a door open on the side of the dumpster, exposing the trash contents. Dumpster #2 (trash dumpster) was observed to have 1 of 2 top lids open that exposed the garbage contents and dumpster #3 was observed to have 1 of 2 top lids open and exposed the recycling contents. On interview the FSD stated, Housekeeping is responsible for the maintenance of the dumpsters. We should close the doors every time we leave, right? The surveyor reviewed an undated, (facility name only) facility provided policy. The following was revealed under the heading Waste Disposal: 1) All garbage shall be handled and stored in a sanitary manner. NJAC 8:39-19.3(c)

Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to a) maintain a Hospice communication record and b) initiate a care plan to address the Hospice services the resident was receiving, for 1 of 2 residents reviewed for Hospice services, (Resident #49). This deficient practice was evidenced by the following: During the initial tour of Unit 2 on 11/22/21 at 10:49 AM, Resident #49 was observed to be lying in bed with the head of bed elevated, on nasal oxygen with 2 people at the bedside who identified themselves as the Hospice nurse and the Residents daughter. A review of the admission Record revealed Resident #49 was admitted to the facility with diagnosis including but not limited to; Cerebral Infarction (stroke). A review of the admission Minimum Data Set (MDS) and assessment tool dated 10/20/21, revealed under section O that Resident #49 received Hospice services while a resident. A review of the Order Summary Report dated 11/25/21 revealed a physician order dated 10/8/21 for Hospice as of 10/7/21. A review of Resident #49's Hospice documentation included a medication recommendations for Facility Patients and a Master Certified Home Health Aide Plan of Care. The facility was unable to provide any further Hospice documentation for Resident #49. A review of the care plan did not include a focus area for Hospice services. During an interview with the surveyor on 11/22/21 at 1:30 PM, the assigned Licensed Practical Nurse (LPN #1) said the Hospice documentation would be in a binder. LPN #1 then looked at the nurses station and said that Resident #49 did not have a binder. During an interview with the surveyor on 11/24/21 at 10:44 AM, the LPN Unit Manger was asked where the Hospice company documents would be kept when the Hospice provides residents a service such as aide, chaplain. The LPN Unit Manger said it is documented in the medical record when they make a recommendation. The surveyor then asked where do the aides, nurse or chaplain document when they come to visit a resident. The LPN unit manager said they usually have a book and LPN #1, who was present at the time, said he/she doesn't have a book. During an interview on 11/29/21 at 8:58 AM, the LPN Unit Manager said for new admission the initial care plan is completed within 24 hours and would be done by myself or the Director of Nursing (DON). She went on to say that the Unit Manager or DON are responsible to update the care plans for any changes in a residents condition. The LPN Unit Manager went on to say if a resident goes on Hospice services, yes this requires updated care plan as that is change in condition. LPN Unit Manager said there should be a separate focus area for Hospice and this would be developed by either myself or DON. She also said Hospice has their own documentation and that no we don't have access to their care plan. During an interview on 11/30/21 at 9:15 AM the DON confirmed there was no binder or care plan for this resident. A review of a facility Hospice-Nursing Facility Services Agreement with an effective date of October 25, 2016 revealed under Agreements section, 1 Definitions (e) Hospice Plan of Care means a written care plan established, maintained, reviewed and modified if necessary in coordination with facility. It further revealed that the Hospice care plan will reflect the participation of the Hospice, Facility and Hospice patient and his or her family to the extent possible. Upon further review of the Agreement under (e) Coordination of Care (ii) In accordance with applicable federal and state laws and regulations, Facility shall coordinate with Hospice in developing a Hospice Plan of Care. Under the Professional Management Responsibility section (e) Provision of Information, At a minimum, Hospice shall provide the following information to the Facility .for each Hospice Patient at the facility: Hospice Plan of Care, medication and orders, Election Form, Certifications, Contact information, on call system, policies and procedures, notifications of services, assist with inquires and investigations, confirmation of unrelated items and services. NJAC 8:39-27.1(a)

Based on observation, interview, and review of other pertinent documentation, it was determined that the facility failed to perform hand hygiene after direct patient contact when a.) a Certified Nurse Assistant (CNA #1) placed her bare hands on the bare legs of Resident #41 to readjust them, then wiped the resident's mouth with a napkin, followed by touching clean utensils to feed the resident, and b.) when a CNA placed a clothing protector that was retrieved from the floor onto a resident (Resident #41). The deficient practice occurred for 1 of 9 residents observed for dining. This deficient practice was evidenced by the following: a.) On 11/23/21 at 11:59 AM, the surveyor observed CNA #1 in Resident #41's room. Resident #41 was seated in a chair while the CNA was preparing to assist in feeding him/her. CNA #1 adjusted Resident #41's legs by placing her bare hands on his/her bare skin. At this time, CNA #1 used a napkin to wipe Resident #41's mouth. CNA #1 then removed clean utensils from a plastic wrap on the meal tray and began to feed Resident #41. b.) On the same date at 12:02 PM, an unidentified staff member entered the doorway of Resident #41's room. The staff member attempted to give CNA #1 a clothing protector but it fell to the floor. CNA #1 retrieved the clothing protector from the floor and placed it onto Resident #41. According to the admission Record, Resident #41 was admitted with a diagnosis of dysphagia followed by cerebral infarction (difficulty swallowing food and liquids as a result of disrupted blood flow to the brain). According to the quarterly Minimum Data Set (an assessment tool) dated 10/14/21, Resident #41 required extensive assistance to eat with physical assistance from one person. On 11/23/21 at 12:03, during an interview with the surveyor, CNA #1 said she should have washed her hands after adjusting the resident. She further said that the clothing protector was on the floor before it was placed on the resident. On 11/24/21 at 10:00 AM, during an interview with the surveyor, the Infection Preventionist explained that staff should perform hand hygiene any time they touch anything in a patient room including after skin to skin contact. A review of an undated facility policy titled, Handwashing under All employees should wash their hands letter e. revealed, After contact with a source that is likely to be contaminated with microorganisms. This includes, but is not limited to, infected or heavily colonized residents or objects or devices contaminated with resident' secretions or excretions and letter k. revealed, Before serving food. N.J.A.C. 8:39-19.4(m)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations on 12/01/2021 in the presence of facility management, it was determined that the facility failed to ensure that 12 of 39 double occupancy resident rooms were provided with the minimum of 80 square feet of useable living space per bed. This deficient practice was evidenced by the following: During the previous facility survey on 2/10/2020, the facility had 30 rooms that did not meet the 80 square feet per resident in a multiple resident room requirement. The following double occupancy resident rooms did not meet the required 80 square feet per resident, - Resident room [ROOM NUMBER] measured 152.033 square feet. - Resident room [ROOM NUMBER] measured 155.971 square feet. - Resident room [ROOM NUMBER] measured 149.662 square feet. - Resident room [ROOM NUMBER] measured 153.281 square feet. - resident room [ROOM NUMBER] measured 156.243 square feet. - Resident room [ROOM NUMBER] measured 156.621 square feet. - Resident room [ROOM NUMBER] measured 153.714 square feet. - Resident room [ROOM NUMBER] measured 151.888 square feet. - Resident room [ROOM NUMBER] measured 156.691 square feet. - Resident room [ROOM NUMBER] measured 153.975 square feet. NJAC 8:39 -31.2

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/22/2021 from 9:09 to 10:24 AM the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. On a middle shelf in the walk-in refrigerator, a can of pineapple crushed had a significant dent on the upper seam. The FSD stated, I'm removing that to the dented cans. 2. On an upper shelf of the walk-in refrigerator 6 unopened containers of plain non fat yogurt had a Best if used by date of 11/7/2021. On interview the FSD stated, I usually check the dates in the morning but we don't use these anymore. They should have been thrown out. 3. On a prep table next to the stove a box of plastic wrap had its lid removed and the plastic wrap was exposed to contamination. On interview the FSD stated, It needs to be covered when not in use. 4. In the walk-in freezer an opened cardboard box contained individual frozen pizzas. The box was opened and the plastic bag inside the box that contained the pizzas was opened to the air, exposing the pizzas. The FSD stated, That's no good it's exposed. The frozen pizzas were removed to the trash. 5. On an upper shelf of the walk-in freezer, an unopened package of bacon was discolored to a light tan color and the package was covered with large particles of ice all over the plastic covering. The FSD stated, That color doesn't look good. The FSD removed the bacon to the trash. In addition, on a middle shelf an 1/8th pan contained frozen pasta. The pasta had no dates and the plastic wrap was ripped, exposing the pasta to the air. The FSD removed the pasta to the trash. On the same shelf a frozen ham wrapped in plastic wrap and in a sealed zip lock type bag had no dates. The Ham was removed to the trash. On 11/29/2021 from 11:10 to 11:28 AM the surveyor, accompanied by the FSD observed the following in the kitchen: 1. On an upper shelf of the walk-in refrigerator an opened plastic container of garlic cloves had a received date of 10/27/2021 and no use by date. The garlic cloves were observed to be covered with what appeared to be white mold. On interview the FSD stated, We usually go through garlic every two weeks, we keep it less than a month. Sometimes we dump it if it goes bad. The FSD removed the garlic to the trash. The surveyor reviewed the facility policy titled (facility name) for Food Receiving & Storage, dated 1/1/2021. The following was revealed: Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS (potentially hazardous foods/time temperature control for safety food) foods stored in the refrigerator or freezer as indicated. The surveyor reviewed the facility policy titled (facility name) Dented Can Policy, undated. The following was revealed under the heading PROCEDURE: 1) Identify all unacceptable dented cans. 2) Place dented can on a designated shelf. 3) Contact purchasing or vendor to replace the can. The surveyor reviewed the facility policy titled LABELING AND DATING, undated. The policy revealed the following: All food in the dietary department must be labeled and dated correctly. Prepared items are good for 72 hours ie. If you prepare an item on 4/1/17 it must be discarded by 4/4/17 (3 days) On delivery days, all items that do not have a packing slip must contain a visible received date label and/or the date written in black permanent marker. Any ready to eat foods must be used with 7 days of opening. IE. cole slaw or cottage cheese. Also, pay attention to the manufacturer's expiration dates. If a container of cole slaw is opened on April 1st it must be discarded on April 8th. N.J.A.C. 18:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to a.) adhere to the accepted standards of infection control practices for the proper storage of respiratory equipment for 3 of 3 residents reviewed for use respiratory equipment (Residents #13, 250, 252), and b.) maintain appropriate infection control practices for wound care for 1 of 5 residents reviewed for pressure ulcers (Resident #7). This deficient practice was evidenced by the following: 1. During the initial tour on 02/04/20 at 10:16 AM, the surveyor observed Resident #13 sitting in a wheelchair being wheeled into their room. The resident was not wearing a nasal cannula and was breathing comfortably. Resident #13 had an O2 concentrator in the room with a nasal cannula from the resident's oxygen tubing, coiled around the grab bar on the resident's bed. The surveyor further observed the oxygen tubing had a piece of tape on it with a date of 1/30/20. During an interview Resident #13 told the surveyor he/she sometimes wore oxygen at night. On 02/05/20 at 11:38 AM, the surveyor observed the nasal cannula draped across the bed, uncovered and the oxygen concentrator was running. Resident #13's roommate stated the resident was not in the room. On 02/05/20 at 11:44 AM, the surveyor returned to Resident #13's room and observed the resident in a wheelchair and interacting with the Registered Nurse (RN). The RN left the room with the O2 concentrator running and the NC draped across the bed. According to the admission Record, Resident #13 was admitted to the facility on [DATE] with diagnosis which included heart failure, acute and chronic respiratory failure with hypoxia, anemia, chronic obstructive pulmonary disease (COPD) and dyspnea (shortness of breath). A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/01/19, reflected that the resident was cognitively intact. A review of Resident #13's February 2019 View All Orders Report (VAOR) revealed a physician's order, dated 02/04/20, for 2 liters/minute of oxygen, delivered by nasal cannula as needed, for oxygen saturation levels less than 92%. 2. During the initial tour on 02/04/20 at 09:38 AM, the surveyor observed Resident #250 sitting in the bed in their resident's room, breathing comfortably. Resident #250 had an O2 concentrator in the back corner of the room against the wall. The resident's oxygen tubing and nasal cannula was draped over the oxygen concentrator, exposed to air. Resident #250 stated he/she has not used oxygen therapy in a week. The surveyor made a similar observation on 02/02/20 at 09:58 AM. Resident #250 stated he/she only used oxygen therapy when the resident needed the humidity because the facility was dry. According to the admission Record, Resident #250 was admitted to the facility on [DATE] with diagnosis which included acute and chronic combined systolic and diastolic heart failure, atrial fibrillation and rheumatic heart failure. A review of the View All Orders Report indicated the resident had a diagnosis of COPD. A review of the admission MDS, dated [DATE], documented that the facility assessed the resident as having moderate cognitive impairment. A review of Resident #250's February 2019 VAOR revealed a physician's order, dated 02/06/20 for 3 liters/minute of oxygen, delivered by nasal cannula as needed, for COPD. A review of Resident #250's care plan revealed the resident was receiving oxygen therapy for shortness of breath related to chronic heart failure. 3. During the initial tour on 02/04/20 at 10:47 AM, the surveyor observed Resident #252 sitting in bed in their room breathing comfortably. Resident #252's O2 concentrator was located between the head of the bed and the bedside table. The nasal cannula and oxygen tubing were coiled up and tucked into the elastic band on the oxygen concentrator that would normally house a humidity bottle. The nasal cannula was exposed to air. Resident #252 indicated that he/she used oxygen therapy every night. Resident #252 further revealed he/she coiled the tubing and tucked it into the elastic like he/she was shown by the Registered Nurse (RN) the previous day. Resident #252 indicated it was better tucked up then, Ending up on the floor. According to the admission Record, Resident #252 was admitted to the facility on [DATE] with diagnosis which included COPD, hypertension (high blood pressure) and an anxiety disorder. A review of the admission MDS, dated [DATE], reflected that the resident was cognitively intact. The surveyor reviewed Resident #252's February 2019 VAOR, but was unable to locate a physician's order for oxygen therapy. A review of Resident #252's care plan which revealed the resident was using oxygen on an as needed basis for a related diagnosis of COPD. During an interview at 12:40 PM on 02/02/20 with the Certified Nursing Assistant (CNA) #1 who cared for Residents #252 and #250, CNA #1 told the surveyor she had not seen Resident #252 using oxygen therapy and Resident #250 uses oxygen therapy occasionally. CNA #1 further stated a nasal cannula should be stored in a plastic bag when not in use. During an interview at 12:32 PM on 02/06020 with CNA #2 who cared for Resident #13, the surveyor was told that Resident #13 wore oxygen at night, in the morning and as needed. CNA #2 confirmed a nasal cannula should be stored in a plastic bag when not in use. During an interview with RN #1 on 02/06/20 at 12:15 PM, the RN told the surveyor oxygen tubing should be stored in a plastic bag when not in use. The RN further revealed Resident #13, Barely uses oxygen therapy during the day, Resident #250 uses oxygen therapy, Infrequently during the day, and Resident #252 used oxygen therapy at night. During an interview with the Licensed Practical Nurse Supervisor (LPNS) #1 on 02/06/20 at 12:55 PM, LPNS #1 confirmed nasal cannulas should be stored in a bag in the patient's room when not in use. On 02/07/20 the Assistant Director of Nursing provided the surveyor with staff education on storage of respiratory equipment, which was initiated on 2/6/20. This education confirmed respiratory equipment should be stored in plastic bags when not in use. A review of a facility policy titled, Storage of Respiratory Equipment with an initiation date of 02/06/2020, revealed equipment should be stored in a plastic bag when not in use. 4. On 02/04/20 at 10:15 AM, during the initial tour of the facility the surveyor observed Resident #7 in the bed receiving back care by a hospice aide. The surveyor observed a dressing on the sacral area of the resident with a date of 2/2/20 and the letters JB. The dressing had dried green and tan substance that had seeped through the small square white dressing. The surveyor reviewed Resident # 7 quarterly Minimum Data Set (MDS), an assessment tool, dated 01/15/2020. The MDS indicated that the facility was unable to complete a brief interview of mental status related to severe cognitive impairment. The resident was a two-person physical assist for bed mobility and a one-person physical assist for dressing, eating and toileting. The MDS also indicated that Resident # 7 had a stage four pressure ulcer of the sacral area. Resident # 7 was admitted to the facility on [DATE]. Medical diagnoses included coronary artery disease (heart disease), hypertension (high blood pressure), renal (kidney) failure, hyperlipidemia (high cholesterol), cerebrovascular accident (stroke), non-Alzheimer's dementia and schizophrenia (psychiatric disorder). On 02/04/20 at 10:20 AM, the surveyor called the nurse caring for the resident to come into the room. The surveyor asked the Licensed Practical Nurse (LPN) what the frequency of dressing changes were, and the nurse told the surveyor daily. The surveyor asked about the date of 02/02/20 and the LPN said she must have written the wrong date on the dressing the day before. The LPN stated the letters on the dressing were her initials. On 02/04/20 at 10:30 AM, the nurse completed Resident # 7 wound care in the presence of the surveyor. The nurse took saline solution (a small bottle dated 2/2/20), a small white gauze dressing with a tape border and a plain 4 x 4 gauze from the treatment cart. The LPN brought the items into the resident's room and placed them on a nightstand. The nurse did not lay down a clean barrier or clean the area prior to setting the items down. The nurse then washed her hands, put on gloves and removed the sacral dressing dated 2/2/20. Next, the nurse took off the gloves. Without washing her hands, the LPN opened the new dressing, removed a pen from a personal pouch the nurse was wearing around her waist. The LPN proceeded to write the date on new dressing and then placed pen back in the pouch. After placing the pen back into the bag, the nurse washed her hands a second time. The nurse placed on another pair of gloves and cleaned the wound with a gauze dressing and normal saline solution. Without washing hands or changing gloves after cleansing the wound the nurse applied the new dressing to the sacral wound. On 02/04/20 at 12:43 PM, the surveyor reviewed the physician orders dated 2/1/2020. There was an order to cleanse sacral wound with normal saline solution, apply triad paste to wound base and pack with gauze including the area of undermining. Cover with dry dressing then cover with border dressing, daily. On 02/04/2020 at 01:30 PM, the surveyor interviewed the nurse who performed the wound care. The surveyor questioned the physicians order and why the triad paste was not applied, and the nurse said the facility was waiting for a delivery from the hospice nurse. On 02/06/20 at 10:22 AM, the surveyor reviewed the facilities policy titled wound care. The policy was not dated. The policy read that prior to placing wound care supplies down, an area must be cleaned, or a barrier was to be laid down. The policy also indicated that the nurse was to wash hands thoroughly after removing the old dressing. On 02/06/20 at 12:50 PM, the surveyor reviewed a wound care competency for the LPN dated 01/08/2020. The competency was completed by the Assistant Director of Nursing (ADON). The wound competency showed that the LPN had to be reminded by the ADON during wound care to wash hands after removing old dressing and removing gloves. NJAC 8:39-19.4 NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation on 2/05/20 in the presence of the facility management, it was determined that the facility failed to ensure that 12 of the 39 double occupancy resident rooms were provided with a minimum of 80 square feet of useable living space per bed. This deficient practice was evidenced by the following: During the previous facility survey on 02/09/18, the facility had 30 rooms that did not meet the 80 square feet per resident in a multiple resident room requirement. All rooms were re-measured using a laser-guided measurement system. The following double occupancy resident rooms did not meet the required 80 square feet per resident: -Resident room [ROOM NUMBER] measured 150.033 square feet. -Resident room [ROOM NUMBER] measured 152.066 square feet. -Resident room [ROOM NUMBER] measured 155.971 square feet. -Resident room [ROOM NUMBER] measured 149.662 square feet. -Resident room [ROOM NUMBER] measured 153.281 square feet. -Resident room [ROOM NUMBER] measured 156.243 square feet. -Resident room [ROOM NUMBER] measured 156.621 square feet. -Resident room [ROOM NUMBER] measured 153.714 square feet. -Resident room [ROOM NUMBER] measured 151.888 square feet. -Resident room [ROOM NUMBER] measured 156.691 square feet. -Resident room [ROOM NUMBER] measured 153.975 square feet. NJAC 8:39 - 31.2 (e).