**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, interviews, and review of facility policy, the facility failed to prevent resident-to-resident abuse on 03/24/23 when Resident (R)54 pushed and hit R411 in the back. This deficiency has the potential to facilitate future resident-to-resident physical altercations resulting in serious injury or serious physical or psychosocial impairment. Findings include: 1. Review of the Census tab located in the electronic medical record (EMR) revealed R411 was admitted to the facility on [DATE]. Review of the Med Diag [Medical Diagnoses] tab located in the EMR revealed R411 had diagnoses including dementia, bipolar disorder, and dementia with agitation. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/13/23 and located in the EMR revealed R411 had a Brief Interview for Mental Status (BIMS) score of six out of 10 indicating severe cognitive impairment. R411 exhibited no behaviors as indicated in Section E. Review of the Care Plan (CP) located in the EMR revealed R411 had a concern related to dementia initiated on 07/14/22 with interventions including administering medications and cueing, reorienting, and supervising R411 as needed. 2. Review of the Census tab located in the EMR revealed R54 was admitted to the facility on [DATE]. Review of the Med Diag tab located in the EMR revealed R54 had diagnoses including end-stage renal disease, vascular dementia, and previous stroke. Review of the quarterly MDS located in the EMR revealed R54 had a BIMS score of 13 out of 15 indicating no cognitive decline. R54 did not exhibit any behaviors as indicated in Section E. Review of a Reportable Event Record/Report dated 03/27/23 and supplied by the Director of Nursing (DON), revealed staff had reported to them on 03/25/23 at around 1pm that on 03/24/23 at around 7pm R411 had been hit by another resident. The facility informed the appropriate authorities, reported the incident within the correct timeframe, and performed an investigation, although not a complete investigation. The facility questioned R54 at which time he admitted to pushing R411to get R41] out of his [R54] room and hitting R411 on the back. R54 stated he did not report anything to staff because R411 left the area. The facility educated R54 on reporting issues. X-rays were taken of R411 showing no injury. Review of R54's CP located in the EMR revealed a concern initiated on 03/25/23 related to R54 having the potential to become physically aggressive related to dementia/anger with interventions including anticipating needs and monitoring/documenting/reporting any signs of posing a danger to himself or others. Review of R411's CP revealed a concern related to being at risk of victimization initiated on 03/25/23 with interventions including monitoring behaviors, monitoring interactions with other residents, and intervening when needed. Review of the Alliance Incident List provided by the DON revealed R54 had not been involved in a resident-to-resident incident since 03/24/23. Review of the Abuse, Mistreatment, Neglect, Misappropriation of Resident's Property - Policy, Procedure, and Information reviewed 01/11/24 and supplied by the DON revealed the facility, .shall provide the residents with considerate and respectful care designed to promote the resident's independence and dignity. Each resident has the right to be free of abuse, mistreatment, neglect, and misappropriation of property. This includes the identification of residents and the development of intervention strategies to prevent occurrence, monitoring changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. Additionally, the facility shall ensure the screening and training of employees, protection of residents, and for the prevention, identification, investigation, and reporting of abuse, mistreatment, neglect, and misappropriation of property. The Purpose of the policy was to ensure that all residents are protected from abuse of any kind by anyone. NJAC 8:39-4.1(a)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJAC 8:39-9.4(f) Based on interview, record review, and facility policy review, the facility failed to thoroughly investigate resident-to-resident abuse incidents for three residents (Residents (R)54, R210, and R411) reviewed for abuse out of a sample size of 31. This failure has the potential for further resident-to-resident abuse occurring and not being investigated so interventions can be put in place. Refer to F600 Findings include: 1. Review of the Census tab located in the electronic medical record (EMR) revealed Resident (R)411 was admitted to the facility on [DATE]. Review of the Med Diag [Medical Diagnoses] tab located in the EMR revealed R411 had diagnoses including dementia, bipolar disorder, and dementia with agitation. Review of the Census tab located in the EMR revealed R54 was admitted to the facility on [DATE].Review of the Med Diag tab located in the EMR revealed R54 had diagnoses including end-stage renal disease, vascular dementia, and previous stroke. Review of a Reportable Event Record/Report dated 03/27/23 and supplied by the Director of Nursing (DON) revealed staff had reported to them on 03/25/23 at around 1pm that on 03/24/23 at around 7pm R411 had been hit by another resident. The facility informed the appropriate authorities, reported the incident within the correct timeframe, and performed an investigation The facility questioned R54 at which time he admitted to pushing R411to get him [R411] out of his [R54] room and hitting him [R411] on the back. R54 stated he did not report anything to staff because R411 left the area. The facility educated R54 on reporting issues. X-rays were taken of R411 showing no injury. The facility investigation indicated the DON, law enforcement, the family, and the physician were notified. Skin checks and care plan updates were completed. The investigation stated staff education related to abuse/timeline abuse allegation was completed. The facility investigation did not contain staff education or resident interviews aside from R54 and R411. Review of the Alliance Incident List provided by the DON revealed R54 had not been involved in a resident-to-resident incident since 03/24/23. In an interview on 10/17/24 at 11:30 AM the DON stated the only investigation information related to the R54 and R411 incident was in the file supplied. The DON stated she started earlier this year, inherited the reported event, and has no more information to provide. She verified the investigation did not contain staff interviews, resident interviews, or staff education related to R54 hitting R411 in the back. 2. Review of R210's electronic medical record (EMR) revealed per the Census tab resident was admitted on [DATE] and discharged on 03/08/23. Review of the facility's Incident list provided by the Regional Nurse indicated on 03/08/24 at 4:00PM, R210 was identified on the document with allegation of abuse. The investigative file provided by the Regional Nurse on 10/17/24 at 11:58 AM, contained a narrative that indicated that the alleged physical abuse occurred on 03/08/24 at approximately 3:00PM, in which R210 stated that the previous Social Service Director (SSD) pushed R210 out of his wheelchair and twisted his arm. The narrative indicated, Social Worker served patient with discharge notice. He became agitated and started screaming at her that he was not going to leave. Resident stood in between the elevator doors and continued to scream at staff members. Social worker was about eight feet from him and never made physical contact with the patient. The narrative contained a witness statement from the Director of Rehab who stated, .previous SSD was six to eight feet away from R210 and the previous SSD did not touch resident. The narrative indicated that Licensed Practical Nurse (LPN)1 witnessed the incident but the narrative nor the investigative file contained LPN1's statement. The investigative file did not include a statement from the previous SSD. Interview with the Regional Nurse on 10/17/24 11:58 AM, she confirmed that everything that was in the investigative file was all the information she could find for this allegation of abuse investigation. Review of the facility's policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident's Property dated 01/11/24 indicated, .Section V-Investigation 17. Upon receipt of the resident's accident/incident report .The investigation shall include a. statement from all parties involved including but limited to the resident involved, family members and other residents and staff .

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a resident was appropriately positioned with head elevated while receiving nutrition through a feeding tube for one of one resident (Resident (R) 91) reviewed for tube feeding out of a sample of 31 residents. The lack of head elevation could result in aspiration. Findings include: Review of the facility's policy titled, Tube Feeding Policy, last reviewed 05/10/24, revealed, All resident [sic] to remain in Semi-Fowler's position [head of the bed elevated between 30 degrees and 45 degrees] during the feeding and for one hour following the feeding to prevent aspiration. Review of R91's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/24 and located in the MDS tab of the electronic medical record (EMR), revealed the resident was unable to complete a Brief Interview for Mental Status (BIMS), and the staff assessment for cognition indicated severely impaired cognition. R91 had a gastrostomy tube and received over half of his nutrition through tube feeding. Review of R91's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, revised 08/08/24, [R91] is NPO [nothing by mouth] and dependent on PEG [feeding tube] as his sole source of nutrition/hydration. Further review of the Care Plan revealed interventions head of bed elevated to 30-45 degrees unless providing care or resident request, revised on 03/01/23 and [R91] needs the HOB [head of the bed] 45 degrees during and thirty minutes after tube feed, revised on 05/29/23. Review of R91's Order Summary Report, located in the Orders tab of the EMR revealed an order, dated 09/27/24, for enteral feeding to run at 90 milliliters (ml) per hour with total volume infused of 1620 ml in 24 hours. Further review revealed an order, dated 09/27/24, to elevate the head of the bed 30 to 45 degrees every shift. During an observation on 10/14/24 at 11:19 AM, R91 laid in bed with the head of the bed elevated less than 30 degrees and the enteral feeding running at 90 ml per hour. During an observation on 10/15/24 at 11:00 AM, R91 laid in bed, on his left side, positioned low in bed so that the head of the bed, which was elevated less than 30 degrees, did not elevate his head. The enteral feeding was running at 90 ml per hour. During an observation on 10/15/24 at 4:21 PM, R91 laid flat in bed on his back without the head of the bed elevated. The enteral feeding was running at 90 ml per hour. During an observation on 10/16/24 at 8:18 AM, R91 laid flat in bed on his back, positioned slightly down in the bed with the head of the bed elevated less than 30 degrees. The enteral feeding was running at 90 ml per hour. During an observation on 10/16/24 at 9:02 AM, Certified Nursing Assistant (CNA) 6 completed cares, with the tube feeding paused, and then positioned R91 with the head of the bed elevated less than 30 degrees. During a concurrent interview on 10/16/24 at 9:02 AM, CNA6 stated if the head of the bed was up, R91 was more likely to fall off the bed. During an interview on 10/16/24 at 9:06 AM, Charge Nurse (CN) 2 stated the head of the bed should be at 45 degrees and raised the head of the bed. During an interview on 10/16/24 at 10:50 AM, Licensed Practical Nurse (LPN) Supervisor stated she noticed R91 lying in bed the day prior without the head of the bed raised appropriately and had raised it. LPN Supervisor stated staff were to keep the head of the bed elevated at least 30 degrees, unless they paused the feeding for cares or another reason. During an interview on 10/16/24 at 5:30 PM with the Director of Nursing (DON), the DON stated she expected staff to follow the standard practice of elevating the head of the bed to 30 degrees or greater when a tube feeding was running, to prevent aspiration. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to have medications available to administer as ordered, document why the medications were not given, and maintain accessible records for a controlled medication for three of seven residents (Resident (R) 141, R261, and R366) reviewed for medication administration or pain. This had the potential to result in adverse health outcomes. Findings include: 1. Review of R366's admission Record under the electronic medical record (EMR) Profile tab revealed she was admitted to the facility on [DATE]. R366 had diagnoses which included failure to thrive. Review of R366's Order Summary Report, located in the Orders tab of the EMR revealed orders which included: -magnesium oxide 400mg 1 tablet twice daily as a supplement, ordered 10/08/24, and -dronabinol 2.5mg twice daily for appetite stimulant, ordered 10/08/24 Review of R366's Medication Administration Record (MAR), located in Orders tab of the EMR, revealed the dronabinol and magnesium oxide were scheduled for 9:00 AM and 5:00 PM. During an interview on 10/15/24 at 4:35 PM, R366 stated she was hungry and had no nausea. During an observation on 10/16/24 at 9:10 AM, Charge Nurse (CN) 3 administered morning medications to R366. CN3 did not administer R366's dronabinol or magnesium oxide. During an interview on 10/16/24 at 9:20 AM, CN3 stated the facility was waiting for the pharmacy to send the dronabinol. It needed a script, which sometimes took a couple of days to get. In addition, CN3 stated the medication cart had no magnesium oxide in it. She had just used the last one and needed to check other carts for a bottle. Further review of R366's MAR on 10/16/24 at 10:00 AM revealed that since she admitted to the facility on [DATE], nursing had documented the administration of dronabinol with a chart code 9 which referred the reviewer to other/see progress notes. Review of R366's Progress Notes under the Prog Notes tab of the EMR revealed the following documentation regarding the dronabinol: -on 10/10/24 at 8:50 AM reschedule -on 10/12/24 at 9:51 AM on order -on 10/12/24 at 6:45 PM on order -on 10/14/24 at 8:56 AM on resident -on 10/15/24 at 10:13 PM reschedule In addition, on 10/09/24, 10/11/24, and 10/13/24, staff documented on order with no specific medication mentioned. During a follow-up interview on 10/16/24 at 10:31 AM, CN3 reported she had not located any magnesium but would order it. She stated the nurse who admitted R366 may have checked for a script for the dronabinol. CN3 stated she planned to follow up with her supervisor and/or the nurse practitioner regarding the medication. During an interview on 10/16/24 at 10:40 AM, Licensed Practical Nurse (LPN) Supervisor stated if a medication required a script and was not available, the nurse should address it. If unable to address it, it should be endorsed to the next shift or passed through to the supervisor. LPN Supervisor was unaware that the dronabinol for R366 had not arrived. LPN Supervisor stated she had instructed the person who stocks medications that they needed magnesium oxide for R366. 2. Review of R141's admission Record under the EMR Profile tab revealed he was admitted to the facility on [DATE]. R141 had diagnoses which included encounter for surgical aftercare following surgery on the digestive system and encounter for attention to colostomy. Review of R141's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/20/24 and located in the MDS tab of the EMR, revealed R141 scored a 12 out of 15 on his Brief Interview of Mental Status (BIMS), which indicated moderately impaired cognition. R141 reported rare, mild pain. During an observation and interview on 10/14/24 at 12:47 PM, R141 grimaced when he moved from a lying to sitting position in bed. R141 reported pain and pulled up his shirt to show a colostomy bag intact to his left abdominal area. He pointed to his colostomy area and reported pain for three months but could not state what helped the pain. Review of R141's Order Summary Report located under the Orders tab of the EMR revealed R141 had two orders, dated 07/15/24, for lidocaine patches. One order was for application to the left rib and one was for application to the right rib, both at 9:00 AM with removal at 9:00 PM. Review of R141's Care Plan, located in the Care Plan tab of the EMR, revealed no focus area on pain or any mention of rib area pain or interventions. During an observation and interview on 10/14/24 at 3:53 PM, R141 again lifted the left side of his shirt, when asked if he had a lidocaine patch placed. R141 stated sometimes he had a lidocaine patch on but not now on either side. No lidocaine patch was observed to the left side. R141 did not show his right side. During an observation and interview on 10/16/24 at 1:00 PM, R141 laid on his right side in bed and reported pain as sometimes but not now. R141 stated he had no patch on his left side and pulled up his shirt to reveal no lidocaine patch. He did not move to show his right side. Review of R141's October MAR located in the Orders tab of the EMR, revealed nurses had initialed the lidocaine patch to the left side as administered both 10/14/24 and 10/16/24 at 9:00 AM. During an interview on 10/16/24 at 1:05 PM, CN3 stated she put a lidocaine patch on the right side but did not have one available to put on the left side. She needed to re-order the patches.CN4 confirm she should not have initialed the patch as being administered. 3. Review of R261's admission Record under the EMR Profile tab revealed she was admitted to the facility on [DATE] and discharged on 06/24/24. She had diagnoses which included malignant neoplasm of cervix, pain in right lower leg, chronic embolism and thrombosis of left popliteal vein, and pain in left lower leg. Review of R261's admission MDS, with an ARD of 01/30/24 and located in the MDS tab of the EMR, revealed R261 scored a 15 out of 15 on her BIMS, which indicated intact cognition. R261 reported occasional pain, rated as nine, at its worst, on a zero to ten scale, with ten being the worst pain possible. R261 reported the pain did not, or seldom, affected sleep, therapy, or day-to-day activities. She received scheduled and prn pain medications, to include opioids. Review of R261's January, February, and March MARs, located under the Orders tab of the EMR revealed she had orders for a fentanyl patch 100mcg/hr to be applied every three days for pain. Further review revealed on 01/30/24, 02/03/24, and 03/01/24, nursing documented the administration of the patch with a chart code 9 which referred the reviewer to other/see progress notes. On 02/09/24, the patch was documented as on hold, and on 02/12/24 and 02/18/24 the fentanyl patch was not signed off as administered. On 02/27/24 and 03/13/24, nursing documented R261 refused the patch. Review of R261's Progress Notes located under the Prog Notes tab of the EMR revealed an entry on 01/31/24 of awaiting for pharmacy to deliver, med faxed and called. There was no documentation about why the fentanyl patch was on hold on 02/09/24, why it was not signed off on 02/12/24 or 02/18/24, or why the resident refused it on 02/27/24 and 03/13/24. The facility was unable to provide controlled substance administration records for fentanyl patches prior to 03/15/24. During an interview on 10/16/24 at 8:30, CN2 stated if a medication was not available, nurses notified the doctor and got an order to hold the medication or replace it with a different medication until it arrived from pharmacy. Pharmacy sent medications stat if needed, and the facility had a pyxis (emergency supply) of many narcotics as well as other medications. During an interview on 10/16/24 at 9:41 AM, Registered Nurse (RN) Supervisor stated a nurse practitioner, who provided scripts, was in the facility Monday through Friday and was available by phone as well. If a medication was not available, staff called the provider to see if the provider wanted to order an alternative medication. During an interview with the Director of Nursing (DON) on 10/16/24 at 5:30 PM, the DON stated she expected nurses to tell the unit manager and/or her when medications had not arrived from the pharmacy. R366 should not have gone eight days without her dronabinol. After the observed medication pass, the facility had called the pharmacy and clarified the medication was on backorder from the manufacturer. The facility notified the physician, who ordered an alternate medication. On 10/17/24 at 12:09 PM CN6 stated the R261 had a lot of pain but was able to make her needs known and ask for pain medication. CN6 did not recall not having fentanyl patches available. NJAC 8:39-29.3(5) NJAC 8:39-29.6(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of less than five percent during observation of medication administration. The facility had three errors in twenty-five opportunities, which resulted in a 12 percent error rate. This affected one (Resident (R) 366) out of four residents observed. Medication errors have the potential to result in adverse health outcomes. Refer to F755. Findings include: Review of the facility untitled policy regarding medication administration, dated 06/22/24, revealed, Medications are to be administered within a two-hour time frame (i.e. one hour before or after the medication order time. The licensed nurse Immediately notifies nursing supervisor if medication is unavailable for administration and notifies Physician/NP [nurse practitioner] of the same. Contacts pharmacy to obtain medication. The licensed nurse Assures the 5 rights: Compares the medication name, strength, route and dosage schedule on the medication administration record against the prescription label. Always checks three times prior to administration of medication. Review of R366's admission Record under the electronic medical record (EMR) Profile tab revealed she was admitted to the facility on [DATE]. R366 had diagnoses which included hypothyroidism and failure to thrive. Review of R366's Order Summary Report, located in the Orders tab of the EMR revealed orders which included: Levothyroxine 75 microgram (mcg). Give two tablets daily, ordered 10/14/24, for hypothyroidism Magnesium oxide 400 milligram (mg). Give one tablet twice daily as a supplement, ordered 10/08/24, and Dronabinol 2.5 mg. Give twice daily for appetite stimulant, ordered 10/08/24 Review of R366's Medication Administration Record (MAR) under the EMR Orders tab revealed the levothyroxine 75mcg 2 tabs, which started on 10/14/24, was scheduled for 8:00 AM, one hour before any other medications. Prior to 10/14/24, the dose was 100mcg daily. R366's other morning medications were all scheduled at 9:00 AM, to include magnesium oxide and dronabinol. During an observation on 10/16/24 at 9:10 AM, Charge Nurse (CN) 3 administered morning medications to R366. CN3 punched two tablets out of a single medication card containing levothyroxine 100mcg tablets and administered them to R366 along with six scheduled 9:00 AM medications. CN3 stated the facility was waiting for the pharmacy to send the dronabinol. It needed a physician order, which sometimes took a couple of days to get. In addition, CN3 stated the medication cart had no magnesium oxide in it. She had used the last tablet for another resident and needed to check other carts for a bottle. During an interview on 10/16/24 at 9:41 AM, Registered Nurse (RN) Supervisor stated a Nurse practitioner, who provided physician order, was in the facility Monday through Friday and was available by phone as well. If a medication was not available, staff called the provider to see if the provider wanted to order an alternative medication. During a follow-up interview on 10/16/24 at 10:31 AM, CN3 reported she had not located any magnesium but planned to order it. She stated the nurse who admitted R366 may have checked for a physician order for the dronabinol. CN3 stated she planned to follow up with her supervisor and/or the Nurse Practitioner regarding the medication. When asked to check the dose on the medication card for levothyroxine, CN3 pulled two medication cards rubber-banded together which contained levothyroxine 75mcg tablets. When asked to check for the 100mcg card used for the observed medication pass, CN3 retrieved a card of 100mcg tablets from the medication cart. CN3 verified two tablets were missing from the 75mcg cards, although the MAR showed two tablets of 75mcg had been signed off for three days (six tablets total). CN3 stated she would remove the card containing the 100mcg tablets from the cart. She verified levothyroxine was scheduled for 8:00 AM. During an interview on 10/16/24 at 10:40 AM, Licensed Practical Nurse (LPN) Supervisor stated if a medication required a physician order and was not available, the nurse should address it. If unable to address it, it should be endorsed to the next shift or passed through to the supervisor. LPN Supervisor was unaware that the dronabinol for R366 had not arrived. LPN Supervisor the nurse who received the order for the change in dose of the levothyroxine should have removed the old medication card from the cart at the time of the order. During an interview with the Director of Nursing (DON) on 10/16/24 at 5:30 PM, the DON stated she expected nurses to tell the unit manager and/or her when medications had not arrived from the pharmacy. R366 should not have gone eight days without her dronabinol. The DON expected nurses to follow the five rights of medication administration. The DON expected that nurses administered medications from one hour prior to one hour after the prescribed time. NJAC 8:39-29.2(d)

Based on observation, record review, interview, and policy review, the facility failed to utilize the proper personal protective equipment (PPE) for enhanced barrier precautions (EBP) and failed to perform proper hand hygiene for one of five residents (Resident (R) 91) reviewed for EBP out of a sample of 31 residents. This created a potential for the transmission of infection to staff and other residents. Findings include: Review of the facility's Enhanced Barrier Precautions policy, dated 04/01/24, revealed it stated: Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . The use of gown and gloves for high-contact resident care activities is indicated, . for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. The following situations would warrant Enhanced Barrier Precautions: (EBP) . Wounds and/or indwelling medical devices (regardless of their MDRO status) [such as] indwelling catheters, . Feeding tubes . Enhanced Barrier Precautions require: Use of gown and gloves during high-contact resident care activities [such as] dressing, bathing, . changing linens, changing briefs, incontinence pads, toileting assistance, device care or use of indwelling catheter, central line, feeding tube, . Review of the facility's Infection Control: Handwashing (hand hygiene) policy, dated 01/11/24, revealed it directed staff to perform hand hygiene at times which included: before rendering care, between providing care where soiling is likely (i.e. incontinent care, removal of soiled dressing), and after touching resident furnishings/belongings. Review of R91's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/24 and located in the MDS tab of the electronic medical record (EMR), revealed the resident was unable to complete a Brief Interview for Mental Status (BIMS), and the staff assessment for cognition indicated severely impaired cognition. R91 had a gastrostomy tube (G-tube). Review of R91's Order Summary Report, located in the Orders tab of the EMR revealed an order for enhanced barrier precautions, dated 09/27/24. Review of R91's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, revised 10/11/24, [R91] is on Enhanced Barrier Precautions. At Risk for MDRO [multidrug-resistant organisms] due to G-tube feeding & right & left arms. Interventions included: We will provide enhanced barrier precautions during times of high contact resident care activities and We will use gloves, gowns and potentially goggles if we're expecting splashing. During an observation on 10/14/24 at 11:19 AM, a sign hung on the wall outside R91's door. The sign stated to wear gloves and gown for dressing, bathing/showering, transferring, changing linens, personal hygiene, device care or use: central line, urinary catheter, feeding tube, tracheostomy. During an observation on 10/16/24 from 8:36 AM to 9:02 AM, Certified Nursing Assistant (CNA) 6 went into R91's room with clean bedding, linens, and a resident gown. CNA6 washed her hands, put on gloves, and filled a basin with water at the sink. While R91 laid on his back in bed, CNA6 raised the bed to working height with her gloved hand. CNA6 then washed R91's face, removed his gown, and washed his armpits and abdomen. CNA6 removed R91's hand splints and two small wedge positioning devices from the bed. CNA6 then unfastened and folded down the front of R91's incontinent brief, which contained urine and stool. CNA6 provided perineal care to R91's front and then used her gloved hands to roll R91 onto his left side. CNA6 removed the incontinent brief and washed R91's back side to complete the perineal cares. CNA6 applied barrier cream to R91's buttocks with her gloved hands and placed a clean incontinent brief, as well as a clean fitted sheet, under R91, after tucking the used fitted sheet under R91. CNA6 rolled R91 the other direction, removed the old fitted sheet from the bed, finished placing the new fitted sheet, and secured the incontinent brief by its adhesive tabs. CNA6 proceeded to dump the old water from the basin and, with the same gloves on her hands, turned on the water at the sink to re-fill the basin. She then washed R91's feet and legs. With gloved hands, CNA6 placed a cushion between R91's legs, removed the old flat sheet, and covered him with a clean sheet. CNA6 lowered the bed before she removed her gloves and washed her hands at the sink. CNA6 did not change her gloves during the cares and did not wear a gown. During an observation on 10/16/24 at 4:02 PM, Charge Nurse (CN) 4 washed her hands at the sink and gloved in R91's room. She removed R91's old feeding bag, disposed of it, retrieved a new bag, and hung it on the hook of the pole near the bed. CN4 then removed a syringe from a bag hanging on the pole, secured the syringe to R91's G-tube, pulled back to check for residual, and then flushed the G-tube with water poured into the syringe. CN4 placed the syringe back in the bag, grabbed the tubing from the feeding bag, and connected it to R91's G-tube. CN4 wore no gown. During an interview on 10/16/24 at 4:05 PM, CN4 stated that for residents with tube feedings and PICC lines, enhanced barrier precautions meant that those sites needed some kind of dressing covering them. Gowns were only expected to be worn when a resident was on isolation precautions for something like MRSA, c-diff, etc, and then the type of PPE worn depended on the type of precautions/isolation. During an interview on 10/16/24 at 5:11 PM, the Infection Preventionist (IP) stated enhanced barrier precautions were used by staff when they provided direct care for residents with central lines, chronic wounds, feeding tubes, tracheostomies, and indwelling catheters. Staff wore gowns and gloves for activities of daily living (ADLs) including dressing, washing, and bed making. When checking the residual of, or flushing a, tube feeding, there was the potential for contact with body fluids so staff wore gloves, and it was also best that they wore gowns. During an interview with the Director of Nursing (DON) on 10/16/24 at 5:30 PM, the DON stated she expected gloves and gowns to be worn for enhanced barrier precautions with contact activities of a resident with a tube feeding. Gloves should be removed, and hand hygiene completed, following incontinence cares. NJAC 8:39-19.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to provide three of three residents (Residents (R)77, R268 and R54) a Centers for Medicare and Medicaid Services (CMS) for Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) when they completed their Medicare A therapy services. This failure to provide the CMS for SNF ABN prevented the resident from knowing they had days remaining under Medicare A. Findings include: Review of the facility's policy titled Policy, Procedures and Information last reviewed 07/06/24, Policy: Medicare will only pay for services which are determined to be no longer meet skilled nursing or rehab need. The facility's policy fails to direct staff to complete the Skilled Nursing Facility Advanced Beneficiary Notice Centers for Medicare and Medicaid (CMS) form 10055 for residents at the anticipated end of their Medicare covered stay. 1.Review of the electronic medical record (EMR), under the census tab, for R77 revealed an admission date of 07/08/24 with physician orders for skilled services including physical and/or occupational therapy. On 09/05/24, the facility determined that Medicare may longer pay for skilled services and issued R77 a Notice of Medicare Non-Coverage but failed to issue the CMS Form 10055. 2. Review of the EMR, under the census tab, revealed R268 was admitted on [DATE] with physician orders for skilled services for physical and/or occupational therapy. The facility determined R268 may no longer qualify for Medicare covered services as of 07/29/24 and issued R268 the Notice of Medicare Non-Coverage but failed to issue the CMS Form 10055. 3. Review of the EMR, under the census tab, revealed R77 was admitted on [DATE] with physician orders for skilled services including physical and/or occupational therapy. The facility determined R77 may no longer qualify for Medicare covered services as of 08/29/24 and issues R77 the Notice of Medicare Non-Coverage but failed to issue the CMS Form 10055. Interview with the Social Services Director on 10/17/24 at 1:00 PM confirmed the facility failed to issue the CMS Form 10055 when the facility determines resident may no long qualify for Medicare covered services. NJAC 8:39-5.4(b)(c)

Based on record review, observation, and interviews, the facility failed to maintain a safe clean homelike environment for residents. This involved three resident rooms affecting four (Resident (R) 25, R26, R27, and R19) of 27 sampled residents who currently reside in the facility. Findings include: Review of R25's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/18/23 located in the MDS tab of the electronic medical record (EMR) revealed she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Observation on 08/03/23 at 8:50 AM, 1:45 PM and on 08/04/23 at 10:50 AM the floor in R25's room had dirt built up along the walls. A fan was observed in the room with the cover off exposing the blades. On 08/03/23 at 8:50 AM and 1:45 PM the fan was running with the blades exposed and not protected. During each of the observations there was a brown spot on the wall next to the outlet located next to the hand sink in the room. R25 stated she had been in the facility for three weeks and the floor and the spot on the wall had been soiled ever since she arrived at the facility. She stated they do not clean the room. On 08/04/23 at 10:50 AM the Administrator was present and verified the observations. Observation on 08/01/23 at 12:06 PM, 1:50 PM, and on 08/04/23 at 10:49 AM the wall and floor under the sink in R26 and R27's room was soiled with an orange color substance. The floor under the hand sink in the room was soiled with a heavy build up along the walls. The privacy curtain located between the two beds in the room was soiled with a brown substance in an oval shape about one inch by one and a half inch. The wall next to the bed by the door was soiled with what appeared to be dried spills, the headboard had fallen off the wall on one side and there was a hole in the wall next to the bed by the door. On 08/04/23 at 10:49 AM the Administrator was present and verified the observation. Observation on 08/03/23 at 9:23 AM and on 08/04/23 at 10:55 AM R19's floor had a heavy buildup of dirt along the walls and in the corners and there was a brown spot resembling feces on the wall next to the outlet located by the hand sink in the bedroom. On 08/04/23 at 10:55 AM the Administrator was present and verified the observation. NJAC 8:39-4.1 (a) 11

Based on observation it was determined that the facility failed to have call bell system in place for two resident (Resident #114 and #119) and on 1 of 4 Resident units. The deficient practice was evidenced by the following: On 11/07/22 at 11:45 AM, the surveyor interviewed Resident #114 while the resident was in a wheelchair in the room. The surveyor did not observe a call bell located near the resident and the inquired to the resident about the call bell. Resident #114 stated I don't even know if it works, and when they come, they come, and I cannot say on time. On 11/16/22 at 7:59 AM, the surveyor observed Resident #114 awake in bed, and there was no call bell attached to the wall, or by the resident. The Certified Nurse Aide (CNA) assigned to Resident #114 was in the room and the surveyor asked about the call bell for Resident #114, and he stated, it is not there. At that time, the surveyor observed the roommate, Resident #119 sleeping in bed and there was no call bell attached to the wall and accessible to the resident. The surveyor inquired to the CNA if he could show the surveyor the call bell for Resident #119, and he stated he was looking and I don't see no call light plugged in. On 11/16/22 at 8:22 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who was overseeing the unit at that time, and had the ADON accompany the surveyor to Resident #114 and #119's room. The surveyor inquired if both resident's had call lights. The ADON looked at the wall, where the call bell would be attached and next to both residents beds, and stated, oh yeah, and confirmed there was no call light attached to the wall for either resident. NJAC 8:39-31.8(9)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and review of pertinent documentation, it was determined that the facility failed to provide a clean, and comfortable homelike environment to residents who resided at the facility. The lack of oversight to ensure equipment, and the environment was clean created a potential environmental hazard to the residents who resided at the facility. The deficient practice was observed in 10 rooms on 1 of 4 Resident units, and was evidenced by the following: On 11/07/22 from 10:10 AM to 11:47 AM, the surveyor conducted a tour of the 300's Unit low side and observed the following: The heating/cooling units in Rooms #303, #306, #310, #340, #344 revealed that all the heating and cooling units were covered with various bed linen, and the metal bases were covered with a rust like substance. The unit covers were missing in some of the rooms exposing copious amounts of embedded dirt, and dusty filters and debris stacked inside the heating and cooling units. Observations of Rooms # 304, # 307, #310, #312, #315, revealed that the curtains surrounding the resident's beds were visibly soiled with various colors of splatters and spots. Observation of room [ROOM NUMBER] revealed a brown substance splattered on the wall and brown substance on the floor. There was a strong urine odor emerging from the room. The bed linen including the pillow were yellow stained and there were flies noted in the room. The surveyor accompanied the Unit Manager (UM) to the room where we both observed the same and the observation was confirmed by the Unit Manager. The UM stated that the resident was non-compliant with care. Observation of room [ROOM NUMBER] revealed brown stains on the floor by the bed, and an odor of urine was prominent throughout the room and the bathroom. An interview with the Certified Nursing Assistant (CNA) of the unit revealed that Resident #19 had a behavior of urinating on the floor and inside the closets in the room. Observations of room [ROOM NUMBER], #338, #353 revealed the curtains were stained with red substance. Observation of room [ROOM NUMBER] revealed stained flooring, and the bed linen and curtain surrounding the bed was yellow stained. Observation on 11/07/22 at 10:45 AM of the 300's Unit high side, revealed flooring with brownish stains, stained walls, heating, and cooling units in disrepair with large amount of dust and debris, and holes noted in the wall (room [ROOM NUMBER]). Observations on 11/07/22 at 11:15 AM revealed a handrail not mounted properly on the 300's unit high side exposing jagged edges. The same was verified with the Unit Manager. On 11/07/22 at 11:30 AM, the surveyor interviewed the occupant in room [ROOM NUMBER]. The resident revealed that the heating and cooling unit had not been working and the room was cold all the time. The temperature 61.9 F (Fahrenheit) was measured with the maintenance staff member. The surveyor observed the heating and cooling unit covered with blankets and was stacked with sheets and towels. The surveyor verified the observation with the maintenance staff and the Unit Manager. On 11/07/22 at 2:30 PM, during an interview with the surveyor, the Regional Licensed Nursing Home Administrator (RLNHA) stated that he would expect that the building be kept clean and in good working condition by maintenance and the housekeeping staff. The RLNHA further stated if repairs needed to be completed, they should be addressed immediately. He informed the survey team that he would take care of the concerns. However, the next day the surveyor entered Room # 338 and observed that the heating and cooling unit was still stuffed with sheets and towels. Room # 312 was observed with large amounts of debris, empty juice container, gloves, towels, and sheets. On 11/09/22 at 8:40 AM, random room temperatures were taken with the maintenance worker, and the following temperature were recorded: room [ROOM NUMBER], 66.2 F, room [ROOM NUMBER], 65 F, and room [ROOM NUMBER], 67 F. On 11/09/22 at 8:45 AM, the surveyor observed room [ROOM NUMBER] with linen on the floor. At that time, the surveyor interviewed the Unit Manager who revealed that the CNAs were all aware that the linen should be bagged not be placed on the floor. The temperature of the room registered 66.2 F. During a tour and interview on 11/09/22 at 8:58 AM, the Maintenance worker explained they had a maintenance log that was kept at each nurse's station. He stated he checked the log each morning when he made rounds and he prioritized the work that needed to be done. He stated that he was not made aware of any work repair for the 300's unit. On 11/09/22 at 9:05 AM, the surveyor reviewed the log with the maintenance worker and verified that there was no work order regarding the heating and the cooling unit not working in the rooms. Random room temperatures were checked with the Maintenance worker and the temperatures registered below 71 F. Normal room temperature for Long Term Care Facility (LTC) should range between 71 F to 81 F. The maintenance worker confirmed that the heating and cooling units needed to be cleaned, the bases were rusty, and multiple units were stuffed with sheets and towels. In the presence of the Unit Manager, the maintenance worker stated that the heating and cooling units were to be cleaned and checked yearly. He confirmed that the heating and cooling units had not been cleaned. He could not provide any documentation regarding when the heating and cooling units were last serviced. On 11/09/22 at 9:17 AM, during an interview with the surveyor, the Unit Manager confirmed that the unsampled resident in room [ROOM NUMBER] had reported that the heating and cooling unit had not been working last month but she forgot to place a work order for repair. Observations of room [ROOM NUMBER] at 9:21 AM, revealed a copious amounts of debris piled in the corner of the room and splattered black substance on the wall. The resident who occupied the second bed called the surveyor to the room and pointed at the base of the cooling and heating unit where a large amount of brown substance was coated. The wall was visibly and soiled. Observation of room [ROOM NUMBER] and #344 at 9:35 AM, revealed the heating and cooling unit covers were missing exposing the dusty filters and rusty parts. The resident stated that the room was always cold at night. In the presence of the Unit Manager the resident stated, room very, very cold, when you asked for a blanket, the staff would say there were no blankets. The surveyor asked for the linen PAR (amount of linen the unit required to have for care of the residents). There were no blankets in the clean utility room to offer to the resident, but the facility had enough blankets in the laundry room. The resident was provided with a blanket that same day. On 11/09/22 at 10:02 AM, the surveyor observed room [ROOM NUMBER] with one urinal on the floor and two urinals hung on the bed rails with urine in them. Observations also revealed black substance splattered on the wall, holes on the wall, and food debris and clothing on the floor. Observation of room [ROOM NUMBER] at 10:27 AM, revealed a heating and cooling unit covered with blankets. The resident indicated that the unit was not working, and he/she informed the staff. The Temperature in the room read 61.9 F. The resident room temperatures for LTC facilities should be maintained between 71-81 F for the comfort and well-being of the residents. Observation of room [ROOM NUMBER] at 11:35 AM, revealed a glass window broken in multiple areas being held in place with tape. At that time, the surveyor interviewed the resident who revealed that the window had been broken for months but could not provide a specific date. A review of the Maintenance log for the last 3 months failed to address the broken window. The surveyor also observed that the heating and cooling unit of room [ROOM NUMBER] was stacked with towels, the exposed filter was covered with dust, and the unit base was very rusty. Observation of Room # 350 at 12:30 PM, revealed a broken light fixture and clogged toilet in the bathroom. The resident stated that he/she reported the concern since yesterday and had not been addressed. On 11/10/22 at 10:10 AM, the surveyor revisited the 300's Unit only to observe that the above concerns were not addressed. The heating and the cooling units were still stacked with towels, sheets, and large amounts of debris. On 11/10/22 at 10:30 AM, during an interview with the surveyor, the resident in Room # 334 revealed that the cooling and the heating unit was leaking, and the facility's staff stacked the units with sheets and blankets to stop the water leakage. On 11/10/22 at 11:03 AM, the surveyor accompanied the Maintenance Director and the Regional Nurse to the 300's Units where we all witnessed the same pile of towels and sheets inside the heating and the cooling units. On 11/10/22 at 11:30 AM, during an interview with the surveyor, the Maintenance Director stated that he was just hired by the facility and had not prioritized the concerns that needed to be addressed immediately. He added that he had never seen something like the towels and sheets stacked in the heating and cooling units before. He further stated that it would be a concern that needed to be addressed immediately. On 11/14/22 at 9:50 AM, the surveyor entered Room # 353 and observed large amounts of debris on the floor. The resident told the surveyor there was no housekeeping service for the weekend. An interview with the housekeeping staff assigned to the floor that day, revealed she was off for the weekend and could not comment why the rooms were not cleaned. On 11/14/22 at 10:10 AM, the surveyor interviewed the Housekeeping Director (HD) who stated that staff were scheduled to work and could not explain why the rooms we not being cleaned. The surveyor toured the units with the HD and noted some curtains visibly soiled and stained. The surveyor and HD observed Rooms # 315, # 326, # 338, and # 353 with stained flooring and large amounts of debris. On 11/16/22 at 11:20 AM, a family member walked in the room and informed the surveyor that she visited on Friday evening and informed the staff that the room needed to be cleaned. The family member was very upset that the room had not been cleaned and wanted the issue to be addressed. On 11/16/22 at 11:40 AM, the surveyor accompanied the HD to the room where we both previously had observed large amounts of debris on the floor. The HD stated that she would clean the room. The HD stated that staff were expected to clean resident's rooms and common areas daily and follow a cleaning schedule. The HD confirmed that the work performance was poor, and she would have to follow up with some disciplinary actions. On 11/16/22 at 11:30 AM, the surveyor observed Room # 318 with brownish stains on the flooring. The bed linen was visibly soiled with food particles. The housekeeper on the unit stated the bed linen was in the same condition yesterday and she alerted the staff after cleaning the floor. On 11/16/22 at 12:30 PM, the above issues were again discussed with the HD. She stated that she would clean and buffer the rooms today. She further added she developed a schedule for the curtains to be replaced and or cleaned. On 11/23/22 at 12:30 PM, the Regional Administrator stated that a plan was developed to address the above concerns. NJAC 8:39-4.1 (a)

Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to a.) apply physician ordered interventions that the staff signed as administered for Resident #105, 1 of 4 residents reviewed for wound treatments, and b.) administer medication with food as prescribed by the physician and improperly dispose of non-administered medication, for Resident #105 and an unsampled resident during medication administration observation. The evidence was as follows. a.) On 11/15/22 at 9:04 AM, Surveyor #2 observed Resident #105 lying in bed on his/her left side with both feet in direct contact with the bed. Surveyor #2 observed there were no heel protectors on the resident and no offloading of the resident's heels. A review of Resident #105's medical records revealed the following: An admission Record revealed he/she was admitted with diagnoses which included but were not limited to peripheral vascular disease (PVD - disease affecting the blood vessels), cellulitis (bacterial skin infection causing swelling and pain), unspecified open wound left foot, and type 2 Diabetes Mellitus with foot ulcer. An Order Summary Report which included the following orders: dated 09/14/21 to apply ACE (elastic bandage) wrap to left lower extremity from foot to knee in the morning and remove at bedtime; dated 10/14/21 to elevate legs above heart level while at rest every shift; dated 09/14/21 heel protectors every shift check placement; dated 10/14/21 no pressure to heels float heels when in bed every shift; dated 09/14/21 offload left foot/heel every shift; and dated 09/14/21 [redacted] boot on when in bed every shift. The ongoing Care Plan (CP) revealed a focus area dated 08/11/21, actual blister with open area to left lateral foot (diabetic wound) related to PVD and Diabetes Mellitus. The goal revealed resident's wound will improve and heal as evidenced by closure within the next review date, and the diabetic foot ulcers will improve and heal as evidence by closure. Interventions included but were not limited to position resident off affected area and [redacted] boot when in bed. Another focus area undated, potential for skin breakdown secondary to Diabetes Mellitus, decreased mobility, and PVD. The goal revealed Resident #105 would have care needs met as evidenced by no skin breakdown. Interventions included but were not limited to pressure relieving devices on bed and wheelchair. The quarterly Minimum Data Set (MDS an assessment tool) dated 10/14/22, revealed Resident #105 had a Brief Interview for Mental Status (BIMS) of 10 out of 15 indicating the resident was mildly cognitively impaired. Section E, Behavior, indicated the resident has not exhibited any behaviors of rejection of care. Section G, Functional Status, indicated Resident #105 required extensive assistance of at least one staff member for dressing which included putting on and removing items. Section M, Skin Conditions, revealed diabetic foot ulcer(s), skin tears, pressure reducing device for bed in use and application of dressings to feet. The Treatment Administration Record (TAR) dated up to 11/18/22, revealed the Licensed Practical Nurse (LPN) #2 caring for Resident #105 had signed off as administered, the offloading of feet [heels] and the [redacted] heel boot on 11/16/22, 11/17/22, and 11/18/22. On 11/15/22 at 9:21 AM, during an interview with Surveyor #2, Resident #105 was asked about the wounds on his/her feet and if he/she was ever provided with special boots or pillows. Resident #105 stated that the staff never puts boots on him/her or a pillow for under his/her feet. On 11/16/22 at 8:00 AM, during an interview with Surveyor #2, LPN #2 who had been caring for the resident, stated the resident would be seen by wound care weekly. LPN #2 stated the nurses would do daily dressing. When asked about any other interventions required for Resident #105's wounds, LPN #2 stated there was nothing else to be done for the wounds on his/her feet. LPN #2 stated that all orders wound show up on the Medication Administration Record (MAR) or the TAR in the electronic medical records in the computer. On 11/16/22 at 10:03 AM, Surveyor #2 observed Resident #105 sleeping in bed. Surveyor #2 observed no Ace wraps had been applied, no heel boots were applied, and no offloading was done. Resident #105's feet were lying directly on the bed. Surveyor #2 observed there were no heel boots visible in the room and no extra pillow available for offloading the heels/feet. On 11/18/22 at 10:10 AM, Surveyor #2 observed Resident #105 in bed with his/her feet dangling on the side of the bed. Surveyor #2 observed no heel boots or Ace bandages on the resident. Again the surveyor observed there were no heel boots or extra pillow available for offloading the heels/feet. On 11/18/22 at 11:27 AM, Surveyor #2 reviewed the CNA tasks in the electronic medical system. There were no interventions listed for the CNAs to apply the heel boots or to offload the resident's heels/feet. On 11/18/22 at 12:02 PM, during an interview with Surveyor #2, the Director of Nursing (DON) stated the resident should always have offloading or heel boots applied while in bed. The DON stated that the application of the heel boots and the offloading of the feet would be documented in the MAR. The DON further stated if the resident refused, she would expect to see that documentation in the MAR or TAR as well as documentation that the doctor was notified of any refusal of treatment or medication. On 11/18/22 at 12:40 PM, Surveyor #2 observed Resident #105 awake lying in bed with both feet directly on the bed with no heel boots, no offloading, and no Ace wraps applied. The surveyor asked Resident #105 if he/she had any boots that were put on his/her feet or a pillow to keep his/her feet off the mattress. Resident #105 stated, nobody ever gives me anything like that. The surveyor observed the resident's room and did not see any heel boots. Resident #105 stated that he/she didn't have any. On 11/21/22 at 9:24 AM, the surveyor observed Resident #105 sitting on the side of the bed with his/her feet dangling over the side of the bed by the floor. The surveyor observed dressings on both feet, but no heel boots or ACE wraps. On 11/21/22 at 11:01 AM, Surveyor #2 observed Resident #105 lying in bed asleep with his/her feet directly on the bed. The resident did not have Ace wraps or heel boots applied and his/her feet were not offloaded. The surveyor observed the room and could not locate any heel boots or extra pillows. On 11/21/22 at 11:04 AM, Surveyor #2 asked LPN #2 to access Resident #105's orders. Surveyor #2 and LPN #2 reviewed the orders, and LPN #2 acknowledged the order for [redacted] heel boot, Ace wraps, and to offload feet. LPN #2 and Surveyor #2 went to Resident #105's room and observed no heel boot, no Ace wrap, and no offloading of the resident's heels/feet. LPN #2 acknowledged that the heel boot and Ace wrap were not in the resident's room. On 11/21/22 at 11:07 AM, Resident #105 informed LPN #2 and Surveyor #2 that the heel boot had been gone for months and he/she never got them back. Resident #105 could not recall who took the heel boot or the exact date they were taken but that it was months ago. On 11/21/22 at 11:10 AM, in the presence of Surveyor #2, LPN #2 reviewed the physician orders and acknowledged she had not been applying the heel boots or Ace wraps to Resident #105. LPN #2 stated she should not have been signing off that she had applied the heel boot and Ace wraps. LPN #2 stated that without the Ace wraps on, the resident's legs could swell more. LPN #2 further stated that Resident #105's wounds could get worse if the heel boot was not applied. LPN #2 stated she would need to reorder and replace immediately the supplies he/she should have had. LPN #2 acknowledged again that she had been signing off the [redacted] heel boot, the Ace wraps, and offloading of the resident's feet without having had applied them. LPN #2 stated that the resident had not refused any treatments. On 11/21/22 at 11:17 AM, during an interview with Surveyor #2, the DON stated if a resident had orders for heel boots, Ace wraps, and offloading and they were not applied, they should not be signed as done. The DON stated Resident #105's wounds or cellulitis could become worse without the ordered treatments. The DON stated the fourth floor did not have a unit manager but there was an Assistant Director of Nursing (ADON) who should have been monitoring. A review of the facility provided, Licensed Practical Nurse Job Description undated, included but was not limited to purpose: to provide direct nursing care to the residents. Nursing Care Functions: review the resident's chart for specific treatments, etc, and administer professional services. A review of the facility provided, Documentation in the EMR (electronic medical record) dated 06/23/22, included but was not limited to purpose: to ensure residents receive appropriate medical care with appropriate documentation. Documentation about treatments received will be located in the TAR. This will include the treatment ordered, frequency and location to administer treatment as well as the date/time administered and who performed the treatment. On 11/22/22, the above concerns were addressed with the facility administration. On 11/23/22, the facility administration had informed Surveyor #2 that LPN #2 had been in-serviced. b.) On 11/16/22 at 7:51 AM, during medication administration observation on the fourth floor, Surveyor #2 observed LPN #2 as she prepared two medications to administer to Resident #105. LPN #2 reviewed the orders and poured one chewable Aspirin 81 milligrams (mg) tablet, give 1 tablet by mouth one time a day; and one Metoprolol Succinate ER (used to reduce high blood pressure, extended release) 25mg, give 1 tablet by mouth one time a day give with food. LPN #2 entered Resident #105's room with the pills and water. Surveyor #2 observed that there was no breakfast tray in the room, no visible food, and LPN #2 did not offer any food. LPN #2 handed Resident #105 the cup with the two pills. Resident #105 stated, I take my medicine with food. I can't take that now. LPN #2 exited the room with the medications and discarded the two pills into the sharp's container (a hard plastic container to put sharp items in) on the side of the medication cart. A review of the admission Record revealed Resident #105 was admitted with diagnoses which included but was not limited to Type 2 Diabetes Mellitus, acute kidney failure, and hypertension (elevated blood pressure). A review of Resident #105's, Order Summary Report included an order dated 09/14/21 for Aspirin Tablet chewable 81 mg give 1 tablet by mouth one time a day for Peripheral Vascular Disease (PVD). An order dated 09/15/21 for Metoprolol Succinate ER tablet 25 mg give 1 tablet by mouth one time a day for hypertension Give with food. A review of the Care Plan included a focus area, undated, has hypertension and is on metoprolol. The Interventions included to give the medication as ordered. On 11/16/22 at 7:56 AM, Surveyor #2 observed LPN #2 prepare medications for an unsampled resident. LPN #2 reviewed the order for Metoprolol Tartrate tablet 50mg give 1 tablet by mouth two times a day .with food. LPN #2 dropped the tablet onto the medication cart. She picked up the pill and discarded it into the sharp's container on the side of the medication cart. LPN #2 poured the Metoprolol Tartrate and three additional medications into the medication cup. LPN #2 entered the resident's room with the pills and water, handed the resident the medications, and observed the resident swallow the pills. Surveyor #2 observed there was no breakfast tray in the room, no visible food in the room, and LPN #2 did not offer any food. Surveyor #2 inquired about when the breakfast trays would be delivered. LPN #2 stated the breakfast trays usually arrive about 8:00 AM. A review of the admission Record revealed the unsampled resident was admitted with diagnoses which included but were not limited to unspecified dementia. A review of the Order Summary Report included an order dated 01/10/22 for Metoprolol Tartrate tablet 50mg give 1 tablet by mouth two times a day for hypertension GIVE WITH FOOD. On 11/16/22 at 8:24 AM, Surveyor #2 observed the carts with the breakfast trays arrived on the unit and the staff were beginning to hand them out to the residents. On 11/16/22 at 8:25 AM, during an interview with Surveyor #2, LPN #2 stated it was the facility policy to dispose of unused medications in the sharp's container. LPN #2 stated she had no reason why she did not bring in food to offer since the breakfast trays were not there yet. LPN #2 stated that the purpose of some medications being taken with food was to coat the resident's stomach. On 11/16/22 at 8:31 AM, during an interview with Surveyor #2, the uncertified Infection Preventionist Registered Nurse (UIP/RN) stated that if medication was ordered to be given with food, the nurse should administer the medication when breakfast was served or provide milk, or cookies, or crackers to coat the stomach. On 11/16/22 at 11:47 AM, during an interview with Surveyor #2, the DON stated that there was a pill buster in each medication cart to be used for the destruction of unused medications. On 11/18/22 at 12:01 PM, Surveyor #2 asked the DON what the facility policy was on medication destruction. The DON stated the facility provided disposal system referred to the drugbuster container in the medication carts. On 11/21/22 at 9:16 AM, during an interview with Surveyor #2, LPN #3 stated if a medication was not administered it would be placed in the drug buster. LPN #3 showed Surveyor #2 the drug buster located in the medication cart. On 11/21/22 at 9:19 AM, during an interview with Surveyor #2, LPN #4 stated medications not given but poured, would be discarded in the drug buster. LPN #4 stated the medication should not be discarded anywhere else because someone could see it and take it. A review of the facility provided, Licensed Practical Nurse Job Description undated, included but was not limited to purpose: to provide direct nursing care to the residents. Drug Administration Function: prepare and administer medications as ordered by the physician. Dispose of drugs and narcotics as required, and in accordance with established procedures. A review of the facility provided medication pass observation for LPN #2, dated 08/02/22, included but was not limited to reviewing medication orders, medication pass oral medications, and documentation nurses notes; use the documentation guidelines for charting. All three tasks were signed off as having been demonstrated to the RN on 08/02/22 and that LPN #2 had successfully completed the skills and was able to work independently. A review of the facility provided, Medication Administration and Documentation Policies, Procedures & Information' dated 07/01/22, included but was not limited to policy: 4. The Electronic Medication Administration Record (EMAR) is the form which all medication orders are transcribed from which medications are poured and administered .; procedure: 1. Ensures all equipment is clean and organized, and adequate supplies are available. A review of the facility provided, Medication Disposal/Destruction dated 08/13/22, included but was not limited to procedure: A. 2. Non-controlled medications may be destroyed by licensed nurse employed by the facility as per state regulations. C. 1.the nurse will place refused medication in the facility provided disposal system. A review of the facility provided, Sharps Containers dated 07/13/22, included but was not limited to Policy: . to ensure sharps containers are used for the disposal of all sharps .General Information: Only sharps should be disposed in the sharps containers. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 11/07/22 at 11:45 AM, the surveyor observed Resident #114 in a wheelchair in their room watching television on the roommate's side of the room. The surveyor observed there was no call bell in the resident's reach. The surveyor asked the resident about using the call bell and Resident #114 stated, I don't even know if it works, and when they come, they come, and I cannot say on time. The surveyor reviewed the electronic medical record for Resident #114 which revealed: The admission Record revealed diagnoses which included, but were not limited to, cerebral infarction, unspecified and type 2 diabetes mellitus. The quarterly Minimum Data Set, dated [DATE], revealed the resident scored 10/15 on the Brief Interview for Mental Status which indicated a moderately impaired cognition. The Functional Status, G revealed the resident was totally dependent on one person for toileting. Section H revealed the resident was always incontinent of bowel and bladder. The resident had a Care Plan focus for bowel and bladder incontinent, Initiated 02/11/22, with a goal to have less than two incontinence episodes per day, Date initiated: 02/11/22 with a Target Date: 11/11/22. The resident had an ADL self-care performance deficit due to generalized weakness status post hospitalization care plan. The Goal was to improve current level of function in .toilet use .Target Date: 11/11/22, Interventions included Toilet Use: totally dependent on staff for toilet use. On 11/16/22 at 7:59 AM, the surveyor observed Resident #114 awake in bed, the call bell was not attached to the wall. The Certified Nurse Aide (CNA) assigned to Resident #114 was in the room and asked about the call bell and he stated, it is not there. The surveyor inquired to the CNA how many briefs should be used on residents, and he stated one. When asked if he had ever found two briefs on residents, he confirmed he has. On 11/16/22 at 8:06 AM, the surveyor asked Resident #114 how many briefs the staff had put on him/her and the Resident stated, I think they have two on me, at that time the CNA stated he was looking for the linen. On 11/16/22, at 8:14 AM, the CNA went to the room to complete incontinence care on Resident #114. The surveyor inquired to the CNA to confirm how many briefs the resident was wearing. The CNA proceeded to show the surveyor the corners of two green colored briefs and confirmed resident #114 was wearing two briefs. On 11/16/22 at 8:22 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who was overseeing the unit at that time, regarding how many briefs should be on a resident. The ADON stated one, the ADON accompanied the surveyor to Resident #114's room and asked the CNA how many briefs were on the resident. The CNA stated two. The surveyor also inquired about the resident's call light and stated, oh yeah, and confirmed there was no call light attached to the wall. On 11/16/22 at 8:31 AM, the surveyor requested the ADL policy, and any training related to how many briefs should be used on a resident. The ADON stated, I know the night staff is doing it (using double briefs). On 11/16/22 at 12:00 PM, the Director of Nursing provided a copy of an ADL inservice Dated 07/05/22. The summary of Presentation revealed: all CNA's when doing incontinence care and resident wearing diaper should follow the protocol to do changing. Diaper every two hours or as needed. Note: No Double Diapers Application at all, this is strictly a must!! On 11/22/22 the surveyor reviewed the facility's ADLs policy dated 07/09/07 and last revised 08/14/22. The policy read, It it the policy of the facility to provide ADL care to all residents based on assessment of needs. ADL care consist of but it is not limited to: Bathing Dressing Eating Transfers Toileting Bed Mobility Nail Care Foot care. Purpose: To ensure all resident's needs are met. Responsibility Licensed Nurse : Assesses resident to determine ADL needs. Completes instructions to reflect residents needs for all aspects of ADL care. CNA reviews nursing instructions for each resident before providing care. Provides care and assistance with care in accordance with the nursing instructions (plan of care ) Reviews the shower schedule to ensure that shower is given on designated day as scheduled. On 11/22/22 at 1:30 PM, during the pre-exit conference the DON stated it was her expectation that dependent residents be provided with ADL,s care. NJAC 8:39-27.2 (g) Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to provide appropriate care for resident's who were dependent on staff to provide Activity of Daily Living (ADL) care. This deficient practice occurred for 4 of 4 dependent residents (Resident #49, #34 and #101 and #114) and on two of four resident care units (3rd and 4th floor) reviewed for ADL care and was evidenced by the following: 1. On 11/07/22 at 10:15 AM, the surveyor toured the 300's Unit of the facility and observed Resident #49 in bed with the head of the bed elevated, and was facing the door, and both feet rested directly on the mattress, and eyes were closed. The fingernails were observed as long and jagged, and contained a black coated substance underneath all of the fingernails. The upper lip and chin were covered with facial hair. When inquired about the resident's status to the Certified Nursing Assistant (CNA) observed in the resident's room at the time, the CNA stated, All [he/she] does was sleeping all day. On 11/07/22 at 11:30 AM, the surveyor returned to the room and observed Resident #49 in bed and was facing the door and his/her eyes were closed. The nails remained long and jagged with a black substance and the facial hair was still present. On 11/07/22 at 11:45 AM the surveyor returned to the 300's unit and observed the lunch meal. The lunch cart arrived on the floor at 11:50 AM. Resident #49 remained in bed in the same position as the surveyor observed one and one-half hours later. The surveyor went to the room at 12:05 PM, and Resident #49 was still sleeping in the same position. Observations on 11/07/22 at 12:15 PM, revealed Resident #49 was in bed. His/her lunch tray was behind the door on the bedside table, and the meal tray was not set up and Resident #49 could not access the tray. On 11/07/22 at 2:03 PM, Resident #49 was still in bed, ADL (Including, but not limited to the following self care activities: Bathing, Dressing, Eating, Transferring, Toileting, Bed Mobility, Nail Care and Foot Care) care was not provided, facial hair remained and nails remained long and jagged. Black coated substance was still present underneath all fingernails. On 11/09/22 at 11:30 AM, the surveyor reviewed Resident #49's electronic medical record. According to the admission Face Sheet, Resident #49 had diagnoses which included, but were not limited to, vascular dementia, unspecified severity, without behavioral disturbances, mood disturbance, visual disturbances and anxiety. Review of the most recent Annual Minimum Data Set (an assessment tool), dated 02/04/22, revealed that Resident #49 was severely cognitively impaired for daily decision making and required assistance with most activities of daily living. Review of Resident #49's Care Plan (CP) dated 05/2019 revealed he/she was care planned for ADL/self care performance deficit related to dementia. The goal was for Resident #49 to improve current level of function in mobility, transfers, eating, dressing, toilet use and personal hygiene. The interventions included the resident required staff participation to use toilet, requires staff participation with transfers, oral hygiene and personal care. Required supervision to turn and reposition, required setup and assistance with meals. On 11/09/22 at 11:30 AM, the surveyor interviewed the CNA responsible for providing care to Resident #49 during the 7:00 AM to 3:00 PM shift. The CNA stated that Resident #49 was totally dependent on staff for care, had not been able to feed self and could not ambulate. The CNA further stated Resident #49 had an open area to the sacrum that had been cared for by the nurse. Resident #49's nails were not trimmed or cleaned. Facial hair remained present on the upper lips, and the chin area after morning care was completed. On 11/10/22 at 9:15 AM, the surveyor observed Resident #49 in bed laying on the backside. Resident #49 had remained in bed in the same position during the morning shift. The surveyor asked the CNA to check Resident #49's brief, the brief was saturated with urine. The CNA stated that she had not provided care yet to the resident. On 11/10/22 at 11:10 AM, the surveyor interviewed the Licensed Practical Nurse /Unit Manager regarding ADL care for dependent residents. The UM stated that nail care was completed every Monday and there was a reminder on the daily assignment to complete nail care. The surveyor reviewed the daily assignment with the UM, there was no notation regarding nail care. The surveyor then asked the UM how she supervised the care provided by the staff to the residents. The UM stated she knew the staff and she trusted them. The surveyor then accompanied the UM to Resident #49, #34 and 101's Room, where we both the surveyor and UM observed that nail care had not been provided. The resident's nails were long, jagged and had a black coated substance embedded from 1/2 to 1 inch underneath the fingernails. On 11/10/22 at 12:15 PM, the UM stated she attempted to shave the resident on 11/09/22 but the resident refused. The surveyor asked the UM to provide the documentation where Resident #49 refused care. She could not provide the surveyor with any documented evidence to support the resident's refusal. On 11/10/22 at 1:30 PM, the UM provided a note dated 11/10/22, that she confirmed she had as a late entry after the surveyor's inquiry. The Progress Notes revealed: Attempted to remove facial hair, resident was resistive with care. The surveyor accompanied the UM and the Regional Nurse to Resident #49's room where we all observed that Resident #49's face remained un-shaven. 2. Resident #34 was admitted to the facility with diagnoses which included, but were not limited to, unspecified dementia, Type 2 diabetes mellitus, muscle weakness, hemiplegia and hemiparesis. On 11/07/22 at 10:25 AM, the surveyor observed Resident #34 lying in bed with the eyes closed. The head of the bed was elevated. The nails were noted to be long and jagged. On 11/09/22 at 09:50 AM, the surveyor observed Resident #34 in bed with the head of the bed elevated. The nails were long, jagged with a dark coated substance underneath the fingernails. The fingers of the right hand were curled into the palm of the right hand. The surveyor observed a hand roll placed to the left hand. On 11/10/22 at 09:30 AM, the surveyor observed Resident #34 in a recliner chair by the bed, eyes closed, Resident #49 did not initiate conversation and did not respond to the surveyor's greetings. On 11/10/22 at 11:00 AM, the surveyor interviewed the CNA who cared for Resident #34. The CNA stated that Resident #34 was non verbal and was totally dependent on staff for all activities of daily living. The CNA also stated that Resident #34 got out of the bed daily. The surveyor asked the CNA to open Resident #34's right hand, the nails were long and jagged, and a sour odor was noted when the right hand was opened. On 11/10/22 at 11:50 AM, the surveyor accompanied the UM to Resident #34's room where we both observed all of Resident #34's nails were long and jagged, and there was a black substance underneath the fingernails. On 11/10/22 at 12:30 PM, review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed that Resident #34 was severely cognitively impaired. Resident #34 scored 00/15 on the Brief Interview for Mental Status (BIMS ). Section G of the MDS which referred to Activities of daily living, Resident #34 was coded as 4:3 indicative of total assistance with 2 persons physical assist. Review of Resident #34's care plan dated 06/01/21 revealed that Resident #34 was not care planned for activities of daily living. Resident #34's care plan addressed the following concern: Resident #34 has a behavior problem of pulling out his/her incontinent brief and scratching himself related to disrobing. The goal was for Resident #34 will have fewer episodes of that behavior by review date (not specified). The interventions included to anticipate and meet needs. Document behaviors, and resident response to interventions. Trimmed his/her nails on a daily basis. The surveyor observed Resident #34 on 11/07/22 10:25 AM, 11/09/22 at 9:50, and 11/10/22 at 9:30 AM. During all three observations, the surveyor observed the nails were all long and jagged. On 11/14/22 at 12:50 PM, the surveyor again interviewed the UM regarding care for dependent residents. The UM stated that the CNA and nurses were to check the nails during shower day and a general assessment was to be completed. The surveyor requested the shower log for review. On 11/14/22 at 1:15 PM, the lead CNA provided the shower log for review, and the surveyor observed that the shower log had not been filled out consistently. Resident #34 most recently completed shower log, which included the daily skin assessment, for November was not completed. The Treatment Administration Record (TAR) was signed off and indicated that the skin assessment was performed every Tuesday on the 7:00 AM-3:00 PM shift. The UM did not have any comment. 3. On 11/07/22 at 11:10 AM, the surveyor observed Resident #101 in bed. The head of the bed was slightly elevated. Resident #101 did not initiate conversation but smile when asked questions. Resident #101 was noted with facial hair around upper lip and chin. The nails were observed as long and jagged. On 11/09/22 at 8:41 AM, the surveyor observed Resident #101 in bed eating breakfast, the nails were long and jagged. 11/09/22 at 10:46 AM, the surveyor returned to the room after care was provided and observed the nails remained long, jagged with a dark coated substance underneath the fingernails. On 11/09/22 at 11:30 AM, the surveyor reviewed Resident #101's electronic medical record. The admission Face Sheet reflected that Resident #101 had diagnoses which included, but were not limited to, other Alzheimer's disease and essential hypertension. Review of the the most Quarterly Minimum Data Set (MDS) dated [DATE], revealed that Resident #101 was severely cognitively impaired. Resident #101 received a score of 99/15 on the Brief Interview for Mental Status ( BIMS ) indicative of severe cognition. Section E 0008 of the MDS which addressed rejection of care was coded with a zero value, indicative of compliance with care. Review of Resident #101's undated Care Plan provided by the facility revealed a care plan for ADL self care performance deficit related to decrease mobility. The goal was for Resident #101 to improve current level of function in bed mobility, transfers eating, dressing, toilet use and personal hygiene. The interventions included praise all efforts at self care. Encourage to participate to the fullest extent possible with each interaction. Monitor, document report to MD PRN [physician as needed] any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. On 11/10/22 at 11:45 AM, the surveyor accompanied the UM to the room where we both observed that nails care had not been addressed. Resident #101's nails were not trimmed/cleaned. Resident #101 did not have a skin assessment completed in the shower log to indicate the last time skin assessment included nails care were last performed. The UM informed the surveyor that resident's care was documented on the Kiosk (Computer system located in the hallway for direct care staff to document care) . On 11/10/22 at 2:00 PM, the Regional nurse accompanied the surveyor and the CNA to the computer to view the care performed for the resident. In the presence of the Regional Nurse, the CNA was unable to show where she documented the care for Resident #101. On 11/14/22 at 12:00 PM, the surveyor observed Resident #101 out of the bed for the first time during the survey. An interview with the CNA who cared for Resident #101 revealed that Resident #101 was dependent on staff for care, and had no behavior. On 11/14/22 at 12:15 PM, the surveyor reviewed the Physician Progress notes and noted an order for skin assessment on the day shift for Tuesday and Friday. Also noted was an order for transfer with [a brand name mechanical lift]( frequency not specified.) The surveyor observed Resident #101 in bed on 11/07, 11/09 and 11/10/22. The surveyor observed Resident #101 out of the bed for the first time on 11/14/22. On 11/14/22 at 12:50 PM, An interview with the UM regarding Resident #101's care revealed that the CNA and nurses were to check the skin and nails, and performed a general assessment on shower day. The surveyor then asked the UM to elaborate on her day. The UM stated, she made rounds, greeted the residents, took care of appointments, checked the assignment, reviewed 24 report, checked the medication carts, attending meeting and made any follow up. The UM did not include following up on resident care to be provided by the staff and she was not aware that nails care had not been provided during her rounds. On 11/15/22 at 1:30 PM, the surveyor interviewed the CNA who cared for Resident #101 on 11/7, 11/09 and 11/10/22. The CNA stated that Resident #101's [brand name mechanical lift] pad was soiled and had to be sent to the laundry for cleaning. The CNA stated that Resident #101 had only one [brand name mechanical lift] pad, and she was unable to get Resident #101 out of the bed. On 11/21/22 at 11:03 AM, the surveyor observed Resident #101 sitting in the room. Facial hair noted on 11/07/22 was still visible. The surveyor informed the UM and she replied that she was not aware that Resident #101 was unshaven. On 11/22/22 at 09:02 AM the surveyor interview a random CNA assigned to the 300's Unit high side. The CNA stated it was not on the assignment to provide shaving care for residents.

b.) On 11/15/22 at 9:04 AM, Surveyor #2 observed Resident #105 lying in bed on his/her left side. The surveyor observed visibly soiled gauze dressings on both feet, the bottom of the left foot had a lollipop stick stuck to it, and both feet were in direct contact with the bed. The surveyor observed there were no heel protectors on the resident, and there was no offloading of the resident's heels/feet observed. At that time, Resident #105 stated he/she was not in pain at that time and that his/her dressings had been changed yesterday. A review of Resident #105's medical records revealed the following: An admission Record revealed he/she was admitted with diagnoses which included but were not limited to peripheral vascular disease (PVD - disease affecting the blood vessels), cellulitis (bacterial skin infection causing swelling and pain), unspecified open wound left foot, and type 2 Diabetes Mellitus with foot ulcer. An Order Summary Report which included the following orders: dated 09/14/21 to apply ACE (elastic bandage) wrap to left lower extremity from foot to knee in the morning and remove at bedtime; dated 10/14/21 to elevate legs above heart level while at rest every shift; dated 09/14/21 heel protectors every shift check placement; dated 10/14/21 no pressure to heels float heels when in bed every shift; dated 09/14/21 offload left foot/heel every shift; and dated 09/14/21 [redacted] boot on when in bed every shift. The ongoing Care Plan (CP) revealed a focus area dated 08/11/21, actual blister with open area to left lateral foot (diabetic wound) related to PVD and Diabetes Mellitus. The goal revealed resident's wound will improve and heal as evidenced by closure within the next review date, and the diabetic foot ulcers will improve and heal as evidence by closure. Interventions included but were not limited to position resident off affected area and [redacted] boot when in bed. Another focus area undated, potential for skin breakdown secondary to Diabetes Mellitus, decreased mobility, and PVD. The goal revealed Resident #105 would have care needs met as evidenced by no skin breakdown. Interventions included but were not limited to pressure relieving devices on bed and wheelchair. The quarterly Minimum Data Set, an assessment tool, dated 10/14/22, revealed Resident #105 had a Brief Interview for Mental Status (BIMS) of 10 out of 15 indicating the resident was mildly cognitively impaired. Section E, Behavior, indicated the resident has not exhibited any behaviors of rejection of care. Section G, Functional Status, indicated Resident #105 required extensive assistance of at least one staff member for dressing which included putting on and removing items. Section M, Skin Conditions, revealed diabetic foot ulcer(s), skin tears, pressure reducing device for bed in use and application of dressings to feet. On 11/15/22 at 9:09 AM, during an interview with Surveyor #2, the Certified Nursing Aide (CNA) #1 stated she had been caring for Resident #105 for at least a few months. CNA #1 stated the resident was alert, takes care of most of his/her own activities of daily living (ADL-bathing, dressing, eating, etc), and that she would need to offer to him/her a shower. CNA #1 further stated the wounds on the resident's feet were better and that the nurse would apply cream to his/her legs. CNA #1 stated there was nothing she was responsible to do for Resident #105's wounds. CNA #1 stated she would get a report in the morning from the nurses, and at that time she would be told if pillows or booties were required for any resident. On 11/15/22 at 9:21 AM, during an interview with Surveyor #2, Resident #105 was asked about the wounds on his/her feet and if he/she had ever been provided with special boots or pillows. Resident #105 stated that the staff never put any boots on him/her, or a pillow for under his/her feet. Resident #105 asked the surveyor what was meant by boots for his/her feet. On 11/16/22 at 8:00 AM, during an interview with Surveyor #2, LPN #2 who was caring for the resident, stated the resident would be seen by wound care weekly. LPN #2 stated the nurses would do daily dressing changes. When asked about any other interventions required for Resident #105's wounds, the LPN stated there was nothing else to be done for the wounds on his/her feet. LPN #2 stated that all orders would show up on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) in the electronic medical records in the computer. On 11/16/22 at 8:31 AM, during an interview with Surveyor #2, the Assistant Director of Nursing (ADON) #1, stated that if a resident had an order to off load their heels or use heel booties, the information would be documented in a book on the unit for the nurses and CNAs to review daily. At that time, CNA #1 was present and stated there was no book and that the nurses would tell them (CNA) and the task would be listed in kiosk (electronic medical computer). On 11/16/22 at 10:03 AM, Surveyor #2 observed Resident #105 sleeping in bed. The surveyor observed no Ace wraps had been applied, no heel boots were applied, and the heels were not off loaded. Resident #105's feet were lying directly on the bed. Surveyor #2 observed there were no heel boots in the room and no extra pillow available for offloading the heels. On 11/18/22 at 10:10 AM, Surveyor #2 observed Resident #105 in bed with his/her feet dangling on the side of the bed. The surveyor observed there were no heel boots, or Ace bandages on the resident. Again, the surveyor observed there were no heel boots, or an extra pillow available for offloading the heels. On 11/18/22 at 11:27 AM, Surveyor #2 reviewed the CNA tasks in the electronic medical system. There were no interventions listed for the CNAs to apply the heel boots or to offload the resident's heels/feet. On 11/18/22 at 12:02 PM, during an interview with Surveyor #2, the Director of Nursing (DON) stated the resident should always have offloading or heel boots applied while in bed. The DON stated that the application of the heel boots and the offloading of the heels would be documented in the MAR. The DON further stated if the resident refused, she would expect to see that documentation in the MAR or TAR as well as documentation that the doctor was notified of any refusal of treatment or medication. On 11/18/22 at 12:40 PM, Surveyor #2 observed Resident #105 awake lying in bed with both feet directly on the bed with no heel boots, no offloading of the heels/feet, and no Ace wraps applied. The surveyor asked Resident #105 if he/she had any boots that were put on his/her feet or a pillow to keep his/her feet off the mattress. Resident #105 stated, nobody ever gives me anything like that. The surveyor observed the resident's room and did not see any heel boots. Resident #105 stated that he/she didn't have any. On 11/21/11 at 9:22 AM, during an interview with Surveyor #2, CNA #2 stated the care she would provide to Resident #105 would be to give him/her clean clothes and towels. CNA #2 stated the resident had wounds, but the nurses would take care of all that. CNA #2 stated she would know what care to provide because the nurses would give report in the morning. On 11/21/22 at 9:24 AM, Surveyor #2 observed Resident #105 sitting on the side of the bed with his/her feet dangling over the side of the bed by the floor. The surveyor observed dressings on both feet, but no heel boots or ACE wraps. On 11/21/22 at 11:01 AM, Surveyor #2 observed Resident #105 lying in bed asleep with his/her feet directly on the bed. The resident did not have Ace wraps or heel boots applied and his/her heels/feet were not offloaded. Surveyor #2 observed the room and could not locate any heel boots or extra pillows. On 11/21/22 at 11:04 AM, Surveyor #2 asked LPN #2 to access Resident #105's orders. Surveyor #2 and LPN #2 reviewed the orders, and LPN #2 acknowledged the order for [redacted] heel boot, Ace wraps, and to offload heels. LPN #2 and Surveyor #2 went to Resident #105's room and observed no heel boot, no Ace wrap, and no offloading of the resident's heels/feet. LPN #2 acknowledged that the heel boot and Ace wrap were not in the resident's room. On 11/21/22 at 11:07 AM, Resident #105 informed LPN #2 and Surveyor #2 that the heel boot had been gone for months and he/she never got them back. Resident #105 could not recall who took the heel boot or the exact date they were taken but that it was months ago. On 11/21/22 at 11:10 AM, in the presence of Surveyor #2, LPN #2 reviewed the physician orders and acknowledged she had not been applying the heel boots or Ace wraps to Resident #105. LPN #2 stated she should not have been signing off that she had been applying the heel boot and Ace wraps. LPN #2 stated that without the Ace wraps on, the resident's legs could swell more. The LPN further stated that Resident #105's wounds could get worse if the heel boot was not applied. LPN #2 stated she would need to reorder and replace immediately the supplies he/she (Resident #105) should have had. The LPN acknowledged again that she had been signing off the [redacted] heel boot, the Ace wraps, and offloading of the resident's heels without having applied them. LPN #2 stated that the Resident #105 had not refused any treatments. On 11/21/22 at 11:17 AM, during an interview with Surveyor #2, the DON stated if a resident had orders for heel boots, Ace wraps, and offloading and they were not applied, they should not be signed as done. The DON stated that if the [redacted] heel boots were removed, they should have been replaced immediately. The DON stated Resident #105's wounds or cellulitis could become worse without the ordered treatments. The DON stated the fourth floor did not have a unit manager but there was an ADON who should have been monitoring these things. On 11/21/22 at 11:20 AM, during an interview with Surveyor #2, ADON #2 stated he had only been in the facility since 10/27/22. ADON #2 stated his involvement with resident care would be to have a proper endorsement of shift but that has not started yet. He stated he was in charge of wound care as of now and he was trying to figure out how many times he should go on wound care rounds. On 11/22/22 at 10:02 AM, during an interview with Surveyor #2, the DON was asked about the Ace wraps, [redacted] heel boots, and offloading not being applied to Resident #105. The DON was also asked about the facility's pressure ulcer protocol. The DON stated she was not aware of the policy and not aware of how the placement (of the ordered treatments) was being monitored. The DON stated she would need to get back to us. On 11/22/22 at 10:23 AM, Surveyor #2 attempted to call the wound care nurse. There was no answer and no availability to leave a voice mail. The surveyor made a second call at 10:25 AM, to an alternate phone number and there was no answer and no availability to leave a voice mail. The facility provided the wound, Progress Note details dated 11/3/22, 11/10/22, and 11/17/22. A review of the reports revealed the following: 11/03/22: Wounds in bilateral feet. Duration date of initial wound evaluation 03/11/22. Context wound etiology is of diabetic origin. Diagnoses included cellulitis, sepsis, Type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer, and unspecified open wound left foot. Wound #2 right, lateral foot is partial thickness vasculitic ulcer, improved. Measurements 1.5 cm (centimeter) length x 1 cm width x 0.1 cm depth with an area of 1.5 sq (square) cm and volume of 0.15 cubic cm. Wound #7 left, plantar foot is partial thickness vasculitic ulcer, no change. Measurements 3.5 cm length x 2 cm width x 0.1 cm depth with an area of 7 sq cm and a volume of 0.7 cubic cm. There is no change noted in the wound progression. Wound #8 bilateral lower legs is partial thickness xerosis cutis (abnormally dry skin), initial exam. Measurements 0 cm length x 0 cm width Wound orders: Wound #2 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. Wound #7 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. Wound #8 included to cleanse and apply prescribed cream. 11/10/22: Wounds in bilateral feet. Duration date of initial wound evaluation 03/11/22. Context wound etiology is of diabetic origin. Diagnoses included cellulitis, sepsis, Type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer, and unspecified open wound left foot. Wound #2 right, lateral foot is partial thickness vasculitic ulcer and not healed. Measurements remained the same as 11/03/22. Wound #7 left, plantar foot is partial thickness vasculitic ulcer, not healed. Measurements 3.3 cm length x 2.2 cm width x 0.2 cm depth with an area of 7.26 sq cm and a volume of 1.452 cubic cm. Wound #9 left, dorsal foot is partial thickness vasculitic ulcer, initial exam. Measurements are 3.5 cm length x 4 cm width with no measurable depth, with an area of 14 sq cm. Wound orders: Wound #2 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. Wound #7 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. Wound #9 cleanse and apply cream. 11/17/22: Wounds in bilateral feet. Duration date of initial wound evaluation 03/11/22. Context wound etiology is of diabetic origin. Diagnoses included cellulitis, sepsis, Type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer, and unspecified open wound left foot. Wound #2 right, lateral foot is partial thickness vasculitic ulcer, improved. Measurements 1.5 cm length x 1 cm width x 0.1 cm depth, with an area of 1.5 sq cm and a volume of 0.15 cubic cm. [same measurements as 11/03/22]. Wound #7 left, plantar foot is partial thickness vasculitic ulcer, no change. Measurements 3.2 cm length x 2 cm width x 0.1 cm depth with an area of 6.4 sq cm and a volume of 0.64 cubic cm. Wound orders: Wound #2 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. Wound #7 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. All three reports noted that the plan of care was discussed with the facility staff. A review of the facility provided, Boots Application in-service dated 04/19/22, revealed all staff must carry out doctor's orders on boots, offloading application. The sign in sheet did not include the LPN. A review of the facility provided, Licensed Practical Nurse Job Description undated, included but was not limited to purpose: to provide direct nursing care to the residents. Nursing Care Functions: review the resident's chart for specific treatments, etc, and administer professional services. A review of the facility provided competencies for LPN #2, dated 08/02/22, included but was not limited to reviewing treatment orders and documentation nurses notes; use the documentation guidelines for charting. The competencies revealed that LPN #2 had successfully completed the above skills and was able to work independently and was signed by the Registered Nurse. A review of the facility provided, Skin Assessment and Skin Breakdown Prevention dated 07/21/22, included but was now limited to ensures that interventions indicated to address the resident's skin risk factors are implemented as per plan of care. Will assess resident to evaluate for any preventative devices (i.e. pillows, booties). A review of the facility provided, Assistive, Adaptive, and Pressure Relieving Devices dated 07/12/22, included but was not limited to policy: to use assistive, adaptive, and pressure relieving devices to aide and improve our residents' quality of care, as well as to prevent further illness and decline. Assistive, adaptive, and pressure relieving devices may include j. heel booties. Procedure: MD (physician) will initiate an order, enter order in the EMR (electronic medical record) along with pertinent instruction. Instructions for the device management will be entered into CNAs task where appropriate. Education regarding device placement and management will be provided to nursing where appropriate. Device placement and management will be monitored by unit charge nurse. NJAC 8:39-27.1(a) Based on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to: a.) ensure that medications were administered in accordance with the physician order for 6 residents reviewed (Resident #3, #14, #24, #42, #92, #102) for two days (11/15/22 and 11/16/22), and b.) implement physician ordered interventions for 1 of 1 resident (Resident #105) reviewed for skin concerns. This deficient practice was evidenced by the following: a.) Surveyor #1 conducted a medication Pass Observation on 11/16/22 on the 300's Unit of the facility and observed that some of the medications were not available for administration. Resident #3 had diagnoses of essential hypertension and edema. Resident #3 had an order for Lasix (a loop diuretic) to be administered daily for edema. The documentation found on the Medication Administration Record (MAR) reflected that Resident #3 did not receive the Lasix on 11/15/22 and 11/16/22. Resident #14 had diagnoses of unspecified atrial fibrillation, hyperlipidemia, and cerebrovascular accident. The Physician Order sheet dated, 11/22, revealed orders for Diltiazem (medication to reduce blood pressure) 120 mg (milligrams) daily, Neurontin 100 mg twice daily for neuropathy, Lasix 20 mg daily for edema, and Naltrexone 0.5 mg daily for alcoholism. Resident 14's medications were not available for administration on 11/15/22 and 11/16/22. Resident #24 had diagnoses of essential hypertension and heart failure. Resident #24 did not receive the following medications for 2 days: Plavix (a blood thinner) 75 mg daily, Lasix 20 mg daily, and Metoprolol Succinate Extended Release (medication to reduce blood pressure) 25 mg daily. Resident #42 had diagnoses of cerebral infarction and unspecified chronic obstructive pulmonary disease. Resident #42 had an order for Eliquis (a blood thinner) 2.5 mg to be administered twice daily and Metoprolol 75 mg to be administered every 12 hours for hypertension. Resident #42 did not receive the Eliquis and the Metoprolol on 11/15/22 and 11/16/22. Resident #94 had diagnoses of hypertension, aphasia, and diabetes. Resident #94 had a physician order for Lisinopril 40 mg to be administered daily for hypertension. Resident #94 did not receive the medication on 11/15/22. Resident #102 had diagnoses of Parkinson disease and essential hypertension. Resident #102 had a Physician Order for Lisinopril 30 mg to be administered daily for hypertension and Amlodipine 10 mg daily for hypertension. Resident #102 did not receive these medications on 11/15/22 and 11/16/22. Further review of the Progress Notes revealed that there was no documentation to show that the resident's Physicians were notified that the medications were not available to be administered to the residents. On 11/16/22 at 11:30 AM, Surveyor #1 interviewed the Unit Manager Licensed Practical Nurse (LPN/UM) who administered medications on the low side of the 300's Unit on 11/14/22. The LPN/UM stated that she was aware that some of the medications were not available. She further stated that the pharmacy was informed. She was unable to comment on the facility's process to reorder medications. On 11/16/22 at 2:30 PM, Surveyor #1 discussed the above issues with the Director of Nursing (DON). The DON stated that she was made aware that only the medication Midodrine was missing and was not administered. The DON stated that medications should be reordered when 8 doses of medications were left on the Bingo (a medication delivery system) card. The DON stated that she was unsure if all staff were aware of the process. On 11/16/22 at 2:45 PM, the surveyor reviewed the Delivery Order Form from the pharmacy and confirmed with the nurse that the medications were not available to be administered. The Bingo card received from pharmacy after 1:30 PM was untouched. On 11/21/22 at 9:02 AM, during an interview with the DON, who stated that residents were to receive medications according to the a Physician order. The surveyor reviewed the facility's policy titled, Medication Reordering dated 04/01/17 last revised 09/15/22. The policy revealed: It is the policy of the facility to reorder medications when supply is running low (2 days prior), Purpose: To ensure that all meds [medications] are available in sufficient quantity to fulfill MD [Physician orders]. Procedure: Individual: Physician/NP 1. Orders medication in the electronic clinical record. Pharmacy: Delivers a 28-day supply of all medications unless ordered for a specific amount of time. Licensed Nurse: Receives medications and verifies appropriate medication. If medication is not received in a timely manner, recalls the pharmacy to obtain estimated delivery time. Notifies nursing supervisor or manager. Responsibility: Licensed Nurse: If medication is not available for the specific medication, notifies MD/NP to obtain hold order or substitute medication which may be available in emergency stock. Reorders medication from the pharmacy. (The process was not being followed. There was no documented evidence that the physicians were made aware that the above residents did not receive their prescribed medications on 11/15/22 and 11/16/22)

Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to: a.) ensure interventions to prevent falls were in place per a resident care plan, b.) complete a fall risk assessment post fall per facility policy, and c.) determine the causal factor after each resident fall and implement appropriate interventions to prevent recurrence. This deficient practice was identified for 1 of 1 resident (Resident #119) reviewed for falls, had experienced four falls, and was evidenced by the following: On 11/07/22 at 11:35 AM, the surveyor observed Resident #119 in the room, sitting in a wheelchair. The resident was alert, and unable to communicate with the surveyor due to a language barrier. A nurse informed the surveyor that there were staff that were able to communicate in Resident #119's native language. On 11/14/22 at 11:45 AM, the surveyor interviewed Resident #119's Certified Nurse Aide (CNA #1), who stated she was able to communicate with the resident in his/her native language. The surveyor asked CNA #1 if Resident #119 had any falls, and the CNA stated no. On 11/14/22 at 10:49 AM, The surveyor reviewed the electronic medical record (EMR) which revealed the following: A Rehabilitation Post-Fall document, signed by the Rehabilitation Director on 09/22/22, revealed Date/Time of fall: 09/22/2022 at 12:50 PM, at around 12:50 PM, the UM [unit manager] nurse was called to resident's room by assigned CNA. Upon entering the room, resident was noted sitting on the floor in front of the [wheelchair]. He/she was facing the bed while wearing nonskid socks .the Notes revealed .is confused with poor safety .No therapy indicated . A Rehabilitation Post-Fall, signed by the Rehabilitation Director on 10/22/22, revealed date/Time of Fall: 10/21/22 at 2:45 PM, per nursing notes: Resident was observed sitting in front of wheelchair at approximately 2:45 PM. Resident was assessed from head to toe with no abnormalities noted. He/she was assisted back to bed by assigned CNA and stated he/she was trying to go to the bathroom. A Nursing Progress Note, (NPN) dated 10/3/2022 at 15:51 [3:51 PM], Resident seated on side of bed alert, oriented and verbally responsive with Assigned CNA who reported to writer of small bump on Right Occipital seen during AM care around 11:00 am . A NPN dated 10/27/2022 at 6:52 [6:52 AM], revealed, There was a call from the room went immediately and found resident sitting on the floor with [his/her] legs outstretched facing the door. Resident was not able to say what had happened due to cognitive status of the resident. Resident was last seen at 2:30 AM in bed, call light was within reach. On 11/15/22 at 9:40 AM, a second surveyor (Surveyor #2) observed Resident #119 was sitting at the nursing station in a wheelchair. Surveyor #2 interviewed the resident in his/her native language. The resident stated he/she had fallen because of high blood pressure. Surveyor #2 conducted telephone interview with an emergency contact (EC) of Resident #119. The EC stated she knew the resident had fallen, and there were concerns that the resident had not always been changed timely. On 11/16/22 at 7:56 AM, the surveyor observed Resident #119 sleeping in a bed in the low position, and the leg portion of the bed was elevated, and the head portion was down with both one-half side rails in place. The surveyor did not see a call bell attached to the wall. At that time, the resident's assigned CNA #2 was in the room. The surveyor interviewed CNA #2 about the bed position for Resident #119 and CNA #2 stated that Resident #119 liked to get up out of bed and that the resident's bed was usually left like that from the overnight shift. The CNA stated the resident has had a few falls. At that time, the surveyor inquired to CNA #2 if the Resident #119 had a call bell and CNA #2 looked for the call bell and stated, I don't see a call light plugged in. On 11/16/22 at 8:22 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who was overseeing the unit at that time, and asked that she accompany the surveyor to Resident #119's room to observe the positioning of Resident #119 in bed. During the observation, the surveyor inquired to the ADON if Resident #119 was supposed to have the bed positioning the feet elevated and the head position lowered while in bed, with the half side rails elevated. The ADON stated no, and stated the bed was supposed to be flat with the head of the bed also flat, and the side rails were used to prevent falls. On 11/16/22 at 8:51 AM, the surveyor reviewed the EMR for Resident #119 which revealed: Resident #119 was admitted to the facility with diagnoses which included, but were not limited to, Type 2 Diabetes Mellitus without complications, and a history of falling. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 08/05/22 revealed a Brief Interview for Mental Status score of 10/15 which indicated a mildly impaired cognition. Section G, functional status revealed the resident required a one person assist for walking, dressing, using the toilet and for personal hygiene. The MDS revealed the resident was not steady with walking, transferring from surface-to-surface and moving on and off the toilet, and only able to stabilize with staff assistance. Three questions in the Fall History on Admission/Entry or Reentry section were left blank and No, Yes or Unable to Determine were not coded. The three questions identified if the resident had a fall in the last month prior to admission /entry or reentry, if the resident had a fall any time in the last 2-6 months prior to admission/entry or reentry, and did the resident have any fracture related to a fall in the six months prior to admission/entry or reentry. Resident #119's Care Plan (CP) revealed a Focus: Resident is at risk for falls [result to] history of falls with Date Initiated: 04/28/22 and Revision on: 10/24/22, [altered mental status] and weakness, 09/22/22 resident had incident of fall resident tried to transfer him/herself from [wheelchair] to bed, no injury noted, 10/21/22 had incident of fall resident found on floor facing the bathroom no injury noted. The goal was for Resident #119 to not sustain serious injury through the review date, Date Initiated 04/28/22, Revision Date: 09/08/22, Target Date: 11/25/22, and Resident #119 will have no incident of falls [until] next review date, Dated Initiated: 09/22/22, Revision: 09/22/22, Target Date: 12/22/22. The CP Interventions: Date Initiated: 04/28/22 included: Anticipate and meet needs, Anticipate toileting needs, Be sure call light is within reach and encourage to use it for assistance as needed, Provide prompt response to all requests for assistance, and Monitor side effects of medication. The CP interventions: Dated Initiated: 09/22/22 included the following: Keep resident in common areas for increased observation and placed resident in front of the nurse's station wherein staff can view resident whereabouts (The surveyor's observation of a missing call bell for Resident #119, on 11/16/22 at 7:56 AM, was inconsistent with the documented CP interventions to prevent falls for Resident #119, and the one-half side rails were not a documented intervention used to prevent falls while the resident was sleeping in bed). A review of Resident #119's Order Summary Report for November 2022 revealed an order for Apply bilateral half-rails to bed for mobility, dated 10/18/22 (This order did not indicate to utilize to prevent falls), and an order dated 04/28/22 for Bed in lowest position every shift (This order was not indicated on the CP for fall prevention). On 11/16/22 at 12:57 PM, the Director of Nursing (DON) provided the surveyor with the facility investigations, as requested, for the prior six months and the documents revealed four Post Fall Investigation Tool documents for Resident #119: The Post Fall Investigation Tool dated 09/20/22, revealed: Date of fall: 09/20/22, at 12:50 PM, Was the patient High Risk prior to fall, Yes, Based on your investigation and assessment what was the causative factor/s: Resident had history of frequent falling result to disease process, alert but confused, unable to follow simple instructions. There were no statements attached to the investigation. The Post Fall Investigation Tool dated 10/03/22, revealed date and time of fall was 10/03/22 at 11:00 AM. Based on your investigation and assessment what was the causative factor/s: Being confused and unable to follow simple instruction is one of causative factors for falls, The nursing description revealed 11:00 AM resident noted seated on side of bed with assigned CNA who reported to writer of small bump on right occipital (forehead) seen during AM care. One statement was attached from a CNA and was undated. The Post Fall Investigation Tool dated 10/21/22, revealed at 10/21/22 at 2:45 PM was the time and date of fall. Based on your investigation and assessment what was the causative factor/s: Resident is having the behavior on and off get up from wheelchair, is alert but with period of confusion, resident unable to follow staff direction, noted most of the times restlessness and can sit still in [wheelchair]. It is the reasons that resident had [history] of falling. The Immediate Action Taken . Resident was educated to call for assistant [sic.] when getting out of bed One statement was attached from a CNA and dated 10/21/22. The Post Fall Investigation Tool dated 10/27/22, revealed Time of Fall 4 (AM and PM were circled), Based on your investigation and assessment what was the causative factor/s: Resident is confused unable to follow simple instructions. Having [history] of frequent falls. There were no statements attached. On 11/18/22 11:59 AM, the surveyor interviewed the DON regarding what process was after a resident sustained a fall. The DON stated there should be a full risk assessment completed, and incident report with statements from the staff, and investigation should be completed. After the completion of the investigation, the DON stated the possible causal factors would be identified and new interventions to prevent falls would be implemented after every fall. The surveyor asked the DON was it ever acceptable to keep a resident's head of bed low, feet up and half side rails up to prevent falls, and she stated 'No. On 11/22/22 11:38 AM, the DON confirmed that there were no fall assessments completed after the four falls sustained by Resident #119. A review of the Accidents: Assessment, Prevention, and Interventions Policy, Effective 7/1/21 revealed: 1. It is the policy of the facility to complete a fall risk assessment for all residents ., after every fall ., Purpose: To ensure that all residents are properly assessed, and appropriate interventions are put in place to prevent falls. Responsibility: The licensed practical nurse completes the fall risk assessment .after every fall .,6. Nursing Staff Initiates and documents following safety measures and initiates fall care plan, Licensed Nurse 7. If resident falls or attempt to get up without assistance, assesses resident's needs to determine the cause of the behavior . Licensed Nurse 9. All interventions must be indicated on the falls care plan, 10. Must ensure that all interventions are in place and functioning if applicable. A review of the Comprehensive Care Planning Policy, effective 05/29/20, revealed a Purpose: To indicate the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being ., Procedure: Interdisciplinary Team, 4. Updates are plan as need with changes in treatment, needs and condition. NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure a.) resident with a gradual weight loss, who was at risk for pressure ulcers with an actual stage 2 pressure ulcer, was identified and interventions put in place to prevent worsening (Resident #49), b.) complete fall risk assessment was done post fall to identify causal factors and put interventions in place (Resident #119), c.) appropriate activities of daily living (ADL) care was provided (Resident #49, #34, #101, #114) and d.) a resident's known behaviors were documented and addressed (Resident #19). This deficient practice was evidenced by the following: Refer to: F 686, F 689, F 677, and F 742 a.) Resident #49 was observed on 11/07/22 in bed on his/her back. The surveyor observed that the lunch cart arrived at 11:50 AM. The surveyor returned to Resident's #49's room at 12:05 PM to find the resident still sleeping. At 12:15 PM, the resident's lunch tray was observed on the bedside table untouched and out of the resident's reach. The Certified Nursing Assistant (CNA) arrived at 12:49 PM to assist the resident who only ate 25%. Resident #49 was dependent on staff and had not been assisted in eating until 34 minutes after the tray arrived. On 11/14/22, the surveyor observed Resident #49 laying on their back in bed from 9:02 AM to 11:30 AM. The surveyor asked the CNA about Resident #49, and the CNA informed the surveyor that she did not provide morning care to the resident yet. The surveyor and CNA both observed that Resident #49's incontinent brief had been soaked with urine. Resident #49 had not been assisted in repositioning for over two hours and had not been assisted with incontinence care. Record review revealed an entry by wound care dated 10/27/22, that Resident #49 had a new sacral stage 2 wound. There were no new interventions in the Care Plan. A review of the progress notes up to 11/18/22, revealed the physician or dietitian had not been made aware as per policy, and no interventions were implemented. On 11/21/22 at 8:42 AM, the dietitian still had not formulated a plan regarding the resident's stage 2 pressure ulcer. The resident was also weighed by the dietitian in the presence of the surveyor and weighed 128.5 pounds. Resident #49 had weighed 134.5 pounds on 11/01/22. The dietitian was not aware Resident #49 was unable to feed himself/herself. The dietitian had not formulated a plan until three days after being made aware. Resident #49 had a weight loss of 6 pounds in 20 days. b.) On 11/14/22 at 11:45 AM, the surveyor interviewed Resident #119's CNA who stated that Resident had not had any falls. The same day, the surveyor reviewed the resident's electronic medical records and discovered four documented falls or incidents between 09/20/22 through 10/27/22. Further review of the incidents revealed incomplete fall risk assessments and incident reports. The direct care CNA was unaware of actual falls for Resident #119. On 11/15/22 at 9:40 AM, during an interviewed with the surveyor, the resident in his/her native language stated that he/she had fallen because of high blood pressure. The surveyor conducted a telephone interview with an emergency contact (EC) of Resident #119. The EC stated she knew the resident had fallen, and there were concerns that the resident had not always been changed timely. On 11/16/22 at 7:56 AM, the surveyor observed Resident #119 sleeping in a bed in the low position, and the leg portion of the bed was elevated, and the head portion was down with both one-half side rails in place. The surveyor did not see a call bell attached to the wall. At that time, the resident's assigned CNA #2 was in the room. The surveyor interviewed CNA #2 about the bed position for Resident #119 and CNA #2 stated that Resident #119 liked to get up out of bed and that the resident's bed was usually left like that from the overnight shift. The CNA stated the resident has had a few falls. At that time, the surveyor inquired to CNA #2 if the Resident #119 had a call bell and CNA #2 looked for the call bell and stated, I don't see a call light plugged in. On 11/16/22 at 8:22 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who was overseeing the unit at that time, and asked that she accompany the surveyor to Resident #119's room to observe the positioning of Resident #119 in bed. During the observation, the surveyor inquired to the ADON if Resident #119 was supposed to have the bed positioning the feet elevated and the head position lowered while in bed, with the half side rails elevated. The ADON stated no, and stated the bed was supposed to be flat with the head of the bed also flat, and the side rails were used to prevent falls. On 11/18/22 11:59 AM, the surveyor interviewed the DON who stated that after a resident falls, there should be a full risk assessment completed, and incident report with statements from the staff, and investigation should be completed. After the completion of the investigation, the DON stated the possible causal factors would be identified and new interventions to prevent falls would be implemented after every fall. On 11/22/22 at 11:38 AM, the DON confirmed there were incomplete assessments and reports on Resident #119's four falls. The staff did not complete the assessments needed to develop and implement interventions for the resident. The resident did not have a call bell available. The resident's emergency contact had concerns about the resident being toileted enough. c.) During facility tour on 11/07/22, surveyors observed dependent residents being reviewed for ADL care. Resident #49 was observed with long jagged fingernails with a black substance under all the nails. Resident #34 was observed with long jagged fingernails with a dark coated substance under the fingernails. Resident #101 was noted with long jagged fingernails with a dark substance under the fingernails. On 11/10/22 at 11:10 AM, the surveyor interviewed the Licensed Practical Nurse /Unit Manager regarding ADL care for dependent residents. The UM stated she knew the staff and she trusted them. [to complete nail care]. The surveyor then accompanied the UM to Resident #49, #34 and 101's Room, where we both the surveyor and UM observed that nail care had not been provided. The resident's nails were long, jagged and had a black coated substance embedded from 1/2 to 1 inch underneath the fingernails. On 11/16/22 at 7:56 AM, Resident #114 was observed awake in bed. The surveyor observed no call bell in the area. The CNA entered the room and confirmed there was no call bell for Resident #114 or his/her roommate. Resident #114 stated that he/she believed there were two incontinent briefs on him/her. In the presence of the surveyor, the CNA checked and confirmed that Resident #114 had two incontinent briefs on. The Assistant Director of Nursing (ADON) was present and stated, I know the night staff is doing it. On 11/22/22 at 1:30 PM, the DON stated it was her expectation that dependent residents be provided with ADL care. d.) On 11/7 at 11:15 AM, the surveyor observed Resident #19 wandering into other resident rooms and talking loudly while in the hallway. The surveyor observed that staff attempted to redirect the resident but were unsuccessful. At 11:50 AM, two residents expressed concern regarding Resident#19 entering their room. The residents stated they were not afraid, but Resident #19 would take snacks of theirs. The surveyor had multiple observations of Resident #19 wandering the halls and in or out of other resident rooms. (11/17/22 at 10:37 AM, 11:15 AM, and 2:22 PM; 11/9/22 at 10:29 AM; 11/15/22 at 9:15 AM, 11/16/22 at 12:20 PM; and 11/18/22 at 10:54 AM) On 11/09/22 at 10:29 AM, the surveyor observed Resident #19 entering Room (308). There was no staff nearby to redirect. On 11/16 at 12:15 PM, the medication nurse could not provide behavior documentation on the behavior monitoring form. The nurse stated she was not familiar with the episodic charting. The staff could not provide documentation of the prevalence and frequency of Resident #19's behaviors. A review of medical records revealed that Resident #19 had a diagnosis which included behavioral disturbances. The Care Plan noted the behaviors for Resident #19 and included that the staff should document behaviors and resident response to interventions. The staff informed the surveyor that Resident #19 wandered daily, all the time, and all over the unit. The staff further stated that the resident could be resistant to care, agitated, and difficult to redirect. Direct care staff had reported that Resident #19 wandered daily into other resident rooms, but there was no data documented to validate the behavior. The monthly summaries provided by the facility also failed to capture the behaviors. Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. The surveyor requested staffing for the weeks of 10/23/2022 to 10/29/2022 and 10/30/2022 to 11/5/2022. Review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report revealed the facility was deficient in CNA staffing for residents on 10 of 14 day shifts as follows: -10/23/22 had 13 CNAs for 125 residents on the day shift, required 16 CNAs. -10/24/22 had 14 CNAs for 124 residents on the day shift, required 15 CNAs. -10/25/22 had 14 CNAs for 124 residents on the day shift, required 15 CNAs. -10/26/22 had 14 CNAs for 124 residents on the day shift, required 15 CNAs. -10/27/22 had 14 CNAs for 124 residents on the day shift, required 15 CNAs. -10/29/22 had 14 CNAs for 124 residents on the day shift, required 15 CNAs. -10/30/22 had 14 CNAs for 125 residents on the day shift, required 16 CNAs. -10/31/22 had 14 CNAs for 125 residents on the day shift, required 16 CNAs. -11/01/22 had 15 CNAs for 125 residents on the day shift, required 16 CNAs. -11/02/22 had 15 CNAs for 125 residents on the day shift, required 16 CNAs. NJAC 8:39-5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, it was determined that the facility failed to: a.) document target behaviors for residents who are receiving psychotropic medications, b.) implement nonpharmacological interventions, and c.) develop care plan interventions to manage the behaviors of residents who displayed combative and wandering behavior and exhibited difficult to redirect behavior that was unpredictable. This deficient practice was identified for Resident #19, one of 2 residents reviewed for behavior, and was evidenced by the following: During the initial tour on 11/07/22 at 10:37 AM, the surveyor observed a resident entering and exiting other residents' rooms. The resident was identified as Resident #19. On 11/07/22 at 10:40 AM, the surveyor asked the Unit Manager about challenging residents on the unit, she stated there were none. On 11/07/22 at 11:15 AM, the surveyor observed Resident #19 wandering in other resident's room. Resident #19 was talking out loud while ambulating in the hallway. A Certified Nursing Assistant (CNA) attempted to redirect Resident #19 to their room but was unsuccessful. On 11/07/22 at 11:50 AM, two residents (Resident #5 and #88) stated a resident would wander into their room at night looking for a snack. Both residents stated they did not fear the resident, but they would like the behavior to be addressed. On 11/07/22 at 2:22 PM, the surveyor observed Resident #19 exiting room [ROOM NUMBER]. Resident #19 was talking out loud. On 11/09/22 at 10:29 AM, the surveyor observed Resident #19 entering Room (308). There was no staff nearby to redirect. On 11/09/22 at 11:30 AM, the surveyor reviewed Resident #19's electronic medical record (EMR). The admission Face Sheet reflected that Resident #19 was admitted to the facility with diagnoses which included but were not limited to Bipolar disorder, current episode manic severe with psychotic, schizophrenia, and unspecified dementia with behavioral disturbances. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #19 as severely cognitively impaired. Resident #19 did not have a score on the Brief Interview for Mental Status. Section E of the MDS which addressed behavior was coded as 0 indicative of no behavior. Section E 0200 received a Zero value for the presence and frequency of behavior. Section E 0800 which addressed rejection of care received also a Zero value indicative of no behavior. Section E 0900 which addressed wandering received a Zero value. Review of an Order Summary Report, with active orders as of 11/23/22 revealed that Resident #19 was prescribed the following medications: Depakote (a mood stabilizer) 250 milligrams (mg) every 8 hours orally for psychosis. Fluphenazine (an antipsychotic medication )10 mg 1 tablet three times a day orally for psychosis. Seroquel (an antipsychotic medication) 25 mg 1 tablet orally every 8 hours for psychosis. Depakote Delayed Release (a mood stabilizer) 250 mg orally for Bipolar Disorder. The Behaviors to be monitored were: Restlessness (agitation) hitting, increase in complaints, spitting, cursing racial slurs, elopement, psychosis, aggression, refusing care. On 11/09/22 at 1:30 PM, the surveyor further reviewed the EMR, and the following entries were noted: 03/14/22, revealed that Resident #19 was involved in a verbal altercation with another resident. 04/16/22, Observed in room, shirt stained, per staff uncooperative with care . 08/05/22, Resident is alert and verbally responsive, confused. Respiration easy and unlabored. Resident mostly quiet during day time, but other residents complaint that he went to their room at night time. Sometimes is he is very loud in the afternoon yelling/screams when approach, unable to redirect at time. Due medications given as ordered. Seen by Psych, meds increase, but behavior is the same. Called Psych again regarding resident behavior wandering to other resident room at night left message. 09/06/22, Resident is uncooperative with taken med at Time non-compliant with care, urinate on the floor, in the closet, take other resident personal snacks, Fall and safety precaution maintained. continue to walk around unit and screaming out sometime, redirect by staff and encourage to stay calm, snack offer and taken well resident vital signs are stable. Will continue monitor resident. On the medication administration record, the nurses were to document the behaviors and indicated with a yes or no for the absence/ presence of the behaviors. The nurses documented N indicated no to a behavior. However, staff revealed that Resident #19 wandered daily, was uncooperative with care and other residents had expressed concerns over the behavior. 10/24/22, Resident is uncooperative with taking meds at time, non-compliant with care, urinate on the floor, in the closet, take other resident personal snacks, Fall and safety precaution maintained. Continued to walk around unit and screaming out sometime, redirected by staff and encouraged to stay calm, snack offer and taken well resident vital signs are stable. Will continue monitor resident. On 11/14/22 at 10:11 AM, the surveyor interviewed the CNA who cared for Resident #19. The CNA stated that Resident #19 had behavior of being resistive with care and wandered in other resident's room. The CNA further stated that Resident #19 would take other resident's snacks, could be very agitated and wandered all the time and all over the unit. On 11/14/22 at 12:15 PM, an interview with the lead CNA confirmed that Resident #19 was accusatory toward staff, wandered around the unit, displayed agitated behavior and was difficult to redirect. On 11/14/22 at 1:30 PM, the surveyor interviewed the UM who confirmed that Resident #19 wandered into other residents' rooms. The UM stated that Resident #19 was ordered medications for the behavior. When asked about other approaches used to curtail the behavior the UM stated redirection helped at times. On 11/15/22 at 9:15 AM, the surveyor observed Resident #19 wandering in the hallway, clothing wet and soiled, talking to self. On 11/16/22 at 12:20 PM, the surveyor Observed in the hallway wandering. Pants stained with urine. The CNA stated she attempted earlier to provide care to Resident #19 but refused. On 11/18/22 at 09:30 AM, the surveyor observed Resident #19 in the hallway, clothing soaked and stained with urine. On 11/18/22 at 10:54 AM, the surveyor interviewed the CNA assigned to Resident #19. The CNA stated that she offered shower to Resident #19 even on days that Resident #19 was not scheduled for shower but Resident #19 refused. The CNA stated when Resident #19 refused shower she would inform the UM and document in the shower log. The surveyor reviewed the shower log and could not find any documentation regarding refusal of care. On 11/21/22 at 12:41 PM, the surveyor interviewed the MDS Coordinator regarding the coding on the MDS. The MDS Coordinator stated to complete the MDS she retrieved data from the EMR, interviewed the staff and the resident if the resident could be interviewed. The MDS Coordinator stated that Social Services staff were responsible to complete Section E of the MDS which addressed behavior. On 11/21/22 at 12:55 PM, the surveyor interviewed the Social Worker (SW) who confirmed that she was aware of some of the behavior, but she could not comment why the behavior was not coded on the MDS. On 11/22/22 at 2:24 PM, the SW informed the surveyor that the behavior was not coded because the look back period had to be within 7 days. The SW provided the Coding Instructions Sheet to the surveyor. Under Steps for Assessment, the following were to be fulfilled: 1. Review the resident's medical record for the 7-day look-back period. 2. Interview staff members and others who have had the opportunity to observe the resident in a variety of situation during the 7-day look-back period. 3. Observe the resident during conversations and the structured interviews in other assessments sections and listen for statements indicating an experience of hallucinations, or the expressions of false beliefs (delusions). 4. Clarify false beliefs. The SW did not have any input from the staff. During the interview the SW stated that she was aware of the behavior but did not elaborate further on actions taken to thoroughly complete the assessment. On 11/16/22 at 12:15 PM, the surveyor interviewed the nurse on the medication cart, regarding monitoring for residents receiving psychotropic medication. The nurse could not provide the documentation. The behavior was not entered on the monitoring form. The nurse was not familiar with that type of charting. The Care plan Resident #19 had a focus for antipsychotic therapy for Depakote (a mood stabilizer) Fluphenazine (an antipsychotic medication). The goal was for Resident #19 to have fewer episode of yelling continuously, paranoia interfering with ADLs. The interventions included: Anticipate and meet needs. Approach in a calm manner. Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. Document behaviors and resident's response to interventions. The behavior of wandering observed by the surveyor, reported by the residents and staff was not documented in the monthly behavior summary. The behavior was not triggered on the MDS. A care plan that addressed the wandering behavior was implemented on 11/18/22, after surveyor inquiry. The care plan for Psychotropic Drug use was not specific and failed to address any non-pharmacological interventions that were utilized by direct care staff to curtail the behavior. The above concerns were discussed with the administrative staff on 11/22/22. On 11/22/22 at 12:36 PM, the DON provided a policy titled, Managing/ Documenting Resident Behaviors dated 05/29/20 last revised 07/12/22. The policy revealed: It is the policy of the facility to monitor residents' behavior and document behaviors in the medical record. Purpose: To provide a method of addressing resident behaviors, documenting behaviors. Procedure: Registered Nurse: Assesses resident for history of behaviors, how behaviors have been managed in the past, what triggers the behaviors, and what pharmacological and non-pharmacological interventions have been successful. Licensed Nurse: Documents episodically in medical record to include where possible, cause, or trigger, all interventions attempted, disruption to others and duration of episode. The monthly summaries provided failed to capture the behaviors. There was no documentation in the Interdisciplinary Progress Notes (IDCPN) regarding what staff's interventions will be utilized to reduce the episodes. The policy was not being followed. NJAC 8:39- 28.1 (c)

Based on interview and record review, it was determined that the facility failed to provide documentation that the Quality Assurance Performance Improvement (QAPI) committee met at least quarterly. This deficient practice was identified for 2 of 4 meetings for the year 2022, and was evidenced by the following: On 11/07/22 at 10:47 AM during the entrance conference meeting, the Licensed Nursing Home Administrator (LNHA) stated the facility held quarterly QAPI meetings. On 11/14/22 at 10:45 AM, Surveyor #2 interviewed the Infectious Disease Doctor (IDD) via speaker phone (with permission) in the presence of the survey team. The IDD stated that his role has been mainly for education and antibiotic stewardship. The IDD stated that he was not aware that the facility had consistent cases of Candida Auris. The IDD stated, That is a new one. He further stated, I did not realize there was an outbreak of Candida Auris at the facility, and if I knew I would have helped them to address it. The IDD stated that he was unaware that here had been cases of Candida Auris at the facility since 2020. The IDD stated that he did not know who had the cultures but would address it and help them out but needed to know what the underlying problem or cause was to do so. He further stated that contributing factors may have been related to environmental cleaning or improper personal protective equipment (PPE, equipment or clothing worn to protect the body from infection) adherence. On 11/22/22 at 10:13 AM, Surveyor #2 interviewed the primary Medical Director (MD) via speaker phone (with permission) in the presence of the survey team. The MD stated that he attended Quality Assurance (QA) Meetings every three months and was unsure who the facility IDD was. The MD stated that he would not know if Candida Auris had been discussed during QA. On 11/23/22 the surveyor requested the QAPI sign in sheets for review. At 8:53 AM, the Director of Nursing (DON) provided the surveyor with sign-in sheets from Quarterly QAPI Meeting dated 07/13/22 and 10/17/22. On 11/23/22 at 9:27 AM, during an interview with Surveyor #1, the LNHA stated that there was a QAPI committee. The LNHA stated that there was a full meeting every three months [quarterly] which included staff such as the Infection Preventionist (IP), DON, the department heads, vendors, Medical Director (MD), and nurses from all units. The LNHA stated the committee would address any issues that were discovered by staff or supervisors, or that were discovered via reports and information or education she had obtained and thought should be included. The LNHA stated the committee would perform a risk analysis to ensure the interventions for the concerns were implemented and if there were revisions to be made. On 11/23/22 at 9:36 AM, surveyor #1 asked the LNHA if the on-going Candid Auris concern had been addressed in QAPI. The LNHA stated she had not been aware of the problem of Candida Auris because of the change of the Infection Preventionist. The LNHA stated that Candida Auris would be the goal of QAPI now. The surveyor requested the missing two QAPI Meeting sign-in sheets for the year 2022. The LNHA stated that she had started at the facility in May 2022 and was unable to locate documentation for any prior QAPI meetings. A review of the facility provided, Infection Prevention and Control Program dated 06/27/22, included but was not limited to responsibilities: infection prevention oversight committee Quality Assurance (QA) committee has ultimate responsibility for overseeing and implementing the infection prevention/control program is delegated to the QA committee. The QA committee shall meet no less than quarterly and maintain written minutes with documentation of agenda items, discussion and actions/recommendations. Responsibilities include but may not be limited to review of findings related to facility-associated infections, outbreak investigations. A review of the facility provided, QUALITY ASSURANCE PERFORMANCE IMPROVEMENT (QAPI) reviewed 07/12/22, included but was not limited to Policy: to create a homelike environment where the needs of residents will be addressed by competent, highly skilled and compassionate staff. The staff [redacted] are committed to enhancing the quality of life of each resident in order to achieve their optimal level of wellness. Purpose: to study, plan, analyze, and validate specific areas of improvement for positive resident care outcomes. Guiding Principles: 3. we will use QAPI to make decisions to guide our day-to-day operations. 4. we will set goals for performance and measure progress towards those goals. 6. we will research best practices and standards of care, to ensure we are delivering the highest quality of care and services to our residents. Reference: Title 42 - Public Health CHAPTER IV - CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES SUBCHAPTER G - STANDARDS AND CERTIFICATION PART 483 - REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES Subpart B - Requirements for Long Term Care Facilities § 483.75 Quality assurance and performance improvement last amended 11/23/22, included but was not limited to: each LTC (Long Term Care) facility .must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must (1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities; and Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program. The facility failed to maintain documents and evidence of the ongoing quarterly QAPI program meetings. NJAC 8:39-33.1(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, it was determined that the facility failed to maintain the kitchen, and pantry areas, in a clean and sanitary manner to limit the spread of infection and potential food borne illness by failing to ensure: a.) the environment and kitchen equipment was maintained in a manner to limit the potential for microbial growth, b.) the dish machine was operated within appropriate temperature specifications per the policy, c.) the chlorine test strips were used per manufacturer's directions, and d.) resident food stored in unit refrigerators was labeled and dated. The deficient practice occurred was observed in the main kitchen, and in the second, third and fourth floor resident pantry, and was evidenced by the following: Reference: U.S. Food & Drug Administration, 2017 Food Code, 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature (B) The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than 49 degrees C (120 degrees F). On 11/07/22 at from 8:58 AM to 9:26 AM, the surveyor conducted an initial tour of the kitchen with the food Service Director (FSD), and Registered Dietitian (RD) and observed the following: 1. The can opener affixed to the metal table was visibly soiled with dark caked on debris on the blade and the blue insert. 2. The walls behind, the floor beneath and the sides and front of the entire cooking equipment area located under the hood, which included the stove, fryer, and ovens was visible soiled with copious amounts of food and dark colored grease like debris. The debris included what appeared to be a burnt potato on the on the floor, and various other debris. The RD acknowledged the area was not clean. 3. The reach in refrigeration units located near the cooking area (Box # 3 and #4) had ripped door gaskets with embedded dark debris. 4. The exterior of the ice machine holder was soiled with debris and when the surveyor asked the FSD how often it was cleaned, the FSD stated weekly. The surveyor inquired to the FSD how often cleaning was completed for the kitchen, and she stated it was not cleaned daily. The surveyor asked to provide a copy of a cleaning schedule and the FSD provided a copy of a cleaning schedule dated 11/01/22 and titled Cleaning list to be done daily by dietary employee. The FSD stated she could not locate a recent daily cleaning schedule and stated the list was completed weekly. At that time the FSD stated she did not have a currently completed cleaning schedule and provided the surveyor with the copy of the most recently completed schedule, dated 11/01/22, which revealed: 1. Clean the two ice cream boxes, 2. Clean the two milk boxes, 3. Clean the oven, 4. Clean the storage room and label everything, 5. Clean the walking in fridge and freezer, 6. Clean the drain waste and sink (meat washer), 7. Clean and remove pots then put back in place, 8. Clean top counter, 9. Clean the two fridge and label the food as well, 10. Clean the vegetables freezer, 11. Clean and remove dishwasher rack to clean the bottom floor,12. Clean all the carts. The FSD also provided the surveyor with a blank copy of the Daily Cleaning schedule four our Dietary Dept [Department] which revealed: Clean legs and wheels for all the carts, Clean behind the kitchen equipment, Clean dollies, Clean all food carts and lids, Clean all garbage cans, Wipe all walls, Coffee urns/ inside out, Stoves, steam tables, steamers, sinks, drains, Broom room, Sweep and mop after each meal, Dish machine is cleaned after each meal, Coffee mugs are cleaned every Thursdays, Milk boxes as needed, Walking refrigerator and freezer as needed, Ice maker once a month is emptied out and cleaned (Usually first week of the month), Power wash floors, Take stove burners top holding parts apart once a week and clean inside. 5. The dry storage room had debris and soiled areas on the container lids that covered the individual ketchup and mustard packets. The surveyor asked the FSD if the lids were cleaned, and she stated weekly. 6. The floor underneath the racks in the dry storage room were soiled with debris and crumbs. 7. The small handwashing sink was soiled with splatters on the sink, debris by the handles and darkened areas in the basin. On 11/07/22 at 1:20 PM, the Licensed Nursing Home Administrator provided the surveyor with a Certificate in Safe Food Handling from the Township of [name] Health Department dated 06/09/22 with the FSD's name. 8. On 11/10/22 at 10:56 Am, the surveyor toured the 4th floor pantry with the Licensed Practical Nurse Charge Nurse (LPNCN #1). The refrigerator contained an unlabeled food item in a bag. The LPNCN #1 picked the item up and stated, it feels like a burrito or something, and confirmed there was no date on the bag. Another item was labeled with Resident #119's name, and the LPNCN #1 confirmed the item was not dated and usually things were brought in by Resident #119's spouse. 9. On 11/10/22 at 11:24 AM, the surveyor toured the 3rd floor pantry with a Certified Nurse Aide (CNA). The surveyor observed food splatters on counter and ice machine baffle. 10. On 11/10/22 at 11:30 PM, the surveyor toured the 2nd floor pantry with the Licensed Practical Nurse, Charge Nurse (LPNCN #2) and observed the floor area and sink area was soiled with debris. 11. On 11/14/22 at 9:33 AM, the surveyor conducted a follow-up tour of the kitchen, in the presence of the Corporate Food Service Director CFSD) and FSD, and observed the dish machine in operation, and the food service staff was removing insulated lids and bowls in racks from the clean side of the machine. At that time the surveyor asked the food service worker (FSW) who was loading the dish machine what the temperature should be for the machine to work properly. At that time the CFSD stated the temperature should be 120 for the wash which was the gauge on the left and 140 degrees farenheight (f) for the rinse, which was the gauge on the right, and the machine was a low temperature machine. The surveyor observed multiple racks being sent through the machine and observed that the wash and rinse temperature was less than 90 f and continued to vary as dish racks were sent through the machine. The surveyor's observations continued, and the rinse did not rise above 130 f. When asked the CFSD if the temperature was acceptable, he stated, we have to wait, it takes time and it will get hot. When asked if the machine had a booster (helps water temperature rise), the CFSD stated the machine had a booster and it was working. The surveyor asked the CFSD if the items sent through the machine should be used if it is not the appropriate temperature, and he stated no, and had the staff bring back the bowls and lids. The CFSD stated that the machine has a chemical sanitizer and when asked how you would know if the sanitizer was working, he proceeded to remove a piece of test strip from a chlorine test strip reel and placed it directly in the water stream that was exiting the dish machine and proceeded to hold up the strip and show the surveyor the color chart as compared next to the strip. The surveyor observed that the strip was black when the CFSD held it up, and the FSD stated it was 100 (parts per million) and stated it was okay. The surveyor then observed the printed manufacture's directions printed on the chlorine strip color chart which revealed Dip and remove quickly. Blot immediately with paper towel. Compare to Color Chart at Once. (The CFSD did not follow the directions printed on the label). The surveyor then observed the dish machine in operation with empty racks being sent through and the temperature was monitored, with varied temperatures between 110-115 f wash and 118 f to 125 f rinse. At that time the FSD stated stop washing it is going down [temperature]. On 11/14/22 at 10:11 AM, the surveyor requested the dish machine policy and manufacture's specifications for the dish machine and policy from the CFSD. On 11/14/22 at 11:45 AM, the Regional Administrator (RA) provided a Dish Machine Policy, dated 10/20/21, which was signed by the CFSD. The Policy revealed Low Temp [temperature] Machine = 120F (or Manufacture's or state Requirement), Policy Statement, Dishes are placed on rack and spray before entering dish machine, Wash and Rinse temperature should be 120F or above while sanitizer should be used at all times .The [brand name] Chlorine test kit can be used to determine the concentration of chlorine solution. The color chart match should be at a minimum 50 to 100 PPM (parts per million to assure sanitation). On 10/14/22 at 12:35 PM, the RD provided the surveyor with the Policy for checking dish machine test strip, dated 10/20/21 and signed by the CFSD.Dip test strip in sanitizing solution for 10 seconds, (Chlorine test kit) compared to chart. The color chart match should be the minimum 50 to 100 parts per million to assure sanitation. On 11/15/22 at 12:50 PM, the CFSD provided another Policy for checking dish Machine/Pot Test Strips dated 10/20/21 and signed by the CFSD. The Policy revealed Dip Test Strip in sanitizing solution for ten seconds, (Chlorine test kit) compared to chart. The color chart match [sic.], should be the minimum 50 to 100 PPM to assure sanitation. Record result in book. Immerse all items in solution for 60 seconds or longer. Testing is done at the end of the washing cycle for dish machine, for pots washing testing should be done before. The policy did not match the label of the chloring test strips and did not specify if the strip should be placed in the water exiting the dish machine. On 11/15/22 at 11:37 AM, the surveyor conducted a follow-up observation during the lunch meal service and observed the tray line process and in the presence of the CFSD. The surveyor observed a carboard box of plastic wrap on the table adjacent to the tray line which had a soiled and stained box. There were two plastic lids on the top of the tray line, both lids were upside down and being used to hold individual sauces and breakfast syrup and were stained with visible debris affixed to the lids. The surveyor showed the CFSD the lids and he proceeded to use his finger to wipe the debris from one of the lids. On 11/18/22 at 1:00 PM, the RA provided the surveyor with the manufacture's Specification Sheet for the chlorine test strips. The Directions revealed Dip the strip into the chlorine sanitizing solution, blot with paper towel, and then instantly compare the resulting color with the enclosed color chart . The Kitchen Cleaning Policy dated 08/21/21 and signed by the LNHA revealed: It is the policy of the [facility] to keep the kitchen clean at all times. Procedure: 1. Staff members must clean as you go at all times, 2. The kitchen must be swept and mopped after each meal, all food trucks after each use, 3. The kitchen walls must be cleaned weekly and as needed, 4. Carts, tables, shelves, containers under and behind equipment as needed. Refrigerators and freezers as needed. The Pantry Cleaning-Housekeeping Policy, dated 11/01/18 and signed by the LNHA revealed: It is the policy of the [facility] to ensure that unit pantries are maintained in a clean and functional order. Purpose: To maintain the cleanliness of areas involving food storage/handling. The Food from Outside: Safe Handling policy, dated 06/27/22 and signed by the LNHA revealed: It is the policy of [the facility] to store any personal resident food items that require refrigeration in the unit refrigerator under safe handling guidelines. Procedure: .3. Writes name/room number and date/time on bag/container. 8. Discards all food remaining in refrigerator after 72 hours. NJAC 8:39-17.2(g)

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that facility wide assessment included the resources required to establish policies and procedures for management of on-going outbreak of Candida Auris (C. Auris, an emerging fungus that presents a serious global health threat) which dated back to October 2020 on the Ventilator Unit. This deficient practice was identified by the following. Reference F880, F882 On 11/07/22 at 10:53 AM, during entrance conference, the facility Licensed Nursing Home Administrator (LNHA) informed the survey team that the facility was currently in an outbreak of C. Auris. The survey team was informed that there were currently nine cases in the facility and the residents resided on the first floor ventilator unit. The LNHA stated the facility Infection Preventionist, communicated with the Department of Health and there was a line listing for the C. Auris cases. On 11/09/22 at 11:16 AM, during an interview with the survey team, the facility regional Registered Nurse (RRN) stated that the facility did not have a C. Auris line list, so he created one. The RRN stated that he had created the list without conferring first with the facility's uncertified Assistant Director of Nursing Infection Preventionist (ADON/IP). On 11/09/22 at 11:44 AM, the ADON/IP stated the nursing staff would test the axilla and groin for C. Auris every three months. She stated that the UM also included other residents on the unit for testing. There were more than 18 residents on the unit during the last test period, but only 9 were tested. The ADON/IP further stated that the results were placed on the resident's chart in the EHR from the lab report. She stated that she was in contact with the local health department. The ADON/IP staff that staff were educated on the proper Personal Protective Equipment (PPE) to use which included gown, goggles, N95 and if serving meals or administering medications, doff (remove) full PPE and except the face shield which could be cleaned and reused. She stated that the cleaning product used in the resident rooms with C. Auris, was Virex. On 11/15/22 at 1:16 PM, the surveyor interviewed the Manager of Housekeeping (MH) in the presence of the survey team. The MH stated that the facility used Clorox Bleach Wipes and Virex II for cleaning. The MH confirmed that Virex II did not kill C. Auris, but that bleach did. On 11/18/22 at 10:23 AM, the surveyor requested a copy of the Facility Assessment (Intent, for the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require). Review of the Facility Assessment revealed that the facility, may accept residents with, or residents may develop, the following common diseases, conditions, physical and cognitive disabilities. We are always working to educate our staff to expand diseases/ conditions, physical, and cognitive disabilities we can care for to expand our service to greater numbers of our community. The facility failed to list C. Auris under the Infectious Disease section. The Facility Assessment revealed that Infection Prevention and Control were provided directly by the facility staff and not by contracted services. The Facility Assessments further revealed that when a resident develops a new diagnosis, condition, or symptom, the Director of Nursing (DON) and the facility educator would ensure staff competency to care for the resident. The facility must update the assessment as needed or at least annually. On 11/22/22 at 12:54 PM, a surveyor interviewed the Regional Licensed Nursing Home Administrator (RLNHA) in the presence of the survey team who stated that the purpose of the Facility Assessment was to communicate the needs of the facility and it was required to be updated yearly. Review of the Facility Assessment indicated that it was updated in 2022, the month and day were not specified. When the surveyor asked if C. Auris should have been included in the Facility Assessment, the RLNHA replied that all of the needs of the facility that are required to provide care for the residents should have been included in the Facility Assessment. The facility had been in C. Auris outbreak since October 2020 per facility interviews. The facility revealed the last review of the Facility Assessment had been in 2022 (no specific date). The C. Auris had not been identified or addressed. Facility staff interviews revealed either discrepancies in how to mitigate the spread of C. Auris, or lack of information. NJAC 8:39-19.1 (a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor B 4. On 11/10/22 at 11:39 AM, the surveyor observed a staff member (who was later identified as a Licensed Practical Nurse Apprentice (LPNA)) wearing an N95 mask, glasses (not protective goggles or face shield) and gloves, deliver a lunch tray to Resident #92. She placed the lunch tray on the bed side table and moved the table over to the side of the resident's bed. The LPNA removed her gloves and exited the room. She then used hand sanitizer donned a gown and gloves and went back into room and assisted the resident with his/her meal. The surveyor observed signage on the outside of the resident's room: a STOP, Must See Nurse sign, a Droplet Precautions Everyone Must: .Make sure their eyes, nose and mouth are fully covered before room entry sign, and a Contact Precautions Everyone Must: .Put on gown before room entry. Discard gown before room exit sign. There was a stocked PPE bin located outside of the room which contained hand sanitizer, gloves, gowns, and masks. A review of the admission Record revealed Resident #92 was admitted to the facility with diagnoses that included, but were not limited to; Osteomyelitis (an inflammation or swelling that occurs in the bone) and Methicillin Resistant Staphylococcus Aureus Infection (a type of bacteria that could be fatal or cause serious infections). Review of Resident #92's Physician Orders revealed two active orders for Contact Precautions for Candida Auris (C. Auris) on Skin, dated 12/30/2021 and 3/29/2022. On 11/10/22 at 11:47 AM, the surveyor interviewed the LPNA when she exited the room. The surveyor pointed to the signs and asked the LPNA what the signage for droplet and contact precautions meant. She stated that before entering the room you must follow the signage requirements. She stated, I did not put on a gown before I dropped the tray, but I shouldn't of gone in the room without a gown. The surveyor asked her about the glasses she was wearing, she stated she was wearing eye glasses and that it was not OK to go in the room without eye protection. She further stated that she should have found a face shield before entering the room. The LPNA stated the resident had C. Auris, which was contagious, and she should have had a gown on to prevent getting into contact with anything in the room because it was an infection barrier, to protect you and the resident. On 11/10/22 at 11:52 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN), assigned to Resident #92, reviewed the Contact and Droplet Precaution signage outside of the resident's room. She stated you must wear a gown, gloves, a N95 mask, and goggles before entering the room and then remove them when exiting the room. The LPN stated the resident was on Contact Precautions because of C. Auris but she was not sure why the resident was on Droplet Precautions. On 11/10/22 at 11:57 AM, during an interview with the Infection Preventionist (IP), the surveyor reviewed the signage on Resident #92's door. She stated that when serving lunch, the proper gown, N95 mask, gloves and goggles should be worn before entering the room. She stated the purpose of the gown was to prevent the spread of Candida Auris and that the purpose of the goggles was to protect the eyes from droplets. The surveyor reviewed what she observed when the LPNA was delivering the lunch tray. The IP stated the staff had just been in serviced on following the signage and donning the proper PPE when delivering the meal trays. The surveyor asked if it was ok for the LPNA to deliver the lunch tray without donning a gown, the IP stated, no it was not. On 11/10/22 at 12:30 PM, review of the facility provided in service sign in sheet dated 11/8/22, revealed the LPNA was in serviced on 3 .donning and doffing PPE re-meal pass. On 11/10/22 at 1:18 PM, the surveyor interviewed the Director of Nursing (DON) on process for PPE during meal delivery. She stated that staff must gown up when delivering the trays and doff (remove) the gown prior to exiting the room. She further stated staff must wear a face shield/goggles for droplet precautions. The DON stated that the IP had made her aware of the above and that the LPNA had been in serviced on the proper PPE. A review of facility policy Infection Control: Prevention and Control of Candida Auris reviewed on 7/26/22, revealed Policy: It is the policy of Alliance Care Rehabilitation and Nursing Center to adhere to the infection control guidelines to limit or prevent residents and staff from the onset of Candida Auris; General Information: .both Standard and Contact Precautions .healthcare personnel should still use gowns and gloves when performing tasks that put them at higher risk of contaminating their clothing. A review of facility policy Transmission Based Precautions reviewed on 6/12/22, revealed Policy: It is the policy of Alliance Care Center to adhere to the basic infection control guidelines to limit or prevent residents and staff from the onset of spread of microorganisms. Transmission Based Tracer: Signs indicating a resident is on transmission based precautions are clear and visible. Staff are able to successfully verbalize the transmission based precautions required before entering the room .Glove and gowns are donned upon entry into the environment (i.e Room or cubicle of resident on contact precautions). A review of facility policy, Infection Control: Prevention and Control of Candida Auris reviewed on 7/26/22, revealed: If residents with C. Auris receives physical therapy or occupation therapy or other shared services (recreation therapy), staff should not work with other residents while working with the affected patient. They should use a gown and gloves when they anticipate touching patient or potentially contaminated equipment. The resident should be the last patient to receive therapy for the day. Shared equipment should be thoroughly cleaned and disinfected after use. Hand Hygiene: Increased emphasis on hand hygiene is needed on the unit where a patient with C. Auris resides. When caring for a resident with C. Auris, healthcare personnel should follow standard hand hygiene practices which include alcohol-based hand sanitizer . As part of contact precautions, health care personnel should: Always wear gloves to reduce hand contamination, Avoid touching surfaces outside the immediate patient care environment while wearing gloves, Perform hand hygiene before donning gloves and following the removal of gloves. Environmental Disinfection: C. Auris can persist on surfaces on health surfaces in health care environments. Quaternary ammonia products that are routinely used for disinfection may not be effective against C. Auris. Until further information is available, CDC recommends use of Environmental Protection Agency registered hospital grade disinfection against Clostridium difficile (c-diff) spores. Thorough daily cleaning and terminal cleaning and disinfections of patient's rooms and cleaning and disinfecting areas outside of their rooms where they receive care (therapy, activities) is necessary. Shared equipment should be cleaned and disinfected before being used by another resident. Screening Close Contacts: Prior to detection someone may have become affected. Therefore, identification of patient's prior healthcare exposures and contacts is necessary. Identify Prior Healthcare Exposures: Patient's current facility, Facilities at which the index patient stayed for more than 7 days in the prior three months. Facilities with longer length of stay (LTC facilities, nursing homes). A review of facility policy, Hemodialysis (approved 08/16/22) revealed the following: Procedure: Individual Responsibility of the Charge Nurse/Licensed Nurse to ensure all pertinent information relating to resident care is communicated with the dialysis center, including but not limited to presence of contagious infections (e.g. Covid-19, C. Auris) . A review of facility policy, Infection Control: Donning and Doffing of PPES Purpose: To prevent the spread of infection. Wash hands using the proper hand hygiene procedure, [NAME] gown first, Ensure the gown opening is in the back ., Gown cuffs are pulled down to cover the wrist, [NAME] a mask, Apply goggles or face shields, Place over face and eyes and adjust to fit. Don gloves extend to cover the wrist of the isolation gown, Cuff of gloves cover the wrist and are placed over the gown cuffs .Perform hand hygiene between removal and donning new gloves .Wash hands or use alcohol-based hand sanitizer immediately after removing all PPE. NJAC 8:39-19.4(a) (1,2)(c)(d)(e)(f) Complaint #NJ00158982 Refer to F882 Based on observations, interviews, medical record review, and review of other facility documentation, it was determined that the facility failed to minimize the spread of infection during a Candida Auris (C. Auris, an emerging fungus that presents a serious global health threat) Outbreak by failing to ensure: a) staff donned (put on) the required Personal Protective Equipment (PPE, garments or equipment used to protect the body from infection) prior to room entry of residents on transmission based precautions (isolation protocol) and performed hand hygiene when indicated b) housekeeping staff utilized cleaning products that were effective against C. Auris c) maintained ongoing communication with the on-site dialysis (kidney treatment) center regarding the status of residents who required transmission based precautions (isolation) during dialysis treatment due to C. Auris d) the facility assessment was updated to include staff roles and responsibilities related to the care of residents diagnosed with C. Auris at the facility. This deficient practice was identified for (three) 3 of 5 (five) residents (Residents #113, #115 and an unsampled resident) reviewed for transmission based precautions on 1 of 1 nursing unit, First Floor Ventilator and Tracheostomy Unit, in accordance with acceptable standards of infection control practice and was evidenced by the following: Surveyor A 1. On 11/10/22 at 10:53 AM, the surveyor observed Resident #113 lying in bed talking on the telephone. There was signage on the outside of the resident's door which indicated that the resident was on transmission based precautions (TBP) and droplet precautions were in place and instructed that everyone who entered must: Clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, remove face protection before room exit. A second sign cautioned that Contact Precautions were also in place and everyone must: Clean their hands, including before and after entering the room. It further instructed providers and staff to: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . On 11/10/22 at 12:16 PM, the surveyor observed the Certified Nursing Assistant (CNA) who wore only a surgical mask and did not perform hand hygiene with the alcohol based hand rub (ABHR) that was present on top of the fully stocked PPE cart that was outside of the resident's room as she prepared to don her PPE. The CNA donned a gown and did not don gloves prior to entering Resident #113's room before she picked up the resident's meal tray with her bare hands and carried it out to the food cart that was outside of the resident's room. The CNA then proceeded to doff her gown and surgical mask and placed it in the trash can inside the resident's room. The CNA came out of the resident's room, obtained a new surgical mask which she donned without first performing hand hygiene. When interviewed, the CNA stated that Resident #113 had C. Auris and was on contact isolation. The CNA stated that gloves, eye protection and hand hygiene were not required if direct care was not provided to the resident. The CNA acknowledged that she failed to perform hand hygiene after she doffed her gown and surgical mask and exited the resident's room. The CNA stated that she also failed to perform hand hygiene before she obtained a new surgical mask from the PPE cart and donned it, because the surveyor wanted to speak with her. The CNA stated that she received an in-service related to contact precautions which required that she must wear full PPE as indicated on the signage to enter the room, doff the PPE in the room and wash her hands when she came out of the room. Review of Resident #113's admission Record, an admission summary, revealed that the resident was admitted to the facility in May of 2022 with diagnoses which included but were not limited to: Candidiasis (fungal infection caused by Candida), Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterium with antibiotic resistance), acute respiratory failure, tracheostomy and chronic kidney disease. Review of Resident #113's quarterly Minimum Data Set (MDS), an assessment tool dated 08/12/22, revealed that the resident's Brief Interview for Mental Status (BIMS) score was 13/15, which indicated that the resident was cognitively intact. Further review of the assessment revealed that the resident required total dependence of two persons for bed mobility and transfers to the wheelchair and required limited assistance of one person for eating. Active diagnoses included Candidiasis, unspecified. On 11/10/22 at 12:33 PM, the surveyor interviewed the Assistant Director of Nursing Uncertified Appointed Infection Preventionist (ADONUAIP) in the presence of the survey team, who stated that the staff on the Ventilator Unit were in-serviced and informed that a gown, N95 mask (respirator that filters 95% of particles), gloves and face shield were required to be worn to enter resident rooms who had C. Auris and hand hygiene was required to be performed both before entry and prior to exiting the room. The ADONUAIP stated that ABHR was preferred over handwashing. When the surveyor informed the ADONUAIP of the observation of the CNA who entered Resident #113's room she stated, That was a big No, No for the aides to go into the isolation rooms without gloves on and a failure to perform hand hygiene. The ADONUAIP stated, She did not know if the staff did not understand or if they just did not want to listen to us. The ADONUAIP explained that an N95 was required to enter the resident's room, though she did not know why, as that was what she had learned. The ADONUAIP further stated, staff may wear a surgical mask in the hallway and when they entered the resident's room they must then wear full PPE as directed to prevent the further spread of infection. On 11/10/22 at 10:23 AM, the surveyor interviewed the Director of Respiratory Therapy (DORT) who stated that Resident #115 was on both Contact and Droplet Precautions due to C. Auris and indicated that full PPE which included an N95 respirator mask was required in order to enter the resident's room. There was signage posted on the outside of the resident's room which provided full instruction for PPE usage and hand hygiene. At 10:25 AM, the surveyor entered Resident #115's room and observed that the resident was ventilator dependent and was unable to speak due to tracheostomy. The resident was able to make his/her needs known by silently mouthing words. Review of Resident #115's admission Record revealed that the resident was admitted to the facility in June of 2022 with diagnoses which included but were not limited to: Acute respiratory failure, chronic obstructive pulmonary disease (condition involving constriction of the airways), pseudomonas (gram-negative bacteria), resistance to multiple antibiotics, ventilator dependence, and dependence on renal dialysis. Review of Resident #115's quarterly MDS, dated [DATE], revealed that the resident's BIMS score was 0/15, which indicated that the resident was severely, cognitively impaired. Further review of the MDS revealed that the resident required total dependence of two persons for bed mobility and transfers. Active diagnoses included Candidiasis, and resistance to multiple antibiotics. On 11/15/22 at 12:27 PM, the surveyor observed the Housekeeper (HK) outside of Resident #115's room. When interviewed, the HK stated she had worked at the facility for one month and filled in for the full-time HK who was off that day and did not normally work on the unit. The HK stated that she used Clorox bleach wipes to wipe the mop and broom handles and used Virex II to wipe down all other room surfaces, and Stride Citrus to mop the floors. On 11/15/22 at 12:42 PM, the surveyor observed the HK as she prepared to enter Resident #115's room. When interviewed, she stated that a face mask, goggles, gown and gloves were required to enter the resident's room. The HK then proceeded to don gloves, then donned a gown and left the gown untied in the back and the arms of the gown hung down past her gloved hands. The HK then doffed (removed) her surgical mask and donned an N95 mask and face shield. The HK entered the resident's room and emptied the resident's trash and swept up a glove that was on the resident's floor into a dust pan. The HK then doffed her gown and gloves and lifted the lid of the trash can with her bare hands in order to dispose of her gown and gloves. The HK then doffed her N95 mask and lifted the lid of the trash can a second time with her bare hands and disposed of the N95 mask. The CNA then came out of the room and failed to perform hand hygiene before she accessed the PPE bin and obtained a new surgical mask which she donned beneath her face shield. When interviewed, the HK stated that she forgot to tie her gown in the back and was unsure of the order that she was supposed to don her PPE and whether her gloves or gown were to be donned first. The HK stated that she put her gown on first which left the gown to hang down over her hands. The HK stated that when she touched the lid to the trash can with her bare hands and then doffed her N95 mask without first performing hand hygiene there was a chance that she was exposed to germs. When asked why she did not use the ABHR that was on top of the PPE bin the HK stated that she normally carried her own personal hand sanitizer in her pocket but she forgot it today. The surveyor noted that there was a reference guide posted on the wall outside of the room which provided instruction for the sequence to don PPE. The HK then proceeded to review the signage that she reportedly had not noticed prior to the observation. On 11/15/22 at 1:16 PM, the surveyor interviewed the Manager of Housekeeping ([NAME]) in the presence of the survey team. The [NAME] stated that the facility used Clorox Bleach Wipes and Virex II for cleaning. The [NAME] confirmed that Virex II did not kill C. Auris, but that bleach did. The [NAME] stated that bleach wipes were required to clean room surfaces and diluted bleach was required to be used to mop the floors in order to be effective against C. Auris. The [NAME] stated that staff were required to wear PPE according to the signage posted outside of the resident's room. The [NAME] stated that if the HK donned her gloves first the band of the gown would be opened. The [NAME] stated that if you donned the gown first and then the gloves, the band of the gown would remain closed to protect clothing. The [NAME] stated that the gown should have been tied in the back so that nothing gets on your clothes. The [NAME] stated if the gown were left open, that would be an infection control problem. The [NAME] stated it was also an infection control problem if the HK did not perform hand hygiene after she doffed her PPE, touched the trash can lid and before she donned a new surgical mask. The [NAME] stated that the HK staff should not have used her own hand sanitizer as staff were required to use the hand sanitizer that was provided on their housekeeping carts. The [NAME] explained that the HK staff did an AM tour, spot cleaned the floors and cleaned the C. Auris rooms last after their AM tour, so the room was already cleaned this morning prior to the surveyor's observation. The [NAME] stated that she would provide the HK with an in-service right now because they should not have cleaned Candida Auris with Virex II or Stride Citrus and should have donned/doffed PPE correctly to prevent the further spread of C. Auris. 2. On 11/10/22 at 11:15 AM, the surveyor reviewed both Resident #113's and Resident #115's Dialysis Communication Binders which contained Dialysis Communication Logs (DCL) that were dated 11/2/22, 11/4/22, 11/7/22, and 11/9/22 and failed to contain documented evidence that the residents required ongoing transmission based precautions due to a diagnosis C. Auris. On 11/14/22 at 11:50 AM, the surveyor reviewed both Resident #113's and Resident #115's DCLs and noted that on 11/11/22, the DCL failed to inform the receiving dialysis center that both residents had C. Auris and required transmission based precautions. On 11/14/22 at 12:36 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to the First Floor Ventilator/Tracheostomy Unit regarding Resident #113's and Resident #115's DCL. The LPN stated that the dialysis center was informed verbally in report that the residents were positive for C. Auris prior to dialysis treatment. The LPN stated that the dialysis center had a list of residents who were positive for C. Auris and also had access to the facility's electronic health record (EHR). The LPN stated that the DCLs were completed by the sending facility nurse and communicated the resident's medications and vital signs but maintained that the diagnosis of C. Auris was not required to be documented on the forms because it was in the EHR. The LPN stated that she did not document that she provided verbal report to the receiving dialysis center in the nursing progress notes contained within the EHR. On 11/14/22 at 1:02 PM, the surveyor interviewed the ADONUAIP in the presence of the survey team, who reported that she had filled in for the facility Infection Preventionist Nurse who was on vacation since the middle of October and was unsure when she would return. The ADONUAIP stated that before a resident was scheduled for dialysis treatment, the diagnosis of C. Auris was communicated so that staff were fully aware. The ADONUAIP explained that nursing called the dialysis center over the phone and she would have expected that nursing would have documented a diagnoses of C. Auris on the DCLs as well. The ADONUAIP stated that she was unsure if the dialysis center had access to the facility's EHR. The surveyor showed the ADONUAIP both Resident #113's and Resident #115's DCLs and the ADONUAIP stated that she did not see that C. Auris status written on the forms as required. The ADONUAIP stated that, We are going to start doing that. The ADONUAIP stated that she would emphasize that this was a C. Auris positive resident. The ADONUAIP provided the surveyor with the contact information for the Nurse Manager (NM) at the dialysis center. The surveyor phoned the NM at 1:20 PM, and provided direct contact information on the voicemail to return the surveyor's phone call. On 11/16/22 at 12:13 PM, the surveyor interviewed the NM at the on-site, non-affiliated dialysis center, who stated that there was an endorsement Dialysis Communication Log that listed several residents who were positive for C. Auris. The NM stated that the LPN from the long term care facility came to the dialysis center today and informed her verbally that Resident #113 was positive for C. Auris. The NM stated that the dialysis was not notified via the DCLs and was not made aware prior to today. The NM stated that she learned of other positive cases of C. Auris at the facility via review of the hospital discharge summary. The NM maintained that Resident #113 was the only resident who was positive for C. Auris that the dialysis center was unaware of. The NM stated that the sending facility nurse should have told the dialysis staff the resident had C. Auris. The NM further stated that the dialysis nurses wore a gown, face shield, mask and gloves during the care of the resident who received dialysis treatments. The NM further stated that since the resident was not on isolation to our knowledge, the nurse would have worn the same gown to treat all assigned residents and only changed his/her gloves between residents. The NM stated that if isolation was required the resident would have been put on the dialysis machine at the end of the room and double disinfected and cleaned the dialysis machines and chairs more thoroughly with bleach. The NM stated that the dialysis center was unable to assign designated staff due to short staffing. The NM stated that the nursing staff were also told not to wear the same gown to care for other residents that they have worn to care for a resident known to have C. Auris to prevent transmission. The surveyor asked the NM to provide a list of all residents at the long-term care facility who received dialysis at the center and were known to have a diagnoses of C. Auris. 11/16/22 12:49 PM, the surveyor interviewed the LPN who stated that she did not speak to anyone at the dialysis center about Resident #113. The LPN stated that she was informed by the facility after she spoke with the surveyor, that the diagnoses of C. Auris was required to have been documented on the DCLs. The LPN maintained that the dialysis center had the same EHR and the dialysis center staff should have reviewed the computer system to confirm that the resident did not have C. Auris prior to treatments. The LPN further stated that she informed the NM of Resident #113's diagnoses of C. Auris along with several others. The surveyor noted that Resident #115 was not identified in the list that the LPN provided orally to the surveyor. The LPN stated that, Some of the residents at the facility were not admitted with a confirmed diagnoses of C. Auris and developed it here because we test the residents monthly. The LPN stated that if she had a new resident, she would not jump to provide care and would instead review the resident's history first to see if the resident had an infection or not. The LPN stated that we do not document that the resident had C. Auris on the DCLs and if it were not documented, it was not done. The LPN further stated that the spread of infection were a problem if the dialysis center was not informed of the resident's diagnoses of C. Auris prior to treatment due to the need to isolate the resident. The LPN stated that the NM asked her today which residents had C. Auris, and she insisted that they did not have a conversation about it. On 11/16/22 at 1:29 PM, two surveyors went to the dialysis center and interviewed the NM who stated that she was unable to demonstrate her view of the facility's EHR, because it was not working right now. The NM instead referred the surveyors to the dialysis Renal Dietician (RD) who demonstrated the EHR view for Resident #113's EHR and stated that they probably forgot to write it on the Dialysis Communication Record. The RD reviewed the Progress Notes and Medical Diagnoses sections with the surveyors. The NM stated that someone should have endorsed the resident's diagnoses of C. Auris to her. The NM stated, I do not remember seeing isolation in the EHR. The RD replied, That is because you do not have access to the EHR. The NM then proceeded to provide the surveyor with a list of residents at the facility for whom she had a confirmed diagnoses of C. Auris that was provided by the facility LPN. The surveyor reviewed the list and noted that Resident #115 was not on the list. When the surveyor asked why the resident was not on the list she stated. Nobody told us that Resident #115 had C. Auris. The NM stated when we received the list today, resident #115 had already had a treatment done earlier that morning. The NM confirmed that there was only one isolation room in the dialysis center and it was not equipped for ventilator residents. So the ventilator residents who have isolation needs were placed at the end of the dialysis unit. On 11/16/22 at 1:39 PM, the NM took the two surveyors to the dialysis unit and the surveyors observed that Resident #113 was in the only available isolation room. The NM stated that the nurse who was assigned to her was at lunch and was unable to be interviewed. The NM stated that the dialysis nurses only changed their gowns between residents if a resident was known to be on isolation. Otherwise the same gown was worn between residents. The NM stated that a 1:100 bleach concentration was used to disinfect the dialysis machines (filters waste products from blood which are passed into the dialysate fluid) and chairs for non-isolation residents and a 1:10 bleach concentration was used to disinfect the dialysis machines and chairs for known isolation residents. On 11/16/17 at 1:47 PM, in a later interview with the NM she stated, Moving forward Resident #115 would now need to be isolated now that we know the resident has C. Auris. On 11/16/22 at 3:06 PM, the surveyor interviewed the LNHA who stated that the facility liaison provided the dialysis center NM with an electronic referral prior to admission for approval of hemodialysis insurance coverage etc. The LNHA stated that the clinical paper was reviewed by the facility and it was determined that the facility had indeed informed the facility prior to acceptance that Resident #113 did have a diagnoses of C. Auris. The LNHA also maintained that the NM also had access to the EHR and could have reviewed the system and determined that the resident was on isolation precautions. The LNHA stated that she could not speak to why the facility nurses had not documented that Resident #113 and #115 had a diagnoses of C. Auris on their DCLs to maintain ongoing communication with the dialysis center as required. The LNHA stated that we told them verbally. The LNHA acknowledged that, If you did not document it, you did not do it. The LNHA stated that the NM did not tell her that she was not aware that Resident #115 had C. Auris. On 11/16/22 at 3:34 PM, the LNHA and the DON were called to the conference room to join the survey team and were informed of the findings that were a public health concern related to the critical information regarding C. Auris that there was not an ongoing communication between the facility and the dialysis center to ensure that the residents were properly placed on TBP. On 11/18/22 at 11:29 AM, two surveyors interviewed the NM and the Regional Coordinator (RC). The RC stated that we received referrals from the sending facility and the NM printed it out and reviewed it. The NM stated she checked COVID-19 status, Hepatitis B antigen (test to detect a contagious liver infection transmitted by blood and body fluids), history and physical (H & P), and a chest x-ray result within the past 30 days. The NM stated that she also reviewed the diagnoses and prescription of the dialysis treatment. The NM stated that the diagnoses of a multi-drug resistant organism was not in those records. The NM stated that she provided the facility with a statement that she received the clinical record and it was an oversight on her part because when she reviewed the Progress Notes and H & P and the present assessment she did not see the diagnoses. The NM further stated that she had not realized that she had forgotten to date the statement. The NM acknowledged that she only learned of Resident #115's need for isolation precautions last Wednesday based on surveyor inquiry. The NM further stated that she overlooked the isolation status in the initial clinical referrals sent by the facility for both Residents #113 and 115. The NM stated that she never spoke to the nurses at the facility prior to treatments as oral report was not given. The NM stated that the Charge Nurse was off and could not be reached. The NM stated that the Charge Nurse did not document having received oral report from the facility prior to resident transfer. The NM stated they just [NAME][TRUNCATED]

Complaint #NJ00158982 Based on facility staff interviews and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) had completed specialized training in infection prevention and control and was qualified by certification and experience for 1 of 1 staff member reviewed in accordance with Center for Medicare and Medicaid Services (CMS) and New Jersey State guidelines. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following: ii. Required Core Practices for Infection Prevention and Control: Facilities are required to have one or more individuals with training in infection prevention and control employed or contracted on a full-time basis or part-time basis to provide on-site management of the Infection Prevention and Control (IPC) program. The requirements of this Directive may be fulfilled by: a. An individual certified by the Certification Board of Infection Control and Epidemiology or meets the requirements under N.J.A.C. 8:39-20.2; or b. A Physician who has completed an infectious disease fellowship; or c. A healthcare professional licensed and in good standing by the State of New Jersey, with five (5) or more years of Infection Control experience. iv. Facilities with 100 or more beds or on-site hemodialysis services must: 1. Hire a full-time employee in the infection prevention role, with no other responsibilities and must attest to the hiring no later than August 10, 2021. On 11/07/22 at 9:36 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that the facility had a Registered Nurse (RN) who served in the role of Infection Preventionist Nurse (IPN) who possessed an Infection Prevention Certification. The LNHA stated that the IPN's job duties included management of residents with Candida Auris (a multi-drug resistant fungus that presents a serious global health threat) infections on the first-floor mechanical ventilator (machine to assist with work of breathing) and tracheostomy (incision in the windpipe made to relieve an obstruction to breathing) unit. The LNHA further stated that the IPN managed the infection with monthly testing in collaboration with the Department of Health (DOH). At 10:53 AM, in a later interview with the LNHA during the entrance conference, the LNHA stated that the IPN's only job responsibility was Infection Prevention which included related education and fit testing for N95 (respirator mask that filters out 95% of particles) mask usage. At 1:33 PM, in a later interview with the LNHA, the LNHA stated that the Assistant Director of Nursing (ADON) covered for the IPN temporarily while the IPN was out on leave for an undisclosed amount of time. The surveyor requested to view the ADON's certifications and or training records and requested to view timecard punch logs for both the IPN and the covering ADON/IP. At 2:16 PM, the LNHA clarified that the ADON did not possess any type of infection control training or certification. The LNHA failed to provide timecard punch logs for either the IPN or the ADON/IP who served as the acting IPN as previously requested. On 11/14/22 at 10:33 AM, the surveyor observed the ADON/IP working in a clinical role, administering medications, on the fourth floor of the facility. On 11/14/22 at 8:59 AM, the surveyor interviewed the Regional Licensed Nursing Home Administrator (RLNHA) who stated that the former Director of Nursing (DON) resigned in October of 2022 (date not specified) and the current DON started working at the facility in the first week of November. The RLNHA stated that when the IPN went out on leave in October, the ADON had covered the position since that time. On 11/14/22 at 9:48 AM, the surveyor interviewed the LNHA who stated that she served in the role since 05/30/22. The LNHA stated that one of the two Medical Directors who served in the shared role, was also an Infectious Disease Doctor (IDD). The LNHA further stated that while the IDD provided education to the facility related to COVID-19, she did not recall that the IDD had provided the facility staff with any education or information related to Candida Auris. The LNHA stated that the building had been in outbreak and accepted residents who previously tested positive with Candida Auris. The LNHA further stated that most ventilator residents were at risk for Candida Auris, so it was not like an actual outbreak. The LNHA further stated that she did not recall any widespread infection as only eight to nine positive residents had resided on the unit since she began working at the facility. On 11/14/22 at 10:45 AM, the surveyor interviewed the IDD via speakerphone (with permission) in the presence of the survey team. The IDD stated that he had been with the facility for a while but due to the pandemic had only been on-site for the past year. The IDD stated that his role has been mainly for education and antibiotic stewardship. The IDD stated that he was not aware that the facility had consistent cases of Candida Auris. The IDD stated, That is a new one. He further stated, I did not realize there was an outbreak of Candida Auris at the facility, and if I knew I would have helped them to address it. The IDD stated that he was unaware that there had been cases of Candida Auris at the facility since 2020. The IDD stated that he did not know who had the cultures but would address it and help them out but needed to know what the underlying problem or cause was to do so. The IDD further stated that contributing factors may have been related to environmental cleaning or improper personal protective equipment (PPE, equipment or clothing worn to protect the body from infection) adherence. On 11/14/22 at 1:02 PM, the surveyor interviewed the ADON/IP in the presence of the survey team. The ADON/IP stated that the IP was on vacation since the middle of October, and she filled in for the position. The ADON/IP further stated that when the former DON resigned and the Unit Manager (UM) resigned, she also filled in for both positions. The ADON/IP stated that the IP was expected to return, though she was not sure when. The ADON/IP stated that she conferred with the Regional Nurse (RN) with infection control questions related to Candida Auris but was unsure if the RN had any Infection Control certification or specialized training. The ADON/IP further stated that the newly hired ADON #2 had specialized IP training. On 11/18/22 at 12:26 PM, the surveyor interviewed the ADON/IP who confirmed that she had no specialized training to fill in for the role of IP while the IP was on a leave of absence. The ADON/IP stated that she consulted with the resident's attending physician's when she had infection control related questions. The ADON/IP clarified that the attending physicians were regular physicians and were not IDDs. The ADON/IP stated that she only just recently found out that the facility had an IDD when he visited the facility last month and did an in-service related to COVID-19. The ADON/IP confirmed that she did not know of the IDD prior to that. The ADON/IP clarified that the newly hired ADON #2 also did not have specialized infection control training as she previously stated. The ADON/IP confirmed that her responsibilities included: employee health services for new hires, and wound rounds in addition to ADON/IP. The DON who was present, stated that she was hired on 10/24/22, and the ADON #2 was hired on 10/27/22. The DON stated that she now attended wound rounds since the ADON #2 was hired. The DON stated that when the ADON/IP was observed passing medications the other day, she did so due to a need for temporary nursing coverage. On 11/22/22 at 10:13 AM, the surveyor interviewed the primary Medical Director (MD) via speakerphone (with permission) in the presence of the survey team. The MD stated that he attended Quality Assurance (QA) Meetings every three months and was unsure who the facility IDD was. The MD stated that he would not know if Candida Auris had been discussed during QA. The MD stated that the IP position changed sometimes, and he did not know who was currently responsible for the role. The MD stated that he observed PPE outside of resident rooms who were isolated for Candida Auris and felt the facility was doing more about it than they used to. On 11/22/22 at 10:23 AM, the surveyor interviewed the DON and requested to see the IP's employee file and proof of the last day worked. The facility failed to provide the information as requested upon the second request. On 11/22/22 at 1:13 PM, the surveyor interviewed the ADON #2, who stated that he did not really have any previous experience in infection control. The DON stated that the ADON #2 would assist the ADON/IP in the role of IP and maintain the line listing reported to the DOH as a group effort and specified that he would not take over the IP role. The DON further stated that the ADON/IP would do that. Review of the undated facility policy, Infection Control Nurse Job Description revealed the following: Education: Must possess valid unencumbered state license. Experience: Two (2) years of experience preferred as a supervisor in a hospital, nursing care facility, or other related health care Facility. Must have, as a minimum of six (6) months experience in rehabilitative and restorative nursing practices. Duties and Responsibilities included but were not limited to: Assist the Director of Nursing and Associate Director of Nursing in planning, developing, organizing, implementing, evaluating, and directing the day-to-day functions of the Nursing department, in accordance with current rules, regulations, and guidelines that govern the Facility. .Provide direct nursing care, as necessary. .Develops and coordinates the infection prevention and control program throughout the facility. Implements the program by formulating, establishing and evaluating policies and procedures relating to patient care infection control measures throughout the facility. Performs annual assessment and develops action plans from the prior year activities . Specific Requirements: .Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities. Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel Acknowledgement: .Unit Manager Infection Control Nurse The policy failed to contain the required elements of the Infection Control Practitioner as outlined in Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020. NJAC 8:39-20.2

Based on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services for a resident who was receiving a continuous oxygen treatment according to standards of practice. This deficient practice was identified for 1 of 2 residents (Resident #45) reviewed. This deficient practice was evidenced by the following: On 9/9/21 at 11:01 AM, the surveyor observed Resident #45 laying on a geri chair inside their room with oxygen via nasal cannula in use. On 9/13/21 at 12:00 PM, the surveyor observed a Certified Nursing Aide (CNA) feeding the resident in their room. The resident had oxygen via nasal cannula attached to the oxygen concentrator at 2 L/M (2 liters/minute). On 9/14/21 at 9:40 AM, the CNA informed the surveyor that Resident #45 was cognitively impaired, required total assistance with activities of daily living (adls) and a feeder. The CNA further stated that it was the nurse's responsibility to take care of the oxygen. The surveyor reviewed the medical record for Resident # 45. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included End-stage renal disease, dependence on renal dialysis, anemia (when the number of healthy red blood cells in the body is too low), diabetes, and hypertension (elevated blood pressure). A review of the 7/7/21 Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate care management, revealed a Brief Interview for Mental Status (BIMS) score was 1, which indicated that the resident's cognition was severely impaired. A review of the Order Audit Report revealed an original order date of 8/30/21 for oxygen inhalation via nasal cannula at 2L/M every shift and to check every shift. Further review of the medical record showed that the August 2021 and September 2021 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) reflected the above orders and were signed by nurses as administered and checked every shift. A review of the personalized care plan revealed that there was no care plan for respiratory care and the use of oxygen of Resident #45. On 9/13/21 at 12:03 PM, the Registered Nurse/Unit Manager (RN/UM) informed the surveyor that it is the responsibility of the admitting nurse to initiate a care plan upon admission. The RN/UM stated that it is the UM, Director of Nursing (DON), and Assistant Director of Nursing (ADON) responsibility to update and revise the care plan when there is a change to a resident which include the new order for oxygen. RN/UM indicated that care plan should be initiated within 24 hours to reflect the current condition of the resident. She further stated that the care plan should be reviewed quarterly and as needed when there is a change. The RN/UM stated it was an oversight on our part, why the care plan for oxygen use and respiratory care was not done. On 9/14/21 at 12:02 PM, the surveyor observed that the resident was not in their room. The 2nd-floor Quality Assurance/Certified Nursing Aide (QA/CNA) informed the surveyor that Resident#45 was transferred to 3rd floor yesterday. On 9/14/21 at 12:05 PM, the surveyor and the Registered Nurse (RN) went inside the resident's room and observed the resident laying on a bed with head of the bed elevated at 45 degrees, with oxygen in use via nasal cannula at 4 L/M attached to the humidified (container with water) oxygen concentrator. The resident was not in distress. On that same date and time, the surveyor asked the RN how much oxygen the resident should be receiving. The RN pointed with her finger toward the oxygen concentrator and stated it's 4 liters. The surveyor then asked the RN to show the order for oxygen. At that time, the surveyor left the resident's room and followed the RN to her medication cart (medcart). The RN opened her computer on top of her medcart and stated to the surveyor the oxygen should be at 2 L/M, and I will change it now. Furthermore, the RN attempted to adjust the oxygen concentrator to 2 L/M multiple times and the machine will not reach the 2 L/M. The RN informed the surveyor that the machine was broken and will have to get the Licensed Practical Nurse/Unit Manager (LPN/UM). On that same date and time, the surveyors observed LPN/UM replaced the broken oxygen concentrator with another concentrator and assessed the resident with the RN. The LPN/UM indicated that the resident was stable and there was no negative effect. On 9/14/21 at 12:21 PM, the RN informed the surveyors that when she came in today at 7 AM, the resident was seen in their room with oxygen. The RN further stated that she was not paying attention when she saw the resident today that was why she was not sure how much oxygen the resident was on that time. On that same date and time, the RN informed the surveyors that it was her responsibility as a nurse to follow the physician's order for oxygen and to check if it is functioning appropriately. The RN stated that she was not aware that the oxygen concentrator was not working properly not until she attempted to correct the oxygen liter order for 2 L/M. On 9/14/21 at 1:04 PM, the surveyors met with the LNHA, DON, ADON, and two Regional Directors and were made aware of the above concerns. The DON informed the surveyors that a care plan for oxygen use and respiratory care should have been done. On 9/16/21 at 9:39 AM, the surveyors met with the DON, LNHA. The DON stated that she spoke to the RN and educated the RN to make sure to check the order for oxygen and oxygen concentrator machine matches the order. The DON further stated that it is the responsibility of the nurse to check the oxygen for function, to replace the broken oxygen concentrator with a portable oxygen tank, and not to attempt to fix the oxygen concentrator. The DON indicated that the resident was assessed immediately and there was no negative effect to the resident. A review of the facility Care Plan Policy/Procedure that was provided by the DON with a revised date of 7/2021 included Purpose of the Care Plan: An interdisciplinary approach to identification of problems and developing solutions provides individualization and coordination of resident care. Policy Interpretation and Implementation: 1. All residents must have a Care Plan that is reviewed, revised, and updated quarterly and more frequently if warranted by a significant change in resident's condition A review of the facility Oxygen Administration Per Nasal Cannula that was provided by the DON with a revised date of 12/2020 included Policy: A physician's order shall be required for administering oxygen Procedure: Verify order in the resident's medical record . NJAC 8:39-11.2 (b); 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 1 of 6 medication carts inspected. This deficient practice was evidenced by the following: On 9/15/21 at 10:15 AM, the surveyor inspected the 3rd floor high side medication cart in the presence of a Licensed Practical Nurse (LPN). The surveyor observed two opened Novolog Insulin vials that were inside a bag that contained a different resident's name than were on the insulin vial. At that time, the surveyor interviewed LPN who stated that the Novolog insulin vials should have been placed in the bag with the corresponding names. She stated that she should have double checked to make sure she was placing the vial into the right bag. On 9/15/21 at 1:15 PM, the surveyor met with the Licensed Nursing Home Administrator and the Director of Nursing (DON), and no further information was provided by the facility. A review of the facility's policy for Medication Storage dated 4/14 that was provided by the DON indicated the following: E). Medications will be stored in the original, labeled containers received from the pharmacy. NJAC: 8:39-29.4 (a) (h) (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 9/14/21 at 9:25 AM, during a medication observation pass, the surveyor observed a Registered Nurse (RN) washed her hands after administering medication to a resident. The surveyor observed the RN put on the faucet, wet her hands then apply soap and immediately rinse her hands under a stream of water without scrubbing her hands for 20 seconds. At that time, the surveyor interviewed the RN who stated that she should have scrubbed her hands away from running water for 20 seconds before rinsing her hands under a stream of water. On 9/14/21 at 1:00 PM, the surveyor met with the DON and Licensed Nursing Home Administrator and no further information was provided by the facility. A review of the facility's policy for Infection Control-Contact Precautions revised 3/24/20 included it is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable disease and infections in accordance with State and Federal Regulations, and national guidelines .Contact precautions are implemented most often for residents who have an infection due to an epidemiologically important organism such as multi-drug resistant organism .Personal protective equipment is to be worn to protect health care workers (i.e. have a barrier) from contact with body fluids .The personal protective equipment worn will vary by task being performed and likelihood of exposure to body fluid. A review of the facility's policy undated policy for Airway Management provided by the DON indicated that the procedure for performing daily tracheostomy care was to utilize universal precautions (gloves, eye protection, face mask and gown) inclusive of hand washing per facility guidelines before and after the procedure. A review of the facility's policy for Handwashing/Hand Hygiene dated 7/12/20 that was provided by the DON indicated the following: Under Procedure: Rub hands briskly, pay attention to areas between fingers, for at least 20 seconds then rinse hands lowered allowed soiled water to drain directly into the sink. NJAC 8:39-19.4 (a) (1) (n) (2) Based on observation, interview, and record review, it was determined that the facility failed to a.) use the appropriate personal protective equipment (PPE) for 1 of 2 staff, b.) disinfect the table prior to setting up equipment for tracheostomy (An opening created at the front of the neck so a tube can be inserted into the windpipe to allow direct access to the breathing tube) care, c.) properly dispose the inner cannula of the tracheostomy and used equipment. This was identified for 1 of 1 resident (Resident #92) reviewed for tracheostomy care, and e.) perform appropriate hand hygiene in 1 of 3 nurses observed during medication pass. This deficient practice was evidenced by the following: According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines Summary for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators during Shortages dated 4/9/21 indicated that Personal Protective Equipment: Respiratory Protection .Use surgical N95 respirators only for HCP [health care personnel] who need protection from both airborne and fluid hazards (e.g; splashes, sprays). If needed but unavailable, use face shield over standard N95 respirator. According to the U.S. CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, page last updated 2/23/21, included Personal Protective Equipment: HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. Hand Hygiene: HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. HCP should perform hand hygiene by using ABHR with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHR. Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location. Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures. According to the Occupational Safety and Health Administration (OSHA) for Respiratory Protection Guidance for the Employers of Those Working in Nursing Homes, Assisted Living, and Other Long-Term Care Facilities During the COVID-19 Pandemic indicated When protection against exposure to splashes and sprays of infectious material from others is also need, an FDA [Food and Drug Administration]-cleared or authorized surgical N95 FFR [filtering facepiece respirators] must be worn by healthcare workers. 1. On 9/9/21 at 12:07 PM, the surveyor observed Resident # 92's door with a stop sign and PPE bin with adequate PPE on the door and alcohol-based hand rub (ABHR). On 9/10/21 at 10:15 AM, the surveyor observed Resident #92 in bed with eyes closed. The surveyor observed the resident with a tracheostomy and on a ventilator machine (a machine that mechanically pumps oxygen into the lungs). At that same time, the surveyor interviewed the Respiratory Therapist (RT) who stated that the resident is on isolation precautions specifically contact precautions due to Candida Auris (a fungal infection). On 9/13/21 at 9:30 AM, two surveyors observed the RT perform tracheostomy care to Resident # 92. The surveyors observed the RT wearing a blue surgical mask. She donned (put on) a blue disposable gown and gloves and entered the resident's room. She then rolled the overbed table to the bedside and without disinfecting the table she set up the required equipment for the tracheostomy care. The surveyors observed the RT dispose of the inner tracheostomy cannula into the regular garbage trash bin and equipment used to render tracheostomy care. The surveyors observed the RT doff (remove) the disposable gown and gloves and dispose into a dedicated red bin with an orange color biohazard plastic bag inside the resident's room near the door. On that same date at 9:46 AM, the surveyors interviewed the RT who stated I'm going back in to disinfect the table. I did disinfect the table earlier this morning. The surveyors inquired if she wore a surgical mask for tracheostomy care. The RT stated that she doesn't have to use an N-95 mask because the resident was not on transmission-based precautions for COVID-19 but for C. auris. She further stated that disposing of the inner cannula into the regular garbage bin was her usual practice as long as there were no blood or body fluids otherwise it would need to go into the red biohazard bag. The RT stated she was trained by the Regional RT and that she followed the facility policy and protocols. On 9/14/21 at 10:40 AM, the surveyor in the presence of the survey team interviewed the Regional RT who confirmed she trained the aforementioned RT. She also acknowledged that placing the inner tracheostomy cannula in the regular garbage trash bin was the facility's practice/protocol. She stated that the use of a surgical mask during tracheostomy care is acceptable for contact precautions. On 9/14/21 at 1:04 PM, the survey team met with the administration staff and discussed the above observation and concerns. The Director of Nursing (DON) stated, We changed our policy to reflect that we will be using an N95 mask for all patients with C. Auris. On 9/14/21 at 1:36 PM, the surveyor in the presence of the survey team interviewed the Infection Control Preventionist who stated, an N95 mask should be worn when providing tracheostomy care and changing of the inner cannula. She stated, this is according to our protocol, not our policy. She further stated that the RT should have worn an N95 mask during tracheostomy and changing the inner cannula because you don't know what is in the splashes. She further stated, the RT should have disposed of the inner cannula in the biohazard covered bin that was inside the resident's room. This was the facility protocol that all staff on the first floor should wear an N95 mask when entering the resident's room. It doesn't matter what kind of infection. The surveyor reviewed the medical record for Resident # 92. A review of the Significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/13/21 reflected that the resident was admitted to the facility on [DATE] with diagnoses which included but were not limited to pneumonia, seizure disorder, and respiratory failure. The MDS assessment further revealed that the resident's cognitive skills for daily decision-making were severely impaired. The MDS further included that the resident was assessed for tracheostomy care, invasive mechanical ventilator, and oxygen therapy. A review of the resident's individual comprehensive Care Plan initiated 8/18/21 reflected that the resident had an infection of the skin Candida Auris suppressed immune system. The intervention included was to maintain contact precautions when providing resident care and to follow facility policy and procedures for line listing, summarizing, and reporting infections. Further review of the care plan revealed that on 8/3/21 the care plan for ventilator-dependent related to respiratory failure was initiated and it did not specify what PPE to use during tracheostomy care as part of interventions. A review of the Order Listing Report indicated an active physician's order dated 8/18/21 for Resident on contact Isolation for Candida Auris.