Complaint #: NJ00186369Based on interviews, record review, and review of pertinent facility documents on 07/23/25, it was determined that the facility failed to ensure a ventilator tubing/circuit and tracheostomy tube were changed as deemed necessary and consistent with the professional standards of practice for Resident #7. This deficient practice was identified in 1 of 9 residents reviewed for tracheostomy care and services and was evidenced as follows: A review of Resident #7's admission Record (AR) revealed the resident was admitted to the facility with the following diagnoses which included but were not limited to: chronic respiratory failure, epilepsy (condition characterized by sudden, uncontrolled jerking or stiffening of the body), aphasia (an impairment in the ability to comprehend or formulate language because of a disorder in specific brain areas), Rett's syndrome (a genetic condition affecting the brain development in children), tracheostomy (a hole made by doctors through the front of neck which allows air to pass into the windpipe to help with breathing), gastrostomy (an opening into the stomach to allow the introduction of food through a feeding tube), and aspiration of fluids (accidental inhalation of liquid into the lungs). A review of the resident's Minimum Data Set (MDS), an assessment tool dated 03/19/25, under Section C revealed that the resident's cognitive skills for daily decision making was severely impaired. The resident's MDS further showed that the resident was totally dependent on staff for the completion of their Activities of Daily Living (ADLs). A review of the resident's individual comprehensive care plan (ICCP) dated initiated 9/11/24, included a focus area that the resident had a tracheostomy (trach) tube for respiratory needs/airway management and at risk for tracheitis and trach dislodgement. The ICCP further revealed that the resident was being maintained on continuous ventilator settings appropriate for the resident's needs. A review of the resident's Respiratory Therapy Record (RTR) for the month of March 2025 reflected an order: Change tracheostomy tube size 4.5 PED [pediatric] every month and further reflected that the tracheostomy tube was changed on 3/1/25. A review of the resident's progress notes (PN) dated 4/3/25 at 12:36 AM indicated that the resident was sent out to hospital due to continuous seizures and fever of 100.8 degrees Fahrenheit around 11:35 PM. The PN dated 4/3/25 at 5:56 AM, revealed that the resident was admitted in PICU (pediatric intensive care unit) hospital [name redacted] with diagnosis of seizure. A PN dated 4/15/25 at 2:31 PM, indicated the resident was received back to facility at around 12:35 PM from the hospital. A review of a document submitted by facility titled, Monthly Trach Change List, Month of April Year 2025, revealed that Resident #7's tracheostomy tube was changed for the month of April on 4/16/25, a day after the resident was readmitted to the facility. The above document had not reflected that the resident's tracheostomy tube was changed as scheduled on 4/1/25, prior to resident's transferred out to hospital on 4/2/25. A review of documents submitted by the facility titled, Ventilator Circuit Change Record Sheet (VCCRS) with dates range with scheduled weekend changes as follows:-The weekend of 2/1/25 and 3/29/25.-The weekend of 2/8/25 and 4/5/25.-The weekend of 5/24/25 and 7/19/25.The VCCRS did not include Resident #7's name. A review of Resident #7's ED [emergency department] to hospital admission notes in PICU dated 4/3/25, revealed the following present on admission: seizure, epilepsy, chronic respiratory failure, C. difficile colitis (inflammation of bowel caused by the bacteria, C. difficile), pneumonia due to Serratia marcescens (respiratory infection caused by the bacteria, S. marcescens), and pneumonia of right upper lobe (right upper part of lung) due to Klebsiella pneumoniae (a bacteria causing respiratory infection). On 7/23/25 at 11:31 AM, during a tour of the ventilator (vent) unit with the Assistant Director of Nursing (ADON), the surveyor interviewed the Head Respiratory Therapist (HRT). The HRT stated every resident on ventilator had schedules for changing the ventilator tubing every eight weeks by the Respiratory Therapist (RT). The HRT further stated the changing of the tracheostomy tubes for the pediatric residents were once a month on the first week of the month by the RT, and that the RT had a schedule. On 7/23/25 at 12:15 PM, during a continued tour of the vent unit with the ADON, the ADON stated that the blue ventilator tubing that was connected to the residents and attached to the ventilators were called the ventilator circuits. The ADON further said the ventilator circuits and the tracheostomy tubes were changed by the RT. On 7/23/25 at 12:30 PM, the surveyor requested from the ADON and HRT the March, April, and May 2025 ventilator circuit and tracheostomy tube changing schedules or log. On 7/23/25 at 2:22 PM, the surveyor interviewed the Director of Nursing (DON) and the Registered Nurse Unit Manager (RNUM) together with the ADON. The RNUM and DON stated the tracheostomy tubes were changed by the RT once a month and as needed. They further stated that the ventilator tubing or circuits which consisted of the blue tubing were changed by the RT according to the schedule. At that time, the surveyor showed the ventilator circuit schedules log submitted by the HRT for the scheduled months which revealed that Resident #7 was not included in the schedule. The ADON stated she would check again. On 7/23/25 at 4:23 PM, during exit conference with the facility, the ADON provided the surveyor with an additional VCCRS, which included Resident #7. According to that VCCRS, Resident #7's ventilator circuit was changed during the weekend of 2/8/25, on 2/8/25, and during the weekend of 4/5/25, on 4/5/25. Both changes were initiated and signed by RT #1 and RT #2. Resident #7 was transferred out to hospital on 4/2/25, and returned to the facility on 4/15/25. The surveyor questioned the accuracy of that VCCRS specifically for Resident #7's ventilator circuit on 4/5/25, because the resident was not in the facility at that time. The facility had no response. A review of facility policy titled, Vent Circuit Changes dated 2/10/22, under Policy: The following outlines the procedure used to change ventilator circuit; Indication: Circuit changes shall be done on an 8 week cycle or may be changed sooner if damaged or for any other reason that would require it; Documentation: Document circuit change in circuit change book and make a progress note; Change Frequency: every 8 weeks or PRN. A review of facility policy titled, Trach Change dated 1/31/22, under Policy: The following policy outlines the procedure used to institute the changing of trach tubes; Scope: Tracheostomy tubes shall be changed once per month on or about the 1st. N.J.A.C. 8:39-25.2 (c)4,6

Based on observation, interview, and record review, it was determined that the facility failed to maintain a dignified living environment for 1 of 35 residents reviewed (Resident # 83). The deficient practice was evidenced by the following: On 1/21/25 at 12:55 PM, the surveyor observed Resident # 83 in bed which was in a low position, with a sheet covering the resident. There was a staff member in the room seated next to the resident and the staff member stated that he was an aide who provided one-to-one care for Resident # 83. There were no personal belongings in the resident's room, and the wall in the resident's room were bare and had nothing on them. There was brown colored cardboard and tape covering over the air conditioning unit in the resident's room. The floor tiles were discolored and mismatched and there was an approximately 8-inch hole in the wall. At 1:00 PM, the surveyor interviewed the aide, who could not explain what happened and why the hole was there. The aide stated that Resident # 83 gets one to one supervision, 24 hours a day because the resident has behaviors of aggression, pulling things off the wall and has a history of knocking furniture over. The aide stated that the resident is blind in both eyes and cannot have furniture or belongings in the room as Resident # 83 will feel around the room and knock them down. At 1:10 PM, the surveyor interviewed the Licensed Practical Nurse, Charge Nurse, (LPN,CN) who stated that Resident # 83 is blind and has aggressive behaviors. She stated that the resident disrobed often and often became destructive of property as well. The LPN, CN stated that the resident cannot have personal belongings in their room. The LPN, CN stated that the air conditioning unit was covered and taped as Resident # 83 often tried to pull parts of the unit apart. The LPN, CN also stated that she did not know why there was a hole in the wall or why the floors looked like they did. A review of the resident's admission Record revealed diagnoses which included, but were not limited to; behavioral and emotional disorders, autistic disorder, blindness to right and eft eye, schizophrenia, anxiety, and intellectual disabilities. The resident has care plans in place for impaired visual function and disruptive and aggressive behaviors. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 11/1/24, revealed Resident # 83 had no Brief Interview for Mental Status, as the resident was assessed as rarely or never understood. On 1/22/25 at 12:27 PM, the surveyor discussed the above concerns with the Director of Nursing (DON) and the Administrator. The DON who stated that the resident is uncontrollable when they are angry, and the resident cannot have belongings in the room because they get ripped down and destroyed. The DON and Administrator stated that they could have done other things to make the room more homelike but had the resident's safety in mind. The DON and Administrator stated that they would look into why there was a hole in the room and will observe the floors too. On 1/22/25 at 1:14 PM, the surveyor interviewed the Maintenance Director (MD), who stated that he was aware of the hole in the resident's wall and the mismatched tiles. The MD did not know how long the hole was in the resident's wall and stated it should have been fixed. The MD stated that the facility does need to replace the flooring. The MD also stated that the facility put the cardboard and tape onto the air conditioning unit and there might be a way to make it look more homelike. A review of the facility's policy titled, Safe and Homelike Environment, dated 10/25/24 revealed that a homelike environment is one that de-emphasizes the institutional character of the setting. NJAC 8:39-4.1(a)12

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 1 of 35 residents reviewed for the accommodation of needs (Resident # 39), and was evidenced by the following: On 1/21/25 at 11:38 AM, the surveyor observed Resident #39 in bed on a specialty mattress. The resident responded to the surveyor's greeting with a thumbs up and a smile. Resident #39 did not respond verbally. The surveyor observed Resident #39 had a tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help air and oxygen reach the lungs), with an oxygen concentrator in place infusing at 1.5 Liters per minute (lpm) via trach collar tubing. The surveyor observed that the resident's call bell (used to summon staff for assistance) was affixed to the left siderail, not within his/her reach. The surveyor reviewed the medical record for Resident #39. A review of Resident #39's admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; tracheostomy, gastrostomy (tube surgically inserted into the stomach to deliver nutrition), aphasia (language disorder that affects a person's ability to communicate) respiratory failure, paraplegia (a condition that causes paralysis in the lower half of the body) urinary tract infection, and hemiplegia (a condition that causes weakness or paralysis on one side of the body) affecting their right dominant side. A review of Resident #39's quarterly Minimum Data Set (MDS), an assessment tool dated 12/18/24, revealed Resident #39 had severely impaired cognition. The MDS further assessed that the resident was dependent on staff for Activities of Daily Living (ADL) care. A review of Resident 39's Individualized Care Plan (CP) included a focus that indicated the resident was unable to verbalize his/her preferences with a goal that he/she would be asked questions that would allow him/her to utilize a thumbs-up/down for communication and facial expression. The CP did not include an intervention that addressed keeping their call bell within reach on their left side (diagnoses of right-sided hemiplegia). On 1/21/25 at 11:40 AM, the surveyor asked the Charge Nurse (CN) to accompany her to Resident #39's room. The surveyor and CN entered the Resident's room and observed the resident in bed and the call bell affixed to the left side rail, not within the resident's reach. The CN confirmed that the resident's call bell should have been placed within the resident's reach. On 1/21/25 at 11:45 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) assigned to Resident # 39's care (7 am-3:00 pm shift), who confirmed that the resident was able to use their call bell and that he should have placed it within the resident's reach. On 1/21/25 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #39's care (7 am-3:00 pm shift). The LPN acknowledged that the call bell should have been placed within Resident #39's reach. The LPN confirmed that Resident #39 was nonverbal and needed their call bell in order to summon staff assistance. A review of the facility's Call Bell Response policy and procedure revised 10/2024 indicated .the CNA will place the call bell within easy access for the resident . On 1/27/25 at 1:45 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The LNHA confirmed that the call bells should be placed within the residents' reach. NJAC 8:39- 31.8 (c)(9)

Based on observation, interview, and record review, it was determined that the facility failed to accurately develop and implement a person-centered comprehensive care plan for care and service needs. This deficient practice was observed for 1 of 35 residents reviewed, Resident # 28, as evidenced by the following: 1. On 1/21/25 at 1:16 PM, the surveyor observed Resident # 28, in the dayroom and the resident was unable to answer the surveyor's questions. The surveyor reviewed Resident #28's Electronic Medical Records. Resident #28's face sheet revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; pulmonary embolism. The Quarterly Minimum Data Set (MDS) an assessment tool dated 10/11/24, which revealed that there was no Brief Interview for Mental Status, as the resident was assessed as rarely or never understood. A review of the Physician's Order Sheet (POS) revealed the resident had a physician's order for Apixaban 5 mg 1 tablet by mouth twice daily. The surveyor reviewed the resident's current care plans. There was no comprehensive care plan developed regarding the resident's order for the anticoagulant medication. On 91/27/25 at 1:45 PM, the surveyor interviewed the Director of Nursing (DON), who stated that a care plan for the anticoagulant medication which was prescribed to Resident # 28 should have been created. The DON was unable to locate the care plan for the anticoagulant medication. The surveyor with the policy titled Care Plan, dated 12/2024, which revealed that the comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment. NJAC 8:39- 11.2 (e)

Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice by not following a physician's order for 2 of 35 of the residents (Resident #39 and #50) reviewed. The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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 regimes 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 state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 1/21/25 at 11:38 AM, the surveyor observed Resident #39 in bed on a specialty mattress. The resident responded to the surveyor's greeting with a thumbs up and a smile. Resident #39 did not respond verbally. The surveyor observed Resident #39 had a tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help air and oxygen reach the lungs), with an oxygen concentrator in place with humidifier infusing at 1.5 Liters per minute (lpm) via trach collar tubing. The surveyor reviewed the medical record for Resident #39. A review of Resident #39's admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; tracheostomy, gastrostomy (tube surgically inserted into the stomach to deliver nutrition), aphasia (language disorder that affects a person's ability to communicate) respiratory failure, paraplegia (a condition that causes paralysis in the lower half of the body) urinary tract infection, and hemiplegia (a condition that causes weakness or paralysis on one side of the body) affecting their right dominant side. A review of Resident #39's Order Summary Report (OSR) reflected Resident #39 had an active Physician's order (PO) Oxygen 28% FIO2 (fraction of inspired oxygen), the percentage of oxygen that a person inhales) to infuse at 3 Liters per minute (lpm) via a trach collar every shift with a start date of 11/11/24. A review of Resident #39's quarterly Minimum Data Set (MDS), an assessment tool dated 12/18/24, revealed Resident #39 had severely impaired cognition. The MDS assessed that the resident was dependent on staff for Activities of Daily Living (ADL) care. The MDS further assessed that the Resident received Respiratory Care, which included Tracheostomy care and Oxygen Therapy. A review of Resident 39's Individualized Care Plan (CP) included a focus that indicated the resident had a Tracheostomy r/t respiratory failure with interventions, which included giving humidified oxygen as prescribed with an initiated date of 3/22/23. On 1/21/25 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #39's care (7 am-3:00 pm shift). The LPN confirmed that the Oxygen gauge was set at 1.5 lpm. The surveyor asked the LPN if that was what the physician ordered. The LPN replied that she would check the doctor's order. The LPN and surveyor reviewed the PO which indicated that the Oxygen was ordered to be delivered at 3 lpm. The LPN confirmed that she had not checked the oxygen settings that morning to ensure the resident had received the proper lpm. A review of the facility's Oxygen Therapy policy and procedure revised 10/2024 indicated .Adjust the rate of flow according to the doctor's orders. A review of the facility's Physician Order policy and procedure revised 10/7/24 indicated .admission orders are verified with the physician . Any order that is in question must be repeated to the physician .Notify the nursing administration and medical director whenever an order that is questioned cannot be verified . On 1/27/25 at 1:45 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The DON stated that the respiratory therapists sometimes change the Oxygen settings but confirmed that the LPN should have been knowledgeable regarding the Oxygen order and administration. On 1/28/25 at 10:16 AM, the survey team met with the LNHA, DON, and Director of Respiratory Therapy (DOR). The DOR stated that the resident had received the appropriate FiO2 at 28% and that the respiratory therapists changed the gauges on the concentrators to ensure the resident received the proper concentration. The DOR further stated that the doctor should not write the order to include the lpm, that the orders come from the hospital, and that was why they were written that way. The DOR confirmed that the order should have been clarified with the physician and followed accordingly. The LNHA confirmed that the LPN should have clarified and followed the PO.

NJ 175442 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain timely assistance with breakfast, and morning care (assistance with, but not limited to feeding, continence care, dressing, and grooming) for a resident who was totally dependent on staff for activities of daily living (ADL). This deficient practice was identified in 1 of 2 residents (Resident #169) reviewed for ADL and was evidenced by the following: On 1/21/25 at 11:07 AM, during the initial tour, the surveyor, from the hallway, observed Resident #169 in their room, seated in a wheelchair, well dressed, and was in the middle of a video conference call. The video conference device utilized by Resident #169 appeared mounted on a stand. The surveyor reviewed the medical record for Resident #169. According to the admission Record, (an admission summary), reflected that Resident #169 was admitted to the facility with diagnoses that included the following: unspecified injury of the cervical spinal cord (damage to spinal cord), and neuromuscular dysfunction of the bladder (urinary incontinence). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 11/7/24 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. In addition, the MDS further revealed there were no behaviors related to rejection of care, had the ability to understand staff, and the ability to be understood by staff. Resident #169 was totally dependent on staff for all activities of daily living (ADL; include eating, bathing, dressing, mobility and continence care). A review of the resident's individual comprehensive care plan (CP) included a focus area, that Resident #169 had difficulty with self-feeding related to paraplegia, initiated on 8/26/24. The associated intervention included a one-to-one feeding assistance by staff, initiated on 8/26/24. Further review of the CP reflected a focus on the resident's bowel and bladder incontinence, initiated on 2/2/24. The associated intervention included frequent and as required checks, cleansing, rinsing, drying of personal areas, change of clothing after incontinence episodes. A review of Resident #169's grievance form, dated 7/7/24 at 11:41 AM, revealed that the Social Worker (SW) was notified by the resident that they had not received any care, breakfast was not offered, and had not been fed. A review of the Certified Nursing Assistant (CNA #1's ) signed statement revealed that Resident #169 was originally assigned to a different CNA (CNA #2) who at that time was not in the building. CNA #1 was not informed that Resident #169 was added to her assignment of 19 residents in total. Resident #169 was not fed and not cleaned by 11:00 AM. The SW went to the facility to ensure care was rendered and the resident ate lunch. On 1/23/25 at 10:25 AM, during an interview with the surveyor, the SW stated that she had initially taken the complaint and notified the Assistant Director of Nursing (ADON) of the grievance. On 1/23/25 at 11:28 AM, during an interview with the surveyor, the ADON stated that she was informed by the SW and the incident had occurred on a Sunday. The ADON also stated that there was miscommunication, wherein the nurse on duty did not inform CNA #1 of the additional assigned residents that included Resident #169. The ADON stated that the breakfast was offered to the resident, but the resident refused since it was almost lunch time. The ADON confirmed that the resident had to be fed and was totally dependent for ADLs. At that time, the surveyor and the ADON reviewed the provided assignment sheet for 7/7/24. The ADON confirmed CNA #1 had 19 assigned residents and acknowledged that they were short staffed on that day. On 1/23/25 at 1:34 PM, in the presence of the survey team, and the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) stated that every resident needed to received care and staffing was a challenge, but they worked hard to meet the staffing needs. The DON acknowledged awareness of the staffing shortage for that day. The DON also stated that the staff was overwhelmed that day, and that the CNA did not know that the resident was re-assigned to her, all of which were summarily contributors to the delayed morning care and feeding of Resident #169, who was totallhy dependent on staff. A review of the provided facility policy, Activities of Daily Living dated/revised 6/1/23, revealed that resident will gain/ or maintain as much independence as possible in ADLs which are essential to the individual's lifestyle. NJAC 8:39-4.1(a)22, 17.2(f)

**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 that urinary drainage bags were stored and secured in a manner to prevent contamination and infection control. This deficient practice was identified for 2 of 3 residents reviewed (Resident # 39 and #70), and was evidenced by the following: 1.On 1/21/25 at 11:10 AM, the surveyor observed Resident #70 in bed. The surveyor observed the resident had a tracheostomy with a large portable oxygen tank infusing at 6 Liters per minute (lpm) via trach collar tubing and two urinary drainage bags lying on top of the resident ' s bed, one on each side of the resident. The surveyor observed there were two privacy bags affixed to the lower aspect of the upper left and right-side rails. The surveyor reviewed the medical record for Resident #70. A review of Resident # 70 ' s admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; acute kidney failure, nephrostomy catheter (a small flexible tube that drains urine from the kidney into a bag outside the body), a suprapubic catheter (a small flexible tube that drains urine from the bladder through a small incision in the lower abdomen and connected to a drainage bag outside the body), tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help air and oxygen reach the lungs), gastrostomy (tube surgically inserted into the stomach to deliver nutrition), aphasia (language disorder that affects a person ' s ability to communicate) and respiratory failure. A review of Resident #70 ' s quarterly Minimum Data Set (MDS), an assessment tool dated 12/27/24, revealed Resident #70 had severely impaired cognition. The MDS further assessed that the resident was dependent on staff for Activities of Daily Living (ADL) care and had an indwelling nephrostomy tube and suprapubic catheter. A review of Resident #70's Individualized Care Plan (CP) included a focus that indicated the resident had a right nephrostomy tube and a suprapubic catheter due to obstructive uropathy from kidney stones initiated on 2/28/20 with interventions that included keeping the drainage bag below bladder level. On 1/21/25 at 11:20 AM, the surveyor asked the Licensed Practical Nurse (LPN) assigned to Resident #70 ' s care (7 AM-3:00 PM shift) to accompany her to Resident #70 ' s room. The surveyor and LPN entered the resident ' s room and observed the two urinary drainage bags on the bed. The surveyor asked the LPN if the drainage bags should be stored in the privacy bags located on the lower aspect of the right and left upper side rails located below the bladder for privacy and proper drainage. The LPN again stated that the resident ' s mother wanted the bags in the bed. On 1/21/25 at 11:25 AM, the surveyor interviewed Resident #70 ' s Certified Nursing Assistant (CNA #1), who stated that the urinary drainage bags should be contained in the privacy bags that were affixed to the lower part of the side rails to ensure privacy and proper drainage. CNA#1 further stated that she had not provided care to the resident that morning and had not observed the urinary drainage bags in the bed. On 1/21/25 at 11:32 AM, the surveyor interviewed the Charge Nurse (CN), who confirmed that the urinary drainage bags should always be stored in privacy bags for privacy and below the bladder level for gravity and to prevent urinary tract infections. 2. On 1/21/25 at 11:38 AM, the surveyor observed Resident #39 in bed on a specialty mattress. The resident responded to the surveyor ' s greeting with a thumbs up and a smile. Resident #39 did not respond verbally. The surveyor observed that Resident #39 had a tracheostomy, with an oxygen concentrator in place, infusing 1.5 Liters per minute (lpm) via trach collar tubing. The surveyor observed the urinary drainage bag was affixed to the lower aspect of the bedframe, not contained within the privacy bag that was hanging on the bedframe next to the drainage bag. The surveyor reviewed the medical record for Resident #39. A review of Resident #39's admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; tracheostomy, gastrostomy, aphasia, respiratory failure, paraplegia (a condition that causes paralysis in the lower half of the body) urinary tract infection, and hemiplegia (a condition that causes weakness or paralysis on one side of the body) affecting their right dominant side. A review of Resident #39's quarterly MDS dated [DATE], revealed Resident #39 had severely impaired cognition. The MDS further assessed that the resident was dependent on staff for Activities of Daily Living (ADL) care and had an indwelling urinary catheter. A review of Resident #39's CP included a focus that indicated the resident had an Indwelling catheter; initiated on 1/18/22 with interventions that included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door initiated. On 1/21/25 at 11:45 AM, the surveyor and CN entered the Resident ' s room and observed the urinary drainage bag affixed to the left lower aspect of the bed frame with the privacy bag hanging next to the urinary drainage bag. The CN confirmed that the urinary drainage bag should have been stored properly within the privacy bag, not next to it. On 1/21/25 at 11:45 AM, the surveyor interviewed the CNA ( CNA #2) assigned to Resident #39 ' s care (7 am-3:00 pm shift), who confirmed that the resident ' s urinary drainage bag should have been stored in the privacy bag that was affixed to the lower left side of the bed for privacy and infection control. On 1/21/25 at 11:50 AM, the surveyor interviewed the LPN assigned to Resident #39 ' s care (7 am-3:00 pm shift). The LPN acknowledged that she should have placed the urinary drainage bag inside the privacy bag for dignity and infection control. A review of the facility ' s Catheterization (Foley) policy and procedure revised 10/2024 indicated .Position tubing and hang the drainage bag on the bed frame to provide optimal gravity drainage .always keep the catheter bag below the level of the bladder . On 1/27/25 at 1:45 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The DON confirmed that all urinary drainage bags should be kept below the level of the bladder and stored in privacy bags. NJAC 8:39- 31.8 (c)(9)

Based on observation, interview, and record review, it was determined that the facility failed to store 1 of 35 residents (Resident # 83) personal clothing in a sanitary manner. This deficient practice was as evidenced by the following: On 1/21/25 at 12:55 PM, the surveyor observed Resident # 83 in bed which was in a low position, with a sheet covering the resident. There was a staff member in the room seated next to the resident and the staff member stated that he was an aide who provided one-to-one care for Resident # 83. The surveyor observed that inside the resident's bathroom, the resident's clothing was on hangers and located hanging on the shower curtain rod, which was approximately 5 feet from the resident's toilet. At 1:00 PM, the aide stated that Resident # 83 gets one to one supervision, 24 hours a day because the resident has behaviors of aggression, pulling things off the wall and has a history of knocking furniture over. The aide stated that the resident is blind in both eyes and cannot have furniture or belongings in the room as Resident # 83 will feel around the room and knock them down. The aide stated that Resident # 83 uses the toilet in the bathroom on occasion and is incontinent at times too but gets showers in the communal shower room. At 1:10 PM, the Licensed Practical Nurse, Charge Nurse, stated that the resident's clothing was stored in their bathroom, on the shower rod because the resident could not have a dresser or closet in their room, but stated that there could be a better way to store it more hygienically, like in a container. On 1/22/25 at 12:27 PM, the surveyor discussed the above concerns with the Director of Nursing (DON) and the Administrator. The DON stated that the clothing was stored in the resident's bathroom because the resident knocks over furniture in their room and they will look into storing the clothing in a different way to prevent concerns with infection control. N.J.A.C. 8:39-19.4(a)

2. On 1/22/25 at 10:30 AM, the surveyor observed Resident #179 in their room and upon interview, the resident stated that they received renal dialysis three times a week. The resident stated that they could not recall if the resident was assessed when they returned to the facility from the dialysis center. The surveyor reviewed the medical record for Resident #179. According to the admission Record, Resident #179 was admitted with diagnoses that included but were not limited to; end stage renal disease and dependence on renal dialysis. A review of the admission Minimum Data Set (MDS), an assessment tool used to manage care, dated 11/5/24, revealed Resident #179 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated that the resident was moderately impaired for cognition. A review of Resident #179's medical record revealed that the resident was scheduled for hemodialysis (HD) on Tuesday, Thursday and Saturday at 10:15 AM. A review of the HD communication log revealed that the facility completed the pre-dialysis assessments and the HD center completed the assessment while the resident was at the HD center. There was no portion on the communication log which reflected if the facility completed a post-HD assessment. The surveyor reviewed Resident # 179's Progress Notes (PN), which revealed that the facility nurses documented a post-HD assessment for some of the dates when the resident returned from the HD center, but it was not consistent. There were no post-HD assessments for the dates of 2/19/24, 12/26/24, 12/28/24, and 1/9/25 in the PN's. On 1/27/25 at 1:45 PM, the surveyor discussed the above concerns with the Director of Nursing (DON) and the Administrator. On 1/28/25 at 10:16 AM, the Administrator stated that the facility is aware that the residents should have post-HD assessments done by the nursing staff and they will address this concern. A review of the facility provided policy End-Stage Renal Disease, Care of a Resident dated/revised 1/28/24 reflected that Agreements between this facility and the contracted ESRD facility included all aspects of how the resident's care will be managed, including how information will be exchanged between the facilities. The general medical nurse should document in the resident's medical record every shift as follows: location of catheter, condition of dressing (interventions if needed), if dialysis was done during shift, any part of report from dialysis nurse post-dialysis being given and observation post dialysis. NJAC 8:39 - 27.1 (a) Based on observation, interview, review of medical records, and other facility documentation, it was determined that the facility failed to complete post-dialysis assessments for residents on dialysis (a treatment that replicates the kidney's function and cleans the waste from blood for individuals with kidney disease or kidney failure). This deficient practice was identified for 2 of 2 residents (Resident # 127 and #179) reviewed for dialysis and was evidenced by the following: 1. On 1/21/25 at 11:00 AM, during the initial tour of the 4th floor unit, the surveyor observed that Resident #127 was not in his/her room. The Charge Nurse (CN) stated that the resident was at dialysis. The CN stated that the resident received renal dialysis three times a week. On 1/27/25 at 8:00 AM, the surveyor observed Resident #127 in bed on a specialty mattress. The resident did not respond to the surveyor's greeting. The surveyor reviewed the medical record for Resident #127. A review of the admission Record reflected Resident #127 was admitted to the facility with diagnoses that included but were not limited to; dependence on renal dialysis. A review of the most recent Minimum Data Set (MDS), an assessment tool dated 12/27/24, revealed Resident #127 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident's cognition was severely impaired. A review of Resident #127's medical record revealed that the resident was scheduled for hemodialysis (HD) on Tuesday, Thursday, and Saturday at 10:00 AM. An active Physician's Order, dated 11/24/23, indicated Blood Pressure monitoring pre and post-HD every Tuesday, Thursday, and Saturday; check BP prior to leaving for Dialysis and upon returning from Dialysis. A review of the HD communication log revealed that the facility completed the pre-dialysis assessments and the HD center completed the assessment while the resident was at the HD center. There was no portion on the communication log which reflected if the facility completed a post-HD assessment. On 1/27/25 at 8:10 AM, the surveyor interviewed the Registered Nurse (RN) on the 4th-floor unit, who stated that the dialysis communication binder would be sent with the resident on dialysis days. The nurse would complete the top section of the form, and the dialysis center would complete the bottom section. When the resident returned from dialysis the facility nurse would sign the bottom of the form and document the time the resident returned to the facility. The receiving nurse would then document the vital signs and post HD assessment in the Progress Notes. The surveyor reviewed Resident #127's Progress Notes, which revealed that the facility nurses documented a post-HD assessment for some of the dates when the resident returned from the HD center, but the documentation was not consistent. There were no post-HD assessments, which included vital signs for the dates of 1/4/25, 1/7/25, 1/11/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, and 1/25/25.

Complaint# NJ00173746 Based on interview, document review, and review of facility policy, the facility failed to ensure it reported the results of their findings for an injury of unknown origin to the State Survey Agency that ruled out abuse and neglect for 1 (Resident #2) of 3 sampled residents. This deficient practice is evidenced by the following According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Cerebral Palsy, Disorders of Psychological Development, Hypothyroidism, and Aphasia. A review of the Resident #2 Physician Progress Notes (PPN), dated 05/08/2024 at 11:50, indicated Resident #2, was .Awake, alert, nonverbal, baseline. The PPN further revealed, Pt [resident] noted with discoloration to forehead and A/P [assessment/plan]: Head injury to frontal lobe of unknown cause without LOC [loss of consciousness] . A review of the document presented to the surveyor by facility staff revealed the following: Resident #2's Incident Report (IR) #1185 Skin Injury dated 05/08/24 at 12:01p.m., documented by Licensed Practical Nurse (LPN) #1, under Nursing Description: Resident has multiple discoloration on his forehead and headline and under Resident Description: Resident Unable to give Description. The IR further revealed under Notes and signed by Unit Manager Registered Nurse (UMRN) showed under the Summary of Incident: During AM [morning] care, [Resident #2] was found to multiple discolorations on his forehead. Conclusion: [Resident #2] is an alert, active child. He has history of rocking himself. He could have hit his forehead on a siderail, head board, or foot board. No substantiated evidence of abuse or neglect. The IR further revealed under Witnesses Statement on 5/8/2024 indicated [CNA #1] went into [Resident #2] room [#] at 8:30 am to do AM [morning] care and to get him ready for school .CNA#1 noticed knots and a small scrape on his [Resident #2] forehead .went to look for his nurse .and called the clinical manager [UMRN] to look at . During the tour and interview with the surveyors on 05/15/24 at 9:40 a.m., the UMRN stated on 5/8/24 at around 8:10 to 8:15 a.m., CNA #1 called her/him to look at Resident #2. UMRN further stated she noted discoloration on his [Resident] forehead, dark bluish with a little abrasion, no bleeding. UMRN stated she investigated immediately. UMRN affirmed the incident was not witnessed and stated that Resident #2 had behavior of rocking back and forth and flailing of arms which were not new. According to UMRN, CNA#1 did not witness the incident and that [Resident #2] was aphasic [cannot talk] and cannot explained what happened. During an interview with the surveyors on 05/15/24 at 3:34 p.m. with the LNHA, DON, and ADON, LNHA stated DON and her/him were responsible for reporting all allegations of abuse, neglect, or misappropriation to the New Jersey (NJ) DOH. LNHA stated that she/he was aware of Resident #2's incident in the morning meeting. Both LNHA and DON asserted that incident was caused by Resident #2 behavior of rocking his [Resident #2] head back and forth. DON stated she/he was aware of the child [Resident #2] behavior. LNHA affirmed that Resident #2's incident was not witnessed, Resident #2 was nonverbal, no staff could explain what happened, and there was injury to the Resident. The facility was unable to provide further explanation. A review of the facility's policy titled Abuse Prevention, revised 01/2024 indicated under REPORTING: In response to allegations of abuse .the facility must ensure that: All allegations of abuse must be immediately reported to the Director of Nursing and or Administrator and no later than 2 hours to other officials (including to the State Survey Agency) after the allegation is made, if the event that caused the allegation involve abuse or result in a serious bodily injury. The alleged violations must be reported no later than 24 hours to the State Survey Agency if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ00169635 Based on interviews and record review, as well as a review of pertinent facility documents on 12/14/23 and 12/15/23, it was determined that the facility staff failed to immediately report an allegation of abuse to New Jersey Department of Health (NJDOH) and follow the facility policy titled Abuse Prevention for 1 of 3 residents (Resident #1) reviewed for reporting. This deficient practice is evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: Cerebral Palsy and Convulsions. A Minimum Data Set (MDS), an assessment tool, dated 11/17/23, revealed that Brief Interview for Mental Status (BIMS) for Resident #1 was unable to be conducted due to resident was resident is rarely/never understood and the resident required assistance with activities of daily living (ADLs). A review of the facility's Grievance Form (GF) dated 11/30/23 at 4:55 p.m. and signed on 12/8/23 by the Social Worker (SW), the GF reflected, Resident's [family member] (FM) called SW [Social Worker] stating [Resident #1] was in a horrible condition and possibly going to not make it the night. [FM] further stated it was 'abuse' that [he/she] is in [his/her] current condition and that [he/she] smells bad. The GF further reflected that the GF had to be redirected to Nursing, and the facility had scheduled to call the FM to discuss care. Furthermore, the GF revealed that Based on the above investigative summary, the facility is able to conclude that no abuse, neglect, mistreatment or misappropriation of Resident property has been identified. A review of the form Summary, dated 12/1/23, documented by the Licensed Nursing Home Administrator (LNHA), reflected On 11/30/2023, social worker spoke to [Resident's family member] and informed [SW] how upset [family member] was on the overall care for [Resident] and that it was abuse and neglect .[SW] informed the Administrator of the phone conversation she had with [family member]. [SW] informed the Administrator that there was no specification on allegation of physical, mental, or verbal abuse but that she was very upset about the overall care for [Resident #1]. The Administrator told DON [Director of Nursing] and started to interview staff to confirm there were no signs of abuse. After interviewing staff on 11/30/23, there were no signs of abuse substantiated. The Summary, After reviewing the interviews with the staff that cared for the [Resident] .there was no evidence of abuse substantiated. Attached to the Summary was a statement from the SW signed on 12/1/23, indicated that Resident #1's FM called and was crying. The FM reported that baby was going to die because [of] our abuse and neglect to [her/him] medically. [FM] did not mention any allegation of physical, mental or psychological abuse but overall was upset on [her/his] care. [SW] assured [FM] we did not abuse or neglect [him/her] .[RFM] was crying during call. During an interview with the surveyors on 12/14/23 at 1:52 p.m., the SW stated that she received the allegation of abuse and neglect from the FM when Resident #1 was admitted to the hospital on [DATE]. The SW further stated that she reported the allegation of abuse and neglect to the DON and LNHA on 11/30/23 after speaking to the FM. During an interview with the surveyor on 12/14/23 at 2:56 p.m. with the DON and the SW, the DON stated that she was not aware of any abuse allegation until today (12/14/23) and that she did not investigate and reported to the NJDOH. The surveyors conducted an interview with on 12/15/23 at 1:01 p.m., the LNHA revealed that any allegation of abuse would need to report to NJDOH. The LNHA confirmed that she was made aware of the allegation of abuse and neglect from the SW on 11/30/23 (unable to recall exact time). The LNHA explained that on 11/30/23, she investigated the allegation of abuse and neglect by collecting verbal statements from staff. The LNHA revealed that she did not report to NJDOH and stated If I felt like there's abuse, I would report it or any suspicion of abuse, but there was no abuse. A review of the facility's policy titled Abuse Prevention, dated 10/4/2023 indicated . IDENTIFICATION: The facility will investigate all incidents involving actual or alleged abuse, complaints/grievances .INVESTIGATION: The facility will investigate all incidents involving actual or alleged abuse, complaints/grievances .PROTECTION: the facility will protect all residents during any abuse investigation by removing staff from direct care and/or removing from schedule pending conclusion. REPORTING: In response to allegations of abuse .the facility must ensure that: all allegations of abuse must be immediately reported to the Director of Nursing and or Administrator and no later than 2 hours to other officials (including to the State Survey Agency) after the allegation is made, if the event that caused the allegation involve abuse or result in a serious bodily injury . NJAC 8:39-9.4(e)

Based on the interview and record review, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment for 1 of 38 residents, (Resident #149) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. Resident #149 was observed to have a Quarterly MDS of 6/06/23 and was due to betransmitted no later than 6/19/23. The Quarterly MDS was not transmitted until 8/28/23. 2. Resident #149 was observed to have a Quarterly MDS of 3/06/23 and was due to be transmitted no later than 3/19/23. The Quarterly MDS was not transmitted until 4/04/23. 3. Resident #149 was observed to have an admission MDS of 12/6/22 and was due to be transmitted no later than 12/19/23. The admission MDS was not transmitted until 1/17/23. 4. Resident #81 was observed to have an Annual MDS of 6/14/23 and was due to be transmitted no later than 6/27/23. The Annual MDS was not transmitted until 8/02/23. On 10/19/23 at 09:10 AM, the surveyor interviewed the facility's Registered Nurse (RN)/MDS Coordinator (MDSC), who was responsible for completing and transmitting the MDS assessments and agreed that the above MDS assessment was transmitted late due to the transition of their system in July 2023. On 10/24/23 at 10:19 AM, the RN/MDSC provided the surveyor a copy of the form titled MDS 3.0 Final Validation Report, which revealed the above resident's name and confirmed the late MDS assessment submission. NJAC 8:39 - 11.1

**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 accurately code the Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care, in accordance with federal guidelines. This deficient practice was identified for 2 of the 38 residents reviewed for resident assessment (Resident#81 and Resident#171). The deficient practice was evidenced by the following: 1. On 10/17/23 at 10:50 AM, the surveyor observed the resident sleeping in bed, covered with a blanket, with an aide sitting in the chair beside the resident's bed. The aide stated the resident was on 1:1 observation since Feb. 2023. The surveyor reviewed the hybrid medical record for Resident #81. The admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to unspecified intellectual disabilities. A review of the quarterly MDS dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 3 out of 15, indicating that the resident had severe cognition. A review of the annual MDS dated [DATE] did not reflect the resident's Preadmission Screening and Resident Review (PASSR) - Is the resident currently considered by state level II PASSR process to have serious mental illness and/or intellectual disability or a related condition? Enter code 0 (zero) No. On 10/20/23 at 11:54 AM, the surveyor interviewed the MDS Coordinator and stated that the resident is PASSR Level 2 (two) and should be captured in the annual MDS assessment on 6/14/23. The form PASSR Level II determination notification dated 09/4/2018 revealed that The Level II for Developmental Disability Evaluation was completed. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual updated October 2023. All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions. 2. On 10/17/23 at 12:22 PM, the surveyor observed Resident #171 in bed with a cover over his/her head. The resident had not responded to surveyor's attempts to interview. The surveyor reviewed the medical record for Resident #171. The admission Record (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to quadriplegia. A review of the electronic MDS entries reflected that the resident had a reentry date of 5/25/23. A review of the quarterly Minimum Data Set (QMDS) with an Assessment Review Date (ARD) of 7/20/23, reflected a BIMS score of 15 out of 15, indicating that the resident had an intact cognition. In addition, in Section A: Most Recent Admission/Entry or Reentry into this Facility reflected that the resident had a reentry date of 5/25/23. A review of a nursing progress note dated 5/24/23 at 19:45 (7:45 PM) reflected that the resident had returned to the facility at 7:45 PM via stretcher. On 10/23/23 at 10:17 AM, the surveyor interviewed the MDS Coordinator who stated that he based the admission or readmission dates of a resident from the notice that he received. At that time, the surveyor with the MDS Coordinator reviewed the MDS entries and the progress note dated 5/24/23 for Resident #171. The MDS Coordinator acknowledgd that Resident #171 was readmitted to the facility on [DATE]. The MDS Coordinator acknowledged that the MDS reentry date of 5/25/23 was incorrect. The MDS Coordinator then stated that he would have to complete a modification to correct the error. On 10/25/23 at 9:57 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA). The LNHA acknowledged Resident #171 had an incorrect readmission date entered on the MDS. The LNHA stated that the MDS Coordinator had corrected the date. The LNHA stated that the facility followed the Resident Assessment Instrument manual for instructions completing the MDS. NJAC 8:39-11.1, 11.2(e)(1), 33.2(d)

Based on observation, interview, record review, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 1 of 2 residents (Resident #39) reviewed for dialysis. This deficient practice was evidenced by the following: On 10/17/23 at 11:09 AM, the surveyor observed the resident was not in their room. The assigned LPN for Resident #39 stated the resident was currently at dialysis and was scheduled for dialysis every Tuesday, Thursday, and Saturday. A review of Resident #39's electronic health record (EHR) revealed the following: According to the admission Record (an admission summary), Resident #39 was admitted with diagnoses that included but were not limited to, End Stage Renal Disease, and Dependence on Renal [kidney] Dialysis. An Annual Minimum Data Set (MDS) assessment, a tool used to facilitate management of care, dated 7/27/23, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #39 scored a 14 out of 15, which indicated the resident was cognitively intact. A physician's order dated 8/6/22 read: Dialysis Binder to accompany Resident to Dialysis each visit one time a day every Tue, Thu, Sat A physician's order, dated 7/28/23 read: [dialysis center's name, address and phone number] Pick-up by [transport company name] at 5AM Chair time: 6:15am A physician's order, dated 4/11/23 read: Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth two times a day for pain A physician's order, dated 6/19/23 read: Lidocaine External Patch 5 % (Lidocaine) Apply to back topically one time a day for pain and remove per schedule A physician's order, dated 8/10/23 read: Metoprolol Tartrate Oral Tablet (Metoprolol Tartrate) Give 25 mg by mouth every 12 hours for HTN hold for sbp<100 hr<60 A physician's order, dated 8/28/23 read: ZyrTEC Allergy Oral Tablet 10 MG (Cetirizine HCl) Give 1 tablet by mouth one time a day for allergy A review of the October 2023 MAR revealed the resident was scheduled to receive the following medications at 9am every day: Lidocaine External Patch 5 % (Lidocaine) Apply to back topically one time a day for pain and remove per schedule which was scheduled to be administered at 0900 [9AM]. ZyrTEC Allergy Oral Tablet 10 MG (Cetirizine HCl) Give 1 tablet by mouth one time a day for allergy which was scheduled to be administered at 0900. Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth two times a day for pain which was scheduled to be administered at 0900 and 1700 [5PM]. Metoprolol Tartrate Oral Tablet (Metoprolol Tartrate) Give 25 mg by mouth every 12 hours for HTN hold for sbp<100 hr<60 which was scheduled to be administered at 0900 and 2100 [9pm]. A review of nursing progress notes from 10/1/23 to 10/23/23 indicated that Resident #39 was out of the facility and returned from dialysis during the scheduled medication times as follows: -A progress note dated 10/21/23 documented the resident returned from dialysis at 11:25 AM. -A progress note dated 10/19/23, documented the resident returned from dialysis at 11:22 AM. -A progress note dated 10/17/23 documented the resident returned from dialysis at 11:25 AM. On 10/23/23 at 11:25 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) who had cared for Resident #39. The LPN stated medications would be scheduled to accommodate for when residents went to dialysis. The surveyor reviewed with the LPN the MAR of Resident #39. The LPN confirmed her signatures on the medications that were scheduled for 9am and documented as administered. The LPN stated that most of the time Resident #39 returned from dialysis at 10 am. The LPN acknowledged the medications should have been scheduled as the resident's other medications, to accommodate for when the resident had dialysis. On 10/23/23 at 11:31 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM), who stated the resident usually returned from dialysis at about 11AM to 12PM. The RN/UM further stated it was expected for medications to be timed to account for the resident's dialysis schedule. The surveyor informed the RN/UM about the interview with the LPN and reviewed the resident's MAR. The RN/UM acknowledged the zyrtec, gabapentin, metoprolol and lidocaine patch medications scheduled at 9am should have been plotted at a time to accommodate the resident's dialysis schedule. The RN/UM further acknowledged that it could not be guaranteed that the resident would return to the facility from dialysis by 10 AM to administer the medications as scheduled. On 10/23/23 at 1:06 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Assistant DON of the concerns for the timing of the resident's medication. There was no verbal response at this time. The surveyor requested any policy related to scheduling of medications for dialysis residents. On 10/24/34 at 9:54 AM, the LNHA provided the policy titled Medication Administration Time for Dialysis, dated 11/2017 with a revised date of 10/23/23. Under Procedure, the policy read: 3. Resident's medication administration time will be accommodated to reflect the days the resident is out of the facility during dialysis days. On 10/24/23 at 10:39 AM, the surveyor interviewed the DON who acknowledged the medications should have been timed to accommodate the resident's dialysis schedule and for when the resident was out of the facility. On 10/24/23 at 12:40 PM, the surveyor interviewed Resident #39 who was alert, oriented, and verbally responsive. The resident stated the time they returned from dialysis varied, could be 10 o'clock, 11, 12 .it depends. Resident stated they had no concerns with their care. NJAC 8:39-27.1(a)

10. Resident #113's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. 11. Resident #32's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. 12. Resident #24's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. 13. Resident #51's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. On 10/23/23 at 11:23 AM, the surveyor in the presence of another surveyor interviewed the Assistant Director of Nursing (ADON) regarding the process of signing the resident's monthly physician's order. The ADON stated that the physicians are expected to review the physician orders monthly and sign on the order tab to acknowledge that the medications were reviewed. The ADON further stated that the last medication review date could be found in the history section. On 10/24/23 at 01:28 PM, the survey team discussed the above concerns to the facility's ADON, Licensed Nursing Home Administrator (LNHA), and Director or Nursing (DON). The LNHA, DON and ADON could not provide further information as to why physician order review was not signed. On 10/25/23 at 10:40 AM, the surveyor in the presence of another surveyor interviewed the Physician via telephone related to the process of signing the resident's monthly physician's order. The physician stated that the medication review as well as the signing is done electronically in each resident's medical record. The physician acknowledged that the monthly medication review signature was not done. A review of the facility's document titled Physician Order revised on 1/5/23 under procedure states, .13. All monthly physician orders must be reviewed, updated as needed, and signed off. NJAC 8:39-11.2(a);23.2(b) 5. Resident #58's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023 and September 2023. 6. Resident #101's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023 and September 2023. 7. Resident #141's hybrid medical record revealed that resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023 and September 2023. 8. Resident #37's hybrid medical record revealed that resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023 and September 2023. 9. Resident #158's hybrid medical record revealed that the resident's physician had not hand signed or electronically signed the monthly physician's orders for April 2023, May 2023, June 2023, and August 2023. Based on record review and interview it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice continued over several months for 13 of 35 residents (#110, 182, 87, 129, 58, 101, 141, 37, 158, 113, 32, 24, and #51) reviewed and was evidenced by the following: 1. Resident #110's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. 2. Resident #182's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. 3. Resident #87's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for August 2023, and September 2023. 4. Resident #129's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for August 2023, and September 2023.

6. On 10/17/23 at 10:48 AM, surveyor observed Resident #32 in bed with eyes open, non-responsive to verbal stimuli. The resident had a tracheostomy on continuous oxygen via trach collar. Observed on feeding tube with feeding Peptamen 1.5 administered by gravity. The resident was non-interviewable. A review of the Resident #32's admission Record (a one-page summary of important information about the patient) that documented the resident's diagnosis which included but was not limited to Acute Respiratory Failure, Dependence on Respirator [Ventilator] Status, Quadriplegia, Tracheostomy, Gastrostomy. A review of the Progress Notes revealed that from April 2023 through September 2023, the Nurse Practitioner (NP) documented that she had seen and examined the resident. There was no documentation that Resident #32's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. 7. On 10/17/23 at 11:13 AM, surveyor observed Resident #24 in bed with eyes open, non-responsive to verbal stimuli. The resident had a tracheostomy on continuous oxygen via trach collar. Observed on feeding tube with feeding Jevity 1.2 administered at 60cc/hr. The resident was non-interviewable. A review of the Resident #24's admission Record (a one-page summary of important information about the patient) that documented the resident's diagnosis which included but was not limited to Anoxic Brain Damage, Chronic Respiratory Failure, Dependence on Respirator [Ventilator] Status, Convulsions, Tracheostomy, Gastrostomy. A review of the Progress Notes revealed that from April 2023 through September 2023, the Nurse Practitioner (NP) documented that she had seen and examined the resident. There was no documentation that Resident #24's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. 8. On 10/17/23 at 10:53 AM, surveyor observed Resident #51 on specialized mattress with eyes open and non responsive to verbal stimuli. The resident had a tracheostomy on continuous oxygen via trach collar. Observed on feeding tube with feeding PediaSure Peptide 1.0 administered at 90cc/hr. The resident was unable to respond to surveyor. A review of the Resident #51's admission Record (a one-page summary of important information about the patient) that documented the resident's diagnosis which included but was not limited to Anoxic Brain Damage, Chronic Respiratory Failure, Dependence on Respirator [Ventilator] Status, Convulsions, Tracheostomy, Gastrostomy. A review of the Progress Notes revealed that from April 2023 through September 2023, the Nurse Practitioner (NP) documented that she had seen and examined the resident. There was no documentation that Resident #51's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. 9. On 10/17/23 at 11:15 AM, surveyor observed Resident #113 in room with eyes closed on a specialized wheelchair. Observed resident with seatbelt and trunk vest in place. The resident had a tracheostomy on continuous oxygen via trach collar. A review of the Resident #113's admission Record (a one-page summary of important information about the patient) that documented the resident's diagnosis which included but was not limited to Epilepsy, Cerebral Palsy, Hydrocephalus, Chronic Respiratory Failure, Respiratory Disorder. A review of the Progress Notes revealed that from April 2023 through September 2023, the Nurse Practitioner (NP) documented that she had seen and examined the resident. There was no documentation that Resident #113's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. On 10/20/23 at 11:49 AM, surveyor interviewed Nurse Practitioner (NP), who collaborates with Primary Physician related to the process of monthly documentation of visits. NP stated she alternates with the primary physician for completing monthly visit progress notes. NP further stated it is expected for the progress notes to be completed every other month for her and documented in the progress notes. On 10/23/23 at 11:23 AM, the surveyors interviewed Assistant Director of Nursing (ADON) related to the concerns above. ADON acknowledged primary physician visit documentation is not up to date. No further information was provided. On 10/24/23 at 01:28 PM, the surveyor discussed with ADON, Administrator, and DON, who couldn't provide information why primary physician visit documentation was not up to date. On 10/25/23 at 10:40 AM, surveyor interviewed Primary Physician related to the process of visitation and documentation frequency in visit. Physician acknowledged that physician visit documentation is not up to date. No further information provided. A review of the facility's policy titled Physician Visits states, The resident should be seen by his/her attending physician, at least monthly for the first ninety days following the resident's admission, and, at least, once every 60 days there after. further review of the policy under Procedure . 2. Once attending physician determines that a resident needs not to be seen by him/her monthly, an alternate schedule of visit maybe established but at least every 60 days. NJAC 8:39-27.1 Based on observation, interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least every 60 days. This deficient practice continued over several months for 9 of 35 residents (Resident #58, 101, 141, 37, 158, 32, 24, 51, and #113) reviewed and was evidenced by the following: 1. On 10/17/23 at 11:06 AM, the surveyor observed Resident # 58 in bed. The surveyor interviewed the resident who was able to respond verbally using yes and no answers while nodding head. The surveyor reviewed Resident #58's hybrid medical records. The resident was admitted to the facility with diagnoses which included but not limited to Spinal Muscular Atrophy, Dependence on respirator and Chronic Respiratory Failure. A review of the Physician Progress Notes revealed that from July 2023 through 2023, the Nurse Practitioner (NP) documented that she had seen and examined the resident. There was no documentation that Resident #22's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. 2. On 10/17/23 at 11:00 AM, the surveyor observed Resident #101 in bed with eyes closed. The resident had a tracheostomy in place connected to continuous oxygen via trach collar. The resident was non-verbal. The surveyor reviewed Resident #101's hybrid medical records. The resident was admitted to the facility with diagnoses which included but not limited to Cerebral Palsy, Encephalopathy and Chronic Respiratory Failure. A review of the interdisciplinary progress notes revealed that from June 2023 through October 2023, the NP documented that she had seen and examined the resident. There was no documentation that Resident #101's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. 3. On 10/18/23 at 11:39 AM, the surveyor observed Resident #141 in bed with eyes open. The resident was non-verbal and unable to respond to the surveyor. The surveyor further observed a tracheostomy in place that was connected to a continuous oxygen via trach collar. The surveyor reviewed Resident #141's hybrid medical records. The resident was admitted to the facility with diagnoses which included but not limited to Anoxic Brain Damage and Acute Respiratory Failure. A review of the interdisciplinary progress notes revealed that there were no documented progress notes from Resident #141's primary physician nor NP since March 2023. 4. On 10/17/23 at 11:20 AM, the surveyor observed Resident #37 in bed with closed. The surveyor further observed that the resident had tracheostomy in place that was connected to a continuous oxygen via trach collar. Resident #37 was non-verbal. The surveyor reviewed Resident #37's hybrid medical records. The resident was admitted to the facility with diagnosis which included but not limited to Chronic Respiratory Failure, Aphasia and Cerebral Palsy. A review of the interdisciplinary progress notes revealed that there were no documented progress notes from Resident #37's primary physician nor NP since October 2022. 5. On 10/17/23 at 10:51 AM, the surveyor observed Resident #158 in bed with eyes closed. The surveyor further observed that the resident had a tracheostomy in place that was connected to a continuous oxygen via trach collar. Resident #158 was non-verbal. The surveyor reviewed Resident #158's hybrid medical records. The resident was admitted to the facility with diagnosis which included but not limited to Cerebral Palsy, Spastic Quadriplegia, and Scoliosis. A review of the interdisciplinary progress notes revealed that from July 2023 through October 2023, the NP documented that she had seen and examined the resident. There was no documentation that Resident #101's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, as well as a review of pertinent facility documents on 10/4/23, 10/4/23, 10/6/23, and 10/11/23, it was determined that the facility staff failed to report an allegation of verbal abuse to the New Jersey Department of Health (NJDOH) and follow their policy titled Abuse Prevention for 1 of 3 residents (Resident #4) reviewed for incident and accident. This deficient practice is evidenced by the following: On 10/4/23 at 9:16 a.m., during the entrance conference with the Administrator and the Director of Nursing (DON), the facility provided the Resident's Scabies Case Line Listing which included Resident #4. During an interview with the surveyor on 10/4/23 at 12:01 p.m. Resident # 4 made an allegation of verbal abuse. Resident #4 reported that About a month ago I asked [CNA #1] to take me out of bed and she said 'NO' then I started yelling at her. Resident #4 stated that the CNA called her/him homeless b*t*h, nobody wants to work with you, nobody wants you, and that she/he was a problem. Resident #4 stated that she felt like a less person after hearing the CNA's comments. According to Resident #4, he/she reported this allegation to the nurse (unable to recall the name of the nurse), and to the Assistant Director of Nursing (ADON #1) was also aware. According to the admission Record (AR), Resident #4 was admitted to the facility on [DATE], with diagnoses that included but were not limited to Schizoaffective Disorder, Borderline Personality Disorder, Major Depressive Disorder, and Anxiety. The Minimum Data Set (MDS), an assessment tool dated 8/18/23, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS also indicated Resident #4's Activities of Daily Living (ADLs) required assistance and was able to feed herself/himself. A review of Resident #4's Care Plan (CP) initiated on 8/15/20, indicated that Resident #4 had mood and behavior problems related to Schizoaffective and Borderline Personality Disorder, emotional irritability, throwing objects (cellphone, remote control, etc.) to the staff, agitated, feeling of worthlessness and impaired social relationship, intentionally falling onto the floor, and suicidal gestures. Further review of Resident's CP initiated on 5/5/23, indicated that Resident #4 had attention seeking/injurious behavior as evidenced by inappropriate behavior of screaming at staff. During an interview with the surveyor on 10/4/23 at 12:15 p.m., ADON #1 stated that on 8/31/23, Resident #4 reported that CNA #1 would not transfer Resident #4 out of bed and told Resident #4 Nobody likes you, you are homeless that's why you are here, and nobody likes to work with you. The ADON further stated that the CNA was educated and was assigned to other residents to provide care. She further stated that the DON was made aware, however, she was not sure if the verbal allegation was reported to the NJDOH. The ADON explained that any allegation of any form of abuse should be investigated thoroughly and reported to the NJDOH. There was no indication in the MR that Resident #4 allegation of verbal abuse was thoroughly investigated and reported to the NJDOH which was not according to the facility policy. The surveyor conducted the interview with the Administrator and Director of Nursing (DON) on 10/4/23. 10/5/23, and 10/6/23. They stated that they were not aware the allegation of abuse involving Resident #4 and CNA #1 occurred 8/31/23 until 10/4/23. The Administrator stated that the aforementioned incident should have been investigated and reported to the NJDOH. A review of the facility's policy titled Abuse Prevention, dated 10/4/2023 indicated . IDENTIFICATION: The facility will investigate all incidents involving actual or alleged abuse, complaints/grievances .INVESTIGATION: The facility will investigate all incidents involving actual or alleged abuse, complaints/grievances .PROTECTION: the facility will protect all residents during any abuse investigation by removing staff from direct care and/or removing from schedule pending conclusion. REPORTING: In response to allegations of abuse .the facility must ensure that: all allegations of abuse must be immediately reported to the Director of Nursing and or Administrator and no later than 2 hours to other officials (including to the State Survey Agency) after the allegation is made, if the event that caused the allegation involve abuse or result in a serious bodily injury . NJAC 8:39-9.4(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C #: 167992 Based on interviews, medical record review, and review of other pertinent facility documents on 10/4/23, 10/5/23, 10/6/23 and 10/11/23, it was determined that the facility staff failed to accurately document in the Treatment Administration Record (TAR) that the care was provided to the resident according to the facility protocol for 1 of 3 residents (Resident #1) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the facility admission Record (AR), Resident #1 was admitted on [DATE], with diagnosis that included but were not limited to: End Stage Renal Disease. The Minimum Data Set (MDS), an assessment tool, dated 8/22/23, revealed a Brief Interview of Mental Status (BIMS) of 99 which indicated the resident's cognition was rarely never understood and the resident needed assistance with activities of daily living (ADLs). Review of Resident #2's Order Summary Report reflected an order for Right Upper Chest Wall Porta Catheter site dressing change every day shift on Thursday. The TAR for 8/2023 confirmed the aforementioned ordered. However, on 8/24/23 the TAR indicated a code 9, meant to check the progress notes. Review of the Resident's PN, there was no indication that the aforementioned order was provided to Resident #1. During an interview with the surveyor in the presence of ADON #2 on 10/4/23 at 1:00 p.m., the Licensed Practical Nurse LPN #5 stated that Resident #1's aforementioned treatment was rendered, however, she made a mistake. Review of the facility policy General Documentation, dated 1/5/23, under POLICY: The clinical team shall document all relevant data and information pertaining to the provision of care and services to the residents in the medical record. Any and all forms of documentation by a clinician should be recorded according to accepted professional standards of practice Failure to keep and maintain certain documentations as required by regulatory agencies, falsifying documentation, and incomplete or inaccurate documentation, may be found to constituent and professional conduct .3. documentation must be clear, concise, the secretive, accurate, and comprehensive . documentation should be recorded both the action taken by the clinical staff the residents needs and/or response to illness and the care they receive. It should be a full account of the clinician's assessment and care provider . NJAC 8:39-35.2(d)(9)

**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 accurately assess a resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 2 of 3 residents, Residents #66, and #67 reviewed for falls. This deficient practice was evidenced by: 1. On 8/9/22 at 10:46 AM, the surveyor observed Resident #66 laying in bed awake with his head at the foot of the bed watching TV (television). The resident told the surveyor that the staff is very nice and helps them when they call for assistance. The surveyor reviewed the medical records of Resident #66: The admission Record (face sheet/admission summary) showed that the resident was admitted to the facility with diagnoses including, but not limited to, chronic systolic congestive heart failure (which occurs when the heart muscle doesn't pump blood as well as it should), atherosclerotic heart disease (a build-up of fats in and on artery walls), schizophrenia (a mental disorder in which people interpret reality abnormally), and traumatic brain injury. The incidents and accidents investigation showed that the resident had five falls dated as follows: 9/13/21, 3/9/22, 3/17/22, 3/18/22, and 7/1/22. The resident sustained no injuries from the falls. The Annual (Comprehensive) MDS (CMDS) dated [DATE] indicated Resident #66 had a Brief Interview for Mental Status score of 8 out of 15, meaning the resident's cognition was moderately impaired. Under section J, titled Health Conditions- any falls since admission to the facility or prior assessment. Section J was entered as NO, meaning Resident #66 had no falls since admission or prior assessment although the resident had a fall on 9/13/2021. The most recent quarterly MDS (qMDS) dated [DATE] indicated the resident had a BIMS score of 8 out of 15, meaning the resident's cognition was moderately impaired. Resident #66's personalized care plan included a focus on falls with appropriate interventions. The care plan also showed updates following September 2021, March 2022, and July 2022 falls. On 8/11/22 at 11:45 AM, the surveyor reviewed Resident #66's medical records again and revealed that the CMDS dated [DATE] that was previously reviewed by the surveyor was modified on 8/11/22. The modified 11/16/21 MDS under section J, titled Health Conditions-any falls since admission or prior assessment was now coded YES. The 11/16/21 CMDS was modified after the surveyor's inquiry. During an interview with the surveyor on 8/18/22 at 11:03 AM, the MDS Coordinator, employed since 12/2019, stated that if a resident had a fall, he will usually be informed about it in the morning clinical report and/or from Risk Management. The MDS Coordinator stated that he will check to make sure that an incident report was completed and that the resident's care plan was updated with new interventions. On that same date and time, the MDS Coordinator stated that section J of the MDS is where a resident's fall will be documented. The MDS Coordinator added that after a resident encounters a fall, the unit managers will initially update section J in the MDS and enter the code for a fall. The MDS Coordinator further stated that he would then check section J in the MDS and code correctly if not coded or updated correctly. On that same date and time, the surveyor reviewed Resident #66 falls with the MDS Coordinator. The surveyor asked the MDS Coordinator why the resident's CMDS dated [DATE], which originally had indicated in section J NO for falls, was modified on 8/11/22 in section J and now coded YES for falls after the surveyor's inquiry. The MDS Coordinator stated that we sometimes do random chart audits and a chart audit was recently done on Resident #66. The MDS Coordinator stated that during the chart audit, it was discovered that the Annual MDS dated [DATE] was coded incorrectly for falls so I did the modification. 2. On 8/03/22 at 10:40 AM, during the initial tour of the facility Resident #67 was observed in bed, awake. There was a fall mat in the room on the floor next to the resident's bed. The resident told the surveyor he/she did get up to walk to the bathroom when needed. The surveyor reviewed the medical records of Resident #67. The admission Record showed that the resident was admitted to the facility with medical diagnoses including, but not limited to, respiratory failure, pneumonia (an infection that inflames the air sacs of one or both lungs), and alcohol dependence. The most recent qMDS dated [DATE] indicated the resident had a BIMS score of 15, meaning the resident was cognitively intact. The resident's functional status was one-person physical assistance for dressing, personal hygiene, and toileting. Under section J, titled health conditions-fall since admission to the facility, the area marked zero, meaning the resident had not fallen since admission to the facility. The incidents and accidents for the past six months for Resident #67 showed that the resident had two falls, one fall on 4/28/22 and one fall on 5/10/22. The resident had no injuries from both falls. Resident #67's personalized care plan showed updates following the April and May 2022 falls. On 8/16/22 at 12:50 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The DON acknowledged the above concerns concerning the accuracy of capturing the fall incidents in the MDS. During an interview with the surveyor on 8/18/22 at 11:58 AM, the Director of Nursing (DON) stated that when a resident falls, the fall would be documented in the progress notes and an incident report completed. The DON added that if the resident's MDS was due for an update, the unit managers would code a fall in the J section of MDS. The DON stated that if the resident's MDS was due for an update, the MDS Coordinator would also follow up and check to make sure that section J was coded correctly for a fall. The DON further stated that the MDS Coordinator was ultimately responsible to make sure falls were documented and coded correctly in section J of the MDS for each resident. NJAC 8:39-11.1

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) follow a Physician's Order (PO) for the treatment of a facility-acquired pressure ulcer in accordance with professional standards of practice and b.) ensure a resident received treatment and services to promote healing of a chronic stage two (Stage II) facility acquired pressure ulcer. This deficient practice was identified during the wound treatment observation for one of four residents, (Resident #153) reviewed for pressure ulcers. The deficient practice was identified by the following: On 8/03/22 at 01:10 PM, the surveyor observed Resident #153 laying in bed on an air mattress in their room. The surveyor further observed that the resident had physical deformities (limitations on both extremities and other parts of the body) and was non-verbal. On 8/17/22 at 12:20 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) prior to the wound treatment observation. The LPN stated the resident had a wound on the back of his/her neck that was chronic due to moisture and the wound measured 0.1 centimeters (cm) by 0.3 cm in size. The LPN further told the surveyor that the resident required total care with Activities of Daily Living (ADLs) and was unable to move without assistance from staff. At 12:30 PM, the surveyor observed the LPN with assistance from the Respiratory Therapist (RT) cleanse the back of the resident's neck with normal saline. The surveyor observed the wound and surrounding skin on the back of the resident's neck and asked the LPN to describe what the wound looked like. The LPN stated that the wound had no drainage and the wound was healing. The surveyor then observed the LPN remove a piece of aquacel dressing (an absorbent material meant to absorb drainage from wounds to promote healing. The material is used as a primary dressing, only to be placed on the wound bed and not on the surrounding skin). The surveyor further observed the LPN place the aquacel dressing directly on top of a foam dressing (hydrosorb dressing) and place the aquacel dressing in direct contact with the back of the resident's neck which consisted of the resident's wound bed and surrounding skin. The LPN secured the dressing in place with assistance from the RT and completed the wound treatment for Resident #153 in the presence of the surveyor. At 12:45 PM, the surveyor reviewed the PO for the treatment in the presence of the LPN. The PO indicated to cleanse the wound with normal saline, pat dry, apply an alginate dressing pad, and hydrosorb. The LPN stated that the expectation when performing a treatment on a wound was to follow the PO. The LPN further stated that she thought aquacel and alginate were the same dressing. At 12:47 PM, the surveyor interviewed the Licensed Practical Nurse/Clinical Nurse Manager (LPN/CNM) who stated the expectation for the nurse while performing a wound care treatment was to follow the PO. The surveyor reviewed the medical record for Resident #153. The admission Record for Resident #153 reflected that the resident had resided at the facility for over a decade and had diagnoses that included but were not limited to anoxic brain damage (lack of oxygen to the brain which results in the death of brain cells), other disorders of lungs, dependence on respiratory ventilator status, and chronic respiratory failure. The resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 6/13/22 indicated that the resident was in a persistent vegetative state with no discernible consciousness. A further review of the resident's MDS, Section M - Skin Conditions reflected that the resident was at risk for pressure ulcers, had one unhealed pressure injury, and the treatments provided included the application of nonsurgical dressings. According to the resident's August 2022 Order Summary Report (OSR) reflected a PO dated 7/10/22 to cleanse wound on the back of the neck with normal saline, pat dry, apply alginate dressing, pad with hydrosorb every day and evening shift for reopen area and evaluate the wound weekly. The resident's August 2022 Treatment Administration Record (TAR) reflected that the nurses were signing on the day and evening shifts that they were cleansing the wound on the back of the resident's neck with normal saline, pat drying, applying alginate dressing and padding the wound with hydrosorb dressing. A review of the resident's personalized Care Plan revised on 6/27/22 revealed a focus area that the resident was at risk for skin breakdown secondary to the presence of a tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to breathe), decreased tissue perfusion, ventilator dependent, posturing episodes, increased tracheal and oral secretions, and immobility. The focus area further reflected that the resident had a reopened area to the back of their neck on 6/27/22. The goal of the resident's Care Plan indicated that the resident's skin and neck would be free from further breakdown and the wound would heal before the next review date. Interventions in the resident's Care Plan included applying treatment as ordered and observing skin integrity every shift. On 8/18/22 at 12:48 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident's physician had ordered the alginate dressing and the treatment order that was performed on the resident should have reflected the PO. At that time, the facility's Administrator provided the surveyor with e-mail correspondence with the facility's Wound and Product Specialist who provided the facility with their wound care products. A review of the e-mail provided by the Wound and Product Specialist dated 8/18/22 and timed at 9:18 AM indicated that aquacel was a brand name product and alginate was a generic name product. Each product's purpose was to remove bacteria from the wound bed and absorb moisture to promote wound healing. The e-mail provided by the wound care specialist indicated that the dressing should only be placed on the wound bed and not on the peri-wound (surrounding) skin because it could cause maceration (softening of the skin surrounding the wound). On 8/19/22 at 12:09 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that the resident's wound was facility acquired and opened on 6/27/22. The ADON told the surveyor that she followed the resident's wound weekly and identified that the resident's wound was decreasing in size, so the same treatment order was continued. The ADON further stated that the nurses should have performed the appropriate PO when performing the wound care treatment and the dressing applied to the back of the resident's neck should have only been applied to the resident's wound bed and not on the resident's surrounding skin. A review of the resident's weekly wound update sheet provided by the ADON indicated that the resident's wound had decreased in size since 6/27/22. A review of the facility's Dressing Changes/Wound Treatment Policy and Procedure dated 11/23/2010 indicated that it was the facility's policy that, Dressing changes/wound care will be completed per physician order and documented on resident's treatment record and weekly wound progress report. NJAC 8:39-27.1(a,e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined that the facility failed to a.) provide an appropriate services to a resident with a Passive Range of Motion (PROM) order and recommendations for 2 of 8 residents (Resident #40 and #174) and b.) ensure that the bilateral ankle/foot splints for Resident #80 and bilateral hand splints for Resident # 86 and were consistently applied for contracture management for 2 of 8 residents reviewed for a limited range of motion (ROM). This deficient practice was evidenced by the following: 1. On 8/3/22 at 10:49 AM, the surveyor observed Resident #40 in bed with their eyes closed. The resident was on a ventilator and was breathing easily. The surveyor reviewed the medical records of Resident #40. The admission Record (face sheet/admission summary) indicated that the resident was admitted to the facility with diagnoses that included Acute hematogenous osteomyelitis right humerus ((infection in the growth in the upper arm between the shoulder and elbow), chronic respiratory failure disorder (the inability to exchange carbon dioxide and oxygen which will result in low oxygen levels), and reduction deformities of the brain (deformation of the brain that develops in the womb and is present at birth). The Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, dated 5/3/22 indicated that Resident #40's Brief Interview for Mental Status (BIMS) was unable to be completed due to severe cognitive impairment. Section G400 of the MDS the functional status assessment for Range of Motion indicated that Resident #40 had impairment of the right and left upper and lower extremities. Resident #40's personalized Care Plan had a focus area dated 8/22/19 for physical and cognitive impairment that contained a goal for Resident #40 to tolerate velfoam adductor strap to be used while in bed while in the supine position, without adverse reactions via staff observation and report. One of the interventions that were dated 6/08/21 was for staff to perform gentle PROM to above joints as tolerated before applying velfoam adductor straps during AM and PM care. Resident #40's August 2022 Order Summary Report (OSR) revealed that Resident #40 had an order dated 11/4/21 for ROM: Bilateral lower extremities every day and evening shift perform gentle PROM to above joints as tolerated especially hips before applying velfoam adductor strap. A review of the August 2022 Task List Report (TLR) which is a list of daily tasks performed by Certified Nursing Assistants (CNAs) revealed a task for Every day and evening shift perform gentle PROM to above joints as tolerated especially hips before applying velfoam adductor strap. The August 2022 Task Care Record under every day and evening shift perform gentle PROM to above joints as tolerated especially hips before applying velfoam adductor strap revealed no initials of CNAs who performed the task. On 8/16/22 at 11:15 AM, the surveyor interviewed the Pediatric Physical Therapist (PPT) who stated that the resident maxed out of physical therapy and that the resident has been endorsed to nursing for ROM. He stated that therapy had nothing in place to oversee and to make sure that nursing is performing PROM. He stated that this program is overseen by nursing. Nursing will reach out to therapy if they have a concern with a resident but usually residents are screened quarterly or when they are admitted or re-admitted to the facility. On 8/16/22 at 12:10 PM, the surveyor interviewed Resident #40's Certified Nursing Assistant#1 (CNA#1) who stated that she performs PROM with her residents. The surveyor asked the CNA to show him how she documents that she performed PROM. The CNA stated that she does not document when she performed PROM. 2. On 8/03/22 at 12:16 PM, the surveyor observed that Resident #80 was laying on the bed. The resident was non-verbal, able to follow with eyes, the neck was positioned backward, and hands extended on the side and bent at the wrist. The resident's bilateral lower extremities were observed to be bent at the knees and the resident's legs were bent to the left in front of the resident and the right leg behind the resident contorted abnormally. No splints or supportive positioning devices were observed that were used for the bilateral lower extremities limitation. On 8/4/22 at 12:38 PM, the surveyor observed Licensed Practical Nurse#1 (LPN#1) wearing an N95 mask and goggles (eye protection) with a medicine cart (med cart) in front of Resident #80's room. LPN#1 informed the surveyor that the resident was on the window bed. LPN#1 then provided the surveyor with an isolation gown. At that same date and time, the surveyor observed Resident #80 laying on the bed with the head of the bed elevated approximately 30 degrees. The resident did not have a splint or assistive device in use for their lower extremities with limitations. There were bilateral leg splints on top of the table with the resident's name on it and underneath was the body assistive device. The surveyor reviewed the medical record of Resident #80. The admission Record indicated the resident was admitted to the facility with diagnoses that included but were not limited to functional quadriplegia (partial to complete motor/sensory loss of both the upper and lower limbs), unspecified convulsions (is a general term that is used to describe uncontrollable muscle contractions), and chronic respiratory failure. The 4/6/22 QMDS indicated a Cognitive Skills for Daily Decision-making were severely impaired. According to August 2022, OSR included a physician order dated 5/20/22 for Splint: Bilateral ankle foot splints one time a day, on after AM care when in bed r out of bed in a wheelchair, or as tolerated, Off during PM care, except when an acute medical condition exists and inspect skin before applying and after removing splints. The order for the bilateral ankle foot splints was transcribed to the electronic Treatment Administration Record (eTAR) for August 2022 and signed by nurses as administered or applied. The personalized care plan focus on significant scoliosis (a sideways curvature of the spine that most often is diagnosed in adolescents) and progressive ankle contracture date initiated on 9/15/20. The interventions/tasks included: to follow instructions for wearing the schedule and scoli (scoliosis) jacket and bilateral ankle/foot splints to be worn AM to PM care when going out of bed except if an acute medical condition exists. Further review of the May through August 2022 medical records showed that there was no further documentation that indicates that the resident declined the use of the bilateral ankle/foot splints, was unable to tolerate them, and complained of pain. On 8/9/22 at 12:00 PM, both the surveyor and LPN#1 entered Resident #80's room and both observed that the resident did not have bilateral ankle/foot splints in use. There were three (3) pieces of paper posted on the wall of the resident near the resident's headboard that included device: B/L (bilateral) splints (with a picture of the resident's lower extremities with splints in use while on a bed) to be used: on after AM care when in or out of bed as tolerated, without the pulse oximeter, except when an acute medical condition exists. On that same date and time, during an interview of the surveyor with LPN#1, the LPN indicated that the bilateral ankle splints should have been placed. The surveyor then asked the LPN why it was not in use today. LPN#1 stated that she was busy admitting a resident that came in last night. Furthermore, the surveyor asked LPN#1 why the bilateral ankle splints were also not in use when the surveyor observed the resident on 8/4/22 at 12:38 PM when the surveyor observed the LPN in front of the resident's room on that day. The LPN had no answer. On 8/9/22 at 12:25 PM, the surveyor informed the Licensed Practical Nurse/Unit Manager about the above concern. On 8/15/22 at 12:17 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and both were made aware of the above concerns. On 8/16/22 at 12:50 PM, the survey team met with the LNHA and the DON. The LNHA informed the surveyors that LPN#1 acknowledged that the bilateral ankle/foot splints should have been placed according to the physician's orders and that the nurse was provided an in-service and education. 3. On 8/03/22 at 11:00 AM, during the initial tour of the facility, Resident #86 was observed in the bed with their eyes open. The resident's hands were contracted and there were no adaptive devices (hand rolls or palm guards) observed in the resident's hands. The surveyor reviewed Resident #86's medical records. According to the admission Record, Resident #86 was admitted to the facility with medical diagnoses including, but not limited to cerebral palsy (congenital disorder of movement, muscle tone, or posture), convulsions (uncontrollable muscle contraction), and asthma (inflamed airways causing breathing difficulty). The admission Minimum Data Set (AMDS) dated [DATE] indicated that Resident #86 BIMS was unable to be completed due to severe cognitive impairment. The resident's functional status was one person assistance for dressing, personal hygiene, eating, and toilet. Section g0400 of the MDS functional status assessment and ROM indicated that Resident #86 had impairment of the right and left upper and lower extremities. The resident's personalized care plan had the following focus: Patient presents with contractures to B/L UE and Les (bilateral upper and lower extremities), and the following goal: Resident will tolerate bilateral hand rolls without adverse reaction via staff observation/report, the care plan was initiated 5/16/22. The intervention for the care plan was to apply Bilateral Hand rolls from AM to PM care except if an acute medical condition exists. The 8/2/22 physician's orders showed the following: 1. ROM: BILATERAL UPPER EXTREMITIES AND LOWER EXTREMITIES one time a day for ROM Perform gentle PROM to both upper and lower extremities as tolerated prior to applying splints during AM or PM care, except if an acute medical condition exists. 2. SPLINT: RIGHT ANKLE/FOOT SPLINT one time a day PUT ON DURING AM care when out of bed, except when an acute medical condition exists. OFF DURING PM CARE when going back to bed. and remove per schedule 3.SPLINT: BILATERAL HAND ROLLS every day shift. To be worn AM TO PM CARE AND OR AS TOLERATED, EXCEPT IF AN ACUTE MEDICAL CONDITION EXISTS. The August 2022 eTAR showed that the nurse signed that the hand rolls were applied including on 8/9/22 in the AM. On 8/09/22 at 12:42 PM, the surveyor observed the resident in bed with their eyes open. The resident had bilateral heel booties. The resident did not have hand rolls placed as signed on the eTAR. On 8/10/22 at 11:08 AM, the surveyor reviewed the eTAR, and hand rolls were not signed as applied at the time of review of the eTAR on 8/10/22. On 8/10/22 at 11:52 AM, the surveyor reviewed eTAR, AM hand splints were not signed as applied as of the time of the review. On 8/11/22 at 12:20 PM, the surveyor observed Resident #86 sitting in a chair on the right side of the bed. The resident did not have hand rolls in place on their right and left palms. The surveyor observed one palm roll on an overbed table and one palm roll on the nightstand to the left side of the bed. On that same date and time, the surveyor interviewed CNA#2 regarding Resident #86 hand rolls. CNA#2 told the surveyor, I only saw one in the room, and this is the first time I ever saw them with the resident. The surveyor asked if CNA#2 had ever seen palm rolls on the resident and she said, the resident has been here about a week in a half, and no I have not. On 8/11/22 at 12:45 PM, the surveyor interviewed LPN#2 regarding hand rolls. The LPN said the CNA was responsible to apply the resident's hand rolls. At that time, the surveyor asked LPN#2 to accompany the surveyor into Resident #86 room and showed the LPN the hand rolls on the overbed table and the nightstand. The LPN said to the surveyor, they ain't doing no good there, and then the LPN applied the hand rolls. On 8/11/22 at 12:49 PM, the surveyor reviewed the eTAR and the hand rolls were not signed as applied for 8/11/22. On 8/16/22 at 11:50 AM, the surveyor met with the LNHA. The LNHA acknowledged that the resident was observed by the surveyor without hand splints on 8/3, 8/9, 8/10, and 8/11. The LNHA indicated that the resident should have a hand splint on those identified dates. 4. On 8/3/22 at 11:11 AM, the surveyor observed Resident #174 in bed and unable to respond appropriately to the surveyor's questions. The resident was observed on a ventilator, and trach, and was breathing easily. The surveyor reviewed Resident #174's medical records. The admission Record indicated that the resident was admitted to the facility with a diagnosis that included anoxic brain damage (harm to the brain due to a lack of oxygen), quadriplegia (paralysis of all four limbs), and age-related osteoporosis (A condition when bone strength weakens and is susceptible to fracture). The QMDS dated [DATE] indicated that Resident #174's BIMS was unable to be completed due to severe cognitive impairment. Section G400 of the MDS the functional status assessment for ROM indicated that Resident #174 had impairment of the right and left upper and lower extremities. Resident #174's's personalized Care Plan had a focus area dated 2/27/20 for Bilateral lower extremities (BLE) contractures and decreased tone limiting optimal position that contained a goal for Resident #174 to maintain BLE PROM and prevent progression of contractures with a target date of 12/21/22. One of the interventions that were dated 02/27/20 was for the resident to perform gentle PROM to the above joints as tolerated during AM/PM care except when an acute medical condition exists. The Pediatrics (Peds) Occupational Therapy/Physical Therapy (OT/PT) screen with an effective date of 7/15/22 revealed that the resident was not tolerating the AFO (ankle-foot orthosis, support intended to control the position and motion of the ankle, compensate for weakness, or correct deformities) and the therapy screen comments included, .Continue PROM of lower extremities during AM and PM care to prevent progressive contracture development Resident #174's August 2022 OSR revealed an order dated 7/12/22 for ROM: Bilateral lower extremities one time a day perform gentle PROM to above joints as tolerated during AM/PM care except when an acute medical condition exists. The August 2022 TLR revealed a task to perform gentle PROM to above joints as tolerated during AM/PM care except when an acute medical condition exists. The August 2022 Task Care Record under perform gentle PROM to above joints as tolerated except when an acute medical condition exists revealed no initials of CNAs who performed the task which means that there was no accountability that the PROM was being done. On 8/16/22 at 11:15 AM, the surveyor interviewed the PPT who stated that the resident maxed out of PT and that the resident has been endorsed to nursing for ROM. When the surveyor asked the PPT if his department oversees the Restorative care program, he stated that therapy had nothing in place to oversee this program and that the restorative program is overseen by nursing. He also stated that nursing will reach out to therapy if they have a concern with a resident but usually residents are screened quarterly or when they are admitted or re-admitted to the facility. On 8/16/22 at 12:10 PM, the surveyor interviewed Resident #174's CNA. CNA#1 stated that she performs PROM with her residents. The surveyor asked the CNA where she documents that she performed PROM to Resident #174. CNA#2 stated that she does not document when she performed PROM. When the surveyor asked the CNA if she performs PROM with the resident's bilateral lower extremities, the CNA stated no and that she works only with the resident upper extremities. On 8/16/22 at 12:15 PM, the surveyor interviewed LPN #3. LPN #3 showed the surveyor the order for Resident #174 and stated that she will perform PROM during morning care. She also stated that she signs off on the eTAR. On 8/16/22 at 12:30 PM, the surveyor reviewed the August 2022 eTAR for Resident #174 which revealed no documentation that the PROM was being done. On 8/17/22 at 1:45 PM, the surveyor met with the facility LNHA and DON. The LNHA stated that PROM is done by the CNAs. The order will be under CNAs Task on the electronic medical record. The LNHA stated that daily CNAs assignments ([NAME]) will be printed out and will be placed at the time clock in the nursing station. She further stated that CNAs know that they will have to check for their daily assignments. On that same date and time, the LNHA further stated that the CNAs will perform the PROM during morning care and stated that they don't sign off after performing PROM. The LNHA and DON were unable to tell the surveyor how the facility accounting for the task is being performed when there are no initials from the CNAs who provided the task. A review of the facility Orthotic Devices Policy with the last review date of 5/22, provided by the LNHA included Orthotic devices include but are not limited to the following: Resting hand splints, Comfy hand splint, Wrist cock up splint, Ankle Foot Orthosis AFO, Knee Immobilizer .When a splint has been issued, an Adaptive Equipment Form will be issued to notify nursing of the type of splint along with the wearing schedule as well as my special instructions in its use or care. Devices will be monitored by nursing Procedure: .4. The CNA performs the Range of Motion during ADL Care. A review of the facility Range of Motion Policy with the last review date of 5/22, provided the LNHA included in the Policy In an effort to maintain the resident's available range of motion, the residents will be assessed on an ongoing basis to determine appropriatness for Range of Motion ([NAME]) protocol. The decision to place a resident on a Nursing Rehabilitation Range of Motion Protocol is made by the therapist, The decision to place a resident on a ROM program will be based on the following criteria: * The resident is not able to independently perform ROM exercises of one or more joints. * The resident displays contracture in one or more joints. Under procedure: 4. The certified Nursing Assistant (CNA) performs the Range of Motion during ADL care. NJAC 8:39-27.2 (m)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review it was determined that the facility failed to clarify physician orders for oxygen therapy and develop a personalized care plan for 1 of 7 residents (Resident #86) reviewed for respiratory care. This deficient practice was evidenced by the following: On 8/03/22 at 11:15 AM, during the initial tour of the facility, Resident #86 was observed in the room. The resident was not wearing oxygen (O2) at the time of the observation. There was an O2 concentrator (oxygen delivery system) in the resident's room that was not in use. The O2 tubing was inside a bag on top of the concentrator. The surveyor reviewed Resident #86's medical records. According to the admission Record (face sheet/admission summary), Resident #86 was admitted to the facility with medical diagnoses including, but not limited to cerebral palsy (congenital disorder of movement, muscle tone, or posture), convulsions (uncontrollable muscle contraction), and asthma (inflamed airways causing breathing difficulty). The admission Minimum Data Set (AMDS) dated [DATE] indicated that Resident #86 BIMS was unable to be completed due to severe cognitive impairment. The Physician Order Sheet (POS) dated 8/1/22 showed an order for O2 at two to three liters for low oxygen saturation. The order read as follows: MAY USE OXYGEN AT 2-3 LITERS VIA NC (nasal cannula-end tubing attached to the resident's nares and the other end tubing to the O2 machine) AS NEEDED FOR LOW SATURATION. The electronic Medical Record (eMR). The eMR showed that between the dates of 5/1/22 to 8/9/22 the resident's O2 saturation ranged from 92 to 98 percent and the pulse oximetry was checked a total of 42 times through that period. Further review showed that on all but three of the days the resident was not wearing O2 when the pulse oximetry was checked. The three days the resident was wearing oxygen were the following: 8/2/2022 at 07:59 97.0 % O2 via N/C 8/1/2022 at 22:03 98.0 % O2 via N/C 7/22/2022 at 17:50 94.0 % O2 via N/C The graphic sheet did not indicate the amount of O2 the resident was wearing via N/C at the time the resident's O2 level was checked. The personalized care plan did not show a focus plan for oxygen and respiratory care. The electronic Treatment Administration Record (eTAR) for August 2022 indicated that O2 was not used from August 1st to the date of the review. The surveyor then reviewed the eTAR for July which showed that the O2 was not applied to the resident although the graphic chart indicated that the resident was wearing oxygen on 7/22/22, 8/1/22, and 8/2/22. On 8/9/22 at 12:47 PM, the surveyor observed Resident #86 in the bed, the resident was not wearing O2 at the time of the observation and there was no longer an O2 concentrator in Resident #86 room or any O2 tubing. On 8/10/22 at 12:25 PM, the resident was observed in bed with their eyes open. There was no O2 in the room. The surveyor asked Licensed Practical Nurse#1 (LPN #1), who was the resident's primary nurse if the resident wore O2. LPN #1 told the surveyor the resident does not wear O2 and has not since being admitted . The nurse could not speak about the one day in July or the two days in August when O2 was applied to Resident #86. On 8/15/22 at 10:40 AM, the surveyor interviewed the resident's nurse regarding oxygen. The surveyor asked if the resident wore O2 and LPN #2 said no. Then, the surveyor asked LPN#2 to look at the physician's order and to show the surveyor the order for O2. LPN#2 reviewed the O2 order and stated, oh there is a PRN (as needed) order, for two to three liters per minute. The surveyor asked what a low saturation was and when would you apply the O2 to the resident, and LPN#2 said, usually 95%, but I would need another order. LPN#2 acknowledged that the order should be clarified to make it clear. On 8/15/22 at 12:15 PM, the surveyor spoke with the Licensed Nursing Home Administrator (LNHA) regarding the O2. The LNHA said she would investigate it. On 8/16/22 at 10:40 AM, the LNHA presented the surveyor with a folder with a Quality Assurance Performance Improvement plan that was initiated on 8/15/22, after the surveyor's inquiry on Resident #86's O2 order that the order should have been clarified. NJAC 8:39-27.1 (a)

Based on observations, interviews, and record review, it was determined that the facility failed to a.) secure 1 of 4 medication rooms, b). properly dispose of expired medications in 1 of 4 medication storage rooms, and c). disposed of expired medications in 2 of 7 medication storage carts inspected. This deficient practice was evidenced by the following: 1. On 8/17/22 at 10:30 AM, two surveyors entered the Central Supply Room (CSR) in the presence of the Head of Central Supplies (HCS). The surveyor observed that the CSR door was unlocked and they were no staff inside. The CSR contained the facility supply of over-the-counter (OTC) medications (which are non-prescription medications) and two bags of expired OTC medications which were in the process of being disposed of per facility policy. They were no residents observed in the vicinity of the central supply room which was in an employee only section of the facility. At that time, the surveyor interviewed the HCS who stated that the Central Supply Room should be locked when they are no employees present. The Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) who were both present, stated that the CSR should be locked at all times. 2. On 8/17/22 at 10:15 AM, the surveyor inspected the OTC medication backup supply in the CSR in the presence of the HCS, DON, and LNHA. The surveyor observed four (4) unopened bottles of Vitamin E 400 that were expired (2 bottles on 5/22 and 2 bottles on 6/22) and 12 bottles of Multivitamin with Iron that expired on 7/22. At that time, the surveyor interviewed the HCS who stated that all expired medication should have been removed from the active medications. On 8/17/22 at 1:45 PM, the surveyor met with the LNHA and DON. No further information was provided by the facility. 3. On 8/18/22 at 10:35 AM, the surveyor, with the third floor Registered Nurse/Unit Manager (RN/UM) performed an inspection of the medications stored in the south side locked treatment cart which revealed one (1) opened a bottle of Aspercreme with 4 % Lidocaine (a pain relief cream) with an expiration date of March 2022. The bottle had no labeling of a resident's name. The RN/UM stated that the Aspercreme bottle was expired and should have been removed from the treatment cart. On that same date and time, the RN/UM stated that usually the night shift nurses check the expiration date of the medications and remove any expired medications. The RN/UM further stated that the opened bottle of Aspercreme was a house stock medication and was not labeled for a specific resident. The RN/UM was unable to speak to which residents had a physician's order (PO) for Aspercreme to be applied. At that time, the RN/UM asked the south side medication Licensed Practical Nurse (LPN) about which residents had a PO for Aspercreme. The LPN stated that there were no residents on the south side with a PO for Aspercreme. The RN/UM was unable to speak to why the Aspercreme remained in the treatment cart. On 8/18/22 at 11:05 AM, the surveyor, with HCS and Central Supply Staff (CSS), inspected the CSR which contained the house stock medications which revealed that there was no Aspercreme in storage. Both the HCS and the CSS stated that they ordered house stock medications and had a list of the house stock medications but were unable to speak to if Aspercreme was previously ordered. On 8/18/22 at 1:46 PM, the LNHA provided the surveyor with the facility Do Not Supply list of medications that were considered house stock and stored in Central Supply. The list provided revealed that Aspercreme was not on the list. On 8/18/22 at 12:41 PM, the survey team met with the LNHA and the DON. The DON stated that the nurses were responsible for removing expired medications that were on the unit. On 8/19/22 at 10:17 AM, the survey team met with the LNHA and DON. The DON was unable to speak to why Aspercreme was in the treatment cart. On 8/19/22 at 11:52 AM, the surveyor reviewed the Monthly Nursing Station Inspection Medication Storage and Labeling report dated 7/25/22 that was provided by the LNHA and completed by the Consultant Pharmacist (CP). The report revealed that the refrigerator, emergency kit, medication rooms, cupboards, drawers, and carts were inspected. There was no indication that treatment carts were inspected. On 8/19/22 at 1:00 PM, the surveyor interviewed the CP via telephone. The CP stated that he performed unit inspections every month and completed a report for each unit for the facility. The CP added that treatment carts were not always completed as part of the unit inspection. The CP also stated that the medication storage room and refrigerator, along with medication carts were inspected as indicated on the reports. A review of the facility's policies for Medication Storage dated June 2022 that was provided by the LNHA indicated the following: Policy: Medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. Access to medications is limited to only authorized personnel. 6. Prior to and after opening, all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself. a. In accordance with expiration date labeling practices, if the manufacturer only specifies the month and year of expiration, this means the product expires on the last day of the calendar month indicated. (e.g.: a product labeled Exp 03/2025 means the expiration date is March 31, 2005). NJAC: 8:39-29.4 (a)(d)(g)(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to provide biweekly COVID-19 rapid antigen testing from July 2022 through August 15, 2022 for two (2) of three (3) staff who are not up to date (up to date means a person has received all recommended vaccines & boosters when eligible) with COVID-19 vaccinations (Certified Nursing Assistant#1 (CNA#1) and CNA#2), in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and when the community transmission level was high. This deficient practice was evidenced by the following: According to the US CDC COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/02/22, showed .1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. HCP [Health Care Provider] should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses. Recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 . On 8/02/22 at 8:46 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) for an entrance conference. The DON stated that the facility was in a COVID-19 outbreak that started on 7/15/22 with seven (7) staff and 15 resident cases of COVID-19. The LNHA stated that COVID-19 positive staff members worked throughout the building and that some were direct care staff. On 8/02/22 at 01:20 PM, the surveyor interviewed CNA#2 who stated that she had been working in the facility for 13 years. She was wearing an N95 mask and face shield. She stated that she was vaccinated with the first and second doses of [name redacted] COVID-19 vaccines in the facility and has not received the booster yet. She stated that she was on medical leave for two weeks and just returned last Thursday and was on light duty due to medical reasons. She stated that when she returned to work, she was reminded by the Infection Preventionist Nurse (IPN) of her Covid-19 booster and stated, I have to get the booster outside the facility. She stated that she was tested for Covid once weekly in the first-floor testing room. She stated that she had to wait in the lobby for 15 minutes to get her results. A review of the COVID-19 Transmission levels as of July 28, 2022, for [name redacted] was listed High, and as such, per CMS QSO-20-38 NH: In nursing homes located in counties with substantial to high community transmission, HCP not up to date with vaccination, should have a viral test twice a week. The surveyor reviewed the [name redacted] Rapid Antigen Testing form (RATf) for the biweekly testing, Payroll-Based Journal (PBJ-electronic submission of staffing hours), and COVID-19 Vaccination-Employees log that included CNA#1 and #2's information that was provided by the LNHA and showed the following: CNA#1 received her COVID-19 vaccines on 01/6/22 and 02/10/22 that completed her primary COVID-19 vaccines. CNA#1 worked on 7/02/22, 7/03/22, 7/06/22, 7/08/22, 7/13/22, 7/16/22, and 7/27/22. She was tested for COVID-19 on 7/06, 7/13/22, and 7/27/22. All COVID-19 test results were negative. CNA#2 received her COVID-19 vaccines on 12/02/21 and 02/22/22 that completed her primary COVID-19 vaccines. CNA#2 worked on 7/02/22, 7/03/22, 7/05/22, 7/06/22, 7/07/22, 8/02/22, 8/03/22, and 8/04/22. CNA#2 was tested for COVID-19 on 7/02/22, 7/11/22, 7/19/22, and 8/02/22. All COVID-19 test results were negative. According to the above information, CNA#1 was eligible to receive a COVID-19 booster vaccine on 7/10/22 and CNA#2 on 7/22/22. The two staff were not up to date on their vaccinations and were not tested biweekly when the facility was in an outbreak and at a high community activity level. On 8/19/22 at 12:15 PM, the surveyor interviewed the LNHA who stated the process for COVID-19 rapid antigen testing is to be completed twice a week during the high community level. The LNHA confirmed that the facility remained in high status and was moved into high status since mid-July. On 8/19/22 at 12:39 PM, the surveyor informed the above concern to the LNHA and the DON. The DON stated that testing should be done in accordance with CDC testing specifications. A review of the facility policy, COVID-19/Testing of Facility Personnel updated 3/22/22 reflected number 3. Routine testing of unvaccinated staff should be based on the extent of the virus in the community. When determining the frequency of testing of unvaccinated staff, facilities should use regional positivity rate reported in the Covid-19 Activity Level index ([NAME]) weekly Report. NJAC 8:39-5.1 (a)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to a.) maintain a safe and sanitary environment by ensuring that a full sharps container (a puncture-resistant, leak-proof container that can be closed for handling, storage, transportation and disposal of medical waste and sharp materials labeled as biohazard) was replaced with an empty one in a timely manner for 1 out of 2 treatment carts on the first floor (Cart R) and b.) maintain a safe and sanitary environment in 1 of 1 laundry rooms in accordance with the facility policy and procedures. This deficient practice was evidenced by the following: 1. On 8/9/22 at 12:15 PM, the surveyor observed a full and closed sharps container on treatment cart R on the first floor. There were no residents or visitors in the vicinity of the treatment cart and were no needles sticking out. On 8/17/22 at 12:11 PM, the surveyor had a second observation of a full and closed sharps container on treatment cart R on the first floor. There were no residents or visitors in the vicinity of the treatment cart and were no needles sticking out. The surveyor requested the Licensed Practical Nurse/Unit Manager (LPN/UM) observe treatment cart R. The LPN/UM stated, that's not a nursing cart, that's a Respiratory Therapist treatment cart and that should have been removed and replaced with an empty one. The surveyor informed the LPN/UM that this was the second time since last week that the sharps container on treatment cart R was observed full. On that same date and time, the LPN/UM directed the surveyor to the Respiratory Therapist (RT). The surveyor interviewed the RT who stated that treatment cart R was used by the RT and that she was not responsible for removing the sharps container. She further stated that she would notify her manager that the sharps container needed to be replaced with a new one once it was full. On 8/18/22 at 9:35 AM, the surveyor interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) in presence of the survey team. Both the LNHA and the DON acknowledged that when a sharps container was full it should have been removed and replaced with an empty container and it should have been the responsibility of whoever was using the treatment cart. On 8/18/22 at 10:35 AM, the surveyor interviewed the Director of RT (DRT) in the presence of the survey team. He stated that when a sharps container was full the RT would be responsible to make sure the container was closed and locked and to then call housekeeping to come to replace it with a new one. The DRT stated that the RT should have called housekeeping or let the UM know the sharps container was full and needed to be replaced. On that same date and time, the DRT further stated that he would expect that the sharps container would be replaced with an empty one within an hour of notification that it was full. He also stated that the RTs did not use sharps frequently so they must have overlooked it. The DRT stated that the sharps container should have been replaced once it was three-quarters full. 2. On 8/17/22 at 10:47 AM, the surveyor toured the laundry room with the Director of Environmental Services (DES) and in the presence of another surveyor. The surveyors observed there were black debris and decolorization on the inside and outside of the sink of the laundry room where residents' gowns, bed sheets, linens, blankets, and towels were being washed. According to the DES, the sink with black debris and decolorization inside and out was where the laundry staff washes their hands. The surveyor asked the DES if there was a log for the cleaning of the utility sink. The DES stated, there was not a log and said, they do it daily. When the surveyor asked when the last time sink had been cleaned, the DES stated he didn't know. At the same time, the surveyors observed a quantity of three washing machines in use. Washer #1 (closest to the laundry detergent storage room) was leaking from the door gasket causing a large puddle to form under and around the washer. When the surveyor asked when the last time the washer had been serviced, he deferred the answer to the maintenance department. DES stated, they call an outside company as needed. When the surveyor asked the DES what might be the problem with that? The DES stated, it is a hazard because of slipping when staff has to get something from the storage room. Then, the surveyors observed a washer drainage trough with a grate on top behind three (3) of three (3) washers. It was heavily soiled with lint, medical gloves, and paper debris. The DES stated, there is not a cleaning log, but it is done as needed. It is caused by linens being mixed with gloves and medical supplies in linen bags. Next to the washer room, the surveyors observed there were black debris and decolorization in the storage room and under a pallet that stored nine boxes of detergent. Upon interview, the surveyor asked if there was a log for the cleaning of the floor, the DES stated, that there was not a log, and he was unsure of the last time it was done. In the soiled utility room, the surveyors observed a power washer and its outstretched cord running through the soiled utility doorway, through the puddle from washer #1and ran through the storage room doorway, ending in an outlet near the laundry soap in the storage room. When the DES was questioned, he stated, there is not an outlet in the soiled linen room, so they plug it in over in the other room. When the surveyor asked the DES what might be the problem with that? The DES stated, it is a hazard because of tripping and electrical shock. Then, the surveyor observed three (3) of three (3) dryers. In the Dryer room, there was a heavy buildup of lint and dust debris on three (3) of three (3) pipes running near the ceiling and the electrical box on the wall. Upon interview, the surveyor asked if there was a log for the cleaning of the pipes and electrical box, the DES stated, there was not a log, and he was unsure of the last time it was done. In the clean linen folding area, the surveyor observed used personal protective equipment (PPE) goggles, N95 face mask, face shield, and facility-obtained hand lotion on the clean linen shelf near bath towels. When asked, the DES stated, they should not be there, and it could cross contaminate with the clean linens. On 8/17/22 at 12:50 PM, the surveyor interviewed the Maintenance Director about washer #1. He stated that there was no contract for monthly service, but the facility used an outside vendor [name redacted] for all as needed maintenance of the washer. The Maintenance Director stated that he would place a call to them regarding the water from washer #1 because someone could slip and fall. He further stated that the power washer cord should not be across the floor between rooms because it posed a tripping hazard to the staff. Review of the facility policy Nursing Sharps Disposal dated 6/2009, reflected that When sharps receptacles are ¾ full, licensed staff close receptacle notify the designated department for a new receptacle. Review of the the facility policy revealed that the facility shall have a written schedule that determines the frequency of cleaning and maintaining all equipment, structures, areas, and systems. NJAC 8:39-31.4 (a) Complaint # NJ 00155798

**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.) follow acceptable professional standards of clinical practice by discontinuing a duplicate physician's order to flush a gastrostomy tube from March 2022 until the surveyor's inquiry in August 2022 and discontinuing a duplicate physician's order for enteral tube feeding formula from 6/7/22 until surveyor's inquiry August 2022, b.) not following physician's order for the correct enteral tube feeding formula for 2 of 8 residents (Resident #153 and #91), and c.) follow through with the Registered Dietitian's (RD's) recommendations for 1 of 8 residents (Resident #174) reviewed for enteral feed physicians' orders, and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 8/3/22 at 1:10 PM, the surveyor observed Resident #153 in their room lying in bed on an air mattress. The surveyor was unable to interview the resident. On 8/4/22 at 11:52 AM, the surveyor interviewed Licensed Practical Nurse#1 (LPN#1) who stated that Resident #153 was cognitively impaired, received nothing by mouth, and was being administered a gastrostomy tube (GT) (a tube inserted in the stomach to provide food and water) feedings. The surveyor reviewed the medical record for Resident #153. The admission Record (face sheet/admission summary) revealed that the resident was admitted to the facility with diagnoses that included anoxic brain damage (damage to the brain because of lack of oxygen) and convulsions. The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 6/13/22 reflected the resident was comatose, in a persistent vegetative state/no discernable consciousness, and had no Brief Interview for mental status (BIMS) completed. The current physician's orders (PO) revealed a PO dated 11/29/2016 for Enteral Feed Order every four (4) hours (Q4H) flush GT with 90 milliliters (ml) water after each feeding. In addition, another PO dated 3/30/2022 for Enteral Feed Order every four (4) hours give 100 ml water via GT Q 4 hours after each feed. A review of the current August 2022 electronic Medication Administration Record (eMAR) revealed the above duplicate PO for water flushes via the GT after each GT feeding: -PO dated 11/29/2016 for Enteral Feed Order Q4H flush GT with 90 ml water after each feeding. -PO dated 3/30/2022 for Enteral Feed Order Q4H give 100 ml water via GT Q4H after each feed. The August 2022 eMAR revealed that the nurses were signing for the administration of both above POs indicating that the 90 ml and 100 ml flushes were being administered Q4H at the times of administration for 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM, and 1:00 AM. Further review of the March, April, May, June, and July 2022 eMARs reflected that the above two (2) PO for the 90 ML and 100 ml flushes were both being signed as administered every 4 hours. The interdisciplinary care plan (IDCP) reflected that a focus with an initiation date of 3/15/2019 was that the resident required a feeding tube for nutrition/hydration and the interventions included providing flushes as ordered. On 8/9/22 at 12:08 PM, the surveyor, with LPN#2, reviewed the eMAR which reflected the two PO for flushes to be administered Q4H. LPN#2 stated that the PO for the 90 ml flush should have been discontinued when the new order for the 100 ml flush was ordered. LPN#2 then stated that she would get in touch with the dietician and physician to discontinue the 90 ml flush PO. On 8/16/22 at 09:31 AM, the surveyor, in the presence of the survey team, interviewed the Registered Dietician (RD) who stated that for the pediatric floors she reviewed recommendations with the Nurse Practitioner (NP) and would then enter the recommendation electronically into a queue (the highlighted area where orders would wait to be approved by the physician). The RD added that putting the recommendation in the queue would make the nurses aware of a recommendation that needed to be verified by the physician to obtain a PO. The RD further stated that she was unable to discontinue an old PO and that she can only put it in the queue for a new recommendation. The RD also stated that the nurse would contact the physician to obtain a new PO and would also obtain a PO to discontinue an old PO. The RD was unable to speak to the two PO for flushes for Resident #153 because she wanted to review the resident's chart. On 8/16/22 at 10:17 AM, the surveyor interviewed the RD who stated that the current PO for the flush should have been for 100 ml Q4H. The RD explained that the PO for the 90 ml flush was older and had not been discontinued. The RD added that it was probably an oversight that the 90 ml PO was not discontinued. On 8/16/22 at 12:50 PM the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The DON acknowledged that there were duplicate PO for flushes for Resident #153. The DON stated that the nurses had not discontinued the old PO to flush 90 ml when the new PO for 100 ml was received. 2. On 8/16/22 at 11:33 AM, the surveyor observed Resident # 91 out of bed seated in a wheelchair inside his/her room. The resident was non-verbal. The surveyor observed enteral tube feeding (a way of delivering nutrition directly to the stomach) in use via a pump at 180 ml/hr (milliliters per hour). The enteral tube feeding formula infusing was Promote 1.0. On 8/17/22 at 11:35 AM, two surveyors observed Resident # 91 awake out of bed seated in a wheelchair inside their room. The surveyors observed that the enteral tube feeding formula infusing was Promote 1.0 via pump at 180 ml/hr. The surveyor reviewed the medical record for Resident # 91. The resident's admission Record reflected that the resident had diagnoses that included but were not limited to obstructive hydrocephalus (water on the brain), epilepsy (a brain disorder that causes recurring, unprovoked seizures), not intractable, without status epilepticus, aphasia (a disorder where you have problems speaking or understanding what other people say), and gastrostomy status. According to the resident's qMDS dated [DATE], reflected that the resident's cognitive skills for daily decision-making were severely impaired. Further review of the MDS reflected that the resident had a feeding tube. The August 2022 Medication Review Report (MRR) reflected a Physician's Order (PO) dated 6/18/21, for Enteral Feed Order five times a day Promote 1.0 237 ml/can via GT via gravity. Flush with 120 ml of water after each feeding to provide 1185 calories per day. Further review of the August 2022 MRR revealed a second PO dated 6/7/22, for Promote 1.0 with fiber liquid (Nutritional Supplements) give 237 ml via GT six times a day related to gastrostomy status add 260 ml water run at 180 ml/hr (1422 kcal/day). The August 2022 eMAR reflected the above two corresponding POs. Further review of the August 2002 eMAR revealed that both POs were documented as administered. The resident's personalized Care Plan (CP) date initiated on 3/5/19, reflected a focus area that the resident has potential malnutrition risk related to enteral nutrition/hydration dependence. The interventions for the resident's CP indicated providing Promote with fiber 237 ml with 260 ml water at 180 ml/hr, six times a day. The Nutritional/Diet Recommendations dated 6/7/22, provided by the RD indicated to change the tube feeding to Promote with fiber, 237 ml with 260 ml water via GT at 180 ml/hr, six times a day at (12 AM, 4 AM, 8 AM, 12 PM, 4 PM, and 8 PM). On 8/17/22 at 11:26 AM, the surveyor interviewed the assigned LPN#3 for Resident #91. LPN #3 in the presence of the surveyor reviewed the electronic PO and acknowledged that there was two enteral tube feeding POs; one dated 6/18/21 and one dated 6/7/22. She also acknowledged that the resident was getting the wrong tube feeding formula. She stated that somebody changed the order and didn't discontinue the old order. She said that the process was that the RD and doctor should have been notified to clarify the order. She could not speak to why the two enteral tube feeding orders were not clarified by the RD and the doctor. LPN #3 also confirmed that the resident was receiving Promote 1.0 without fiber. On 8/17/22 at 12:40 PM, the surveyor interviewed the RD who stated and acknowledge that there should not be two enteral tube feeding POs and that she would have to look into it. She further stated that once the 6/7/22, order was entered into the electronic medical record, then the 6/18/21, the order should have been discontinued. She then stated that the orders were probably changed because the tube feeding formula may not have been available. On 8/17/22 at 2:00 PM, the RD returned to speak with the surveyor who stated that the 6/18 PO was from 2021. She provided a copy of a 6/7/22 Nutritional/Diet Recommendation which indicated that she recommended changing the tube feeding to Promote with fiber. The RD further stated and acknowledged that the resident had a duplicate enteral tube feeding order and acknowledged that the resident was not receiving Promote with fiber as per the 6/7/22 PO. She further stated, because the distributor doesn't always have the feeding product and they send what they have. On 8/17/22 at 2:35 PM, the surveyor interviewed the DON who acknowledged that the 6/18/21 PO should have been discontinued and stated she will look into who entered the order and why the order was not discontinued. She further stated that the 11-7 nurse conducts the order recaps and should have picked up on the duplicate enteral tube feeding orders. On 8/18/22 at 12:01 PM, the surveyor interviewed the Director of Central Supply in the presence of the survey team. He acknowledged that he ordered the enteral tube feeding formula and was familiar with Promote 1.0 and the one with fiber. He stated, that the Promote with fiber has been on backorder and then stated, only this week he ordered a case of Promote with fiber for the week and did not have any Promote with fiber in backup supply. He stated he orders just what is needed to stay on budget. I communicate to the dietician so she can change the orders. He further stated, this week was the first time we did not get the Promote 1.0 with fiber. On 8/18/22 at 12:38 PM, the surveyor met with the LNHA and the DON. The DON acknowledged there were two enteral tube feeding physician orders and she stated, the old order was continued and should have been discontinued. She further stated that the physician's order for Promote with fiber should have been changed since the distributor could not send the Promote 1.0 with fiber and that the RD and doctor should have been notified. The LNHA and DON acknowledged that the distributor sends what they have and do not always have Promote 1.0 with fiber. 3. On 8/4/22 at 10:24 AM, the surveyor observed the resident in their room, alert and about to receive care from a Respiratory Therapist (RT). On 8/10/22 at 10:25 AM, the surveyor observed the resident inside their room in a wheelchair. The resident was unable to verbally respond to the surveyor. The surveyor observed that the resident was receiving the tube feeding nutritional formula of Pediasure Peptide 1.0 through a tube feeding pump being infused at a rate of 50 ml per hour. The surveyor reviewed the medical records of Resident #174. The admission Record reflected that the resident had diagnoses that included but were not limited to quadriplegia (paralysis of all four limbs), dysphagia (difficulty swallowing), anoxic brain damage (brain damage due to lack of oxygen), Down's Syndrome, chronic respiratory failure and dependence on a ventilator. The resident's qMDS dated [DATE] reflected that the resident had severely impaired cognition. It also reflected that the resident had a feeding tube by which he/she was totally dependent for nutrition and hydration. The resident's Order Summary Report (OSR) for August 2022 reflected that there was a PO for Pediasure Peptide 1.0 liquid nutritional supplement. The OSR reflected that 150 ml should be given four times per day at an infusion rate of 50 ml per hour. The OSR indicated an initial order date for 7/13/22 and the start date was not indicated until 8/7/22. Further review of the resident's OSR dated 7/13/22, reflected that there was a physician's order for Pediasure Peptide 1.0 liquid nutritional supplement for 150 ml to be given four times per day at an infusion rate of 50 ml per hour. This order was queued by the RD on 7/13/22 at 12:39 PM, it was indicated as an active order by the Medical Director on 7/13/22 at 12:36 PM, and was created by LPN#4 on 8/6/22 22:23 PM. A review of the resident's Progress Notes (PN) reflected the following: A nursing PN dated 7/12/22 at 5:22 AM reflected that Resident #174 returned to the facility from a hospital stay at 3:45 AM. An RD re-admission nutrition assessment dated [DATE] at 12:28 PM reflected that the resident was re-admitted with a tube feeding order for Pediasure Peptide 1.0 120 ml via the feeding tube at 50 ml/hour, three times per day. The RD recommended changing this to Pediasure Peptide 1.0 150 ml via the feeding tube at 50 ml/hour, four times per day. A nursing PN dated 8/6/22 at 23:26 PM reflected that Pediasure Peptide formula increased as per order, 150 ml 4 times a day at 50 ml/hr. An RD progress note dated 8/17/22 at 9:05 AM reflected that the resident weighed 70.4 pounds on 7/12/22 and 72 pounds on 8/8/22. There was no further documented evidence provided by the facility to explain why there was a delay in carrying out the physician's order promptly from the initial RD recommendation on 7/13/22. On 8/16/22 at 9:31 AM, the surveyor interviewed the RD who stated that if a pediatric resident was assessed and required a change in approach for medical nutrition therapy, she would discuss this with the NP. The RD would then enter the recommendation in the electronic medical record (EMR) as a queue (which was a set of orders that required approval). She further stated that this would have been reflected in the PN. She also stated that she reviewed this with the NP before completing the readmission assessment. On that same date and time, the RD stated that she would expect that by the end of the day the queued order would be active, and the previous order would have been discontinued. She further stated that at this time she did not have a process to follow up if recommendations were carried out prior to her next assessment. On 8/16/22 at 10:35 AM, the surveyor interviewed the RD who stated that she could not remember writing the order in the que and further stated that the nurses, NP, and physician were expected to review her PN. On 8/16/22 at 11:00 AM, the surveyor interviewed LPN #2 who stated that an RD recommendation needed to be reviewed by the NP and/or Physician before an order change was created. On 8/17/22 at 2:32 PM, the surveyor interviewed the DON in the presence of the LNHA and the survey team. She stated that the 11 PM-7 AM nurse/nursing supervisor was responsible to review and ensure physicians' orders and change requests were reviewed and carried out promptly. In addition, she stated that if there were any questions or concerns that it would be the nurse's responsibility to call the physician for clarification. On 8/18/22 at 10:23 AM, the surveyor interviewed the RD in the presence of the survey team. The RD acknowledged that she queued a change in tube feeding order on 7/13/22, which was not created till 8/6/22 and not started until 8/7/22. The RD stated that she discussed her recommendations with the NP prior to queuing the order change and discussed this with the Unit Manager or nurse to ensure that they were aware. She further stated that it's all in my notes. On 8/18/22 at 11:55 AM, the surveyor interviewed the DON in the presence of the survey team. She stated that when the RD queued a nutritional order change, she communicated that to the nurse so she could review and verify approval with the physician and create the change. The DON stated that if the physician did not approve the recommendation that the nurse should have written a progress note. On that same date and time, the DON further stated that the que would then go away and the RD should have been notified. We reviewed the Order Audit Report and the DON acknowledged that the RD queued the recommendation on 7/13/22 and the order was not created by the nurse until 8/6/22. She could not speak to delay and stated that the RD probably did not communicate with the nurse. She stated that she would investigate what occurred. On 8/19/22 at 10:31 AM, the surveyor interviewed the DON. The DON stated that she interviewed LPN#4 who acknowledged that she received the physician's order from the NP to create a change for a tube feeding order for Resident #174 in accordance with the RD recommendation. However, LPN #4 could not speak to the delay. A review of the facility policy Nutrition Assessment Policy with a revision date of 6/2022, reflected that the RD will complete a comprehensive medical nutrition therapy assessment for each individual that is referred or identified for assessment. It further reflected that the RD will identify nutritional risk factors and nutrition diagnosis and recommend nutrition interventions based on each individual's medical condition, needs, desires and goals. A review of the facility policy Nutrition Recommendation Policy with a revision date of 1/2022, reflected that the RD will write the recommendation on the Nutritional Recommendation form or queued on EMR. It also reflected that the RD will review recommendation with the nurse on the floor after submitting the form or queuing the recommendation on EMR. The nurse will need to follow up on the recommendations, writing in a comment as to whether it was completed, or if the physician deferred the recommendation, and the reason for deferring it, if one was given. The nurse will document accordingly in the resident's medical record after verifying with the physician. It further reflected that the RD will address those recommendations not answered during monthly weight assessment if there is a significant change. Review of the facility policy Physician Orders with a revision date of 3/2022, reflected that Any order that is in question must be repeated to the physician. It also reflected to Notify nursing administration and medical director whenever an order that is questioned, cannot be verified, or carried out. It reflected that Nurse carrying out orders will enter date and time the order was carried out. In addition, it reflected that .orders must be signed electronically by nurse within 7 days, except for orders for non-prescription drugs or treatments, which shall be signed at the physician's or advanced practice nurse's next visit to the resident. It reflected that Nursing will then follow up through on the order. It also reflected that Night shift nurses will review orders entered for the day by verifying orders and reviewing that all orders are entered in accurately in EMR. Lastly, it reflected that If night shift nurses find discrepancy, night shift nurse will reach out to MD for verification. 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 ensure that: a.) appropriate hand hygiene was performed by 2 of 16 staff observed during recreation activity and care, b.) PPE (personal protective equipment) is properly disposed of for 1 of 7 receptacles in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for infection control and facility policies, c.) the Covid-19 testing wait time was followed according to the facility's posted instructions and the manufacturer's Covid-19 instruction card for COVID-19 testing for 1 of 10 visitors, d.) staff performed daily COVID-19 screening and monitoring for 3 of 5 staff reviewed, e.) residents received daily COVID-19 Screening and Monitoring every shift for 6 out of 12 residents reviewed (Resident #7, #23, #80, #153, #629, and #630) to mitigate the spread of infection and COVID-19. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included, When to Perform Hand Hygiene? Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an Alcohol-Based Hand Sanitizer: Immediately before touching a patient .Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Immediately after glove removal . According to the U.S. CDC Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes Nursing Homes & Long-Term Care Facilities Updated Feb. 2, 2022, included, Testing: Create a Plan for Testing Residents and HCP for SARS-CoV-2 Expanded screening testing of asymptomatic HCP should be as follows: In nursing homes, HCP who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, these HCP should have a viral test twice a week. If these HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift) Evaluating and Managing Personnel and Residents: Evaluate Residents at least Daily .Ask residents to report if they feel feverish or have symptoms consistent with COVID-19 or an acute respiratory infection .Actively monitor all residents upon admission and at least daily for fever (temperature =100.0°F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry . According to US CDC COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/22, showed .1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. HCP [Health Care Provider] should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses. Recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 . 1. On 8/03/22 at 9:47 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Assistant Director of Nursing (ADON). The LNHA stated that visitors and staff must wear a surgical mask and eye protection when in the common area of the facility. The LNHA further stated that visitors and staff must wear an N95 mask and full PPE including gown, gloves, and eye protection when inside a PUI and COVID-19 resident room. On 8/03/22 at 10:33 AM, the surveyor met with the LNHA and Director of Nursing (DON) for an entrance conference. The LNHA stated that the facility was in an ongoing COVID-19 outbreak. The LNHA and the DON confirmed the website outbreak most recent posted was 7/15/22. At the same time, the LNHA stated that the last date of COVID-19 positive for both resident and staff was on 8/2/22. The LNHA further stated that the outbreak included 7 staff cases (out isolating) and 15 resident cases of COVID-19 in unit four (4). The COVID ActNow Community Risk Level for [name redacted] provided by the LNHA and updated on July 28, 2022 indicated that the community risk level for [name redacted], the county in which the facility was located, was high. On 8/4/22 at 12:12 PM, the surveyor observed the Activity Staff (AS) wearing an N95 mask and a face shield while providing an activity to the 7 residents inside the 2nd-floor room on the right side upon exiting the elevator. The surveyor observed the AS did not perform hand hygiene in between direct contact with Residents #35, #148, #161, #29, and #43. On that same date and time, the surveyor observed the AS was fixing and touching the middle part of his N95 mask without performing hand hygiene before and after touching his N95 mask. During an interview of the surveyor with the AS, the AS stated that he's been working in the facility for almost three (3) months, and was educated about hand hygiene by the Infection Preventionist Nurse (IPN). The surveyor asked the AS if he should have performed hand hygiene in between direct contact with the residents and if he should be fixing his N95 mask without performing hand hygiene before and after touching his N95 mask. The AS stated, I will need to refer your question to the handbook because things change sometimes. On 8/4/22 at 12:26 PM, the surveyor was unable to find and talk to 2nd-floor staff at this time regarding the above concerns because the nurses were attending to an emergency and another facility staff was distributing lunch trays. Immediately, the surveyor went to the LNHA and discussed the above concerns. The LNHA stated that the AS was new and that he should have performed hand hygiene. The LNHA further stated that she will now go and talk to the AS about it. On 8/15/22 at 12:17 PM, the survey team met with the LNHA and the DON, and both were made aware of the above concerns with hand hygiene. On 8/16/22 at 11:11 AM, the surveyors interviewed the IPN regarding facility practice with regard to hand hygiene. The IPN stated that it was expected that the staff washes their hands when caring for residents and when there is direct contact between residents. At the same time, the surveyor informed the IPN of the above concerns with the AS. The IPN stated that the same thing, the AS should sanitize their hands between direct contact with residents. She further stated that the AS received the same education as nursing staff with regard to their mask and eye protection, and the expectation should be for the staff to perform hand hygiene in between each activity. On 8/16/22 at 12:50 PM, the surveyor met with the LNHA and DON. The LNHA stated that the AS acknowledged that he should have performed hand hygiene in between direct contact with the residents and about his N95 mask on 8/4/22. The LNHA further stated that the AS forgot and was nervous when the AS mentioned that he will refer to the employee handbook when asked if he should have performed hand hygiene in between direct contact with residents and about his N95 mask. 2. On 8/8/22 at 12:45 PM, the surveyor observed Resident #7 in bed awake with two nursing staff at the resident's bedside. Both nursing staff was wearing an N95 mask, gown, gloves, and face shields, while washing, dressing, and adjusting Resident #7's urinary catheter. One of the nursing staff members, Certified Nursing Assistant#1 (CNA#1) stated that they were preparing Resident #7 for transfer into the wheelchair. On that same date and time, the surveyor observed that CNA#1 removed her gown and gloves, discarded the gown and gloves in a black trash bin at the resident's doorway, and exited Resident #7's room without performing hand hygiene. CNA#1 then grabbed the Hoyer lift (electronic body lift) in the hallway and pushed the Hoyer lift down the hall toward Resident #7's room positioning the Hoyer lift outside the resident's room. The surveyor reviewed the medical records of Resident #7. The admission Record (face sheet/admission record) reflected Resident #7 was admitted to the facility with medical diagnoses, which included, but were not limited to, quadriplegia (paralysis of all 4 limbs), acute cystitis without hematuria (urinary tract infection without blood in urine), tracheostomy status (tube in windpipe/trachea to help breathe), neurogenic bowel (loss of normal bowel function), neuromuscular dysfunction of the bladder, and anxiety disorder. The Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, dated 7/5/22, reflected a BIMS (Brief Interview for Mental Status) score of 15 out of 15, which indicated that Resident #7's cognition was intact. During an Interview with the surveyor on 8/10/22 at 11:40 AM, the ADON, employed at the facility since 2004, stated that the IPN was responsible for educating the staff on hand hygiene, Covid-19, and Infection Control Practices. On that same date and time, the ADON stated that currently, the staff on the second-floor pediatric unit are to wear an N95 mask and eye protection in the hall, and full PPE, an N95 mask, eyewear, gown, and gloves when entering all resident's rooms. The ADON further stated that before entering a resident's room, staff should perform hand hygiene first and then don (apply) the disposable blue gown and gloves, in addition to the N95 mask and eyewear, such as a face shield or goggles. Furthermore, the ADON stated that before exiting a resident's room, staff should doff (remove) their gown and gloves, discard them in the black trash bin near the doorway inside the resident's room, and then perform hand hygiene before exiting the resident's room. The ADON added that if the staff was giving direct care to a resident and/or gloves were soiled after care, staff should wash hands before exiting the resident's room. At that time, the surveyor informed the ADON of the surveyor's observation on 8/8/22 of CNA#1 giving direct care to Resident #7, removing and discarding her PPE in the black trash bin inside the resident's room, exited Resident #7's room without performing hand hygiene, and then grabbed the Hoyer lift in the hallway to position outside Resident #7's room. The ADON stated that the CNA should have performed hand hygiene after removing and discarding his/her gown and gloves, and before exiting Resident #7's room. The ADON stated that hand hygiene is important to prevent the spread of infection and for the protection of Resident #7 and the other residents on the unit. 3. On 8/03/22 at 10:15 AM, the surveyor during the initial tour observed resident rooms had an open trash receptacle and PPE was overflowing in them, and outside the room in the hallway were 6 covered trash cans, one had PPE in it. On 8/03/22 at 10:45 AM, the surveyor observed an uncovered hamper lined with a clear trash bag being utilized as a trash can for PPE in front of the elevator in unit four. On 8/04/22 at 12:11 PM, the surveyor interviewed the Unit Manager of the 4th floor regarding the uncovered hamper used as a receptacle for used PPE. The Unit Manager stated, it is for staff to doff (remove), and for visitors who accidentally walked out of a resident's room with PPE on. The Unit Manager further stated that she was not sure who placed the uncovered hamper in front of the elevator over the weekend. On that same date and time, the surveyor asked the Unit Manager should the uncovered hamper be in front of the elevator. The Unit Manager stated, no. they should be doffing in the resident's room. On 8/04/22 at 12:12 PM, the surveyor interviewed the IPN. The IPN stated that she was not aware of the hamper that was being used as trash can and it was possibly being used by recreation and visitors to doff their PPE prior to getting on the elevator. On 8/04/22 at 13:12 PM, the surveyor interviewed the LNHA. She stated, housekeeping frequently changes the bags in the trash cans in the resident's room. We have always used open trash receptacles. 4. On 8/03/22 at 9:02 AM, the surveyor observed the facility posted instructions in the facility front lobby indicating the requirements for visitors to perform a 15-minute rapid test before visitations regardless of their vaccination status. On 8/3/22 at 9:12 AM, the surveyor observed a visitor who entered the designated Covid testing room after the visitor completed the Covid 19 screening questionnaires and then proceeded to wait in the lobby. The visitor informed the surveyor that he/she was Resident #629's representative (RR) and was visiting the resident in the second-floor unit. The RR informed the surveyors that he/she had been frequently visiting the resident and usually waited for 5 minutes after getting tested for Covid-19 before being allowed to go to the resident's room. On that same date at 9:17 AM, during the surveyor's interview, the IPN informed the RR that he/she was ok and was negative for Covid-19. On that same date at 9:22 AM, the surveyor asked the IPN why the 15 minutes waiting time for the Covid-19 rapid test result was not followed when she instructed Resident #629's RR to proceed for visitation within his/her 5 minutes wait time after Covid-19 rapid test was performed. The IPN stated, that was ok because the negative result showed up already. On that same date at 9:47 AM, the surveyor informed the LNHA and ADON about the above concerns. The LNHA and ADON did not provide an answer to the surveyor. On 8/18/22 at 12:42 PM, the LNHA provided the surveyor with the Covid-19 Ag (antigen) test Card that was utilized for Covid-19 testing which reflected the manufacturer's Procedure Card instructions with a four-step sample test procedure. It was indicated in step four of the instructions, under Part 1- Sample Test Procedure, to read the result in the card window 15 minutes after closing the card. It also reflected In order to ensure proper test performance, it is important to read the result promptly at 15 minutes, and not before. On 8/23/22 at 9:43 AM, the surveyor conducted a post-survey interview with the IPN [NAME] concerning the facility's posted instructions of 15 minutes wait time for COVID-19 testing that was not followed. She indicated that it was previously discussed by surveyors on the day it happened. She also stated that she should have followed the protocol for testing. 5. On 8/17/22 at 12:20 PM, the surveyor requested the Licensed Nursing Home Administrator (LNHA) to provide the facility's documents for screening COVID-19 of Housekeeper#1 (HK#1), HK#2, and the Physical Therapist Assistant (PTA) for dates 8/7 and 8/8/22. The surveyor asked the LNHA for a copy of [name redacted] Rapid Antigen Testing form (RATf) The surveyor reviewed the facility Employee Temperature Log-Covid 19 (ETL=a form that showed the name of employees, the shift they worked, and the temperature. The ETL also included two questions: asking if the staff was experiencing Covid-19 symptoms and if the staff was scheduled to get tested today that day), the Bi-weekly Schedule from July 31st to August 13th, 2022 schedule of Housekeepers, the Rehab Department schedule on 8/8/22, Vaccination for COVID-19 Staff log, Payment Based Journal (PBJ-attendance records), and the RATf that was provided by the LNHA. The documents included the following information: HK#1 was on the schedule for 8/7 and 8/8/22 and had the RATf completed on 8/7/22 but there was no documented evidence in the ETL that the screening was done at the start of the shift on 8/7 and 8/8/22. HK#1 was up to date with his COVID-19 vaccines. HK#2 was on the schedule for 8/7 and 8/8/22 and had the RATf completed on 8/7/22 but there was no documented evidence on the ETL that the screening was done at the start of the shift on 8/7 and 8/8/22. HK#2 was up to date with his COVID-19 vaccines. The physical Therapist Assistant (PTA) was on the schedule for 8/8/22 and had the RATf completed on 8/8/22 but there was no documented evidence on the ETL that the screening was done at the start of the shift on 8/8/22. The PTA was up to date with his COVID-19 vaccines. On 8/23/22 at 9:43 AM, the surveyor interviewed the IPN about the missing staff screenings. The IPN stated that she was aware of the concern and confirmed that staff must sign before their shift start, and the screening for COVID-19 should be for all staff. The IPN was aware also of the three staff who did not screen for COVID-19 before their shift and confirmed that the three staff identified, HK#1, HK#2, and PTA did not screen but did complete COVID-19 tests with negative results. On 8/23/22 at 11:59 AM, the surveyor completed a post-survey interview with the PTA. The PTA stated that when he came to the facility in the morning, he normally do a temperature check and completed the Covid screening in the front desk lobby, and do the Covid testing on the testing day. The PTA informed the surveyor that he did not work on 8/7/22 but stated I believe August 8th I was in the building. On that same date and time, the surveyor asked if he was in the facility on 8/8/22 working and he responded, I don't remember exactly, but it was the Monday, so I was most likely here. The surveyor asked the PTA if he remembered completing the Covid-19 screening questionnaires on 8/8/22. He stated that he does not remember and stated, I have poor memory as it is anyway. On 8/23/22 at 2:13 PM, the surveyor completed a post-survey interview with HK#1. HK#1 stated that no matter what day it was, the protocol was immediately upon entering the building at the receptionist desk, he will use the sign-in log, where his temperature was checked before signing in, then put his temperature on the form. He stated if the temperature was fine then he will go and punch in and added that he does Covid testing on Mondays if he works. When asked by the surveyor if he worked on 8/7/22, the staff could not recall if he worked on 8/7/22. On 8/24/22 at 02:47 PM, the surveyor conducted a post-survey interview with HK#2. HK#2 stated that whenever she entered the facility to work, she will check her temperature, sign in, and answers a couple of questions on the log before she punched in. HK#2 further stated that once a week on Mondays, she is being tested for COVID-19 on the main floor of the building and had to wait for 15 minutes for the results before she could proceed onto the floor. On that same date and time, the surveyor asked HK#2 if she worked on 8/7/22 and 8/8/22, and if she remembered using the log for COVID-19 screening for staff. HK#2 stated that she was definitely working on Monday, 8/8/22 but was not sure about 8/7/22 if that was her Sunday off. Then, HK#2 stated, yes I believe that was my weekend, and added that HK#2 usually uses the log every day. A review of the facility policy, COVID-19/Testing of Facility Personnel updated 3/22/22 reflected Addendum: 2. Regardless of the required frequency of testing, the vaccination status of staff or facility's Covid-19 status, facilities must continue to screen all persons entering the facility including all staff, visitors and residents daily for signs and symptoms of covid-19 as outlined in ED 20-026. 6. On 8/16/22 at 12:07 PM, the surveyor reviewed the electronic medical records and showed that 6 out 12 residents were not monitored for signs and symptoms of COVID-19 every shift (q shift) when the facility was on continued outbreak from 7/15/22 through 8/19/22 according to the facility provided outbreak letter from 7/15/22 through 8/12/22. The surveyor reviewed the July and August 2022 electronic Medication Administration Record (eMAR), electronic Treatment Administration Record (eTAR), Weights & Vitals record, and facility provided documentation and revealed the following: Resident#7's vital signs (v/s) i.e. (that is) temperature (temp), blood pressure (BP), pulse, respiratory rate (RR), and oxygen saturation (O2 sat) were not checked q shift from 7/15/22 through 7/26/22 not until 7/27/22. Resident#23's v/s were not checked q shift from 7/15/22 through 7/25/22 not until 7/26/22. Resident#80's BP was not checked as part of v/s q shift from 7/15/22 through 7/30/22 not until 7/31/22. Resident#153's BP was not checked as part of v/s q shift from 7/15/22 through 7/29/22 not until 7/30/22 Resident#629's v/s were not checked q shift from 8/2/22 through 8/16/22 not until 8/17/22. Resident#630's BP was not checked as part of v/s q shift from 7/15/22 through 7/27/22 not until 7/28/22. On 8/18/22 at 12:17 PM, the survey team met with the LNHA and the DON, and they were made aware of the above concerns. On 8/23/22 at 9:43 AM, during a telephone interview of the surveyor with the IPN, the IPN stated that she was aware of the residents that were not being monitored q shift for signs and symptoms of COVID-19 during an outbreak. When the surveyor asked the IPN if the residents should have been monitored q shift for COVID-19, the IPN stated absolutely, residents should be monitored for signs and symptoms of COVID 19 every shift per facility protocol. A review of the facility's Hand Washing/Hand Hygiene Policy dated 4/31/11 by the LNHA included Policy: Hand hygiene is a basic requirement for infection prevention. It is the facility's policy that all staff is trained in proper technique and is monitored for proper hand hygiene practices Use of Alcohol Based Hand Rubs: 1. Hands should be decontaminated with alcohol based rubs at the following times: b. Before having direct contact with patients d. After contact with a patient's intact skin (e.g. when taking a pulse or BP, and lifting a patient.). e. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressing if hands are not visibly soiled .g. After contact with inanimate objects in the immediate vicinity of the patient . According to facility's Outbreak Plan E.D. 20-026 that was provided by the LNHA on 8/8/22 at 8:46 AM showed that .Implement the isolation protocol in the facility (isolation rooms, cohorting, cancelation of group activities and social dining) as described in the facility's infection prevention and control plan and/or recommended by local, state, or federal public health authorities .Evaluation and Management of Residents and Healthcare Personnel: During an outbreak, facility will assess close contacts including HealthCare Personnel (HCP) and other residents based on their exposures to positive case(s) of the infectious disease Facility conduct active screening of all residents: Nursing staff will monitor residents every shift for symptoms of the ID and any other illness. Vital signs should include heart rate, blood pressure, temperature, pain and pulse oximetry Facility shall screen and log HCP and everyone entering the facility for symptoms of the infectious disease. Screening will include: a. Temperature checks including subjective and/or objective fever equal to our greater than 99.5 degrees Fahrenheit or as further restricted by the facility. b. Completion of questionnaire about symptoms and potential exposure which shall include at a minimum: 1. Exhibit signs and symptoms of and infectious disease, including COVID-19, such as fever equal to or greater than 99.5, chills, cough, shortness of breath or difficulty of breathing, sore throat, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, nausea or vomiting, or diarrhea According to Occupational Safety and Health Administration (OSHA), Disposal of blood and other potentially infectious materials (OPIM) (1910.1030 1910.1030(d)(4)(iii)(B)(1)(iii) 1910.1030(d)(4)(iii)(C) In general, regulated wastes, other than contaminated sharps, must be placed in containers which are: (i) Closable; (ii) Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping; (iii) Labeled or color-coded in accordance with paragraphs (g)(1)(i); (iv) Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping [29 CFR 1910.1030(d)(4)(iii)(B)(1)(i)-(iv)]. A regulated medical waste is any solid waste, generated in the diagnosis, treatment (for example, provision of medical services), or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals, that is not excluded or exempted under (b) below, and that is listed or meets any waste characteristic classification criteria described in the following table: 6 .Isolation Wastes Biological waste and discarded materials contaminated with blood, excretion, exudates, or secretions from humans who are isolated to protect others from certain highly communicable diseases, or isolated animals known to be infected with highly communicable diseases. N.J. Admin. Code § 7:26-3A.6 The following web sites can be accessed for additional information: Regulated Medical Waste Regulations: N.J.A.C. 7:26, Subchapter 3A. Guidance Document for Regulated Medical Waste: https://www.state.nj.us/dep/dshw/rrtp/rmw.htm OSHA Standard 1910.1030 - Bloodborne Pathogens: https://www.osha.gov/laws regs/regulations/standard number/1910/1910.1030 OSHA Control and Prevention Guidance for COVID-19 https://www.osha.gov/SLTC/covid-19/controlprevention.html#health USDOT - Definition of an Infectious Substance, Division 6.2 https://ecfr.io/Title-49/se49.2.173_1134 According to Occupational Safety and Health Administration (OSHA), Disposal of blood and other potentially infectious materials (OPIM) (1910.1030 1910.1030(d)(4)(iii)(B)(1)(iii) 1910.1030(d)(4)(iii)(C) In general, regulated wastes, other than contaminated sharps, must be placed in containers which are: (i) Closable; (ii) Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping; (iii) Labeled or color-coded in accordance with paragraphs (g)(1)(i); (iv) Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping [29 CFR 1910.1030(d)(4)(iii)(B)(1)(i)-(iv)]. A regulated medical waste is any solid waste, generated in the diagnosis, treatment (for example, provision of medical services), or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals, that is not excluded or exempted under (b) below, and that is listed or meets any waste characteristic classification criteria described in the following table: 6 .Isolation Wastes Biological waste and discarded materials contaminated with blood, excretion, exudates, or secretions from humans who are isolated to protect others from certain highly communicable diseases, or isolated animals known to be infected with highly communicable diseases. N.J. Admin. Code § 7:26-3A.6 The following web sites can be accessed for additional information: Regulated Medical Waste Regulations: N.J.A.C. 7:26, Subchapter 3A. Guidance Document for Regulated Medical Waste: https://www.state.nj.us/dep/dshw/rrtp/rmw.htm OSHA Standard 1910.1030 - Bloodborne Pathogens: https://www.osha.gov/laws regs/regulations/standard number/1910/1910.1030 OSHA Control and Prevention Guidance for COVID-19 https://www.osha.gov/SLTC/covid-19/controlprevention.html#health USDOT - Definition of an Infectious Substance, Division 6.2 https://ecfr.io/Title-49/se49.2.173_1134 NJAC: 8:39-19.4(a)(b)(l)(n)(2)