Based on observation, interview, and record review, it was determined that the facility failed a.) to treat each resident with respect and dignity and b.) care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life recognizing each resident's individuality. This deficient practice was identified for 1 of 35 residents reviewed for dignity (Resident #206), and was evidenced by the following: On 4/29/25 at 11:09 AM, during initial tour of the facility, the surveyor observed a Certified Nurse Aide (CNA #1) walking alongside Resident #206 in the hallway towards the shower room. CNA #1 and Resident #206 entered the shower room, and the door closed. The surveyor then heard Resident #206 begin to yell inside the shower room. At that time, CNA #1 opened the door and asked for the facility's translator to assist with translating the resident's needs. The Translator entered the shower room, and the surveyor observed the resident, who was still fully dressed, speaking with the Translator who then informed CNA #1 that the resident did not want to be showered by him. At that time, CNA #2, who was a few doors down the hallway, came out of a resident's room and was laughing, approaching CNA #1. CNA #2 stated, I won the bet, I told you [the resident] wasn't going to shower. At that time, CNA #1, CNA #2, and Resident #206 left the vicinity of the shower room and escorted the resident back to their room. CNA #1 and CNA #2 then came out into the hallway, away from the resident's room, stood by the nurse's station and CNA #2 stated to CNA #1, I told you (the resident) only wants the son or daughter to shower. That was when CNA #1 began to imitate in a mocking manner the resident's yelling as the resident did in the shower room, both CNA #1 and CNA #2 laughed and walked away from the nurse's station and continued with other duties. On 4/29/25 at 11:13 AM, the surveyor interviewed the Chinese Program Manager (CPM), who stated Resident #206 refused showers and only wanted their son or daughter to provide showers to them. On 4/29/25 at 11:15 AM, the surveyor interviewed CNA #2, who stated that she usually was assigned to care for Resident #206, but today she was not. On 5/6/25 at 1:39 PM, the surveyor interviewed CNA #2, who stated that she was provided training and education by the facility upon hire regarding resident rights, dignity, and respect. CNA #2 stated Resident #206 was confused at times, but was consistent with wanting only family to provide their shower. CNA #2 stated that she informed CNA #1 that Resident #206 would refuse to be showered, but CNA #1 bet that he could give Resident #206 a shower. CNA #2 acknowledged that CNA #1 and CNA #2 laughed and stated it was because CNA #1 lost the bet and the resident refused to shower. On 5/6/25 at 1:51 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) and the Director of Nursing (DON), who both acknowledged that all residents were to be treated with respect and dignity and for all staff to always respect their preferences. The surveyor informed them of the observation made of CNA #1 and CNA #2 with Resident #206, and both the DON and LPN/UM stated that was absolutely not acceptable behavior and should not be tolerated. A review of the facility's Dignity policy with effective date of 2/1/24, included but was not limited to: a facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality . NJAC 8:39-4.1(a)(12)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order to carry out a resident's wishes for code status. This deficient practice was identified for 2 of 38 residents reviewed for code status and advanced directives (Residents #167 and #230), and was evidenced by the following: 1. On 4/29/25 at 12:34 PM, the surveyor reviewed Resident #167's electronic medical record (EMR). A review of the admission Record face sheet (an admission summary) indicated that the resident was re-admitted to the facility with diagnosis which included but were not limited to; malignant neoplasm of colon (malignant colon cancer), malignant neoplasm of the liver (liver cancer), and malignant neoplasm of the lung (lung cancer). A review of the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) indicated the resident's wishes were to be a Do Not attempt resuscitation (DNR) and allow natural death and Do not intubate (DNI) in the event the resident had no pulse and/or was not breathing (code status), which was signed and dated 12/13/24. A review of the Physician Order Summary did not include a physician's order for the resident's code status to honor the resident's wish to be DNR and DNI. On 5/1/25 at 11:07 AM, the surveyor interviewed the Certified Nursing Aide (CNA #1), who stated she was not aware of Resident #167'2 code status and that she would have to ask the nurse. On 5/1/25 at 11:20 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated a physician's order was required in the resident's medical record to indicate the code status of the resident so that the nursing staff knew what to do to honor the wishes of the resident in the event of an emergency. On 5/1/25 at 11:44 AM, the LPN approached the surveyor, and stated that Resident #167's DNR/DNI code status order was not in place previously, and she had since added it to the medical record after surveyor inquiry. The LPN stated whoever took the order did not enter it into the resident's EMR. On 5/1/25 at 11:47 AM, the surveyor interviewed the Registered Nurse/Charge Nurse (RN/CN), who stated that when the POLST form was completed with the resident's wishes for code status and signed by the physician, the code status should have been entered into the resident's EMR as a physician's order to be carried out. The RN/CN confirmed that there had not been an order for the resident's code status. On 5/5/25 at 9:03 AM, the surveyor interviewed the Director of Nursing (DON), who stated that when the POLST form was completed for a resident, then a physician's order should absolutely be put in place and entered into the resident's EMR for code status identification. 2. The surveyor reviewed the closed medical record for Resident #230. A review of the admission Record face sheet indicated that Resident #230 was admitted to the facility with diagnosis which included but were not limited to; benign prostatic hyperplasia (benign prostate enlargement), dementia, and chronic kidney disease and was discharged due to death at the facility on 3/7/25. A review of the POLST which was completed and signed dated 9/29/19, indicated that Resident #230's code status wishes were to be a DNR, DNI, and no artificial nutrition. A review of the Physician Order Summary did not include a physician's order for code status to honor the resident's wish to be DNR, DNI, and no artificial nutrition. A review of the Progress Notes included a Health Note dated 3/7/25 at 4:56 PM, that while doing rounds, CNA #2 reported to this writer that the resident was not responding. The writer attended to the room and found the resident unconscious and non-responsive. The writer attempted to take vital signs, but was unable to obtain. The resident's code status was obtained, and the resident's status was DNR and DNI. The Nursing Supervisor was called to the unit, and they pronounced the resident at 4:05 PM. On 5/1/25 at 11:20 AM, the surveyor interviewed the LPN, who stated a physician's order was required in the resident's medical record to indicate the code status of the resident so that the nursing staff knew what to do to honor the wishes of the resident in the event of an emergency. On 5/1/25 at 11:47 AM, the surveyor interviewed the RN/CN, who stated that when the POLST form was completed with the resident's wishes for code status and signed by the physician, the code status should have been entered into the resident's EMR as a physician's order to be carried out. On 5/5/25 at 9:03 AM, the surveyor interviewed the DON, who stated that when the POLST form was completed for a resident, then a physician's order should absolutely be put in place and entered into the resident's EMR for code status identification. A review of the facility's undated Advance Directives policy included but was not limited to: the director of nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care . NJAC 8:39-4.1(a)

Complaint #NJ183871, NJ183873 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan for a.) a resident who was receiving dialysis (a medical procedure that acts as an artificial kidney filtering waste and excess fluid from the blood) treatments and b.) a resident with a surgical wound. This deficient practice was identified for 2 of 35 residents reviewed for care plans (Resident #73 and Resident #531), and was evidenced by the following: 1. On 4/29/25 at 12:13 PM, the Resident #73 was observed in bed with a blanket pulled over their head. The resident did not want to be interviewed. The surveyor reviewed the medical record for Resident #73. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; end stage kidney disease, heart failure, difficulty in walking, and diabetes (high blood sugar). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/22/25, revealed that the resident had a Brief Interview of Mental Status score of 10 out of 15, meaning the resident had moderate cognitive impairment. A review of Section O, Special Procedures, indicated the resident was receiving dialysis treatments on admission to the facility. A review of the physician's orders included an active order dated 2/17/25, for dialysis treatments every Tuesday, Thursday, and Saturday. A review of the resident's dialysis communication book revealed that the facility completed the book every time Resident #73 went out to the dialysis facility. A review of the individualized comprehensive care plan (ICCP) did not include a focus area for dialysis treatments. On 5/6/25 at 1:22 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding care plans. The surveyor asked who was responsible for initiating and updating resident care plans, and the LPN stated it was the responsibility of the Unit Manager. On 5/6/25 at 3:30 PM, the surveyor met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) regarding care plans and who was responsible to initiate, revise, and update care plans on the sub-acute unit. The LNHA informed the surveyor that the Charge Nurse was responsible. The LNHA said the Charge Nurse shared the sub-acute unit and the second floor. 2. The surveyor reviewed the closed medical record for Resident #531. A review of the Face Sheet reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; fracture of the left femur (thigh bone), depression, and cancer of the pancreas. A review of the discharge MDS reflected under Section M, Skin Conditions, the resident had a surgical incision. A review of the physician's orders included order dated 2/13/25, for resident to follow-up with surgeon regarding left hip surgical site. A review of the ICCP did not include a focus area of skin or surgical incision. A review of the Progress Notes dated 2/12/25, revealed that the resident was admitted from an acute care facility and had a surgical incision on the left hip covered with gauze and transparent tape. On 5/6/25 at 1:22 PM, the surveyor interviewed the LPN regarding care plans. The surveyor asked who was responsible for initiating and updating resident care plans, and the LPN stated it was the responsibility of the Unit Manager. On 5/6/25 at 3:30 PM, the surveyor met with the DON and the LNHA regarding care plans and who was responsible to initiate, revise, and update care plans on the sub-acute unit. The LNHA informed the surveyor that the Charge Nurse was responsible. The LNHA said the Charge Nurse shared the sub-acute unit and the second floor. A review of the facility's undated Care Plans policy included that the resident's care plan was developed using the completed resident's comprehensive assessment using the Baseline Care Plan template and care plan were revised as changes in the resident's condition may dictate . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure recommendations by the wound care consultant were implemented to prevent worsening of a pressure ulcer. This deficient practice was identified in 1 of 4 residents reviewed for pressure ulcers (Resident #333), and was evidenced by the following: The surveyor reviewed the medical record for Resident #333. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; kidney failure, hypertension (high blood pressure), and pneumonia. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 4/26/25, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, meaning the resident was cognitively intact. A review of Section M, Skin Conditions, reflected that the resident had a pressure ulcer upon admission to the facility and used a pressure relieving device on the bed. A review of the Nursing admission assessment dated [DATE], indicated that the resident had a sacral wound measuring 4.5 centimeters long (cm) by 2.5 cm wide by 0.1 cm deep. A review of the individualized comprehensive care plan dated initiated 4/19/25, had a focus area of actual alteration in skin integrity as evidenced by a sacral pressure wound. A review of the Wound Consultant Note dated 4/23/25, revealed the resident had an unhealed sacral pressure ulcer with recommendations that included a low air loss mattress to the resident's bed. On 4/30/25 12:16 PM, the surveyor observed Resident #333 in their room in a wheelchair visiting with family. The surveyor then asked the Licensed Practical Nurse (LPN) if the resident was on a low air loss mattress for the pressure ulcer. The nurse replied, No, just a regular mattress. On 5/6/25 at 1:14 PM, the surveyor interviewed the LPN regarding the residents with pressure ulcers or potential to develop them. The LPN informed the surveyor a Braden scale (tool used to assess and predict a patient risk of developing pressure ulcers) was done on admission which would indicate if a resident was at risk for a pressure ulcer. The surveyor asked who would need a low air loss mattress, and the LPN stated if the Braden scale classified them at risk for developing pressure ulcers or a resident had a pressure ulcer, then the resident needed one. The surveyor asked if a low air loss mattresses were available, and she stated that they came from the maintenance department and were in the facility all of the time. On 5/7/25 at 12:15 PM, during an interview with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) regarding Resident #333 and the low air loss mattress, the LNHA informed the surveyor, I can't speak to why there was no air mattress on the resident's bed. A review of the undated facility's Prevention of Pressure Ulcers policy included General Preventative Measures .2. determine if the resident needs a special mattress . NJAC 8:39-27.1(e)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) store all drugs and biologicals in locked compartments and b.) properly store medications and maintain clean and sanitary medication storage areas. This deficient practice was identified in 1 of 1 observed treatment cart and 2 of 6 observed medication carts, and was evidenced by the following: 1. On 4/30/25 at 12:12 PM, the surveyor observed a wound treatment cart on the Second-floor nursing unit by the nurse's station in front of the elevators which was unattended and left unlocked. The surveyor remained near the treatment cart and observed two nursing staff members walk past the treatment cart and did not acknowledge or identify that the treatment cart was unsecured. On 4/30/25 at 12:29 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that treatment carts contained medications and should be treated as medication carts and should always be locked when unattended by the nurse. At that time, the surveyor asked the LPN/UM if the treatment cart was unsecured, and the LPN/UM acknowledged that the treatment cart was left unattended and unlocked and that it should have been locked since it contained medications used for wound treatments and other medications. On 5/1/25 at 12:51 PM, the surveyor interviewed the Director of Nursing (DON), who stated that treatment carts should be treated as medication carts as they contained medications. The DON further confirmed that treatment and medication carts should remain locked and secure when not attended to ensure residents cannot gain access to medications and potentially sharp objects that were stored in treatment carts. A review of the facility's undated Storage of Medications policy included compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if opened or otherwise potentially available to others . 2. On 5/1/25 at 11:30 AM, the surveyor, in the presence of the LPN, inspected the 2B nursing unit's medication cart labeled 2BC. The surveyor observed 17 unidentifiable loose medication pills of various shapes, colors, and sizes. At that time, the LPN confirmed that there should be no loose pills in the medication cart drawers, and all medications should be contained in the packaging as received from the pharmacy. On 5/1/25 at 12:17 PM, the surveyor, in the presence of the Registered Nurse (RN), inspected the 2B nursing unit's medication cart labeled 2B. The surveyor observed 11 unidentifiable loose medication pills of various shapes, colors, and sizes. At that time, the RN confirmed that there should be no loose pills in the medication cart drawers, and all medications should be contained in the packaging as received from the pharmacy. On 5/1/25 at 12:42 PM, the surveyor interviewed the LPN/UM, who confirmed that all medications in the medication carts should be kept in the pharmacy packaging and there should be no loose pills in the medication cart drawers. On 5/1/25 at 12:51 PM, the surveyor interviewed the DON, who stated that all nurses assigned to each medication cart were responsible to ensure the organization and cleanliness of the medication cart and that all medications should be stored in the pharmacy packaging and there should be no loose pills in the drawers. A review of the facility's undated Storage of Medications policy included drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received . NJAC 8:39-29.4(h)

Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents. This deficient practice was identified for 4 of 5 observed resident pantry rooms as evidence by the following: On 5/6/25 at 1:00 PM, the surveyor toured the 1st floor Subacute unit pantry room in the presence of the Food Service Director (FSD). The surveyor observed the following: the counter around the sink and backsplash had black discoloration. The caulking was peeling and blackened along the edge of the sink, behind the sink, and around the faucet. On 5/6/25 at 1:11 PM, the surveyor toured the 2nd floor, 2A, and Chinese unit pantry room, in the presence of the FSD. The surveyor observed the following: the counter around the sink and backsplash had black discoloration and caulking was peeling and blackened along the edge of the sink, behind the sink, and around the faucet, and worn-down laminate countertops exposing the wood type surface under the laminate. On 5/6/25 at 1:23 PM, the surveyor toured the 3rd floor 3B unit, pantry in the presence of the FSD. The surveyor observed the following: the counter around the sink and backsplash had black discoloration and caulking was peeling and blackened along the edge of the sink, behind the sink, and around the faucet. On 5/6/25 at 1:36 PM, the surveyor toured the 3rd floor 3A Indian unit pantry room in the presence of the FSD. The surveyor observed the following: the counter around the sink and backsplash had black discoloration and caulking was peeling and blackened along the edge of the sink, behind the sink, and around the faucet. On 5/6/25 at 1:07 PM, the surveyor interviewed 1A Registered Nurse (RN) charge nurse, who stated it was the nurse's responsibility to enter in electronic requisition system if they are told about an issue or notice an issue themselves. On 5/6/25 at 1:10 PM, the surveyor interviewed the Maintenance Director (MD), who stated, my staff and myself audit and make rounds daily to the pantry rooms. The MD proceeded to say that his expectations of his staff were to report any issues noted during the audit directly to him. If other staff identify a concern, they should be putting it into the electronic system to generate a ticket requisition. The MD confirmed he did not see any issues in the pantries, and there were not any request tickets for pantry room repairs. The MD further stated the issue was not verbalized either. On 5/6/25 at 1:27 PM, the surveyor interviewed the RN, who stated the staff were required to report any issues on the unit verbally to the unit manager and enter a requisition in the facility's electronic maintenance program. The RN further stated she had not entered a ticket for the black discoloration in the pantry. On 5/6/25 at 1:54 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), Regional Chief Operating Officer (RCOO) and the Director of Nursing (DON), who explained that the facility had an electronic request system in place that was monitored by maintenance staff. The surveyor confirmed that all staff have access to the electronic maintenance reporting system. They acknowledged the concerns of the surveyor and pictures visually provided. They had nothing further to provide the survey team regarding their concerns. A review of the facility's undated Homelike Environment policy included the residents are provided with a safe, clean, comfortable and homelike environment .clean, sanitary, and orderly environment . NJAC 8:39 -31.2(e)

Deficiency Text Not Available

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to administer ten doses of an anti-convalescent medication (clonazepam) prescribed for seizures according to physician's orders. This deficient practice was identified for 1 of 35 residents reviewed for quality of care (Resident #47), and was evidenced by the following: On 4/29/25 at 11:324 AM, during initial tour of the facility, the surveyor observed Resident #47 lying in their bed with the bed positioned low with a fall mat located at the side. On 4/30/25 at 10:49 AM, the surveyor reviewed the medical record for Resident #47. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; hypertension (high blood pressure), seizures (abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control and behavior), and mood disorder (mental health condition that primarily affects your emotional state). A review of the most recent significant change Minimum Data Set (MDS), an assessment tool dated 4/1/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated a severely impaired cognition. A further review included the resident had an active diagnosis of seizure disorder or epilepsy. A review of the Order Summary Report included a physician's order (PO) dated 3/25/25, for clonazepam oral tablet 1 milligram (mg); administer one tablet by mouth one time a day for seizure. A further review revealed a PO dated 3/25/25, for lamotrigine (anti-convalescent medication) oral tablet 100 mg; administer one tablet by mouth two times a day for seizure. A review of the individualized comprehensive care plan (ICCP) included a focus area date initiated on 5/17/21, that the resident has a seizure disorder. Interventions included but were not limited to; give seizure medication as ordered by the doctor, seizure documentation, and seizure precautions. On 4/30/25 at 1:06 PM, the surveyor reviewed the March 2025 and April 2025 Medication Administration Records (MAR) which revealed the clonazepam 1 mg oral tablet was not administered on the following dates: 3/26/25, 3/27/25, 3/29/25, 3/30/25, 3/31/25, 4/1/25, 4/3/25, 4/4/25, 4/5/25, and 4/6/25. A further review of the March 2025 and April 2025 MAR revealed Resident #47 received the lamotrigine oral tablet 100 mg tablet by mouth two times a day for seizure as ordered by the physician. On 5/1/25 at 12:23 PM, the surveyor reviewed the Progress Notes in the electronic medical record (eMR) which revealed the resident did not have any seizure activity during March 2025 or April 2025. On 5/6/25 at 12:54 PM, the surveyor interviewed the Registered Nurse (RN #1), who stated medications were delivered three times a day. RN #1 further stated that the process when a medication was not delivered was to call the pharmacy, call the Nurse Practitioner (NP), complete a progress note and endorses it to the next shift. RN #1 acknowledged that the clonazepam was not administered as ordered. RN #1 also confirmed that the resident did not have any seizures during that time. On 5/6/25 at 1:00 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated medications delivery times vary but if a medication did not come in, the nurse should call the pharmacy to request it immediately (STAT). LPN #1 acknowledged that the resident did not receive the clonazepam as ordered on 3/26/25. LPN #1 further stated that the resident had not had any seizures during that time. On 5/6/25 at 2:35 PM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Nurse, and the survey team, acknowledged that the clonazepam was not administered as ordered. On 5/7/25 at 11:12 AM, the LNHA, in the presence of the Director of Nursing and survey team, could not provided any additional information. A review of the facility's Orders and Transcription policy undated, included 1. The nurse receiving the order must add it into [the electronic medical system] orders as a verbal order or telephone order. A review of the facility's Delivery of Medications from Satellite (Back-Up) Pharmacy, revised 9/6/19, included Purpose: To provide medications in a timely manner by utilizing satellite (back-up) pharmacies to dispense medications that are needed by a facility sooner than the facility's regularly scheduled delivery .1. The facility may call the pharmacy and request STAT delivery. Specialty Rx (prescription) has a 3-4-hour window to deliver a medication as a STAT from our main location. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to a.) maintain kitchen equipment in a clean and sanitary manner and b,) maintain 2 of 6 nourishment room refrigerators in a sanitary manner. The evidence was as follows: On 4/29/25 at 10:20 AM, in the presence of the Food Service Director (FSD) and the Regional FSD, the surveyor observed the following during kitchen tour: 1. The steamer unit floor drain was filled with debris and sediment. The FSD acknowledge it was not properly cleaned according to facility policy. 2. Two convection ovens were soiled with baked on brown coloring on the glass doors and interior of the unit. The FSD acknowledged and stated, it was not cleaned according to facility policy. 3. Two steamer units were drained into a floor trap and the trap screen had debris covering it. The FSD acknowledged and stated, it was not cleaned according to facility policy. 4. The six-burner stove top and oven were covered with cooked on grease and sediment crusted around the burners. The oven had food sediment and debris on the interior and the interior door. The catch tray that was lined with foil had burnt liquid, and food debris covering the entire tray and foil. The FSD acknowledged and stated, it was not cleaned according to facility policy. On 5/6/25 at 1:31 PM, in the presence of the FSD, the surveyor observed the nourishment rooms as evidence with the following . 5. Both Unit 3A and 3B nourishment room refrigerators for resident use on the unit were observed to have discoloration and debris in the gaskets of the refrigerator door and freezer door. The FSD acknowledged and stated it was not cleaned according to facility policy, and it was his departments responsibility to maintain or report any issues in the nourishment rooms. 6. In the 3A (locked unit) nourishment room microwaves had crusted brown colored debris stuck to the roof of the microwave. The FSD acknowledged and stated, it was not cleaned according to facility policy, and it was his departments responsibility to maintain or report any issues in the nourishment rooms. 7. In all six nourishment rooms did not have properly documented temperatures for the freezer. The surveyor observed the temperatures to be in the correct range. The FSD acknowledged the logs his staff were documenting on only had a date column, AM temp column, and PM temp column for only the refrigerator. On 5/6/25 at 1:36 PM, the surveyor interviewed the FSD, who stated that he acknowledged that the equipment should have been cleaned and maintained in a sanitized way to prevent food borne illness and contamination for safety of our residents and staff. On 5/6/25 at 12:45 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), who both acknowledged the surveyor's concerns. No additional information was provided. A review of the facility's undated, Sanitation policy included food service area shall be maintained in a clean and sanitary manner .all kitchens and kitchen area, shall be kept clean .to protect from rodents, roaches, flies and other insects . A review of the facility's undated Resident Rights handout included the facility must provide a safe, clean, comfortable, homelike environment, allowing you the opportunity to use your personal belongings to the extent possible . NJAC 8:39-17.2(g)

Complaint # NJ160740, NJ166295, NJ167271, NJ169912 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 07/24/2024, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice for 1 of 3 residents (Resident #3) . The facility also failed to follow its policy titled Administering Medications. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem. According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to, Essential Hypertension (high blood pressure), Hyperlipidemia (elevated cholesterol), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Diabetes (high blood sugar levels). A review of the 05/08/2024 Quarterly Minimum Data Set (MDS), an assessment tool reflected that the Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was cognitively intact. A review of the Order Summary Report (OSR) Active Orders as of 07/24/2024 included the following Physician's Orders (Pos): Clopidogrel Bisulfate Tablet 75 mg Give 1 tablet by mouth one time a day. Escitalopram Oxalate Tablet 20mg Give 1 tablet by mouth one time a day. Amlodipine Besylate Tablet 5mg Give 1 tablet by mouth two times a day. Eliquis 2.5mg Tablet Give 1 tablet by mouth two times a day. Metformin HCL Tablet 1000mgs Give 1 tablet by mouth two times a day. Vitamin D3 5000 Unit Tablet Give 1 tablet by mouth one time a day. During an interview with Resident #3 on 07/24/2024 at 10:13 A.M., the Surveyor observed six pills in a medicine cup on Resident # 3's bedside table. Resident #3 stated the nurse left the pills and never gave me water. On 07/24/2024 at 10:20 A.M., the Surveyor notified the Charge Nurse of pills in medicine cup on Resident #3's bedside table. The Charge Nurse removed the medicine cup with pills from Resident #3's bedside and notified the Registered Nurse (RN#1) assigned to Resident #3. The Surveyor attempted to interview RN #1 on 07/24/2024 at 10:23 A.M., but RN #1 was not available at that time. During an Interview with the Surveyor on 07/24/2024 at 10:23 A.M., the Charge Nurse stated, the expectation was not to leave medications unattended in a resident's room. The Charge Nurse further stated the expectation for nurses was to ensure residents took their medications before leaving the resident's room. During an interview with the Surveyor on 07/24/2024 at 1:02 P.M., RN #1 stated, this morning was a mistake. RN #1 further stated she became distracted with Resident #3's roommate and did not observe Resident #3 take their medications. RN #1 stated expectation was to make sure resident took medications prior to leaving room. RN #1 stated she should not leave room without ensuring medications are taken by resident. RN #1 was able to confirm that medications in the medicine cup found at Resident #3's bedside were Clopidogrel Bisulfate Tablet 75 mg, Escitalopram Oxalate Tablet 20mg, Amlodipine Besylate Tablet 5mg, Eliquis 2.5mg Tablet, Metformin 1000mg, and Vitamin D3 5000 Unit. During an interview with the Director of Nursing (DON) on 07/25/2024 at 4:45 P.M., the DON stated the expectation was the nurse should have ensured that the resident swallowed the pills with water or juice. The DON further stated, I would never expect the nurse to leave medications at the resident's bedside. The DON stated, it was important that the nurse ensures the resident swallows their medication to ensure they are getting the medication that they need. Review of the undated facility policy titled, Administering Medications revealed under Policy Statement, Medications shall be administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation, 15. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. NJAC 8:39-29.2(d)

Based on observation, interviews, review of the medical record and other facility documentation, it was determined that the facility failed to ensure that a resident's mattress was maintained in a clean, sanitary, and homelike manner on 1 of 8 nursing units (Memory Care Unit). This deficient practice was evidenced by: During the initial tour of the facility on 02/21/21 at 11:08 AM, the surveyor observed Resident #108 seated in a wheelchair at the bedside beside his/her bed which was stripped. The mattress was heavily stained and soiled, with deep creases noted to the upper portion of the mattress. There was a strong smell of urine in the resident's room. The resident appeared well groomed and dressed and was not able to be interviewed due to his/her cognitive status. The surveyor inspected the bathroom and trash cans in the room which did not contain any waste products that would have contributed to the odor in the room. During an interview with the surveyor on 03/01/23 at 11:39 AM, Certified Nursing Assistant (CNA) #2 stated that Resident #108 sometimes did not make it to the restroom in time and was incontinent. CNA #2 stated that the resident would remove the sheets off of the bed if they were wet and even attempted to place them in the soiled laundry. CNA #2 stated that housekeeping wiped the bed down prior to the CNA making the bed. During an interview with the surveyor on 03/02/23 at 12:49 PM, CNA #2 stated that she reported the condition of the resident's mattress and ensured that it was replaced with a new one as the old mattress was stained despite being sanitized daily by housekeeping. During an interview with the surveyor on 03/06/23 at 11:41 AM, Registered Nurse Unit Manager (RNUM) #1 stated that the CNA or Housekeeping should have told the nurse or called housekeeping who would switch out the resident's mattress. RNUM #1 stated that everything was done verbally by phone, but there was a book where staff could document concerns for maintenance to address. RNUM #1 reviewed the book in the presence of the surveyor and stated that she did not see that the soiled mattress was referenced for replacement. During an interview with the surveyor on 03/06/23 at 11:49 AM, Housekeeper #1 stated that she notified the [NAME] about the condition of Resident #108's mattress and requested that it be replaced. Housekeeper #1 stated that there was a brand new mattress in the resident's room now. During an interview with the surveyor on 03/06/23 at 12:17 PM, the [NAME] stated that he discarded Resident #108's soiled mattress in the garbage and replaced it with a new one. During an interview with the surveyor on 03/07/23 at 11:51 AM, the Infection Preventionist (IP) stated that Resident #108's mattress should have been discarded if it were stained and smelled of urine. The IP stated that the Housekeeper should have been notified and the mattress should have been discarded. The IP stated, the mattress was a harbor for bacteria. During an interview with the surveyor on 03/10/23 11:24 AM, the District Manager (DM) and the Administrator were present. The DM stated that she had documentation to demonstrate that Resident #108's mattress was inspected in January and February. The surveyor presented the DM and the Administrator with a photograph of the resident's mattress for review. DM confirmed that there was visible staining and a white, chalky, raised residue was noted on the bottom portion of the mattress. The DM also stated that there was a visible crease on the mattress which could retain odors and harbor bacteria. The Administrator stated that the mattress was brown in color and the remainder of the mattresses at the facility were blue, so he was unable to determine the age of the mattress. The Administrator stated that he was unable to provide the surveyor with documented evidence that a staff member had reported a concern with the condition of the mattress prior to surveyor inquiry. The Administrator viewed the photo of the mattress once more and stated, That was a good call, that was a bad mattress. The Administrator was in agreement that the mattress should have been replaced for sanitary reasons. Review of the facility policy titled, Mattress Care (Reviewed 01/11/23) revealed the following: Policy: It is the policy of Embassy Manor to provide its residents with clean and comfortable bedding experience. Procedure: 1. C.N.A. (Certified Nursing Assistant) will strip the bed of any/all soiled linen 2. Housekeeper will remove the mattress from the bed and spray the frame down with a disinfectant. Housekeeper will allow for proper dwell time. 3. Spray the mattress front and back with proper disinfectant. Housekeeper will allow for the proper dwell time. 4. Housekeeper will wipe the mattress down with a clean rag from front to back. 5. Then spray the mattress again with the disinfectant and wipe again. 6. If there are any holes or worn indications please report to the Housekeeping Supervisor for replacement. NJAC 8:39-31.4

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to develop a person-centered comprehensive care plan to address a resident's contracture for 1 of 3 Residents (Resident #77) reviewed for range of motion. This deficient practice was evidenced by the following: On 2/21/23 at 11:52 AM, Resident #77 was observed in wheelchair with their right hand contracted and bent at wrist with downward flexion. The resident was unable to follow commands. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 1/22/23, identified the resident as severely impaired and with impairments on both sides of the upper and lower extremities. A review of the medical record indicated that Resident #77 was admitted to the facility with diagnoses which included, but not limited to: Hemiplegia (severe or complete loss of strength) and Hemiparesis (mild loss of strength) following nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain) affecting the right dominant side. A review of Resident #77 care plan on 2/23/23 did not reflect this resident's contracture. During an interview with the surveyor on 3/2/23 at 11:51 AM, Licensed Practical Nurse (LPN) #1 confirmed that contractures should be identified on the care plan. During an interview with the surveyor on 3/2/23 at 12:09 PM, Registered Nurse Unit Manager (RNUM) #1 stated that contractures should be identified on the care plan, especially on the baseline care plan. Upon reviewing the Resident's electronic medical record, RNUM#1 confirmed that there was no care plan for contractures. During an interview with the surveyor on 3/8/23 at 1:05 PM, Assistant Director of Nursing (ADON) confirmed that Resident #77's contracture and interventions should have been identified on the care plan. A review of the facility's policy titled Care Planning for Long Term Care, with a reviewed date of 1/26/23, revealed under Policy that, The care plan is designed to ensure that residents receive appropriate care and treatment to address problems and needs on an ongoing basis. The goal of the care plan is to implement interventions that help achieve optimal outcomes, and to communicate and coordinate the support of resident needs and goals. A review of the facility policy titled Comprehensive Care Plan, with a reviewed date of 1/26/23, revealed under Policy that, The Comprehensive Care Plan includes the instructions needed to continue to provide effective and person-centered care that meets the professional standard of quality care. Each patient will have a person-centered comprehensive care plan that is developed and implemented to meet all of their preferences, goals and addresses all clinical, physical, mental and psychosocial needs. NJAC 8:39-11.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, it was determined that the facility failed to revise and update the care plan (CP) in a timely manner for residents who had falls. This deficient practice was identified for 2 of 35 residents reviewed for comprehensive care plans, (Residents #130 and #264) and was evidenced by the following: 1. On 2/21/23 at 11:22 AM, Resident #130 was observed sleeping in bed. According to the admission Record, Resident #130 was admitted to the facility in July 2022 with diagnoses which included but were not limited to; unspecified dementia. Review of the Quarterly Minimum Data Set (MDS), an assessment tool dated, 2/13/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 5 out of 15 which indicated that the resident had severely impaired cognition. Additional review revealed that the resident had a diagnosis of dementia, required extensive assist of one staff with transfers, and had two falls since the prior assessment. Review of an incident report (IR) dated, 1/11/23 at 8:25 AM, revealed that Resident #130 was observed lying on the floor next to their bed. Neurological checks were initiated, the resident denied pain and there were no visible injuries. The resident was seen by the Nurse Practitioner and orders were obtained for laboratory work, and bilateral hip and knee X-rays. Further review of the IR indicated an investigation was completed on 1/12/23. The investigation summary did not indicate if the care plan was revised or if an intervention was put into place after the fall. Review of the resident's CP included a focus dated 5/19/22 which indicated that the resident was at risk for falls due to confusion, gait/balance problems, incontinence, poor comprehension, unaware of safety needs and a history of falls. The goal was for the resident to be free from falls for 90 days. The care plan included interventions dated, 5/19/22, to anticipate and meet the resident's needs, ensure the resident was wearing appropriate footwear, encourage the resident to participate in activities, the call light was within reach, follow facility fall protocol, safe environment, referral to rehab. Additional interventions for rehab referral for post fall screening were dated 8/9/22, 10/10/22 and 11/28/22. There was no documented evidence that Resident #130's care plan was revised or updated with an intervention for the fall that occurred on 1/11/23. 2. On 2/21/23 at 11:27 AM, Resident #264 was observed awake and in bed. According to the admission Record, Resident #264 was admitted to the facility in June 2022 with diagnoses which included but were not limited to; Alzheimer's disease. Review of the resident's Quarterly MDS dated [DATE], revealed that the resident had short and long term memory impairments, required extensive assist of one staff for bed mobility and transfers. Further review revealed that the resident did not have any falls since the last assessment. Review of an IR dated 1/4/23 at 5:30 AM, revealed the resident was observed sitting on the floor in their room with active bleeding from an opened area to the resident's left hand. A pressure dressing was applied, and the resident was transferred to the emergency room. A referral was made to rehab for a post fall evaluation upon return from the emergency room. Review of the Progress notes dated 1/5/23 at 5:37 PM, revealed the family had requested a bed alarm. Review of the resident's January 2023 Treatment Administration Record (TAR) revealed, bed alarm check for function every shift with a start date of 1/5/23. Review of Resident #264's CP revealed a focus dated 6/3/22 that the resident was at risk for falls related weakness of bilateral lower extremities. The goal date 6/3/22 was that the resident would not sustain serious injury through next review date. Interventions dated 6/3/22, included but were not limited to: anticipate and meet the resident's needs, call light within reach, ensure the resident is wearing appropriate footwear. Additional review of the CP revealed that the intervention for a rehab referral was added to the CP on 1/28/23 (24 days after the 1/4/23 fall) and the bed alarm was added to the CP on 2/9/23 (over a month after the 1/4/23 fall). During an interview with the surveyor on 3/2/23 at 09:40 AM, the Licensed Practical Nurse Unit Manager (LPNUM) #1 stated that the staff had a fall meeting after every fall to discuss interventions, and what could be done to prevent another fall. She stated the CP would be updated by the Assistant Director of Nursing (ADON), unit managers, or nurses. During a follow up interview with the surveyor on 3/3/23 at 11:49 AM, the surveyor reviewed Resident #130 and Resident #264's CP with the LPNUM #1. The LPNUM #1 stated there should be a CP intervention on Resident #264's 1/4/23 fall care plan. She stated Resident #130 may have had the same interventions in place. She stated resident falls were discussed in morning meeting to see if there were new interventions for the CP. She stated the CP may not be updated during the meeting, but would updated when interventions were in place. During an interview with the surveyor on 3/6/23 at 11:30 AM, the Director of Nursing (DON) stated that falls were discussed daily at morning meetings. Physical therapy would look at every fall and would do a screen and evaluation. She stated that the ADON was responsible for review of every fall investigation and update of interventions. She stated the ADON called staff to determine what happened and would put in the summary of the IR. The DON stated that every fall should have an intervention on the care plan. During an interview with the surveyor on 3/7/23 at 11:03 AM, the ADON stated falls were thoroughly discussed in the morning meeting, and that the Rehab Director would be present. She further stated falls were discussed to determine the cause, and then the resident's care plans were updated. The ADON stated she reviewed falls, and made sure the CP's were updated. The surveyor reviewed the IR and careplans for Resident #130 and Resident #264 with the ADON. The ADON confirmed she did not see the interventions on the printed copy of the CP. The ADON went on the computer to review the CPs and stated the interventions for #264's fall on 1/4/23 was a referral to rehab but she did not click save on the CP so it did not go on to the CP timely. The ADON continued to look on the computer for interventions for Resident #130's 1/11/23 fall and confirmed she did not see that the CP was updated. She stated,interventions were aspirin on hold, reeducate immediately, kept in line of site, when in room increase supervision, and increased group activity. The ADON confirmed that those interventions were not on the CP or on the investigation summary and should have been. She stated the purpose of the investigation summary was to discuss what was done to prevent further falls. During a follow up interview with the surveyor on 3/8/23 at 11:02 AM, the ADON stated she was supposed to ensure that interventions were updated on the resident's CP timely. Review of the facility's Fall Prevention and Post Fall Management Policy, dated February 1, 2021 with a revised date of February 1, 2022 revealed, The Interdisciplinary Team (IDT) would review on admission, and update the resident's fall prevention care plan at least quarterly, whenever a significant change occurs and after a fall occurrence. Review of the facility's Care planning for Long Term Care Policy, dated February 1, 2021 with a reviewed date of January 26, 2023, revealed, Purpose: the care plan provides a systematic, comprehensive, and interdisciplinary method for the resident to identify treatment and care. Policy: The care plan is designed to ensure that residents receive appropriate care and treatment to address problems and needs on an ongoing basis. The goal of the care plan is to implement interventions that help achieve optimal outcomes, and to communicate and coordinate the support of resident needs and goals. NJAC 8:39-11.2(e)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure a resident who was dependent on supplemental oxygen via a tracheostomy tube (a surgically created hole (stoma) in the windpipe (trachea)) received supplemental oxygen in accordance with physician orders for 1 of 2 residents reviewed for tracheostomy care (Resident #66). This deficient practice was evidenced by: During the initial tour of the building on 02/21/23 at 12:36 PM, the surveyor observed a stop sign posted outside of Resident #66's room which cautioned that an N 95 mask (filters 95% of particles) was required to enter the resident's room. From the doorway, the surveyor observed Resident #66 lying in bed asleep with the head of bed elevated. The resident had a tracheostomy tube and was noted to have a positive cough. According to the admission Record (an admission summary) Resident #66 was readmitted to the facility in August of 2022 with diagnoses which included but were not limited to: Cerebral infarction (stroke), aphasia (a language disorder that affects a person's ability to communicate) respiratory failure, tracheostomy, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and gastroesophageal reflux disease without esophagitis (occurs when stomach acid repeatedly flows back into the tube connecting the mouth and stomach (esophagus)). Review of Resident #66's Annual Minimum Data Set (MDS), an assessment tool dated 02/25/23, revealed that the resident was rarely/never understood, had a memory problem and never/rarely made decisions. Further review of the MDS revealed that the resident was totally dependent with the assistance of two persons for both bed mobility and transfers and was totally dependent with assistance of of one person for feeding assistance. Further review of the MDS revealed that the resident received nutrition via a feeding tube and also received a mechanically altered diet (e.g. purred food, thickened liquids). The MDS specified that the resident received special treatments which included oxygen therapy, suctioning and tracheostomy care. Review of Resident #66's Care Plan (CP) revealed an entry initiated on 07/27/22 which detailed that the resident had a tracheostomy related to respiratory failure. Further review of the CP revealed an intervention that was also initiated on 07/27/22 for oxygen settings of eight liters per minute (lpm) via tracheostomy, humidified, suction as necessary and trach care every shift. Review of Resident #66's Order Summary Report revealed an entry dated 08/05/22 for O2 (oxygen) at eight lpm via trach collar continuously every shift for chronic respiratory failure. On 02/23/23 at 9:36 AM, the surveyor observed Resident #66 lying in bed awake with the head of bed elevated. The resident had a portable concentrator (medical device that delivers continuous, concentrated oxygen) that was set to deliver oxygen at 10 lpm. The resident was able to speak in short, simple sentences when spoken to and voiced no concerns. On 02/24/23 at 10:13 AM, the surveyor observed Resident #66 lying in bed asleep with the head of bed elevated. The oxygen concentrator was set at seven lpm via trach collar. On 02/28/23 at 11:21 AM, Resident #66 was observed lying in bed with the head of bed elevated and the resident's oxygen concentrator was set at seven lpm via trach collar. On 03/01/23 at 12:30 PM, Resident #66 was observed lying in bed asleep with the head of bed elevated and the resident's oxygen concentrator was set at seven lpm via trach collar. During an interview with the surveyor on 03/03/23 at 10:55 AM, Licensed Practical Nurse (LPN) #4 stated that Resident #66 was ordered continuous oxygen at eight lpm delivered via the concentrator. LPN #4 looked at the concentrator setting and agreed that the concentrator was set to deliver seven lpm instead of eight lpm of oxygen as ordered. LPN #4 then attempted to turn the dial to increase the oxygen setting from seven liters to eight but was unable to do so. LPN #4 stated that she would obtain a new concentrator. During an interview with the surveyor on 03/03/23 at 1:29 PM, the Director of Nursing (DON) stated that there was an order for Resident #66 to have oxygen at eight lpm and nursing was responsible to check the rate and ensure accuracy. During an interview with the surveyor on 03/06/23 at 11:15 AM, Registered Nurse Unit Manager (RNUM) #1 stated that oxygen orders were based on physician orders and nurses were required to round and ensure that the settings were maintained. RNUM #1 stated that she thought that Resident #66's oxygen order was changed to five lpm via concentrator after the weekend supervisor phoned the primary physician. On 03/06/23 at 12:09 PM, the surveyor observed Resident #66 lying in bed asleep with the head of bed elevated. The surveyor observed that the concentrator was placed in the corner of the room and was not in use. The resident had an air compressor (device used to deliver compressed air) on the night stand to the left of the resident that was set at 35% humidification and there was no concentrator beside the resident to deliver oxygen as described by RNUM #1. During an interview with the surveyor on 03/06/23 at 12:14 PM, LPN #4 stated that they had to change Resident #66's concentrator, so she changed it. LPN #4 stated that the resident's current oxygen order was for five lpm with 35% humidification. When the surveyor asked LPN #4 to demonstrate how the oxygen was delivered to the resident if the concentrator was not utilized she was unable to answer the question and instead stated, A technician set it up for us. During an interview with the surveyor on 03/06/23 at 12:48 PM, RNUM #1 accompanied the surveyor into Resident #66's room to view and clarify the resident's respiratory equipment against the current physician's order for five lpm of oxygen via trach collar continuously via compressor with 35% FIO2 (fraction of inspired oxygen). The RNUM #1 viewed the equipment and stated, I do not know why they set it up like that. RNUM #1 stated that she was unable to tell if the resident received five liters of oxygen as ordered. RNUM #1 stated that she would find out and report back to the surveyor. During an interview with the surveyor on 03/07/23 at 12:39 PM, RNUM #1 stated that when she saw Resident #66's order for five lpm of oxygen which did not match the respiratory equipment that was set up in the room she spoke with LPN #4 who informed her that a respiratory supply company technician came in and set it up that way. RNUM #1 stated that she informed LPN #4 that the resident had not received five liters of oxygen because the concentrator was in the corner of the room. RNUM #1 stated that the Assistant Director of Nursing (ADON) had the respiratory supply technician come back out to the facility last night (3/6/23). RNUM #1 explained that when the respiratory supply technician came to the facility initially, they did not bring the adapter (blue piece) that was required to connect the tubing from the concentrator to the compressor and they did not have the attachment either. RNUM #1 further stated the respiratory supply technician should have spoke with the nursing staff and confirmed the oxygen order prior to delivery and set up. RNUM #1 stated that a new concentrator was ordered because the oxygen level would rise and fall on its own and needed to be fixed. RNUM #1 stated, It was important that the resident received the right amount of oxygen because it helped you to breathe and without it, you could stop breathing. On 03/07/23 at 1:03 PM, Resident #66 was observed lying in bed awake with the head of bed elevated. The concentrator was set to deliver 5 lpm of oxygen and the compressor was set to deliver 35% humidification as described by RNUM #1 in accordance with the physician's order that was written on 03/05/23. During an interview with the surveyor on 03/08/23 at 11:16 AM, RN #1 stated that when he cared for Resident #66 over the weekend he was told in report that the resident had new equipment, a compressor, which delivered oxygen to the resident and had replaced the concentrator. RN #1 stated that he was unsure why the resident's equipment was changed. He stated that you could check the dial on the humidification bottle to determine if the settings were correct. During an interview with the surveyor on 03/08/23 at 11:16 AM, ADON stated that the respiratory supply company came to the facility on [DATE] to train the nursing staff regarding trach care as nursing was primarily responsible for trach care. The ADON stated that the plan was to wean Resident #66 from the oxygen for now and later from the trach. During a phone interview with the surveyor in the presence of the survey team on 03/08/23 at 1:27 PM, the Respiratory Therapist (RT), who was employed by the respiratory supply company, stated that she was asked to come out to the facility on [DATE] to perform a whole assessment to assess patient care, what they needed and to take an inventory of supplies. The RT stated that she did not see a problem with Resident #66's concentrator and made a recommendation to maintain the resident on five liters of oxygen with 35% humidification. The RT explained that she was not part of the compressor delivery. She stated that the compressor was air to bleed in oxygen, it was called an air compressor by definition. The RT stated that the concentrator was required in order to delivery oxygen. The RT stated that no concerns were noted as the resident was verbal, cooperative and was in no distress. During an interview with the surveyor on 03/10/23 at 10:19 AM, the DON stated that LPN #4 was not fully educated on the use of Resident #66's compressor prior to surveyor inquiry and required additional in-service training. Review of the facility policy titled, Oxygen Administration (02/01/21) revealed the following: Policy: It is the policy of this facility to provide comfort to residents by administering oxygen when insufficient oxygen is being carried by the blood to the tissues. Procedure: Check physician's order for liter flow and method of administration .A reserve oxygen concentrator/oxygen tank should be available to provide continuity of care . For PRN oxygen order the nurse will provide the oxygen concentrator or tank when needed .Oxygen Concentrators: Set the flow meter to the rate ordered by the physician. Properly affix mask or cannula to concentrator. Unused concentrators will be kept in Central Supply . NJAC 8:39-11.2(b);27.1(a)

**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.) provide privacy and promote dignity during podiatry care for 3 of 3 residents observed (Residents #180, #205 and #264) and b.) provide care and services in a dignified and respectful manner during dining in 1 of 4 dining rooms observed. This deficient practice was evidenced by the following: 1. During the initial tour of the 2A unit on 2/21/23 at 11:13 AM, the surveyor observed the facility's podiatrist and his assistant enter Resident #205's room. Resident #205 was awake and seated in their wheelchair. The podiatrist sat on the floor in front of the resident, put on gloves and removed the resident's socks exposing the resident's toe nails. The Podiatrist opened a blue pad, chux (a disposable under pad) and placed it on the floor underneath the resident's feet. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. The surveyor reviewed the medical records of Resident #205 which revealed the following: Resident #205 was admitted in December 2022 with diagnoses which included but were not limited to: Type 2 diabetes mellitus and cognitive communication deficit. Review of Resident #205's admission Minimum Data Set (MDS), an assessment tool, dated 12/6/22 revealed that the resident had a Brief Interview for Mental Status (BIMS) of 3 out of 15 which indicated that the resident's cognition was severely impaired. On 2/21/23 at 11:27 AM, the surveyor observed the podiatrist enter Resident #264's room. Resident #264 was awake and in bed. The podiatrist put gloves on and introduced himself to the resident as the foot doctor. The podiatrist removed a blue pad from his bag and placed it under the resident's feet on the bed. The door to the resident's room remained opened as the podiatrist stood at the end of the resident's bed and performed toenail care to the resident which was visible to the surveyor in the hallway. The surveyor reviewed the medical records of Resident #264 which revealed the following: Resident #264 was admitted in June 2022 with diagnoses which included but were not limited to: Type 2 diabetes mellitus and Alzheimer's disease. Review of Resident #264's Quarterly MDS, dated [DATE], revealed that Resident #264 had short- and long-term memory impairments. On 2/21/23 at 11:31 AM, the surveyor observed the podiatrist enter Resident #180's room. Resident #180 was awake and seated in a wheelchair. The podiatrist sat on floor, put gloves on, unfolded a blue pad from his bag and put it down onto the floor under the resident's feet. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. The surveyor reviewed the medical records of Resident #180 which revealed the following: Resident #180 was admitted in July 2022 with diagnoses which included but were not limited to Type 2 diabetes mellitus, and dementia. Review of Resident #180's Quarterly MDS dated [DATE], revealed that Resident #180 had BIMS of 3 out of 15 which indicated that the resident's cognition was severely impaired. During an interview with the surveyor on 2/21/23 at 11:36 AM, the podiatrist stated that he usually provided privacy during toenail care by pulling the curtain or sitting in front of the resident to block anyone from seeing, but acknowledged that he did not during those times. During an interview with the surveyor 3/2/23 at 9:40 AM, the Licensed Practical Nurse Unit Manager (LPNUM) #1 stated that the residents should be provided privacy during care, exams, and procedures for dignity of the resident. During an interview with the surveyor on 3/6/23 at 11:38 AM, the Director of Nursing (DON) stated the podiatrist should provide privacy during care. She stated that the Assistant Director of Nursing (ADON) and the Infection Preventionist (IP) had previously spoke to the podiatrist about privacy. 2. On 2/22/23 at 1:21 PM, the surveyor entered the 2A dining room. There were 10 residents present. The surveyor observed a certified nurses aide (CNA) #3 collect two unsampled resident's lunch trays (one after the other) and placed them on the food cart while talking on her cell phone. CNA #3 did not interact with the residents while approaching them to remove their lunch trays. CNA #3 saw the surveyor and put her phone down. At that time, the surveyor interviewed CNA #3 who stated she was on her phone because her son's daycare had called, and she had answered the phone in case it was an emergency. During an interview with the surveyor on 3/2/23 at 10:01 AM, the LPNUM #1 stated that CNAs should not be on their phones in the dining room. If there was an emergency, they should leave the resident area and come back after. During an interview with the surveyor on 3/6/23 at 11:50 AM, the DON stated that staff should not be on their cell phone in front of the resident because it was the resident's home. She added that the staff had been previously in serviced not to use cell phones during care or in the dining room. Review of a facility policy titled, Quality of life, dignity dated February 1, 2021, revised January 3, 2023, included but was not limited to; 1. Residents should be treated with dignity and respect at all times. 6. Resident's private space and property should be respected at all times. 10. Staff shall promote, maintain and protect resident privacy during assistance with personal care and during treatment procedures. Review of a facility policy titled, Cell Phone Usage (including texting, headsets, handsfree, IPADS, tablets, and any other electronic communication devices) dated February 1, 2021 and reviewed on January 26, 2023, included but was not limited to: 1. Employees are not permitted to use cell phones while on their individual work units. Incoming calls to employees should not be answered. If there is an emergency, the employee's family and friends should be instructed to call the main number to the facility. NJAC 8:39-4.1(a)(12)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to: a.) accurately transcribe a physician's order for enteral flushes for 1 of 2 residents reviewed for tube feeding (Resident #23), b.) accurately transcribe a physician's order for contractures for 1 of 3 residents reviewed for range of motion (Resident #77), c.) follow a physician's order for weekly weights for 1 of 5 residents reviewed for weights (Resident #183), d.) ensure urinary output was accurately documented in the medical record for 1 of 3 residents reviewed for foley catheters (Resident #199), and e.) ensure neurological assessments neuro checks were completed for 2 of 4 residents reviewed for accidents (Residents #130 and #264). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 2/24/23 at 9:33 AM, the surveyor observed Resident #23 in bed as staff entered room to perform morning care. A review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 12/8/22, identified Resident #23 as severely impaired and dependent on staff for all aspects of care. A review of the medical record indicated that Resident #23 was admitted to the facility with diagnosis which included, but not limited to: Severe Intellectual Disability, Dysphagia (difficulty in swallowing) and Gastronomy Status (a tube inserted through the abdomen that brings food directly to the stomach). A review of the Order Summary Report (OSR) revealed an order to Flush GT/PEG Tube with 500mL of water every six hours. Flush GT/PEG Tube with an additional 100mL every shift, with a start date of 10/1/2021. The order was implemented with the specific administration times of 0900, 1200, 1700, 2100. A review of the corresponding February and March 2023 Medication Administration Record (MAR) revealed the above order with a check mark and the administrating nurse's initials. During an interview with the surveyor on 03/06/23 at 10:45 AM, Licensed Practical Nurse (LPN) #2 confirmed that medication orders should not be combined into one order but separate. During an interview with the surveyor on 03/06/23 at 10:50 AM, Licensed Practical Nurse Unit Manager (LPNUM) #1 stated that everyone had the responsibility of reviewing orders for accuracy when you give meds you review them. LPNUM #1 also confirmed that 24 hours chart checks were completed by the night shift. Upon reviewing the MAR, LPNUM #1 confirmed that the orders should be separated, and the identified hours were not spaced correctly to correlate every 6 hours. When asked what the dietitian's impression would be upon reviewing the MAR, LPNUM #1 stated, she would be under the impression that the nurses were giving all the hydration. When asked why having two separate orders for the flushes would be important LPNUM #1 responded, there is no way to determine if each flush was given. During an interview with the surveyor on 3/6/23 at 11:30 AM, the Registered Dietitian (RD) reported that she used the nurse's documentation in the progress notes and the MAR for her nutritional assessment. When asked how she determined if the residents received their hydration, the RD reported that she contacted the nurse and they confirm with the MAR. Upon reviewing Resident #23's MAR, the RD confirmed that she was under the impression that the resident was receiving both flushes. The RD also stated that hydration flushes are very specific, and this incorrect order was something that should have been brought to her attention. During an interview with the surveyor on 3/8/23 at 1:05 PM, the Assistant Director of Nursing (ADON) stated that the night shift was responsible for completing 24-hour chart checks and the unit manager was responsible for completing chart reviews. Upon reviewing Resident #23's MAR, the ADON confirmed that the orders should be separated. The ADON also confirmed it was not possible to determine if the resident had received the ordered hydration based on how it was transcribed on the MAR. 2. On 2/21/23 at 11:52 AM, Resident #77 was observed in the wheelchair with right their hand contracted and bent at the wrist with downward flexion. The resident was unable to follow commands. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 1/22/23, identified the resident as severely impaired and with impairments on both sides of the upper and lower extremities. A review of the medical record indicated that Resident #77 was admitted to the facility with diagnosis which included, but not limited to: Hemiplegia (severe or complete loss of strength) and Hemiparesis (mild loss of strength) following nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain) affecting right dominant side. A review of the Order Summary Report (OSR) revealed an order to separate digits at all times with gauze, with an order date of 1/26/23. A review of the corresponding February and March 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect this order. On 2/24/23 at 9:54 AM, Resident #77 was observed without gauze between the fingers of either hand. On 2/28/23 at 10:25 AM, Resident #77 was observed without gauze between the fingers of either hand. On 3/2/23 at 10:07 AM, Resident #77 was observed without gauze between the fingers of either hand. On 3/6/23 at 11:44 AM, Resident #77 was observed without gauze between the fingers of either hand. On 3/8/23 at 11:16 AM, Resident #77 was observed without gauze between the fingers of either hand. During an interview with the surveyor on 3/6/23 at 10:45 AM, Licensed Practical Nurse (LPN) #1 confirmed that she did not have any orders for Resident #77 regarding contractures. During an interview with the surveyor on 3/2/23 at 12:09 PM, Registered Nurse Unit Manager (RNUM) #1 confirmed that the order was received to use gauze to separate the fingers. When asked if this order could be located on the MAR or TAR, the RNUM#1 responded, no. During an interview with the surveyor on 3/8/23 at 1:05 PM, the Assistant Director of Nursing (ADON) stated that the night shift was responsible for completing 24-hour chart checks and the unit manager was responsible for completing chart reviews. Upon reviewing Resident #77's MAR and TAR, the ADON reported that the orders were located on the OSR, so it will never transcribe over. When asked if this order should have been clarified, the ADON responded, yes, it should have. When asked if this order should have been transcribed to the MAR or TAR the ADON stated, yes . A review the facility Policy Titled Physician Orders, with Reviewed Date of 2/1/2023, revealed under Procedure that: 1.The discipline requesting the order will complete the appropriate request in its entirety in the electronic orders Portal and submit on behalf of the resident. 2.The nurse will notify the attending physician or physiatrist to ask for an order based on the disciplines request and then Confirm the orders in the Orders Pending Confirmation Tab. If the physician chooses not to give the order, the nurse must inform the discipline that requested the order. 4.Verbal telephone orders may only be received by licensed personnel (e.g RN, LPN, Physician, etc). Orders must be reduced to writing by the person receiving the order and recorded in the resident's medical electronic record. The entry must contain the instructions from the physician, date, time and the signatures and title of the person transcribing the information. 5.Upon receiving the telephone order, the nurse will transcribe the order in the electronic record, read the order back to the physician, sign with his/her name and document ordered by the physician's name, date, and time the order. 3.On 2/22/2023 at 10:40 AM, Resident #183 was observed in bed sleeping. According to the admission Record, Resident #183 was readmitted to the facility in 10/2022 with diagnoses which included but were not limited to; Type 2 diabetes mellitus and hypothyroidism. Review of the Quarterly MDS dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, which indicated that the resident's cognition was intact. The MDS also revealed that the resident had a weight loss and weighed 146 pounds (lbs). Review of Resident #183's care plan, created on 3/30/22, revised 2/22/23, included that the resident was at risk for altered nutrition/hydration status related to abnormal labs and significant weight loss. An intervention created on 3/30/22 and revised on 2/22/23, included to monitor weights monthly and that the resident had a history of refusing weights despite encouragement and education. Review of the Registered Dietician's (RD) progress notes (PN) dated 11/18/22 included, to initiate weekly weights for four weeks to monitor. Review of a physician's order dated 11/18/22 with a start date of 11/22/22, revealed weekly weight for four weeks, one time a day, every Tuesday, for monitoring. Review of the Resident's November and December MAR did not reflect the 11/18/22 order for weekly weights. Review of Resident #183's weight summary report revealed a weight of 146.2 lbs documented on 12/9/23. There were no weekly weights documented as ordered for 11/22/22, 11/29/22, 12/6/22, and 12/13/22. During an interview with the surveyor on 3/2/23 at 9:50 AM, the LPNUM #1 stated the RD would recommend weekly weights, and would put an order in the computer. She stated the Certified Nurses Aides (CNAs) would obtain the weight, document the weight on paper and the RD would enter the weight in the computer. During an interview with the surveyor on 3/2/23 at 10:43 AM, the RD stated she would put in the order for weekly weights and provided a list to the CNAs and the unit managers. In the presence of the surveyors, the RD reviewed Resident #183's weights and progress notes. She stated that the resident's appetite improved, and the resident's weights were trending up. She confirmed that she did not see the November 2022 ordered weekly weights documented and would follow up. During an interview with the surveyor on 3/3/23 at 10:59 AM the Director of Nursing (DON), in the presence of the RD, stated that there was a documentation error when the RD put the order for weekly weights in the computer. The RD selected no documentation required which was why the order was on the physician order sheet (POS) only and not on the MAR where the nurses would see the order. The DON and RD confirmed there was no documentation of weights based on the order. The DON stated that there should have been documentation if resident refused to be weighed, but the order was only on the POS, it was an error, and the RD clicked the wrong thing. Review of the facility's policy titled, Physicians Orders, revised on February 1, 2022, reviewed on February 1, 2023, included that it was the policy of Embassy Manor to receive requests/recommendations through electronic medical record, orders portal from dietary departments for patient/resident physician orders. Procedure: the discipline requesting the order will complete the appropriate request in it's entirety in the electronic Orders Portal and submit on behalf of the resident .A 24 hour check will be conducted so any transcription errors will be picked up, clarified and then corrected. Upon receiving the telephone order, the nurse will transcribe the order on the electronic record .It is the responsibility of the discipline requesting the order to assure that the order they have requested has been obtained in a timely manner. Review of a facility policy titled, Weights/Weight loss revised January 3, 2023, included Policy: In order to ensure an ongoing and accurate record of a resident's weight as part of the medical record .Procedure: 2. A monthly weight shall be obtained by the assigned certified nurses aide, under the supervision of the licensed nurse or RD. The certified nurses aide shall record the weight on the units monthly tracking sheet. The dietician shall then transcribe the weight on the electronic medical record. 3. A resident may be reweighed for various reasons, i.e significant changes in weight. This shall be recorded in the same manner as procedure #2. 4. On 2/28/23 at 10:35 AM, Resident #199 was observed sleeping in bed. The resident's foley catheter was draining amber colored urine. According to the admission Record, Resident #199 was admitted to the facility in December 2022 with diagnosis which included but were not limited to: urinary tract infection. Review of the resident's admission MDS dated [DATE], revealed that the resident had short and long term memory impairments, and had an indwelling catheter. Review of the resident's care plan dated 12/8/22, revealed that the resident had an indwelling catheter related to obstructive uropathy due to benign prostatic hyperplasia (enlarged prostate). Interventions included to monitor and document intake and output per facility policy. Review of the resident's Order Summary report included an order dated 12/15/22 to monitor urine output every shift for foley catheter. Review of the resident's February 2023 Medication Administration Record (MAR) included the aforementioned order. Additional review of the MAR revealed that 0 was coded as the output for the shift on the following dates and times: 2/6/23 night shift, 2/7/23 day and evening shift, 2/15/23 evening and night shift, 2/17/23 evening and night shift, 2/23/23 evening shift, 2/25/23 night shift, and 2/27/23 night shift. During an interview with the surveyor on 2/28/23 at 10:44 AM, Licensed Practical Nurse (LPN) #4 stated that the nurses entered the resident's output every shift in the Treatment Administration Record (TAR), and Resident #199 had urine output every shift. During an interview with the surveyor on 3/7/23 at 12:17 PM, Registered Nurse (RN) #2 stated nurses monitored and assessed foley catheters, and the urine in the urine bag. The CNAs emptied the urine from the foley bags and notified the nurses of the resident's output. The nurses then documented the output on the MAR. If there was 0 output, the nurse would notify the physician and obtain an order. During an interview with the surveyor on 3/7/23 at 01:03 PM, LPNUM #1 stated nurses observed the resident's foley catheter to make sure it was patent, flowing and there was a certain amount of urine each shift. She stated the CNA's emptied the urine and report the output to the nurse who would document the output on the MAR. The surveyor reviewed Resident #199's February 2023 MAR with LPNUM #1. LPNUM #1 stated, that no one should have a 0 documented, and that she would ask the nurse if the foley was already emptied prior to the documentation on the MAR or if the foley catheter was flushed. During an interview with the surveyor on 3/8/23 at 10:41 AM, the DON stated that nurses should monitor foley catheter output and document the output every shift. She stated the CNAs emptied the foley catheter, measured the output and notified the nurse who would document on the MAR. The DON stated Resident #199 always had urine output and was disappointed that the nurses did not document correctly. The DON stated LPNUM #1 was contacting the nurses for clarification. During an interview with the surveyor on 3/9/23 at 11:30 AM, LPN #5 stated Resident #199 always had urine output on the days she worked, but she inadvertently clicked 0 on the MAR. She stated it was a human error and if there was no output, she would have called the physician. Review of an employee statement form written by LPN #6, dated 3/8/23, revealed that LPN#6 was the assigned nurse for Resident #199 on 2/6/23 and that the resident's foley catheter was patent and draining urine. LPN #6 wrote that the resident had an output of 300 milliliters at the end of the shift, and LPN #6 mistakenly entered 0. Review of a facility's policy titled, Intake and output, effective February 1, 2021, with a reviewed date of January 26, 2023, included but was not limited to; Policy: Accurate intake and output shall be documented, when indicated by a resident's medical condition .Measure and record the amount of each voiding. If the resident has a catheter or other drainage collection device, empty at the end of each shift and record the amount. 5. a. On 2/21/23 at 11:22 AM, Resident #130 was observed sleeping in bed. According to the admission Record, Resident #130 was admitted to the facility in July 2022 with diagnoses which included but were not limited to: unspecified dementia. Review of the Quarterly MDS, an assessment tool, dated 2/13/22, revealed that the resident had a BIMS of 5 out of 15 which indicated that the resident had severely impaired cognition. Additional review revealed that the resident had a diagnosis of dementia, required extensive assist of one staff with transfers, and had two falls since the prior assessment. Review of the resident's CP included a focus dated 5/19/22, that the resident was at risk for falls due to confusion, gait/balance problems, incontinence, poor comprehension, unaware of safety needs and a history of falls Review of an incident report (IR) dated 11/26/22 at 4:00 PM, revealed that Resident #130 was observed lying on the floor on their right side, and the resident had a bump on their forehead. A cold compress was applied, vital signs were checked, neurological checks were initiated. The resident was assisted back to bed. Review of an IR dated, 1/11/23 at 8:25 AM, revealed that Resident #130 was observed lying on the floor next to their bed. The resident was unable to provide a description of the fall. Neurological checks were initiated, the resident denied pain and there were no visible injuries. Review the Neurological Flow Sheet indicated the following: Note: This checklist should be completed at the following intervals for follow up for all unwitnessed falls or falls in which head is struck, initial assessment followed by every 15 minutes x 4, every 30 minutes x2, every hour x2, once per shift for 72 hour[s]. Review of Resident #130's neurological assessment flow sheet's dated 11/26/23 and 1/11/23 revealed neurological assessments were completed for the first four hours after each fall, however there was no documented neurological assessments on the flow sheet for the interval of once per shift for 72 hours. b. On 2/21/2023 at 11:27 AM, Resident #264 was observed awake and in bed. According to the admission Record, Resident #264 was admitted to the facility in 6/2022 with diagnosis which included but were not limited to: Alzheimer's disease. Review of the resident's Quarterly MDS dated [DATE], revealed that the resident had short and long term memory impairments, required extensive assist of one staff for bed mobility and transfers. Further review revealed that the resident did not have any falls since the last assessment. Review of Resident #264's CP revealed a focus dated 6/3/22 that the resident was at risk for falls related to weakness of bilateral lower extremities. Review of an IR dated 1/28/23 at 2:15 PM, revealed that the resident was observed sitting on the floor in front of their wheelchair in the dining room. The resident was unable to provide a description of the fall. Neuro checks were initiated and there were no injuries. The resident was assisted back to the wheelchair. Review of an IR dated 1/28/23 at 10:43 PM, revealed that the resident was observed sitting on the floor by the side of the wheelchair in the activity room. The resident was unable to provide a description of the fall. Neuro checks were initiated and there were no injuries. The resident was assisted to their wheelchair and to their bed. Review of Resident #264's Neurological Assessment Flowsheet dated 1/28/23, revealed that neurological assessments were completed from 2:15 PM though 8:15 PM. There was no further assessments documented on the flow sheet for the interval of once per shift 72 hours. During an interview with the surveyor on 3/2/23 at 10:12 AM, LPNUM #1 stated neurological assessment should be in the resident's chart. The surveyor reviewed Resident #130's and Resident #264's neurological flow sheets with LPNUM #1. The LPNUM #1 was unable to provide additional information. During an interview with the surveyor on 3/7/23 at 11:03 AM, the ADON stated neuro checks would be completed for unwitnessed falls and would be completed to identify any deficits. LPNUM #1 would be responsible to ensure completion. The surveyor reviewed Resident #130 and Resident #264's IRs and neurological assessments with the ADON. The ADON confirmed the assessments were incomplete. Review of a facility policy titled, Fall prevention and post fall management, revised February 1, 2021 included, if an unwitnessed fall occurs or there is a suspected head injury, or if ordered by a physician, a neurological evaluation status post fall will be completed. Documentation for neurological evaluation starts with the time of the fall. The neurological form must be completed. Neurological evaluation will be completed by a nurse only and documented as follows: Initial neurological evaluation includes: Vital signs, level of consciousness, orientation, pupillary reflexes, motor and sensory function. NJAC 8:39-11.2(b), 27.1(a)

Based on interviews, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis schedule for 1 of 2 residents (Resident #71) reviewed for dialysis. This deficient practice was evidenced by the following: During the initial tour of the facility on 02/21/23 at 11:22 AM, the Licensed Practical Nurse (LPN) #3 informed the surveyor that Resident #71 had begun dialysis (the process of removal of excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) approximately one month ago and was presently out of the facility for dialysis treatment. According to the admission Record (an admission summary), Resident #71 was admitted to the facility in January of 2023 with diagnoses which included but were not limited to: End stage renal (kidney) disease, dependence on renal dialysis, anemia (a deficiency of red blood cells or of hemoglobin in the blood that results in pallor (pale appearance) and weariness, essential hypertension (high blood pressure), artherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls), and a nondisplaced fracture of the greater trochanter (located at the top of thigh bone, the widest part of the hip) of the left femur. Review of Resident #71's admission Minimum Data Set (MDS), an assessment tool dated 01/10/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated that the resident's cognition was severely impaired. Further review of the MDS revealed that Resident #71 received dialysis treatments while a resident at the facility. Review of the Order Summary Report revealed a physician's order dated 01/06/23 for Dialysis three times per week on Tuesdays, Thursdays, and Saturdays at 10:25 AM, transport at 9:25 AM. Review of a Consultant Pharmacist (CP) Evaluation contained within Resident #71's paper chart revealed an entry dated 02/17/23, in which the CP recommended that the facility adjust the resident's medications for dialysis. Review of Resident #71's Medication Administration Record (MAR) dated 01/01/23-01/31/23 revealed the following: 1. Gabapentin Capsule 100 mg. Give 1 (one) capsule by mouth one time a day for Neuropathy (dysfunction of peripheral nerves causing numbness or weakness) for 1 (one) month with a start date of 01/25/23 and D/C (discontinue) date of 02/08/23. The medication was plotted on the MAR for administration at 9:00 AM, and all doses were charted as administered. 2. Auryxia Oral Tablet 1 (one) gm 210 mg (Fe) (Ferric Citrate, Iron) Give 1 (one) capsule by mouth three times a day for anemia. Start date 01/23/22 and D/C date 02/23/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM) and 1700 (5 PM). On Saturday 01/28/23 at 1300 the medication was charted as OO which indicated that the resident was Out on Pass. On Tuesday 01/31/23 at 1300, the status of the medication administration for this medication was not documented as evidenced by a blank space on the MAR. 3. Tylenol PM Extra Strength Tablet 500-25 mg (Diphenhydramine-Acetaminophen) (Sleep) Give 2 tablets by mouth four times a day for pain management Max-3 (three) grams acetaminophen/day from all sources. Start date 01/23/23 and D/C date 02/20/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1200 (12 PM), 1700 (5 PM) and 2100 (9 PM). On Saturday 01/28/23 at 1200 the medication was charted as OO which indicated that the resident was Out on Pass. On Tuesday 01/31/23 at 1200, the status of the medication administration for this medication was not documented as evidenced by a blank space on the MAR. 4. Heparin Sodium (Porcine, of a pig) Solution 5000 Units/ML Inject 5000 units subcutaneously every 8 (eight) hours for clotting prevention. The start date of the medication was on 01/25/23 and the D/C Date was on 02/20/23. The medication was plotted on the MAR for administration at 0600 (6 AM), 1400 (2 PM) and 2200 (10 PM). On Saturday 01/28/23 at 1400, the medication was charted as OO which indicated that the resident was Out on Pass. On Tuesday 01/31/23 at 1400, the status of the medication administration for this medication was not documented as evidenced by a blank space on the MAR. 5. Clonidine HCL Tablet 0.3 mg Give 1 (one) tablet by mouth every 8 (eight) hours for HTN (hypertension). Hold SBP (systolic blood pressure) less than 125. Start date 01/23/23 and D/C date 02/28/23. The medication was plotted on the MAR for administration at 0400 (4 AM), 1200 (12 PM) and 2000 (8 PM). On Saturday 01/28/23 at 1200, the medication was charted as OO which indicated that the resident was Out on Pass. On Tuesday 01/31/23 at 1200, the status of the medication administration for this medication was not documented as evidenced by a blank space on the MAR. Review of Resident #71's Medication Administration Record (MAR) dated 02/01/23-02/28/23 revealed the following: 1. Gabapentin Capsule 100 mg. Give 1 (one) capsule by mouth three times a day for Neuropathy for 1 (one) month until 03/08/23 at 07:43. Start date of 02/08/23 and D/C date of 03/06/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM) and 1700 (5 PM). On Thursday 02/09/23, Saturday 02/11/23, Thursday 02/16/23, Saturday 02/18/23 Tuesday 02/21/23, Thursday 02/23/23, and Saturday 02/25/23 at 1300, the medication was charted as OO which indicated that the resident was Out on Pass. 2. Auryxia Oral Tablet 1 (one) gm 210 mg (Fe) (Ferric Citrate, Iron) Give 1 (one) capsule by mouth three times a day for anemia. Start date 01/23/22 and D/C date 02/23/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM) and 1700 (5 PM). On Thursday 02/02/23, Saturday 02/04/23, Tuesday 02/07/23, Thursday 02/09/23, Saturday 02/11/23, Thursday 02/16/23, Saturday 02/18/23, Tuesday 02/21/23, and Thursday 02/23/23 at 1300, the medication was charted as OO which indicated that the resident was Out on Pass. 3. Auryxia Oral Tablet 1 (one) gm 210 mg (Fe) (Ferric Citrate, Iron) Give 1 (one) capsule by mouth three times a day for anemia. Start date was 02/24/23 and the D/C date was 03/06/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM), and 1700 (5 PM). On Saturday 02/25/23 at 1300, the medication was charted as OO which indicated that the resident was Out on Pass. 4. Heparin Sodium (Porcine, of a pig) Solution 5000 Units/ML Inject 5000 units subcutaneously every 8 (eight) hours for clotting prevention. Start date of the medication was on 01/25/23 and the D/C Date was on 02/20/23. The medication was plotted on the MAR for administration at 0600 (6 AM), 1400 (2 PM) and 2200 (10 PM). On Thursday 02/02/23, Saturday 02/04/23, Tuesday 02/07/23, Thursday 02/09/23, Saturday 02/11/23, and Saturday 02/18/23 at 1400, the medication was charted as OO which indicated that the resident was Out on Pass. 5. Heparin Sodium (Porcine) Solution 5000 Unit/ML Inject 1 ml subcutaneously every 8 (eight) hours for clotting prevention. The start date of the medication was on 02/20/23 and the D/C date was 03/06/23. The medication was plotted on the MAR for administration at 0600 (6 AM), 1400 (2 PM) and 2200 (10 PM). On Tuesday 02/21/23, Thursday 02/23/23 and Saturday 02/25/23 at 1400, the medication was charted as OO which indicated that the resident was Out on Pass. 6. Clonidine HCL Tablet 0.3 mg Give 1 (one) tablet by mouth every 8 (eight) hours for HTN. Hold SBP (systolic blood pressure) less than 125. Start date 01/23/23 and D/C date 02/28/23. The medication was plotted on the MAR for administration at 0400 (4 AM), 1200 (12 PM) and 2000 (8 PM). On Thursday 02/02/23, Saturday 02/04/23, Tuesday 02/07/23, Thursday 02/09/23, Saturday 02/11/23, Thursday 02/16/23, Saturday 02/18/23, Tuesday 02/21/23, Thursday 02/23/23, and Saturday 02/25/23 at 1200, the medication was charted as OO which indicated the resident was Out on Pass. 7. Tobramycin Solution 0.3% Instill 2 (two) drop in left eye four times a day for Conjunctivitis (inflammation or infection of the conjunctiva of the eye) for 7 (seven) days. Start date 02/12/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1200 (12 PM), 1700 (5 PM) and 2100 (9 PM). On Thursday 02/16/23 and Saturday 02/18/23 at 1200, the medication was charted as OO which indicated that the resident was Out on Pass. 8. Tylenol PM Extra Strength Tablet 500-25 mg (Diphenhydramine-Acetaminophen) (Sleep) Give 2 tablets by mouth four times a day for pain management Max-3 (three) grams acetaminophen/day from all sources. Start date 01/23/23 and D/C date 02/20/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1200 (12 PM), 1700 (5 PM) and 2100 (9 PM). On Thursday 02/02/23, Saturday 02/04/23, Tuesday 02/07/23, Thursday 02/09/23, Saturday 02/11/23, Thursday 02/16/23, and Saturday 02/18/23 at 1200, the medication was charted as OO which indicated that the resident was Out on Pass. Review of Resident #71's Medication Administration Record (MAR) dated 03/01/23-03/31/23 revealed the following: 1. Gabapentin Capsule 100 mg. Give 1 (one) capsule by mouth three times a day for Neuropathy for 1 (one) month until 03/08/23 at 07:43. Start date of 02/08/23 and D/C date of 03/06/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM) and 1700 (5 PM). On Thursday 03/02/23 at 1300, the medication was charted as OO which indicated the resident was Out on Pass. 2. Auryxia Oral Tablet 1 (one) gm 210 mg (Fe) (Ferric Citrate, Iron) Give 1 (one) capsule by mouth three times a day for anemia. The start date was 02/24/23 and the D/C date was 03/06/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM), and 1700 (5 PM). On Thursday 03/02/23 at 1300, the medication was charted as OO which indicated the resident was Out on Pass. 3. Heparin Sodium (Porcine) Solution 5000 Unit/ML Inject 1 ml subcutaneously every 8 (eight) hours for clotting prevention. Start date of the medication was on 02/20/23 and the D/C date was 03/06/23. The medication was plotted on the MAR for administration at 0600 (6 AM), 1400 (2 PM) and 2200 (10 PM). On Thursday 03/02/23 at 1400, the medication was charted as OO which indicated that the resident was Out on Pass. Review of Resident #71's Order Summary Report provided by the Administrator on 03/07/23, which contained active orders as of 02/01/23, revealed the following Pharmacy Orders: 1. Gabapentin Capsule 100 mg Give 1 (one) capsule by mouth one time a day for Neuropathy. For 1 (one) month. 2. Auryxia Oral Tablet 1 (one) gm 210 mg (Fe) (Ferric Citrate) Give 1 (one) tablet by mouth three times a day for anemia. 3. Heparin Sodium (Porcine) Solution 5000 Unit/ML. Inject 5000 unit subcutaneously every 8 (eight) hours for clotting prevention. 4. Clonidine HCL Tablet 0.3 mg Give 1 (one) tablet by mouth every 8 (eight) hours for HTN (hypertension). Hold SBP <125 Monitor B/P per policy. 5. Tylenol PM Extra Strength Oral Tablet 500-25 mg Diphenhydramine-Acetaminophen (sleep) Give 2 tablets by mouth four times a day for pain management. Review of Resident #71's Care Plan revealed that the resident was ordered antibiotic therapy Tobramycin Solution 0.3% Instill 2 (two) drops in left eye four times a day for Conjunctivitis for 7 (seven) days on 02/13/23. Interventions included administer medications as ordered. During an interview with the surveyor on 03/02/23 at 1:01 PM, LPN #3 stated that Resident #71's medications were adjusted to correlate with the resident's dialysis schedule on Tuesday, Thursday, and Saturday as the resident was scheduled for transport at 9:25 AM and received dialysis treatment at 10:25 AM. LPN #3 further stated that the physician discontinued the resident's scheduled dose of Clonidine (medication used to treat high blood pressure) last week as the resident was out of the facility to dialysis when the medication was scheduled. LPN #3 further stated that the resident's blood pressure medications were administered at dialysis. During an interview with the surveyor on 03/06/23 at 10:58 AM, Registered Nurse Unit Manager (RNUM) #1 stated that the CP reviewed the resident's medications on a monthly basis and provided the Director of Nursing (DON) with the recommendations. RNUM #1 further stated that the DON then distributed the CP's recommendations to the unit managers. RNUM #1 stated that, A recommendation to adjust medications for dialysis indicated that the orders needed to be changed right away. RNUM #1 stated that oral medications scheduled for 9:00 AM were administered to Resident #71 at 8:00 AM before the resident left for dialysis. RNUM #1 stated that she spoke with the resident's primary physician during rounds regarding the resident's medication scheduling. RNUM #1 further stated that the DON had the documentation that directly related to the interventions that were implemented to the resident's medications in response to the CP recommendations. On 03/07/23 at 8:44 AM, the Administrator provided the surveyor with Resident #71's Consultant Pharmacist's Monthly Report which was dated 02/17/23 and revealed the following entry: A review of the Medication Administration Record indicated medication doses are being held due to the resident Out to dialysis. The times of administration should be modified to accommodate the needs of the resident. Please obtain a physicians order for changes in administration times. Review: Clonidine, Auryxia (medication that can lower the amount of phosphate in the blood for adults with chronic kidney disease who are on dialysis), gabapentin (nerve pain medication), heparin (anticoagulant used to prevent blood clotting), tobramycin (antibiotic), Tylenol PM (pain reliever, sleep aid). Further review of the Consultant Pharmacist's Monthly Report revealed a handwritten entry next to the recommendations which specified, Changed to accommodate dialysis days. During an interview with the surveyor on 03/07/23 at 11:01 AM, the CP stated that she visited the facility monthly and made recommendations based off review of the resident's Medication Administration Record (MAR). The CP stated that once the unit review was complete the office sent the report to the DON and Administrator to distribute to the unit managers. The CP stated that she reviewed the medical record on her next scheduled monthly visit to ensure the recommendations were addressed. The CP stated that she made recommendations for Resident #71 to ensure that the doses were given as ordered, rather than to reflect that they were going to be dialyzed out of the resident. During an interview with the surveyor on 03/08/23 at 11:25 AM, RNUM #1 stated that she first learned of the issue with Resident #71 who had not received his/her medications on dialysis days from the CP in February. During an interview with the surveyor on 03/09/23 at 11:33 AM, the DON stated that any resident who was on hemodialysis had to have their medications changed to match the dialysis days and times. The DON stated that if a medication was scheduled when the resident was out of the facility to dialysis, then the nurse had to call the doctor to obtain an order to change the time of administration to accommodate the resident's dialysis schedule. The DON stated that all nurses were trained to ensure that if a medication was missed, then they were required to call the doctor who would provide orders and instructions on how to proceed. The DON stated that the facility did not wait for the CP to review the resident's orders before they reviewed medications that were required to be administered on scheduled dialysis days. The DON stated the unit manager should have reviewed the medications when she initiated and prepared the resident's dialysis communication binder to ensure that the binder was complete and contained all related dialysis information. The DON stated that the nurses had a one-hour window of time to administer medications and if the medication was not administered within that time frame, then the nurse was required to notify the doctor. The DON further stated, If a medication was not administered, then you have to handle it immediately and ensure that the medications were given at alternate times when the residents are in the facility. Review of the facility policy titled, Dialysis-Care of the Patient Receiving (Reviewed 05/11/22) revealed the following: .Re-arrange medication and treatment times as needed to accommodate resident/patient being out of the building. NJAC 8:39-27.1(a)

Based on observation, interview and policy review it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 2/21/23 at 9:43 AM, the surveyor, in the presence of the Dietary Director (DD), observed the following during the kitchen tour: 1. In the food preparation area, Dietary Aide #1 and Dietary Aide #2 were observed wearing baseball caps with their hair at the back of the head exposed and were not wearing hairnets. The DD acknowledged the dietary aides should have been wearing hairnets. 2. In the food preparation area, Dietary Aide #2 was observed wearing a surgical mask above his chin area and his facial hair was exposed. The DD stated Dietary Aide #2 should have facial hair covered and provided a facial hair restraint to the dietary aide. 3. On a shelf in the walk-in refrigerator, the surveyor observed an 8-lb container of macaroni salad, which had a manufacturer's label that had a best used by date of 01/03/23. The DD confirmed the date and stated the food item would be disposed. 4. On a shelf in the walk-in refrigerator, in a box containing cabbage, a half-cut head of cabbage wrapped in plastic, was observed undated and had an area that was grey in color to the cut side of the cabbage. The DD inspected the cabbage and stated it should be thrown away. On 2/22/23 at 10:25 AM, the Administrator provided the surveyor with the policy for expired foods and dietary personnel standards. The Administrator stated the macaroni salad was not being used as their menu had previously changed, and that the macaroni salad had not been thrown out at the time. The surveyor asked the Administrator how often and who was responsible for checking the refrigerated food items. The Administrator stated it was indicated in the policies provided. On 3/7/23 at 11:00 AM, the surveyor interviewed the DD about refrigerator storage being checked for expired items. The DD stated that himself or an assigned dietary staff would check for expired food items. The DD further stated they used a FIFO [First In, First Out] policy for food items stored. On 3/9/23 at 1:15 PM, the surveyor informed the Administrator, and the Director of Nursing of the above concerns. The surveyor reviewed the facility's policy titled, Personnel Standards with an effective date of February 2021. Under Procedure, it read All staff members will have their hair off the shoulders, confined in a hairnet or cap, and facial hair properly restrained. The surveyor reviewed the facility's policy titled, Food Service with an effective date of 2/1/2021. The policy read Maintain a clean, safe, and sanitary storage for all items. Under Procedures, it read F-I-F-O (First In First Out) rule will be followed at all times and Put a date, label as necessary, all foods stored in walk-in refrigerators and freezers that are out of its original packaging from the time it was opened. The surveyor reviewed the facility's policy titled, Expired Foods with a revised date of 7/1/2022. The policy indicated The Dietary aide/designee will ensure proper dating for all food upon delivery and All expired food will be discarded immediately. The policy did not further address checking food item expiration dates. NJAC 8:39-17.2(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.) perform hand hygiene before and after podiatry care for 3 of 3 residents (Residents #180, #205 and #264). This deficient practice was evidenced by the following: 1.During the initial tour of the 2A unit on 2/21/23 at 11:13 AM, the surveyor observed the facility's podiatrist and his assistant enter Resident #205's room. Resident #205 was awake and seated in their wheelchair. The podiatrist sat on the floor in front of the resident, put on gloves and removed the resident's socks exposing the resident's toe nails. The Podiatrist opened a blue pad, chux (a disposable under pad) and placed it on the floor underneath the resident's feet. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. After the podiatrist completed the resident's toenail care, the podiatrist folded the blue pad, stood up off the floor, removed his gloves and left the resident's room. There was no hand hygiene observed. The surveyor reviewed the medical records of Resident #205 which revealed the following: Resident #205 was admitted in 12/2022 with diagnoses which included but were not limited to; Type 2 diabetes mellitus and cognitive communication deficit. Review of Resident #205's admission Minimum Data Set (MDS), an assessment tool, dated 12/6/22 revealed that the resident had a brief interview for mental status (BIMS) of 3 which indicated that the resident's cognition was severely impaired. On 02/21/23 at 11:27 AM, the surveyor observed the podiatrist enter Resident #264's room. Resident #264 was awake and in bed. The podiatrist put gloves on and introduced himself to the resident as the foot doctor. The podiatrist removed a blue pad from his bag and placed it under the resident's feet on the bed. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. After the podiatrist completed the resident's toenail care, the podiatrist folded the blue pad and placed it back into his bag, removed his gloves and left the resident's room. There was no hand hygiene observed. The surveyor reviewed the medical records of Resident #264 which revealed the following: Resident #264 was admitted in 6/2022 with diagnoses which included but were not limited to, Type 2 diabetes mellitus and Alzheimer's disease. Review of Resident #264's Quarterly MDS, dated [DATE], revealed that Resident #264 had short- and long-term memory impairments. On 02/21/23 at 11:31 AM, the surveyor observed the podiatrist enter Resident #180's room. Resident #180 was awake and seated in a wheelchair. The Podiatrist touched resident's hand to greet the resident and explained to the resident that he would look at their feet. The podiatrist sat on floor, put gloves on, unfolded a blue pad from his bag and put it down onto the floor under the resident's feet. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. After the podiatrist completed the resident's toenail care, the podiatrist folded the blue pad, discarded it, removed his gloves and left the resident's room. There was no hand hygiene observed. The surveyor reviewed the medical records of Resident #180 which revealed the following: Resident #180 was admitted in 7/2022 with diagnoses which included but were not limited to Type 2 diabetes mellitus, and dementia. Review of Resident #180's Quarterly MDS dated , 1/4/23, revealed that Resident #180 had a BIMS of 3 which indicated that the resident's cognition was severely impaired. During an interview with the surveyor on 2/21/23 at 11:36 AM, the podiatrist stated he kept hand sanitizer in his bag and would do hand hygiene after care. The podiatrist acknowledged that he did not perform hand hygiene in between the three residents. During an interview with the surveyor 3/2/23 at 9:40 AM, Licensed Practical Nurse Unit Manager (LPNUM) #1 stated that hand hygiene should be performed before and after resident care for infection control. During an interview with the surveyor on 03/06/23 at 11:38 AM the Director of Nursing (DON) stated the podiatrist should perform hand hygiene because of infection control. She stated that the Assistant Director of Nursing (ADON) and the Infection Preventionist (IP) had previously spoke to the podiatrist about hand hygiene. During an interview with the surveyor on 03/08/23 at 01:19 PM, the IP stated that she and the ADON had previously went over hand hygiene, use of the blue pad (chux), with the podiatrist. She stated between each resident the podiatrist should perform hand hygiene for infection control because he touched toes, and the blue pad (chux) should be individualized for infection control. Review of a facility policy titled, Handwashing and hand hygiene purposes, dated 2/2021, revised on 2/2022, included but was not limited to; It is the policy of Embassy Manor that hand washing and hand hygiene will be performed in accordance with the Center of Disease Control (CDC) Guidelines. Definitions: Hand hygiene cleansing the hands with facility-approved alcohol- based antimicrobial hand cleanser. Procedure: Hand washing and hand hygiene indications. 1. The use of gloves does not eliminate the use of hand hygiene. 2. Indications for hand washing and hand hygiene include, but are not limited to the following: After situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes blood or body fluid secretions or excretions .Before and after performing invasive procedures .After removing gloves. Handwashing Method: Scrub the hands for at least 20 seconds. NJAC 8:39-19.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to address in a timely manner the recommendations made by the Consultant Pharmacist (CP) during the Monthly Medication Review. This deficient practice was identified for 1 of 6 residents reviewed for unnecessary medications (Residents #73) and was evidenced by the following: The surveyor reviewed Resident #73's 08/2020 Physician Order Sheet (POS) which revealed a physician Order (PO) dated 07/03/20 for Voltaren 1% gel (topical gel medication used to treat pain) to be applied twice daily to the left shoulder. The surveyor noted that there was no dosage amount documented for the Voltaren gel. The surveyor noted that both the 09/2020 and 10/2020 POS had the same order for Voltaren 1% Gel and no dosage amount. Review of Resident #73's 08/2020, 07/03/20,09/2020 and 10/2020 Medication Administration Record (MAR) had the same order as written on the POS and without dosage amount. Further review of Resident #73's POS revealed a handwritten readmission PO dated 10/11/20 for Voltaren 1% gel to be applied twice daily to the left shoulder and no dosage amount. Review of Resident #73's 11/2020 MAR that corresponded to the 10/11/20 PO for Voltaren 1% gel showed no dosage amount. A review of Resident #73's 12/2020 POS revealed PO dated 10/23/20 for Voltaren 1% gel to be applied twice daily but no dosage amount. The 01/2021 POS also reflected the same order for Voltaren 1% gel to be applied twice daily but no dosage amount Further review of the resident's 08/2020 POS revealed PO dated 07/03/20 for Docusate (Colace) 100 milligrams (mg) once daily as needed for constipation. Further review of Resident #73's POS revealed a handwritten readmission PO dated 10/11/20 for Colace 100 mg once daily as needed for constipation. Review of Resident #73's 08/2020, 09/2020, 10/2020, 11/2020, and 01/2021 MAR, revealed the corresponding orders for Docusate 100 mg to be administered once daily as needed for constipation. The surveyor then reviewed the Consultant Pharmacist's Report (CP Report) dated 09/03/20, which showed that the CP reviewed Resident #73's medication management and recommended that Resident #73's Voltaren 1% Gel needed a dosage and frequency. The CP further documented that the recommended frequency for Voltaren 1% Gel, was four times daily, and to apply four grams (GM) to lower extremity joints and two GM to upper extremity joints. The CP Report reflected a second recommendation which indicated: Regarding the comment made on 08/06/20: Regarding the comment made on 07/20/20: Ducosate (Colace) (stool softener) is not effective when dosed PRN [as needed]. It must be used continuously to obtain therapeutic effect. The Pharmacy Consultant further documented in the report that his previous recommendations had been not addressed. The surveyor observed that there were no handwritten notations on the 09/03/20 CP Report or a physician's signature to indicate that the CP's recommendations had been reviewed or addressed. A review of the CP Report dated 10/12/20, showed that the CP made another recommendation regarding Resident #73's Colace and explained the therapeutic criteria to order and administer the Colace for maximum effectiveness. The surveyor noted no documented evidence to show that the 10/12/20 CP Report was addressed by the facility staff or the Physician. A review of the CP Report dated 11/05/20, revealed that the CP recommended again that a dosage and frequency was needed for the Voltaren 1 % Gel, and explained the proper dosing and frequency for the medication which included: four times daily, and to apply four grams (GM) for lower extremity joints and two GM to upper extremity joints. The CP Report also reflected a second recommendation regarding the resident's Colace and noted that Colace was not effective when dosed as a PRN instead of continuous daily dosing. The surveyor noted no documented evidence to show that the 11/05/20 CP Report was addressed by facility staff or the physician. A review of the CP Report dated 12/04/20, revealed that the CP made reference to the previous recommendations and repeated the same recommendations as documented on the CP report of 09/03/20, 08/06/20 and 07/20/20. The CP also documented that the Pharmacy recommendations were not addressed The surveyor noted no documented evidence to show that the CP Report dated 12/04/20 was addressed by facility staff or the physician. During an interview with the Director of Nursing (DON) on 02/26/21 at 1:15 PM, the surveyor requested a copy of Resident #73's 12/2020 MAR but the DON stated that they were unable to locate the resident's 12/2020 MAR in the medical record. A review of Resident #73's Nursing Narrative Notes from 08/14/20 to 12/24/20 did not reveal documentation that the physician had been informed of the 09/03/20, 10/12/20, 11/05/20, and 12/04/20 CP recommendations. A review of Resident #73's Physician's Progress Notes dated 09/01/20, 09/27/20, 10/29/20, 11/12/20, and 12/13/20 revealed that Resident #73's attending physician examined the resident but did not document a review of the CP recommendations. During an interview with LPN #1 on 02/25/21 at 01:23 PM, LPN #1 stated that it was the responsibility of all nurses to follow up and address CP recommendations. LPN #1 further stated that the facility process was for someone to flag the recommendations in the resident's chart and the floor nurse would follow up with the Physicians by calling to inform the physician of any CP recommendations. LPN #1 further stated the CP recommendations would remain flagged on the resident's chart until it had been addressed by the nurse. The surveyor interviewed the DON on 02/25/21 at 02:34 PM and was told the CP recommendations were usually flagged in the residents' charts for nurses to follow up on. The DON further stated that the facility process was changed and that they now had a designated nurse to follow up with CP recommendations. During a follow up interview with the DON on 02/26/21 at 11:34 AM, the DON stated that if the physician was not called regarding the CP recommendation, the document would remain flagged in the resident's chart for the physician to view on their next visit. A review of the facility's Drug Regimen Review policy, with the effective date of February 2021, indicated that the CP must report irregularities to the physician, medical director, and the DON. The policy further indicated that the CP reports must be addressed prior to the next monthly medication regimen review. NJAC 8:39-29.3(a)

Based on observation, interview and record review, and review of other facility documents, it was determined that the facility failed to ensure that residents were free from unnecessary psychoactive medications. This deficient practice was identified for Resident #17, 1 of 2 resident reviewed for psychoactive medications and was evidenced by the following: Review of Resident #17's clinical record revealed that the resident was admitted to the facility with diagnoses which included: Coronary Artery Disease (Heart disease), Hypertension, aphasia (difficulty speaking) and cerebro-cascular accident (CVA- stroke). The resident's Quarterly Minimum Data Set (MDS) an assessment tool dated 02/02/2021, reflected that the resident was severely cognitively impaired. The surveyor observed the resident in bed with eyes closed during the initial unit tour on 02/19/2021 at 11:30 AM. On 02/23/21 at 11:39 AM, the surveyor observed Resident #17 in bed with eyes closed. At this time the resident was receiving nutrition through a gastrointestinal tube feeding which was infusing at the time of the surveyor observation. The surveyor reviewed Resident #17's clinical record on 02/25/2021 at 11:19 AM. The surveyor noted a Physician Order Sheet ( POS ) dated 02/28/2021, with a physician's order dated 07/11/2019 for Ativan (an anti-anxiety medication). The order indicated to administer the Ativan every 6 hours for agitation/ anxiety. The target behaviors for which the Ativan was being administered were identified on the Monthly Psychoactive Summary (MPS) and included the behaviors of screaming and kicking. The surveyor reviewed the Consultant Pharmacist's Evaluation form from 10/04/19 to 02/05/2, and noted that Resident #17 had not had a Gradual Dose Reduction (GDR) for the Ativan since the original order date of 07/11/2019. The surveyor further reviewed the Monthly Psychoactive Summary behavior from August 2020 to February 2021. There was no documented evidence to show that Resident #17 exhibited any of the targeted behaviors. There was only one episode of hitting recorded during an 11:00 PM to 7: 00 AM shift. On 02/25//2021 at 01:05 PM, the surveyor had an interview with the Certified Nursing Assistant (CNA#4 ) who cared for the resident. CNA#4 stated that Resident #17 was not combative with care but would flare his/her legs occasionally during care. The surveyor interviewed Resident #17's Registered Nurse (RN#2) on 02/26/2021 at 11:30. RN#2 stated that the resident received all his/her medications daily and was not combative. A review of the Medication Administration Record (MAR ) for October 2020, revealed that 12 doses of Ativan were not administered in October because the Ativan was not available. There was no documentation to show that Resident #17 exhibited any agitation /anxiety during the entire period when the Ativan was not available. Review of the MAR also showed that in November 2020, three doses of the Ativan were not administered and staff documented that the resident did not exhibit agitation/ anxiety. A review of the psychiatric follow up evaluation dated 12/05/2020, reflected the following documentation from the Psychiatrist: Pt[ Patient ]continues to have agitation /restlessness during care. The surveyor did not find any documentation of agitation or anxiety in the Nursing Narrative Notes or in other sections of the resident's record. The facility did not provide information as to where the psychiatrist obtained his information. On 12/05/2020 the psychiatrist recommended to continue the Ativan. He also documented that Resident #17 continued to have agitation/ restlessness during care. The Psychiatrist did not indicate where he obtained the information regarding the resident's behavior. On 02/26/2021, the facility provided a recommendation from the consultant pharmacist dated 12/01/2020, which indicated the following: As per CMS guidelines, Ativan when ordered for insomnia, should be reviewed quarterly for a tapering of the dose. If a tapering of the dose is clinically contraindicated, remember to provide a short progress note. On 02/25/2021 the surveyor interviewed the Director of Nursing (DON) regarding the Ativan being administered in the absence of the identified target behaviors. The DON stated that the facility followed the psychiatrist recommendations. Review of the facility's unnecessary Drugs- psychotropics policy dated 2/2020 indicated that residents who used psychotropic medications would receive GDR and behavioral interventions unless contraindicated. The policy also indicated that the psychotropics would be routinely re-evaluated to check for need to continue. NJAC:8-39-29.3 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) identify the use of bilateral hand mittens as a physical restraint, b.) assess and implement the least restrictive measures prior to the use of a physical restraint, and c.) obtain a consent with disclosure of risk versus benefits for the use of a physical restraint. This deficient practice was identified for 2 of 2 residents (Residents #131 and #330) who were reviewed for the use of physical restraints and was evidenced by the following: 1. On 02/19/21 at 12:21 PM, the surveyor observed Resident #330 in his/her bed, wearing white hand mittens on both the right and left hands. The hand mitts were tied at the wrist to hold them in place on the resident's hands but were not tied to the side rails or any other surface. The resident was able to move both arms freely. The surveyor attempted to interview the resident, but the resident did not verbally respond but mumbled to himself/herself. The surveyor observed a tube feeding pump (a machine used to provide a person with nutrition- G. Tube) in the resident's room which was not connected to the resident at this time. On 02/23/21 at 10:18 AM, the surveyor observed the resident again lying in bed with his/her eyes closed. The surveyor noted that the bilateral hand mittens were secured on the resident's wrist and were stained with a tan-brownish color substance. On 02/24/21 at 9:52 AM, the surveyor observed the resident in bed with the head of bed elevated. The resident's eyes closed and the G. tube feeding formula was infusing at the rate of 60 ml/hr. The surveyor observed that the resident's right-hand mitten was in place and secured at the resident's wrist. The surveyor was unable to observe the resident's left hand because it was positioned underneath the resident's bed sheet. On 02/25/21 at 9:26 AM, the surveyor entered Resident #330's room accompanied by the unit Licensed Practical Nurse (LPN#2). Upon interview, LPN#2 stated that the resident wore the hand mittens because he/she was fighting when the nurses administered his/her medications and would pull at the G-tube. LPN# 2 added that the mittens was stained because the resident pulled at the G. tube. LPN#2 then removed the resident's hand mittens in the presence of the surveyor. The surveyor observed that the resident's skin was intact on his/her left and right hands. The resident's eyes remained closed when LPN #2 removed and replaced the hand mittens. The surveyor reviewed the medical record for Resident #330. According to the resident's Face Sheet (An admission Summary), the resident was admitted to the facility in 2021. Review of the resident's 02/09/2021 admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that Resident #330 had short term and long-term memory problems and that the resident's cognitive skills for daily decision making was severely impaired. The MDS further indicated in Section P- Restraints and Alarms that there were no physical in use for the resident. Review of the resident's February 2021 Physician Order Sheet (POS) reflected that the resident had diagnoses which included but were not limited to; cerebral aneurysm (a weakness in a blood vessel in the brain that balloons and fills with blood), diabetes mellitus, glaucoma (an eye condition where the nerve connecting the eye to the brain is damaged usually due to high pressure which can cause blindness), hypertension, and macular degeneration (a condition where the center of the retina deteriorates and causes vision loss). Further review of the February 2021 POS reflected a physician's order dated 02/02/21 for bilateral hand mittens to prevent the resident from pulling out the feeding tube and to check the resident's skin integrity every shift. Review of the hospital discharge medication list dated 02/02/21 and timed at 12:58 PM, indicated that the right- and left-hand mittens were discontinued for the resident upon discharge from the hospital. Review of the resident's February 2021 Treatment Administration Record (TAR) reflected that from 02/02/21 through 02/23/21 the nursing staff signed every shift on the 11:00 PM - 7:00 AM shift, 7:00 AM - 3:00 PM shift, and 3:00 PM - 11:00 PM shift that the resident was wearing the bilateral mittens to prevent the resident from pulling out the feeding tube. Review of Facility To Facility Phone Report/Patient Transfers Form dated 02/02/21, revealed documentation which indicated that Resident #330 was confused, had a G-tube (a device surgically inserted into an individual's stomach to provide nutrition for people who cannot obtain nutrition by mouth), and bilateral hand mittens due to pulling out the G-tube. Review of the resident's re-admission nursing assessment dated [DATE] and timed at 2:20 PM, indicated that the resident had limb restraints - mittens to the right and left hand. Review of the resident's comprehensive care plans dated 02/02/21 did not reflect a focus care area that addressed the fact that the resident had restraints or hand mittens and no care plan interventions written to address the use of the hand mittens. A complete review of the resident's medical record did not reflect that the resident had a comprehensive assessment or restraint consent signed by the resident's family member or guardian with an explanation of the risk versus benefits for the physical restraint. There was also no documented evidence of other least restrictive forms of a restraint the facility tried prior to the implementation of the bilateral hand mittens. On 02/25/21 at 9:32 AM, the surveyor conducted an interview with LPN #2 who stated that she did not know Resident #330 was admitted to the facility with the bilateral hand mittens. The LPN #2 further stated that physical restraints needed an assessment by a Registered Nurse and a physician's order for the usage of the restraints. LPN #2 stated that Resident #330 waved or swung his/her arms around and was combative when she administered medications to the resident. LPN #2 further stated that she normally approached the resident slowly and calmly explained things to the resident before she performed any procedure to calm the resident down. The surveyor reviewed the resident's chart in the presence of LPN #2 and could not find a care plan for the hand mittens or a consent form signed by a family member or guardian. There was also no assessment or documentation that regarding the least restrictive form of a restraint and alternative care interventions the facility tried for the resident prior to the implementation of the bilateral hand mittens. LPN #2 further stated that the bilateral hand mittens were placed on the resident because the resident came from the hospital with them. On 02/25/21 at 9:57 AM, the surveyor interviewed the resident's Certified Nursing Assistant (CNA#5) who stated that the Resident #330 was confused, non-verbal, and could not make their needs known. CNA#5 stated that the resident was a fighter during care and that she normally slowed down, and spoke to the resident calmly before she performed the resident's care. On 02/26/21 at 11:24 AM, the DON acknowledged that there was no restraint assessment performed upon the resident's admission to the facility on [DATE], because at the time of admission, the bilateral hand mittens were not considered a restraint since they were used for non-purposeful movements such as pulling out his/her G-tube. The DON further stated that the resident should have had an assessment and a care plan for the bilateral hand mittens. The DON added that she did not think the resident's family was notified regarding the usage of the hand mittens. Review of the facility's Restraint Policy and Procedure dated 02/2021 indicated that the definition of a physical restraint was any manual method, physical or mechanical device, or piece of equipment that is attached or adjacent to the resident's body that cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body. The Restraint Policy and Procedure further identified hand mitts, lap trays, and seat belts as physical restraints. The Restraint Policy and Procedure further indicated; The facility will implement alternatives to restraints prior to using the least restrictive option for the least amount of time and document on-going re-evaluation of the need for the restraint. Interventions will be designated to minimize or eliminate medical symptoms that prompt the usage of the restraint. An informed consent will be obtained from the resident/patient when clinically feasible; otherwise, informed consent will be obtained from the responsible party. 2. Review of the medical record showed that Resident # 131 was admitted to the facility with diagnoses which included, hypertension and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set (MDS ) an assessment dated [DATE], revealed that Resident #131 was severely cognitively impaired. On 02/19/2021 at 12:45 PM, the surveyor observed Resident #131 seated in a chair in the room wearing hand mitts on both hands. The hand mitts were not tied to the bed side rails or any other surface and the resident was able to move both arms freely. On 02/19/2021 at 1:20 PM, the surveyor observed a Certified Nursing Assistant (CNA #4) in the room assisting the resident with lunch. The surveyor noted that Resident #131 was sitting quietly while eating and wore with the hand mitts on both hands. At 1:25 PM, the surveyor interviewed CNA #4. CNA #4 stated that the resident was confused and required total assistance with care. Upon further inquiry, CNA#4 informed the surveyor that Resident #131 wore the hand mitts to prevent him/her from scratching. On 02/23/2021 at 8:39 AM, the surveyor observed Resident #131 again being fed lunch by staff and wearing both hand mitts. On 02/23/2021 at 12:45 PM, the surveyor observed Resident #131 again being fed by staff and wearing both hand mitts. On 02/23/2021 at 1:30 PM, the surveyor reviewed Resident #131's clinical record and noted that Resident #131 was readmitted to the facility on [DATE]. A Physician Order Sheet (POS) dated 1/14/21 revealed an order for bilateral hand mittens to be used PRN ( as needed ) to prevent disruption of medical treatment. On 02/23/21 at 2:00 PM, the surveyor reviewed the POS with the nurse. The nurse informed the surveyor that Resident #131 had a Peripheral Insertion Central Catheter (PICC line) which is a flexible tube inserted and guided into a large vein used to administer intravenous fluid . The nurse added that the hand mitts were ordered to prevent Resident #131 from removing the PICC line. Further review of the clinical record revealed another physician order dated 02/06/2021 timed 05:00 PM, to discontinue the Intravenous hydration. There was no documentation in the clinical record to justify the continued use of the hand mitts after the intravenous hydration was discontinued on 2/6/21. A review of Resident #131's Care Plan dated 01/14/2021 and revised 02/01/2021 identified the following problems: Non purposeful movement and increased risk of self injury. Prevent disruption of medical treatment and self -harm The Goal was for the resident was to be injury free for 90 days. The Interventions included: Bilateral hand mitts- remove and do skin care every 2 hours or more often as needed. Remove during meals when 1:1 supervision . Re-evaluate the need for continued use weekly. The facility staff did not remove the mitts during meals and did not evaluate the need for continued use until after surveyor inquiry. On 02/25/21 at 02:20 PM the team shared the above observations with the administrative staff. The Director of Nursing (DON) informed the survey team that she did not view mitts as a restraint. The DON further stated that the mitts were used to control non-purposeful movement. On 02/26/21 at 11:43 AM, the DON informed the surveyors that the mittens should have been discontinued when the PICC Line was removed. The DON further stated that staff were aware that all restraints should be released during lunch and supervised activities. NJAC 8:39-27.19(d)

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to don appropriate Personal Protective Equipment (PPE) while in the rooms of residents placed on transmission-based contact and droplet precautions residing on the units designated for Persons Under Investigation (PUI) and on the COVID-19 positive unit. This deficient practice was identified for 6 of 6 staff members observed on 2 of 2 PUI units and for 2 of 2 staff members a COVID-19 positive unit in the facility. The deficient practice was evidenced as follows: 1. On 02/19/21 at 12:48 PM, the surveyor observed lunch meal service on the second floor unit, A/C- wing which had been designated as a PUI area for new and readmissions. The surveyor observed a PUI room with signs on the door which indicated to stop. There was another sign on the door that indicated to follow Contact and Droplet precautions and to wear gown, gloves, masks, and eye protection before entering the room. The surveyor observed a metal bin hanging on the resident's door which contained gowns and gloves. The surveyor observed a staff member inside the room, standing next to a resident setting up the lunch tray. She was not observed to have direct contact with the resident. The surveyor observed that there was another resident in the room in the bed by the window. The surveyor noted that the staff member wore a respirator mask, a surgical mask over the respirator and a face shield. She was not wearing a gown or gloves. The staff member was identified as a Certified Nursing Assistant (CNA #1). CNA #1 disposed of the surgical mask at the garbage can by the resident's door and used ABHR. CNA #1 exited and at that time, the surveyor interviewed CNA #1 who stated that the signage on the door meant that the resident was admitted from the hospital and was on observation for COVID-19. CNA#1 and the surveyor reviewed the signage together. CNA #1 acknowledged that she should have worn a gown and gloves before entering the room as indicated on the door signage. She stated that she was in a hurry and that she was aware that wearing the proper PPE was to prevent the spread of infection. CNA#1 continued delivering meal trays and wore PPE gown, gloves and a new surgical mask over the KN95 into the other PUI rooms. CNA #1 was not observed to leave the unit. On 02/19/21 at 12:54 PM, the surveyor interviewed the second floor Registered Nurse Supervisor (RNS) for A/C - wing. She stated that all staff should wear an N95 mask with a surgical mask over it, gown, face shield or goggles and gloves while in the rooms on the PUI unit, in order to prevent contamination or the spread of infection. The PUI rooms on A/C wing were on droplet and contact precautions. The RNS stated that staff should wear full PPE which would be an N95 mask with a surgical mask over it, gown, face shield or goggles and gloves in the transmission-based precaution rooms regardless of their reason for being in the room. The RNS further stated that the residents in the room were on precautions because they were newly admitted from hospital. The facility had stated that the new and readmissions were all tested prior to admission, upon admission and weekly. The residents on A/C wing had all tested COVID negative to date and would be on PUI for 14 days of observation. 2. On 02/22/21 at 01:40 PM, the surveyor observed the second floor B Wing which was a PUI unit because the residents had been exposed to a COVID positive staff member. On the second floor B-Wing, the surveyor observed a staff members inside a room and feeding a resident. The staff member was wearing a respirator mask with a surgical mask over it and a face shield but no PPE gown or gloves. The surveyor also noted a sign on the door which indicated to adhere to Contact and Droplet precautions and to wear gown, gloves, masks, and eye protection prior to entering the room. The surveyor observed a metal bin that contained gowns and gloves hanging on the resident's room door. The surveyor noted three residents in the room with two of the residents visible and not wearing masks and the third resident was behind a curtain. As the surveyor was standing by the entrance to the room, another staff member walked past the surveyor and made her way into the same transmission-based isolation room. The staff member was wearing a respirator type mask, a surgical mask over it, goggles and no isolation gown. At that time, the surveyor interviewed the staff member. The staff member identified herself as the Social Worker Secretary (SWS). When questioned about PPE, the SWS acknowledged the signs on the resident's room door and stated that she had sanitized her hands prior to entering the room and that she was not touching the residents. Upon review of the signage again, the SWS acknowledged that she should have worn a gown and gloves before entering the room. The SWS stated she had been trained on PPE and the reason to wear PPE was to prevent the spread of infection. The staff member who was feeding the resident was identified as CNA #2. CNA #2 also walked towards the door and the surveyor interviewed her. CNA #2 acknowledged the signage on the door and stated that she should have worn gown and gloves before going into the room. CNA #2 also stated that she had been in-serviced and that the PPE was needed to prevent the spread of infection. CNA #2 immediately removed her surgical mask and disposed of it in the garbage can by the resident door. CNA #2 used ABHR, donned PPE gown, new surgical mask and gloves and entered the room to continue feeding the resident. The SWS removed her surgical mask and disposed of it in the garbage can by the resident door, used ABHR, donned another surgical mask and left the unit. During an interview on 02/22/21 at 01:48 PM, the Registered Nurse (RN #1) working on the second floor B-Wing/PUI stated that all staff members should wear an N95 mask, a surgical mask cover, gown and gloves prior to going into the transmission-based precaution rooms, to prevent the infection from spreading. 3. On 02/23/21 at 08:04 AM, on the second floor B-wing/PUI the surveyor observed two residents in a TBP room. The surveyor observed a staff member wearing a respirator mask covered by a surgical mask and goggles as he walked into the room carrying a breakfast tray. The staff member walked past the first resident and went over to the second resident and placed the tray on the resident's bedside table. The surveyor did not observe any direct contact with the resident by the staff member. The staff member was not wearing an isolation PPE gown or gloves. The surveyor noted a sign on the room door which indicated to adhere to Contact and Droplet precautions and to wear gown, gloves, masks, and eye protection to enter the room. The surveyor also observed a metal bin hanging on the door which contained PPE gowns and gloves. The surveyor interviewed the staff member who identified himself as certified nursing assistant (CNA #3). CNA #3 stated that he should have worn gown and gloves before entering the room. CNA #3 also stated that the purpose of wearing PPE was to protect staff and residents against infection. CNA #3 walked to the door, disposed of the surgical mask, used ABHR and exited the room. CNA #3 moved the food cart to the next TBP room, donned a PPE gown, gloves and new surgical mask, entered the room and another staff member handed him the food tray to deliver. The facility had stated the B wing residents who had been exposed to the positive staff member had been rapid tested for COVID and were negative. The residents would continue to be monitored and tested. None of the CNA's listed in the deficiency were noted to leave the unit. During interview on 02/24/21 at 10:32 AM, the IP stated that staff should be wearing an N95 mask, surgical mask over it, and a face shield or goggles. The IP stated that PPE was required on the units whether staff were walking in the hallway or going into the residents' room. The IP stated that staff were supposed to don a gown and gloves prior to entering residents' room and confirmed that was the facility process for the PUI unit (new or re admissions) and on COVID-19 positive rooms. The IP further stated that the reason for wearing the PPE was because the residents on PUI units may have unknown exposure to COVID-19 and that the PPE was to prevent the spread of infection. During an interview on 02/26/21 at 11:44 AM, the DON stated that the SWS should have been in-serviced on PPE use but she was not sure if the SWS was in-serviced on donning and doffing of PPE. The DON stated that the CNAs were in-serviced on proper PPE use. Review of the facility document titled: Use of Goggles/Face shields, Storage No PPE going home in-service dated 11/9/20, revealed that the SWS attended the in-service. Review of the facility document titled: Dual Member Checklist: Donning PPE for COVID 19 and Dual Member Checklist: Doffing PPE for COVID 19 revealed that CNA #1 had shown competency in donning and doffing of PPE on 03/19/20. Review of the facility document titled: Dual Member Checklist: Donning PPE for COVID 19 and Dual Member Checklist: Doffing PPE for COVID 19 revealed that CNA #2 had shown competency in donning and doffing of PPE on 04/02/20. Review of the facility document titled: Donning Personal Protective Equipment (PPE) and Doffing Personal Protective Equipment (PPE) revealed that CNA #3 had shown competency in donning and doffing of PPE on 02/17/21. Review of the facility's Post-Acute COVID-19 - Pandemic Preparedness Infection Control Policy and Procedure (Outbreak Response Plan) updated 02/11/2021 indicated in regard to Universal Source Control, Eye protection (face shields, goggles, safety glasses) will be worn by staff when providing direct patient care or having close (within 6 feet) contact with a patient or other individual. Team Members should wear eye protection and an N95 or higher respirator at all times while on the COVID-19 positive of Quarantine area with gown and gloves added when entering entering patient/resident rooms. Review of the facility's Transmission Based Precautions Policy and Procedure revised 02/2021 indicated regarding Contact Precautions, Gowns and gloves must be worn by all personnel upon entering the room. This is a proactive measure, as unexpected resident contact or contact with environmental surfaces or items in the resident's room cannot always be anticipated. 4. On 2/23/21 at 1:00 PM, the surveyor went to the COVID-19 unit, (unit-1A) and observed the Housekeeping Director (HKD) and a housekeeping staff member in training as they walked through the hallway of the COVID-19 unit wearing an N95 mask and a surgical mask over it. The surveyor did not observe the HKD or the housekeeping staff member in training wearing a face shield or goggles. At that time, the surveyor interviewed the HKD and housekeeping staff member in training. Both confirmed that the unit (unit-1A) was the COVID-19 positive area and that the required PPE to be worn included an N95 mask, surgical mask over, face shield or goggles. The HKD further stated that he forgot to put on his eye protection, and that eye protection was required to be worn while in the COVID-19 area. On 2/24/21 at 10:34 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that all staff members working on the COVID-19 unit were required to wear an N95 mask with a surgical mask over it, including a face shield or goggles when on the unit. On 2/26/21 at 11:47 AM, the Director of Nursing (DON) stated that the most recent facility policy and procedure on the COVID-19 unit is for every staff member to wear goggles or a face shield, N95 mask with a surgical mask over it while on the unit. Review of the facility's Post-Acute COVID-19 - Pandemic Preparedness Infection Control Policy and Procedure (Outbreak Response Plan) updated on 02/11/2021, indicated that: Eye protection (face shields, goggles, safety glasses) will be worn by staff when providing direct patient care or having close contact (within 6 feet) with a patient or other individual. The policy further indicated that team Members should wear eye protection and an N95 or higher respirator at all times while on the COVID-19 positive or Quarantine area with gown and gloves added when entering patient/resident rooms. Review of the facility's Transmission Based Precautions Policy and Procedure revised on 02/2021, indicated that Gowns and gloves must be worn by all personnel upon entering the room. This is a proactive measure, as unexpected resident contact or contact with environmental surfaces or items in the resident's room cannot always be anticipated. Review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/23/21, indicated that HCP (health care provider) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. Review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Using Personal Protective Equipment (PPE), updated 8/19/20, included the following steps 1. Identify and gather the proper PPE; 2. Perform hand hygiene; 3. Put on isolation gown; 4. Put on N95; 5. Put on face shield or goggles; 6. Put on gloves; 7. HCP may now enter patient room. Review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Responding to COVID-19 in Nursing Homes, updated 04/30/2020, included that a designated care area unit for resident's positive for COVID-19 should be established in the nursing facility. The CDC guidance further indicated to place signage at the entrance of the COVID-19 care unit that instructs HCP (healthcare personnel) that they must wear eye protection and an N95 respirator while on the unit. NJAC 8:39-19.4(a); 27.1(a)