Complaint #: NJ185063 Based on interviews, closed medical record review, and review of pertinent facility documentation on 4/3/25, it was determined that the facility failed to follow standards of clinical practice by not obtaining a physician's order for oxygen for a resident (Resident #2) that utilized continuous oxygen therapy. The facility also failed to follow its policy titled Oxygen Administration. This deficient practice was identified in 1 of 3 residents (Resident #2) reviewed for oxygen therapy and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem. According to the admission Record (AR), Resident #2 was admitted to the facility in March of 2025 with diagnoses which included but were not limited to: Acute Respiratory Failure (occurs when the lungs cannot adequately exchange oxygen and carbon dioxide), Obstructive Sleep Apnea, and Acute Kidney Failure. According to the admission Minimum Data Set (MDS), an assessment tool dated 3/27/25, revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed that the resident was on oxygen therapy on admission and while a resident at the facility. According to Resident #2's March 2025 Progress Notes (PN) revealed that the resident was admitted to the facility and continuous oxygen via nasal cannula (medical device used to deliver supplemental oxygen to individuals with low oxygen levels) was initiated. The PNs further revealed that the resident wore oxygen therapy via nasal cannula throughout his/her stay at the facility. According to Resident #2's Order Summary Report (OSR) dated 3/30/25, there were no physician's orders for as needed or standing oxygen therapy. On 4/3/25 at 11:36 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who confirmed that Resident #2 had worn continuous oxygen while at the facility. LPN #1 stated that if a resident required continuous oxygen, they would have a physician's order for it and it would be on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). On 4/3/25 at 12:44 PM, the surveyor interviewed the Meadows Unit Manager (UM) who confirmed that Resident #2 was supposed to wear oxygen all the time. The UM stated Yes, a resident has to have an order for oxygen if they use it. The UM stated that the nurse was responsible for putting in oxygen orders and it was important to have an order because it was considered a drug. The UM stated No, I do not see an order for oxygen for Resident #2, there should have been an order since admission. On 4/3/25 at 3:44 PM, the surveyor interviewed the Regional Director of Nursing (RDON) in the presence of the Licensed Nursing Home Administrator (LNHA) who confirmed that Resident #2 did not have an order for oxygen but required it. The RDON stated, Yes, there should be an order to know administration route and amount of liters. The RDON stated that the admitting nurse should have put in Resident #2's oxygen orders. Review of the facility's policy titled Oxygen Administration with an adopted date of August 2021 revealed under Preparation, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of the facility's job description titled LPN Nurse revealed under Duties and Responsibilities, Charting and Documentation: Complete the admission process for all newly admitted residents including completion of checklists, evaluations, treatments, physician orders and all other nursing responsibilities as required by Center policy, procedure, or practice. NJAC 8:39-11.2 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ175300 Based on interviews, medical record review, and review of other pertinent facility documents on 08/05/2024, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status, follow the Certified Nursing Assistant (CNA) job description and follow its policy titled Charting and Documentation for 3 of 3 residents (Resident #2, Resident #12, and Resident #15) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses that included but were not limited to Hemiplegia and Hemiparesis (loss of the ability to move and sometimes to feel anything on one side of the body), Pressure Ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and Weakness. The Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 06/27/2024 revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe impairment. The MDS also indicated that Resident #2 required substantial/maximal assistance to roll left to right. Review of Resident #2's Care Plan (CP) revealed a Focus, initiated on 01/24/2024, that Resident #2 had skin impairment on the sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis), right buttocks, left buttocks, left heel, right and left breast, bilateral groin. The CP indicated that the resident required reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Resident #2's DSR for July 2024 showed the following: On the 7:00 A.M. to 3:00 P.M. shift, there was no documentation for Bed Mobility- Turn and Positioning for a total of 18 days: On 07/01/2024, 07/02/2024, 07/04/2024 through 07/07/2024, 07/09/2024, 07/11/2024, 07/12/2024, 07/14/2024 through 07/18/2024, and 07/23/2024 through 07/26/2024. On the 3:00 P.M. to 11:00 P.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning. for a total of 22 days: On 07/01/2024 through 07/10/2024, 07/12/2024, 07/14/2024 through 07/17/2024, 07/19/2024, 07/20/2024, 07/26/2024, 07/27/2024, and 07/29/2024. On the 11:00 P.M. to 7:00 A.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning for a total of 21 days: On 07/01/2024, 07/04/2024, 07/10/2024, 07/11/2024, 07/13/2024 through 07/16/2024, 07/18/2024, and 07/20/2024 through 07/31/2024. Review of Resident #2's Progress Notes (PNs) for July 2024 revealed no documentation that Resident #2 was turned and repositioned during the aforementioned shifts. There was no documentation in the PNs for the month of July 2024 for any worsening in skin condition. 2. According to the AR, Resident #12 was admitted to the facility with diagnoses that included but were not limited to Muscle Weakness (generalized), Unspecified Dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and Lack of Coordination. The MDS dated [DATE] revealed that Resident #12 had a BIMS score of 0 out of 15, which indicated severe impairment. The MDS also indicated that Resident #12 required substantial/maximal assistance to roll left to right. Review of Resident #12's CP revealed a Focus, initiated on 08/03/2023, that Resident #12 had an ADL self-care performance deficit related to deconditioning after hospitalization and requires assistance with ADLs. The CP indicated that the resident required 1 staff assist with turning and repositioning. Resident #12's DSR for July 2024 showed the following: On the 7:00 A.M. to 3:00 P.M. shift, there was no documentation for Bed Mobility- Turn and Positioning for a total of 5 days: On 07/06/2024, 07/07/2024, 07/20/2024, 07/28/2024, and 07/29/2024. On the 3:00 P.M. to 11:00 P.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning for a total of 11 days: On 07/02/2024, 07/07/2024, 07/13/2024, 07/15/2024, 07/18/2024, 07/22/2024, 07/25/2024, 07/26/2024, and 07/31/2024. On the 11:00 P.M. to 7:00 A.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning for a total of 7 days: On 07/02/2024, 07/07/2024, 07/13/2024, 07/15/2024, 07/18/2024, 07/22/2024, 07/25/2024, 07/26/2024, and 07/31/2024. Review of Resident #12's Progress Notes for July 2024 revealed no documentation that Resident #12 was turned and repositioned during the aforementioned shifts. 3. According to the AR, Resident #15 was admitted to the facility with diagnoses that included but were not limited to Muscle Weakness (generalized), and Spinal Stenosis, Lumbosacral Region (Narrowing of the spinal canal, compressing the nerves traveling through the lower back possibly causing pain, tingling, numbness, and muscle weakness). The MDS dated [DATE] revealed that Resident #15 had a BIMS score of 11 out of 15, which indicated moderate impairment in cognition. The MDS also indicated that Resident #15 required partial/moderate assistance to roll left to right. Review of Resident #15's CP revealed a Focus, initiated on 05/25/2024, that Resident #15 had ADL self-care performance deficit related to unsteady gait and impaired balance. The CP indicated that Resident #15 requires the assist of 1 staff and a sheet for turning and repositioning. Resident #15's DSR for July 2024 showed the following: On the 7:00 A.M. to 3:00 P.M. shift, there was no documentation for Bed Mobility- Turn and Positioning for a total of 5 days: On 07/06/2024, 07/18/2024, 07/20/2024, 07/24/2024, and 07/31/2024. On the 3:00 P.M. to 11:00 P.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning for a total of 2 days: On 07/01/2024 and 07/06/2024. On the 11:00 A.M. to 7:00 P.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning for a total of 18 days: On 07/02/2024, 07/04/2024 through 07/07/2024, 07/08/2024, 07/09/2024, 07/11/2024, 07/13/2024 through 07/16/2024, 07/18/2024, 07/21/2024, 07/23/2024, 07/27/2024, 07/28/2024, 07/30/2024, and 07/31/2024. Review of Resident #15's PNs for July revealed no documentation that Resident #15 was turned and repositioned during the aforementioned shifts. During an interview on 08/02/2024 at 2:40 P.M., Certified Nursing Assistant (CNA#1) stated that CNAs were responsible for ADL care and that documentation was done in the electronic system. She further stated that changes of position were provided every two hours, or more frequently if the resident requested or appeared uncomfortable. CNA #1 stated that blank spaces in DSR may be due to staff forgetting to document the care that was provided, or staff having issues with access to the electronic record. On 08/05/2024 at 10:49 A.M., the Unit Manager/Registered Nurse (UM/RN) stated that it was expected that all documentation was completed by staff by the end of their shift. The UM/RN stated that there should be no missing documentation on the DSR. The UM/RN stated that if residents refused treatment, this should be documented in the progress notes. On 08/05/2024 at 2:11 P.M., during an interview with the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA), stated that CNAs were responsible for completing ADL care and for documenting care provided before the end of their shift. The LNHA stated the expectation is that documentation is 100% complete. The LNHA stated that blank spaces on the ADLs sheet may not mean the task was not completed because the blank could be due to a documentation error. The DON revealed that the facility changed the format of documentation in August of 2023. The DON reported that she has previously recognized that CNAs required additional education related to the format change for documentation. DON reported that auditing of CNA documentation was done routinely, and CNAs were reminded frequently to document care provided to residents. Review of the facility's job description document for the position Certified Nurse Assistant/Geriatric Nursing Assistant revealed under Duties and Responsibilities: Record all entries on flow sheets, notes, charts, computers etc., in an informative and descriptive manner. Duties and Responsibilities also include: assist with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. Review of the facility's policy last revised July 2012, titled Charting and Documentation, under Policy Statement revealed: All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Under Policy Interpretation and Implementation #3 the policy stated Documentation in the medical record will be objective .complete, and accurate. NJAC 8:39-35.2(f)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident. This deficient practice was identified for 1 of 32 residents reviewed for accommodation of needs (Resident #89), and was evidenced by the following: On 3/27/24 at 12:09 PM, the surveyor observed Resident #89 in their room, seated in a wheelchair with their eyes closed. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was on the floor, not within his/her reach. On 3/27/24 at 12:17 PM, the surveyor observed Resident #89 in his/her room seated in a wheelchair with their call bell located on the floor, not within his/her reach. On 4/4/24 at 1:18 PM, the surveyor observed Resident #89 in his/her room seated in a wheelchair eating their lunch meal. The surveyor observed the call bell was positioned in the middle of the resident's bed; not within their reach. The surveyor asked the resident how he/she called the staff when they needed assistance, and the resident pointed to the call bell and stated that he/she would hit the buzzer. The resident then reached out his/her arms and stated, I have long arms, but not that long. On 4/4/24 at 1:25 PM, the surveyor interviewed the Certified Nursing Aide (CNA) who stated the resident used their call bell to alert staff they needed assistance. At that time, the surveyor accompanied by the CNA and the Licensed Practical Nurse (LPN) entered Resident #89's room, and they observed the call bell in the middle of the resident's bed, not within the resident's reach. The CNA and LPN acknowledged the call bell should have been left within the resident's reach and proceeded to place it within reach. The surveyor reviewed the medical record for Resident #89. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included a history of falling, fracture of the right pubis, and urinary retention. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, reflected the resident had a brief interview for mental status score of 12 out of 15, which indicated a mild cognitive impairment. A further review indicated they required moderate assistance from staff for transfers and toileting. A review of the individual comprehensive care plan included a focus area dated 12/4/23, I am at risk for falls. Interventions included keeping the call [bell] within reach and providing reminders to use it to call for assistance. On 4/8/24 at 10:18 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), Regional LNHA, and survey team acknowledged that all residents should have their call bells within reach, and confirmed that the staff member who set the resident up with their lunch tray should have ensured the call bell was within reach. A review of the facility's Certified Nursing Assistant job description included .the primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services .which included keeping the nurses' call system within easy reach of the resident. NJAC 8:39- 31.8 (c)(9)

Complaint # NJ169996; NJ172438 Based on interviews and review of pertinent facility documentation, it was determined that the facility failed to report an alleged theft (wedding ring) to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident # 35), and was evidenced by the followning: According to Resident #35's admission Record face sheet (an admission summary), the resident was admitted to the facility with diagnoses which included unspecified dementia and atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls). According to the most recent quarterly Minimum Data Set (MDS), an assessment tool, Resident #35 had a brief interview for mental status (BIMS) score of 5 out of 15, which indicated a severely impaired cognition. The MDS further indicated the resident was dependent on staff for Activities of Daily Living (ADL). A review of the facility provided Grievance Summaries included an incident date of 9/26/2023, reported date of 1/4/2024, and a resolved date of 12/15/2023 which was completed by the Director of Nursing (DON), included a missing ring reported to facility 10/26/23 and the police report filed in December. This was reported to the facility at least a month after the occurrence at which point the family was explained it would difficult to follow-up on; family upset. Summary of Actions Taken included, resident's [representative] decided to report to the local police. The grievance did not include documentation that the NJDOH was notified of the alleged theft. On 4/3/24 at 9:36 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the previous Administrator was in charge of this grievance and they were aware of the missing wedding ring. The LNHA stated the incident was not reported to the NJDOH and acknowledged that it should have been. A review of facility provided policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating with a revised date of September 2022, included if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility . A review of an undated facility provided policy titled Investigating Incident of theft and/or Misappropriation of Resident Property included .if an alleged or suspected case of the theft, exploitation or misappropriation of resident property is reported, the facility administrator, or his/her designee, notifies the following persons or agencies within twenty-four (24) hours of such incident, as appropriate: a. State licensing and certification agency . NJAC 8:39-4.1(a)15

Complaint #NJ 169996; NJ172438 Based on interviews and review of pertinent facility documentation, it was determined that the facility failed to complete a thorough investigation for an alleged theft (wedding ring) for 1 of 4 residents reviewed for abuse (Resident #35). This deficient practice was evidenced by the following: According to Resident #35's admission Record face sheet (an admission summary), the resident was admitted to the facility with diagnoses which included unspecified dementia and atherosclerotic heart disease. According to the most recent quarterly Minimum Data Set (MDS), an assessment tool, Resident #35 had a brief interview for mental status (BIMS) score of 5 out of 15, which indicated a severely impaired cognition. The MDS documentation also identified that Resident #35 is dependent on staff for Activities of Daily Living (ADL). A review of the facility provided Grievance Summaries included an incident date of 9/26/2023, reported date of 1/4/2024, and a resolved date of 12/15/2023 which was completed by the Director of Nursing (DON) included a missing ring reported to facility 10/26/23 and the police report filed in December. Summary of Investigation included resident's [representative] had no explanation when asked why [he/she] did not report missing item immediately. Summary of Findings included difficult to investigate due to time lapse in reporting. Summary of Actions Taken included resident's [representative] decided to report to the local police. On 4/2/24 at 11:30 AM, the surveyor interviewed the Director of Nursing (DON) who stated they were unaware if the previous Administrator had completed an investigation or if there were any statements from staff written. The surveyor asked if incident should have been investigated, the DON replied, it was hard to investigate, due to being reported a month later. On 4/8/24 at 10:17 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, Regional LNHA, and survey team stated they were aware that the resident lost a wedding ring but the previous Administrator was at the facility at the time. The LNHA acknowledged the incident should have been investigated. A review of the undated facility provided policy titled Investigating Incident of theft and/or Misappropriation of Resident Property included .when an incident of theft and/or misappropriation of resident property is reported, the administrator appoints a staff member to investigate the incident . A review of facility provided policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating with a revised date of September 2022, included all allegations are thoroughly investigated. The administrator initiates investigations . NJAC 8:39-5.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure an electronic pharmacy drug interaction alert was communicated to a physician in accordance with professional standards of practice. This deficient practice was identified for 1 of 30 residents reviewed for professional standards of practice (Resident #450). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. This deficient practice was evidenced by the following: On 3/27/24 at 12:12 PM, the surveyor observed Resident #450 lying in bed with a wound vacuum (enclosed wound suction device) on the left lower leg. The resident stated that he/she had a blood clot (a mass of blood that forms when blood platelets, proteins, and cells stick together) in their left leg and they were leaving for doctors appointment. The surveyor reviewed the medical record for Resident #450. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included generalized muscle weakness, complete traumatic amputation, and acute embolism (a clot that moves to another part of the body) and thrombosis (stationary blood clot). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating a fully intact cognition. A review of the Progress included a Physician's Order Note dated 4/2/24 at 11:11 PM, included the order you have entered Keflex oral capsule 500 milligram (mg), an antibiotic, give one capsule by mouth every twelve hours for wound healing for ten days; has triggered a drug to drug interaction. The system has identified a possible drug interaction with the multivitamin with minerals oral tablet order. A review of the corresponding April 2024 Medication Administration Record, revealed Keflex and the multivitamin were scheduled to be administered at 9:00 AM. A further review of the Progress Notes did not include the physician was made aware of the possible drug interaction. On 4/4/24 at 11:28 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that when a physician order was inputted into the electronic medical record, the Pharmacy will automatically generate a drug interaction alert that the facility was responsible to address. The CP stated Keflex interacted with the iron in the multivitamin which affected the absorption of the antibiotic (Keflex). On 4/4/24 at 1:05 PM, the surveyor interviewed the Registered Nurse (RN) who stated when a drug interaction was identified, the nurses called the physician to inform them, and the physician determined how to proceed. The nurse then documented in the Progress Notes that they spoke to the physician, and how the physician wanted to proceed. At this time the surveyor and the RN observed the facility's house stock multivitamin with minerals bulk bottle which contained iron as one of the minerals. On 4/4/24 at 1:10 PM, the surveyor interviewed the Unit Manger/Licensed Practical Nurse (UM/LPN) who confirmed the nurse notified the physician of any drug interactions, and documented the notification with any new orders. The UM/LPN acknowledged Keflex should not be administered at the same time as the multivitamin with minerals, and that the physician was never notified. On 4/8/24 at 10:00 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Regional LNHA, and survey team confirmed the nurses should be contacting the physician at the time a pharmacy drug interaction alert was generated, and document the notification in the Progress Notes. The LNHA acknowledged the physician was not notified of the interaction between the Keflex and multivitamin with minerals until surveyor inquiry. A review of the facility's Medication and Treatment Orders policy dated revised July 2016, did not include a procedure for pharmacy drug interaction alerts. NJAC 8:39-27.1(a)

Complaint#: NJ167771; NJ168132 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure activities of daily living (ADLs) including incontinence care and assistance with meals were performed for a resident. This deficient practice was identified on 1 of 30 residents reviewed for sufficient staffing (Resident #57), and was evidenced by the following: On 4/1/24 at 11:58 AM, the surveyor observed Resident #57 awake in bed with their untouched breakfast tray on their overbed table. At this time, the surveyor requested from the Unit Clerk a copy of the Certified Nursing Aide (CNA) assignment sheet for that day. A review of the assignment sheet revealed the Registered Nurse (RN) was scheduled and assigned as Resident #57's CNA for the 7:00 AM to 3:00 PM (7-3) shift. On 4/1/24 at 12:00 PM, the surveyor interviewed the RN who confirmed that they were scheduled as a CNA for the care of Resident #57. The surveyor asked if the resident ate breakfast that morning or received their morning care. The RN responded that they had not yet assisted the resident with their breakfast or performed incontinence care for that shift. The RN stated they had fifteen assigned residents for the day and still needed to provide care for Resident #57. The RN confirmed that the resident received nutrition through an enteral feeding tube (tube inserted in the stomach to provide nutrition) but also received regular meals that the resident needed assistance with. On 4/1/24 at 12:01 PM, the surveyor in the presence of the RN requested the Unit Manager/Licensed Practical Nurse (UM/LPN) to accompany them to Resident #57's room. The surveyor asked the UM/LPN to check if the resident's incontinent brief was soiled, and the UM/LPN confirmed the brief was saturated with urine and needed to be changed. At this time, the surveyor asked the UM/LPN if the the resident had been assisted with breakfast that morning. The UM/LPN confirmed the breakfast tray was untouched and the resident still needed to eat. The UM/LPN stated the breakfast tray was delivered around 8:30 AM. The surveyor reviewed the CNA assignment sheet for the 7-3 shift on 4/1/24, which revealed the census for the nursing unit was 59, and there were four assigned CNAs for the residents. The RN who was assigned as a CNA had fifteen residents on her assignment for the day. The surveyor then reviewed the medical record of Resident #57. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included dysphagia, (swallowing problems occurring in the mouth and or the throat), gastrostomy status (enteral feeding tube), and gastro-esophageal reflux disease. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, reflected the resident had long and short-term memory problems with a severely impaired cognition. A further review revealed the resident received more than 51% of their total calories via a feeding tube, and the resident was dependent on staff for eating and toileting. A review of the individualized comprehensive care plan (ICCP) dated effective 1/8/24, included a focus area that the resident was at risk for alteration in nutrition in regards to his/her varying by mouth intake. Interventions included to provide me with a diet as ordered regular pureed consistency; monitor intake and tolerance; monitor for changes in chewing or swallowing. An additional focus area included Activities of Daily Living (ADL) self-care performance with interventions that included to provide hands-on-assistance for eating, drinking, and toileting. A review of a Nutrition Note dated 2/2/24 at 11:50 AM, the resident received a pureed diet with nectar thick liquids and no concerns with weight were identified. A review of the CNA tasks included eating and nutrition required hand-on assistance for eating and drinking with total assistance with eating and drinking. The tasks also included for toileting to check resident approximately every two hours and provide incontinence care as needed. On 4/3/24 at 11:18 AM, the surveyor interviewed the Director of Nursing (DON) who stated the CNAs began morning care around 7:30 AM, and morning care should be completed by 11:00/11:30 AM. The DON stated the CNAs also conducted rounds to ensure residents incontinence brief were changed every two hours. The DON stated there should be one CNA assigned to eight residents for the 7-3 shift. On 4/8/24 at 10:17 AM, the DON in the presence Licensed Nursing Home Administrator (LNHA), Regional LNHA, and survey team acknowledged it was not acceptable that the resident was not seen by the CNA that morning; the resident should have been fed breakfast and received morning care before 12:00 PM. A review of the facility's Activities of Daily Living (ADLs), supporting policy dated revised March 2018, included resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living . A review of the facility's Urinary Continence and Incontinence-Assessment and Management policy dated August 2022, included the physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible . NJAC 8:39-5.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident's food preference of no gravy on meals was honored. This deficient practice was identified for 1 of 5 residents reviewed for nutrition (Resident #27), and was evidenced by the following: On 3/27/24 at 12:41 PM, the surveyor interviewed Resident #27 who stated they disliked gravy on his/her food because it upset their stomach. The resident stated they informed the Registered Dietitian (RD) their concern, but they still received gravy on his/her dinner meal every night. The surveyor then reviewed the medical record of Resident #27. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses that included unspecified escherichia coli (E. coli; bacteria found in the lower intestine) and hypertension (high blood pressure). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A review of the individualized comprehensive care plan (ICCP) dated effective 3/2/24, included a focus area that the resident had a nutritional problem. Interventions included my food preferences will be recorded and updated as needed. A review of the admission Nutrition assessment dated effective 3/8/24, included the resident received a therapeutic diet (such as low salt, diabetic, low cholesterol), and had no dietary preferences. A review of the Progress Notes did not include any Dietary/Nutrition Notes with the resident's dietary preferences. On 4/1/24 at 12:30 PM, the surveyor observed Resident #27 in their room eating lunch which consisted of soup, apple pie and iced tea. The surveyor reviewed the resident's lunch Selection Sheet (meal ticket) which indicated no preferences or dislikes. On 4/2/24 at 11:47 AM, the surveyor interviewed the RD in the presence of the Regional RD who stated she spoke to Resident #27 on 3/11/24, and the resident stated he/she disliked gravy on their food, but she failed to document it. The RD also acknowledged that she should have communicated the dislike to the kitchen. The RD stated the resident attended the Food Committee Meeting on 3/21/24, and the resident informed her that he/she did not want gravy on their food. A review of the Food Committee Meeting dated 3/21/24, included Resident #27 asked for the facility to not put gravy on all his/her food because it upset their stomach. On 4/3/24 at 11:31 AM, the surveyor interviewed Resident #27 who informed them that last night he/she received meat and noodles on their dinner tray that had gravy on it. On 4/3/2024 at 12:00 PM, the surveyor interviewed the RD who stated she had spoken with the resident this morning who informed her they received gravy on their dinner meal last night. The RD stated she did inform the kitchen yesterday that the resident did not prefer gravy, so their should have been no gravy on the resident's dinner last night. On 4/8/24 at 10:17 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Regional LNHA, Director of Nursing (DON), and survey team acknowledged the facility should honor resident's food preferences. A review of the facility's Resident Food Preferences Orders policy dated revised July 2017, included upon the resident's admission the dietician and /or nursing staff will identify a resident's food preferences . NJAC 8:39-17.4(a)1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received occupational therapy services in accordance with their therapy plan. This deficient practice was identified for 1 of 2 residents reviewed for rehabilitation (Resident # 131), and was evidenced by the following: On 3/27/24 at 12:29 PM, the surveyor observed the resident in bed with a pressure relieving device in place. The resident stated that he/she had not received rehabilitation (rehab) therapy since last Thursday (3/21/24) when his/her Certified Occupational Therapist Aide (COTA) went out sick. Resident #131 further stated that their COTA came back today, and informed the resident that she thought they had been discharged from therapy since they received no therapy while she was out of the facility. On 4/1/24 at 12:41 PM, the surveyor interviewed Resident #131 who stated he/she had extended their stay at the facility for rehab in order to practice transferring from the bed to the commode, but had not received therapy for the week because his/her therapist was out sick. The resident further stated that the Director of Rehabilitation (DOR) had gone to his/her room on 3/27/24, after the COTA had seen him/her, and the DOR apologized for having left them off the schedule. The resident continued that the DOR assured them that they would receive therapy for the following four days which included Thursday, Friday, Saturday, and Sunday. Resident #131 stated that their COTA came on Thursday and Friday, but no one from rehab showed up on Saturday. On 4/2/24 at 11:12 AM, the surveyor interviewed the COTA who confirmed that the facility held a Care Conference for Resident #131 on 3/18/24, where the resident decided that even though he/she had exhausted their insurance covered therapy days, he/she would continue with rehab services and pay privately. The COTA stated that she had notified the DOR who was responsible for scheduling residents for rehab, and confirmed there should not have been a lapse in Resident #131's therapy. The COTA stated when she returned to the facility from leave, she informed the DOR that Resident #131 had not received therapy. On 4/2/24 at 11:26 AM, the surveyor interviewed the Occupational Therapist (OT) who confirmed Resident #131 had not received therapy from 3/21/24 to 3/27/24, and that the DOR was responsible for scheduling residents for rehab. On 4/2/24 at 11:50 AM, the surveyor interviewed the DOR who confirmed that Resident #131 should not have had a lapse in therapy; that he had mistakenly left the resident off the rehab schedule during the time the COTA was out of the facility. The DOR further stated he was not aware of this until the COTA returned and brought it to his attention. The DOR confirmed that he had promised the resident he/she would receive therapy for the four days following the return of the COTA. The surveyor asked if he should have followed up to ensure that the resident received their therapy sessions, and the DOR acknowledged that he should have, but that he did not work on weekends. At this time, the surveyor requested from the DOR the rehab notes including the Interdisciplinary Care Plan (IDCP) meeting notes, discharge plans, and policies. The surveyor reviewed the medical record for Resident #131. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included a pressure ulcer of the right heel, muscle weakness, and gout. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, reflected the resident had a brief interview for mental status of 14 out of 15; which indicated a fully intact cognition. On 4/8/24 at 10:52 AM, the surveyor interviewed the Campus Director of Rehab (CDOR) who provided the surveyor with a copy of the Occupational Discharge summary dated [DATE], which included the discharge plan was to continue therapy with the resident paying privately for services. The CDOR confirmed that the resident should have been scheduled for occupational therapy within twenty-four to forty-eight hours after the discharge. On 4/8/24 at 11:21 AM, the surveyor reviewed the Occupational Discharge summary dated [DATE] with the Licensed Nursing Home Administrator (LNHA), who acknowledged the resident should have received therapy during the time period paying privately. No additional documentation was provided. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during wound care treatment. This deficient practice was identified for 1 of 1 wound observations observed for 1 of 3 residents reviewed for pressure ulcer and injury (Resident #16), and was evidenced by the following: On 3/28/24 at 9:39 AM, the surveyor observed Resident #16 in bed with their eyes closed. The surveyor reviewed the medical record for Resident #16. A review of the admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included dementia, diabetes mellitus, and hypertension. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, reflected the resident had a brief interview for mental status score of 3 out of 15; which indicated a severe cognitive impairment. A review of the Physician's Orders included a physician's order (PO) dated 2/14/24, to cleanse the coccyx (tailbone) wound with a quarter strength wound cleansing solution; apply collagen followed by calcium alginate (used to aid in wound absorption and healing); and apply a bordered gauze dressing daily. On 4/4/24 at 10:25 AM, the surveyor observed the Registered Nurse (RN) perform a wound care treatment on Resident #16, while the Unit Manager/Licensed Practical Nurse (UM/LPN) assisted with the positioning of the resident. The surveyor observed the following: The RN entered the resident's room and placed a clean barrier onto the resident's overbed table. The RN placed the disposable single-use wound treatment supplies onto the clean barrier and placed a multi-use bottle of wound cleansing solution directly onto the overbed table, not on the clean barrier. The RN then washed her hands with soap and water lathering for eleven seconds outside the flow of water. The RN then put on gloves; cleaned the resident's wound, removed her gloves and without performing hand hygiene put on a new pair of gloves. The RN proceeded to apply the collagen and calcium alginate; removed her gloves; dated and initialed the bordered dressing, and without performing hand hygiene, put on a new pair of gloves and covered the wound with a bordered dressing. After repositioning the resident with the assistance of the UM/LPN, the RN removed her gloves, and performed hand hygiene using soap and water lathering her hands outside the flow of running water for six seconds. The RN put on a new pair of gloves and removed the trash from the resident's room. The RN returned to the resident's room and washed her hands lathering with soap outside the flow of running water for six seconds. The RN then placed the multi-use wound cleansing solution back into the treatment cart without disinfecting it. On 4/4/24 at 10:53 AM, the surveyor interviewed the RN who confirmed she should have lathered her hands outside the flow of running water for 20-30 seconds; should have performed hand hygiene between glove changes; should not have brought the multi-use wound cleansing solution into the resident's room; and should have discarded the bottle or disinfected it before she placed it back into the treatment cart. On 4/4/24 at 11:06 AM, the surveyor interviewed the Director of Nursing (DON) who confirmed the facility handwashing policy included washing and lathering hands outside the flow of water for 20-30 seconds, and hand hygiene should be performed between glove changes. The DON also acknowledged any multi-use items brought into the resident's room, should be disinfected before placed back into the treatment cart. On 4/4/24 at 11:23 AM, the surveyor interviewed the Infection Preventionist/Licensed Practical Nurse (IP/LPN) who confirmed hand hygiene included washing and lathering hands outside the flow of running of water for 20 seconds; hand hygiene should be performed between glove changes; and any multi-use supplies should not be brought into the resident rooms, the amount needed should be poured into a plastic cup or poured onto gauzes. On 4/4/24 at 12:00 PM, the surveyor interviewed the UM/LPN who had assisted with the positioning of Resident #16 during the wound treatment. The UM/LPN confirmed that she observed the RN did not perform hand hygiene during glove changes, and that the RN should not have brought the wound cleansing solution into the room but rather poured a small amount into a plastic medication cup or onto gauze pads. On 4/8/24 at 10:18 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, Regional LNHA, and the survey team, confirmed hand hygiene should be performed between glove changes, and that hands should be lathered with soap outside the flow of running water for at least 20 seconds. At this time, the DON stated that all supplies brought into the resident's room should be discarded and that the nurses should only bring in the amount that was needed for that treatment. A review of the facility's Handwashing/Hand Hygiene, policy dated revised October 2023, included the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .washing hands .wet hands first with warm water, then apply an amount of product recommended by the manufacturer to hands .rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers, rinse hands with water and dry thoroughly with a disposable towel . A review of the facility's Wound Care policy dated revised October 2010, included the purpose of this procedure is to provide guidelines for the care of wounds to promote healing .steps in the procedure .use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table .take only disposable supplies into the resident's room .place all items to be used during the procedure on the clean field .after the treatment is completed use a clean field saturated with alcohol to wipe the overbed table .wipe reusable supplies with alcohol and return reusable supplies to treatment cart . NJAC 8:39-19.4(a)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to complete performance review of Certified Nurse Aides (CNA) at least every twelve months and provide regular in-service education based on the outcome of these reviews. The deficient practice was identified for 5 of 5 CNAs (CNA #1; #2; #3; #4; and #5) reviewed for performance evaluations and was evidenced by the following: On 4/3/24 at 10:01 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with five randomly selected CNA employees' education for 2023. The LNHA stated that she could not locate the CNAs' employee performance reviews for 2023. The LNHA stated that the facility took ownership of the building in February of 2023 and were starting to complete performance reviews now. A review of the education revealed: CNA#1: date of hire 8/16/21; no performance review for 2022 or 2023; most recent performance review 4/1/24 CNA #2: date of hire 10/11/15; no performance review 2022 or 2023; last performance review 2/17/24 CNA #3: date of hire 6/10/22; no performance review 2023; last performance review 2/7/24 CNA #4: date of hire 8/12/19; no performance review 2022 or 2023; last performance review 3/30/24 CNA #5: date of hire 9/20/21; no performance review 2022 or 2023; last performance review 2/6/24 On 4/4/24 at 9:43 AM, the LNHA informed the surveyor that the facility had no performance reviews for 2023 and acknowledged that CNAs should have an annual review that was stored in their employee file. The LNHA stated that the facility started this year reviewing the CNAs, and all the CNAs have not been reviewed. On 4/5/24 at 9:19 AM, the surveyor interviewed the Human Recourses Director who confirmed CNAs should have performance evaluations completed yearly. On 4/8/24 at 10:17 AM, the LNHA in the presence of the Director of Nursing (DON), Regional LNHA, and survey team who acknowledged CNAs needed annual performance reviews to determine any additional inservices and education they needed for improvement. A review of an undated facility provided policy titled Performance Evaluations included the job performance of each employee shall be reviewed and evaluated at least annually. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review . NJAC 8:39-43.17(b)

Based on observation, interview, and document review, it was determined that the facility failed to maintain resident call bells that were accessible and within reach of all residents. This deficient practice occurred for 2 of 30 residents reviewed (Resident #120 & Resident #58) and was evidenced by the following: On 12/09/21 at 12:05 PM, two surveyors interviewed Resident #120 in the resident's room. Resident #120 was in the wheelchair and stated he/she was unable to reach the call bell. At that time, the resident showed the surveyors the white call bell cord that was on the floor and the cord was wrapped abound the bed rail and covered by the bedding to the side of the bed and not accessible to the resident. The resident proceeded to try to pull the call bell cord to reach the button and was unsuccessful. The Unit Manager (UM) entered the room and the surveyors inquired as to where the call bell should be located. The UM stated, it should be on bed where [the resident's] can reach it. On 12/09/21 at 12:17 PM, two surveyors interviewed a Certified Nurse Aide (CNA #1) who stated she worked on the first floor. The surveyors inquired as to the protocol for setting up a resident call bell. The CNA #1 stated that once a bed is made, the call bell should be placed on the bed so a resident who is able to use it, can reach it. The surveyors inquired if it was appropriate to wrap a call bell around a resident's bed rail. The CNA #1 further stated that it was not appropriate to wrap a call bell around a bed because a resident would not be able to reach it. CNA #1 stated I know it is not appropriate because the resident has to have access to call light at all times. On 12/09/21 at 2:16 PM two surveyors entered Resident #58's room and observed the bed was made, and the call was bell tied around the side rail which was located between the bed rail and the nightstand. The surveyors pressed the call bell and a Certified Nurse Aide, (CNA #2) responded. The surveyors inquired to the location of the resident call bell and CNA #2 stated the resident must have tied it to the bed and stated, I didn't tie it and it would be on the bed at all times and like this. CNA #2 then proceeded to untie the call bell and place it along the top of the bed and then stated she was assigned to provide care for Resident #58 that day and the resident was very alert. On 12/10/21 at 10:50 AM, the surveyor interviewed Resident #58, while the resident was seated in a chair eating lunch in the resident's room. The surveyor observed that the call bell was wrapped around the side rail. The surveyor inquired to the resident about the call bell being wrapped around the side rail. The resident stated it was always wrapped and that he/she did not know why it was left like that. The surveyor inquired to the resident if the resident tied the call call bell to the side rail that day or the prior day. Resident #58 laughed and adamantly denied wrapping the call bell to the side rail either day. On 12/16/21 at 8:43 AM, the surveyor interviewed a Certified Nurse Aide (CNA #3) who worked on the first floor. CNA #3 stated she provides care for Resident #120 and stated the resident used the call light for assistance and she placed the call light on the resident's bed. CNA #3 stated the call bell should not be tied in a knot, there was a clamp to use to attach the call bell to the bedding. A review of the Call Bells Policy, Effective December 2016 revealed it was the policy of the facility to ensure that resident have the use of a call bell. The procedure revealed, The call bell must be placed within the resident's reach. NJAC 8:39-4.1(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of other facility documentation, it was determined that the facility failed to follow resident rights for the distribution of funds from a resident's personal needs allowance (PNA). This deficient practice was identified for 1 of 1 resident (Resident #61) reviewed for personal funds and was evidenced by the following: On 12/10/21 at 11:22 AM, during resident council meeting, Resident #61 stated that last October he/she wanted to give a wedding gift of $200.00 to his/her grandson. The resident revealed that the resident account manager told him/her that he/she could not have the money to give as a gift, and that the money from the PNA needed to be spent only on his/her personal needs. The resident inquired to the surveyor about what the PNA account was to be used for, because he/she thought that the money provided to him/her monthly by Medicaid was his/her money to spend anyway that he/she wanted. The surveyor reviewed Resident #61's electronic medical record which revealed the following information: According to the admission Record (AR), Resident #61 was admitted to the facility with the diagnose of Atrial Fibrillation, Diabetes Mellites, Macular Degeneration and Osteoarthritis. The AR also indicated that the resident's primary payer source was Medicaid. The quarterly Minimum Data Set (MDS) an assessment tool dated 10/08/21, reflected that the resident was able to express ideas and wants and was able to understand verbal content. The MDS also indicated that the resident was cognitively intact and required limited to extensive assistance with activities of daily living (ADLs). On 12/10/21 at 11:31 AM, the surveyor interviewed the Director of Social Service (DSS) who explained that there was not a limit on how much money can be withdrawn from a resident's PNA account and that the residents could spend the money on whatever they wanted to. The DSS stated that residents had the right to use their money as they see fit. The DSS also revealed that residents could use the PNA money to buy or give gifts. On 12/10/21 at 11:37 AM, the surveyor conducted an interview with the Resident Account Manager (RAM) who stated that it was within her job description to perform all the billing for the facility and that she was also in charge of residents PNA accounts. She explained that when a resident needed money from their PNA account, that the resident would see the Administrative Assistant (AA) to request the money. The AA would then submit a receipt to the RAM who would then post the withdrawal of funds to the resident's PNA account. She explained that Resident Council decided a limit of $50.00 would be applied to the amount that could be withdrawn, but if the resident was doing something special, they would be able to withdraw more money. She also added that the money can be taken and used for whatever they want, even if it was a gift. The RAM admitted that she told Resident #61 that he/she was not allowed to take $200.00 out of his/her PNA to give to his/her family member as a wedding gift. The RAM then stated that it was a Medicaid regulation that money from the PNA account could only be used for the resident's personal needs, but then contradicted herself and said they could use their money for whatever they wanted. She could not explain to the surveyor why she told the resident this a why she did not provide the resident the money as the resident requested. On 12/10/21 at 11:45 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with an untitled an undated page from the Medicaid regulations regarding PNA. The LNHA stated that the page was from Medicaid regulations. She explained that the Medicaid regulations were 300 pages long, so she just provided the surveyor with a page from the regulation that indicated what PNA was to be used for. According to this page #6 Examples of personal items for which PNA is intended for indicated: Community contacts, such as home visits, transportation, trips to special events or places of interest, telephone calls, stationary, stamps and gifts. On 12/10/21 at 12:06 PM, the surveyor interviewed LNHA. The surveyor showed the Administrator the verbiage on the Medicaid page that she provided to the surveyor, that indicated residents could use their PNA to give gifts. The LNHA stated that she would reach out to the resident's family and the resident to explain this and admitted that the RAM did not provide the resident with his/her monies as the resident requested. The LNHA stated, It's important for us to know what the residents could use their PNA for and was not sure about providing personal money to residents to give as gift. She indicated that she would have to reach out to other entities to find out exactly what PNA was to be used for because she did not exactly know and did not want to provide the residents with the wrong information. On 12/16/21 at 9:18 AM, the surveyor interviewed the LNHA who stated that there was still a gray area regarding giving PNA as gifts and that there was nothing in the facility policy regarding what PNA was to be used for. The facility policy titled, Personal needs Account (PNA) with a revised date of February 2019, indicated that the residents of [NAME] Hall are encouraged to open a PNA account. This account was available for them to use for expenses in and outside [NAME] Hall. Medicaid allotted amount to be withdrawn for the resident's social security check and placed in a PNA for the resident's personal use. The policy also indicated that all Medicaid residents have a personal needs account where the facility can deposit the amount Medicaid allotments for personal expenses from the resident's social security check. All residents are encouraged to open and PNA which acted like a bank account in the facility. There was no documentation on this policy that indicated a resident could not use the money to give as a gift. The facility policy titled, Promoting and Maintaining Resident Dignity, Effective date: December 18, 2002, revealed It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life. The Compliance Guidelines revealed, 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights, 3. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. NJAC 8:39-4.1(a)7-9

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility failed to complete a thorough investigation for an allegation of abuse. This deficient practice occurred for 1 of 2 residents investigated for abuse (Resident #121) and was evidenced by the following: On 12/07/21 at 1:04 PM the surveyor conducted an interview with a volunteer resident advocate (RA) from a New Jersey agency. The RA informed the surveyor that Resident #121 was fearful regarding a staff member reporting the resident because of an interaction the resident had with the staff member a few weeks ago. The RA stated that she had alerted the Director of Nursing (DON) at that time of regarding the resident concerns. The surveyor reviewed the medical record for Resident #121 which revealed the following: The admission Record revealed the resident was admitted with diagnoses which included, but not limited to, osteoarthritis, polyneuropathy and hyperlipidemia. The surveyor reviewed the electronic Progress Notes from November 2021 through December 7, 2021. There was no documentation regarding an incident between Resident #121 and a staff member. The current resident Care Plan revealed a focus area I enjoy my independence and do not feel I need assistance for care, to go to the bathroom or get out of bed. I have a history of attempting to transfer myself on and off my wheelchair and bed as I feel necessary despite nurse education telling me I need to call for assistance. I can be combative with care and accusatory of staff hitting me. Although, I am the one that is combative towards them; Date initiated: 08/28/20, revised 05/25/21. Goal: I will have fewer episodes of refusal of care throughout the next 90 days; Date initiated: 08/28/20, Revised: 11/01/21, Target Date: 02/06/22. Interventions included: Due to my accusatory behavior ensure that I have two people for care, Date initiated: 05/25/21, I make allegations against the staff, please investigate them as needed, Date Initiated: 05/25/21, Two Assists for Care due to my accusatory behavior, Date initiated: 11/06/20. The annual Minimum Data Set (MDS), an assessment tool, dated 11/01/21 revealed the resident scored 15/15 on the Brief Interview for Mental Status which indicated the resident was cognitively intact. The section for potential indicators of psychosis was not checked off, behavioral symptoms were mot exhibited and the rejection of care section was coded 0 for behavior not exhibited. On 12/08/21 at 11:56 AM, the surveyor interviewed Resident #121 while the resident was in his/her room eating lunch. The resident stated that he/she recalled speaking with the RA and that he/she accidentally touched one of the nurse aides a few weeks ago. Resident #121 stated that the nurse aide (CNA #1) was mad about that and threatened the resident that she would report the resident. Resident #121 stated that he/she reported the incident to the RA, because he/she did not know what to do because CNA #1 told her/him that no one wants to take care of him/her. On 12/08/21 at 12:43 PM the surveyor interviewed the DON regarding if there was any investigations for concerns expressed by Resident #121. The DON stated that she had spoken with the RA about a week ago regarding a concern that Resident #121's had voiced about the resident accidentally hitting the Resident's primary CNA (CNA #1). The DON then stated she unaware of anything occurring between Resident #121 and staff, and contacted the Unit Manager (UM) regarding any concerns that CNA #1 had reported to her. The surveyor inquired to the DON if an investigation was initiated regarding Resident #121's concerns. The DON stated no. The surveyor inquired to the DON if the DON had interviewed Resident #121 and the DON stated that she did not speak with the resident regarding the concerns and stated the RA would follow up with the resident's concerns. The DON stated if it was some type of potential abuse, it would be the facility's responsibility to follow up. The DON then stated I know [Resident #121] has some confusion at times and I don't know that it actually happened and knowing CNA #1, the CNA #1 would have reported it to me. The surveyor inquired to the DON regarding what were the types of abuse and the DON stated verbal, physical, mental and emotional. The DON stated that the only thing that was reported to her was from the RA. The surveyor inquired as to what should be done per the facility policy after a resident makes an allegation of abuse. The DON stated it there should be follow-up, and interview the staff. The DON stated she did not interview CNA #1 and she was unaware if the facility Administrator (LHNA) was informed of the concerns. At 1:00 PM, the LHNA joined the interview and stated she was unaware that anything was reported by the RA. The LHNA stated she would at least get a statement from the staff because Resident #121 is cognizant, and is also extremely accusatory. On 12/08/21 the surveyor reviewed CNA #1's employee file, there were no investigations in the file. CNA #1 received a General Orientation on 08/04/21, which included, Report any abuse or neglect and resident rights which was signed by CNA #1. A [NAME] Hall, Abuse/Neglect Prevention quiz was signed by CNA #1 on 08/25/21. On 12/08/21 at 2:04 PM, the LHNA provided statements that she stated were completed on 12/08/21 regarding Resident #121's concerns, and the statements included a statement from the DON, UM and the Director of Social Services (DSS) documenting an interview with Resident #121. The statements did not include any direct care staff, including CNA #1. On 12/08/21 at 2:17 PM the surveyor, in the presence of the survey team interviewed the UM regarding Resident #121. The UM stated she interviewed Resident #121 on 11/30/21 and asked the resident who did you beat up? The UM stated the resident has a long history of combativeness and hitting staff. The UM stated she had nothing else to investigate at that time, because the resident did not remember any incident and did not report anything to the UM. The UM stated after she interviewed Resident #121, and because there was no report of the resident getting hit, or abuse, the UM did not notify the social worker. The UM stated she did not follow up with an additional interview with Resident #121, and confirmed that nothing was documented. The UM stated Resident #121 was able to make his/her needs known, has had a cognitive decline, and the resident had behaviors. The UM stated a resident that had behaviors and had a cognitive decline was at a high risk for abuse. On 12/09/21 at 12:17 PM, the surveyor interviewed CNA # 1, in the presence of another surveyor. CNA #1 stated she was the regularly assigned nurse aide for Resident #121. She stated that recalled an incident with Resident #121 while she was caring for Resident #121 and getting the resident dressed and the resident had difficulty controlling one leg and she hit CNA #1. Resident # 121 expressed to CNA #1 that the resident did not want the incident reported for concerns of not receiving candy from the UM. CNA #1 stated she was not asked about any concerns with Resident #121 specifically, and she was not asked to write a statement and never told anyone about the incident. On 12/10/21 at 11:35 AM, the surveyor interviewed the DSS who stated that if she was informed there was a complaint made by Resident #121, she would have spoken with the resident at that time. On 12/10/21 at 11:44 AM, the surveyor conducted a follow up interview with the DSS in the presence of another surveyor. The DSS stated that she confirmed that she interviewed Resident #121 on 12/08/21, and the resident spoke with the DSS about attitude, however the resident did not want to share the whole story at that time. The DSS stated whether an allegation was substantiated or not, if there was any complaint from a resident, every single complaint received an unbiased investigation regardless of the resident's history of complaining. The DSS further stated that anything related to abuse or retaliation would be considered abuse. The DSS stated that if she had been made aware, that she would have interviewed the resident for clarity and stated, immediacy is important. The Abuse, Neglect and Exploitation Policy, Date Implemented 01/2020, revealed: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions included: Mental Abuse: includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . Neglect: means failure of the facility, it employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will develop and implement written policies and procedures that: b. Establish policies and procedures to investigate any such allegations. Investigation of Alleged Abuse, Neglect and Exploitation, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. NJAC 8:39-9.4(f)

Based on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to provide the resident and or the resident's representation written notification of the reason for transfer to the hospital and also send a copy to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 1 resident's reviewed for hospitalization (Residents #140). This deficient practice was evidenced by the following: On 12/7/21 at 11:10 AM, the surveyor reviewed Resident #140's medical record which revealed a Universal Transfer Form (UTF), a communication tool, dated 11/3/21. The UTF indicated that the resident was transferred to the hospital for vomiting and decreased oxygenation of the blood. There was no documented evidence of written notification to the resident or resident's representative and the Ombudsman of the reason for transfer to the hospital. On 12/14/21 at 9:51 AM, during surveyor interview, the Assistant Licensed Nursing Home Administrator (ALNHA) stated that the facility does not notify the Ombudsman of hospitalizations. She further stated that the facility runs a monthly report and the report only had the discharges, not the hospitalizations and that the facility notified the Ombudsman of discharges. At 10:16 AM, during surveyor interview, the ALNHA, stated that the facility will call the family and tell them the reason why the resident was being sent to the hospital. She further stated that the facility does not notify the family in writing. A review of the facility provided policy titled, Transfer and Discharge, with a revised date of 2019, included the following: 7. Emergency Transfers/Discharges-initiated by the facility for medical reasons . b. notify resident and/or resident representative . j. Provide transfer notice as soon as practicable to resident and representative. K. Assistant Administrator, or designee, shall provide notice of transfer to a representative of the State Long-Term Ombudsman via monthly list. NJAC 8:39-4.1(a)31

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to: 1) appropriately store a nasal cannula while not in use, 2) clarify a physicians order for oxygen, 3) ensure a resident was consistently utilizing oxygen per physician order, and 4) update the Care Plan (CP) and Treatment Administration Record (TAR) for a resident prescribed oxygen therapy (Resident #70). This deficient practice occurred for 1 of 1 resident for respiratory therapy and was evidenced by the following: On 12/07/21 at 11:00 AM, the surveyor observed Resident #70 sitting in a wheelchair (w/c) next to his/her bed. The surveyor observed an oxygen concentrator inside the room, oxygen tubing attached to a nasal cannula (tubing that is inserted into the nostrils to deliver oxygen), and the nasal cannula was lying directly on the resident's bed without a protective covering. The surveyor entered the room and was interviewing the resident, when a steward (S1) entered the room and then made the resident's bed. The S1 exited the room and left the nasal cannula lying directly on the resident's bed and without a protective covering. At that time, Resident #70 stated he/she would wear the oxygen when they wanted to. A review of Resident #70's medical record revealed the following: The admission Record revealed the resident was admitted with diagnoses which included, but were not limited to, interstitial pulmonary disease, heart failure, hypertension (high blood pressure), and anemia. The Physician Order Sheet revealed an order dated 02/14/20 for Oxygen Orders, check every shift, oxygen at 2 to 3 liters per minute (lpm) via nasal cannula around the clock. Review of the TARs dated 12/21, 11/21, 10/21, 9/21, 8/21, and 7/21 revealed staff on all three shifts, every day, signed off as having administered 2 to 3 lpm of oxygen. The CP revealed an entry focus area that the resident used oxygen daily for shortness of breath, revised on 04/28/21, and included an intervention, revised on 10/20/21, to provide with oxygen at 3 lpm. The most recent quarterly Minimum Data Set, an assessment tool used to facilitate care, dated 10/08/21, revealed a Brief Interview for Mental Status (BIMS) of 12/15, which indicated the resident had a moderate cognitive impairment and utilized oxygen. On 12/08/21 at 11:03 AM, the surveyor observed Resident #70 sitting on the side of his/her bed and watching television. The surveyor observed Resident #70's oxygen nasal cannula lying directly on the bed by the pillow and was not in a protective covering. Resident #70 stated that he/she would take it (the nasal cannula) off sometimes and would place it next to him/her. When the resident was asked about having a covering or anything that was used to place the nasal cannula inside, the resident replied that nobody ever gave him/her anything to place the oxygen (nasal canula) into and the resident stated so I tuck it right here. At that time the resident showed the surveyor the nasal cannula that was tucked was under the bed pillow. On 12/08/21 at 11:44 AM, the surveyor observed S1 wheel the resident out of his/her room to the kitchen table. The resident was not wearing oxygen at that time. S2 informed Resident #70 that he/she was going to participate in activities before lunch. Resident #70 had a portable oxygen tank behind the w/c without oxygen tubing or a nasal cannula. On 12/08/21 at 11:45 AM, the surveyor observed Resident #70's room with the oxygen tubing tied to the bed side rail with the nasal cannula tucked under the bed covers. On 12/09/21 at 8:29 AM, the surveyor observed Resident #70 in his/her room sitting in a chair next to the bed and while eating breakfast. Resident #70 was not wearing oxygen and the nasal cannula was lying across the bottom sheet of the bed with the bed covers pulled down. The nasal cannula was not in a protective bag or covering. On 12/09/21 at 8:32 AM, the Certified Nursing Assistant (CNA) stated she would help Resident #70 to get washed and dressed and that the resident wore oxygen as needed, and when the oxygen was not needed it would be kept in a bag. The CNA went with the surveyor to Resident #70's room and observed and acknowledged there was no bag to place the nasal cannula in, and that the nasal cannula with the oxygen tubing was lying directly on the bed sheet. The CNA stated the nasal cannula should be in bag to keep it clean. On 12/09/21 at 8:34 AM, the Registered Nurse Supervisor (RNS) stated that the nasal cannula should be in kept in a bag to stay clean. The RNS, in the presence of the surveyor, reviewed Resident #70's medical record which revealed a physician order for oxygen, check every shift, oxygen at 2 to 3 liters per minute (lpm) via nasal cannula around the clock. The RNS stated it was not a correct order because the nurses would have to guess the amount of oxygen to administer to the resident. The RNS showed the surveyor where the nurses had been signing for the application of 2-3 lpm of oxygen and there was no documentation to specify how many lpm they were actually applied. The RNS stated it would have been the responsibility of every nurse to question the physician order, and confirmed that nobody had noticed the mistake for almost two years. On 12/14/21 at 9:15 AM, the Director of Nursing (DON) stated that if a resident's oxygen nasal cannula was turned off, it would be stored in a bag for infection control purposes. The DON stated oxygen was a physician order and must have a specific lpm because it was not to be increased. The DON stated there would be a monthly review of physician orders and the managers and nurses should be mindful of the orders. Review of the facility provided, Administration of Oxygen policy and procedure revised 2019, included but was not limited to the following: Procedure: check physician's oxygen order; adjust oxygen flow rate as ordered; ensure that the nasal cannula/mask with tubing is kept in a plastic bag and hung neatly when not in use; document all adjustments made during the course of oxygen therapy; and check cannula/mask and tubing and humidifier bottle content frequently. Review of the facility provided, Physician's Orders-Recapping and Updating MARS and TARS, revised no date, included but was not limited to the following: the RN will review all physician's orders for each resident; check against all orders started or discontinued, add new orders and make changes as necessary to assure current complete orders before physician re views and signs; and when completed place on chart, check orders against MAR and TAR. Yellow out incorrect orders and handwrite correct orders. NJAC 8:39-27.1(a)

Based on staff interview, facility document review, and clinical record review, it was determined that the facility failed to ensure that 1 of 3 residents observed during medication administration was free of significant medication errors, (Resident #7). The deficient practice was evidenced by the following: Resident #7 was admitted to the facility with diagnoses which included, essential primary hypertension, ventricular tachycardia, atrioventricular block second degree, and the presence of a cardiac pacemaker. On 12/02/2021 at 7:39 AM, the surveyor observed the Licensed Practical Nurse (LPN) in the [NAME] Hall and informed her that she would be observed for medication administration. The LPN wheeled the medication cart in front of Resident #7's room and informed the resident that she will be coming to administer the morning medications. The resident agreed. The following medications were scheduled to be administer at 9:00 AM. Meloxican 20 mg (milligram) PO[orally] Acetaminophen 325 mg 2 tablets. Mirapex 0.5 mg 1 tablet Lisinopril 20 mg 1 tablet. Metoprolol Succinate 25 mg 1 tablet.(beta -blocker used to treat angina and hypertension). On 12/08/21 at 8:00 AM, the surveyor observed that the LPN checked and poured the medication and informed the surveyor that the Metoprolol was not available. The nurse went to the medication room and returned without the medication. The nurse told the surveyor that she could not locate the medication in the medication room and would follow up later. On 12/08/21 at 10:30 AM, the surveyor returned to the [NAME] Hall and the nurse was still working at the medication cart. The surveyor again inquired about the Metoprolol that was not available. The nurse indicated that she had not checked or called the pharmacy yet. The surveyor inquired about the process to obtain medication if the medication was not in the medication cart. The LPN stated, first the nurse had to do a draw search, then call the pharmacy and then notify the doctor that the medication was not available. The nurse further stated that once the medication was faxed it could take 24 hours for delivery. The process was not being followed. Resident #7's Metoprolol ordered on 12/02/2021 had not been on the medication cart and the facility could not provide documentation that pharmacy was called for follow up. On 12/08/21 at 10:30 AM, the surveyor reviewed the Medication Administration Record (MAR). On 12/03/2021 the MAR was left blank which indicated that the Metoprolol was not administered. On 12/04/21 and 12/05/21, the nurses signed that the Metoprolol was administered. On 12/06/21, the nurse circled that the Metoprolol was not available and on 12/07/21, the MAR was left blank. On 12/08/21 during the medication pass the Metoprolol was not available. The LPN circled the MAR and documented the rationale in the back of the MAR. On 12/08/2021 at 10:45 AM, in the presence of the surveyor, the Unit Manager (UM) called the pharmacy, and she was told that the order for the Metoprolol had not been received. On 12/08/21 at 10:47 AM, the surveyor approached UM LPN and inquired about the date the Metoprolol was faxed to the pharmacy. The UM informed the surveyor that the medication was faxed on 12/02/21. On 12/08/21 at 10:56 AM, the UM provided the faxed copy, and the surveyor reviewed the transmission verification report which indicated that the medication was faxed on 12/03/2021 at 01:01. The surveyor showed to the Unit Manager the message that indicated that the fax did not go through. The message read NG : Poor Line condition. A second interview with the UM at 11:14 AM, revealed that she was not aware that the Metoprolol had not been available. Upon further inquiry, the UM stated that Resident # 7 had a Cardiologist appointment on 12/02/21 and the Metoprolol was added to the medications. She called the primary physician, and the physician approved the order for Metoprolol. Review of the Cardiologist notes revealed the following: Resident #7 had 8 seconds of NSVT (Non-Sustained Ventricular Tachycardia ) on 08/21/21 per remote device interrogation (Pacemaker reading). Recommend starting Metoprolol Succinate 25 mg once daily. Cont [continued] rest of medication. Follow up in 6 months for device interrogation in office. An entry regarding the Metoprolol not being available was entered in the Progress Notes on 12/08/2021 at 10:46 AM by the UM, and indicated the following under Health Status : Resident #7 has an order for Metoprolol which is awaiting delivery from pharmacy at the time of the med (medication) pass. Pharmacy was called and made aware, and the order was refaxed. AP (attending physician) was called and made aware of the delay in the administration of medication. He just said to monitor the BP (blood pressure) and give medication when it comes in. Pharmacy called to request medication and order refaxed to pharmacy. Resident #7 is in no distress and BP 133/68 P68 at this time. Lisinopril was given and Metoprolol to be given when received as ordered. The physician was notified on 12/08/2021 at 10:50 AM, that the Metoprolol had not been administered. The physician gave an order to monitor Resident #7 and to administer the Metoprolol once arrived from the pharmacy. On 12/08/21 at 11:20 AM, in the presence of the surveyor the nurse administered the Metoprolol 25 mg to Resident #7 with crackers. On 12/09/2021 at 10:20 AM, the facility provided the surveyor with the following written statements: A written statement from the UM: Resident #7 was seen by cardiologist on 12/02/2021 and on this visit was a recommendation to start Metoprolol 25 mg daily. This order was ok' d by the primary physician and the order was written and faxed to the pharmacy. The medication had not come in from the pharmacy on 12/02/2021 evening delivery pass. On 12/03/2021 I informed the [NAME] Hall nurse that there was a new order for Resident #7 for Metoprolol, and it had not come yet. However, it should arrive by the first pharmacy drop off. Unfortunately, the [NAME] Hall nurse never informed that the medication did not come in. On 12/04/21 -12/07/21 I [UM] was not aware that the medication was not received. On 12/08/21 during the State medication Pass, I was made aware by the surveyor that Metoprolol was not present on the cart. The nurse was not able to give it at the time of medication administration. The nurse did not report to writer that the medication was not available. She [the nurse] took the blood pressure of the resident as requested which was within normal limits of 133/68 HR [heart rate] 68. Primary physician was called and made aware that this medication that was ordered on 12/02/2021 by cardiology had not come in from pharmacy and was not given. His order was to just monitor the blood pressure and administer the medication when it becomes available. Writer also called pharmacy to let them know that we are still waiting for the Metoprolol. Pharmacist was unable to locate an order for the medication and requested to please refax. The original order faxed appears to not have gone through and was not noted by writer. Pharmacy did deliver the medication and it was administered upon delivery. Review of medication administration record shows that although the medication was not in the drawer it was signed for on 12/04, 12/05. Another written statement by the nurse who worked on 12/03/21, 12/06/21 and 12/07/21 revealed the following: I did not follow up with pharmacy and I thought it was going to be delivered. I was aware that it was a new medication. I worked on 12/06 and 12/07 and I did not give the medication. Another written statement from the nurses who signed that the Metoprolol was administered on 12/04/21 and 12/05/2021 revealed that they had used another resident Metoprolol to administer to Resident #7. On 12/09/2021 at 2:28 PM, the survey team interviewed the Administrator (LHNA) about the findings as stated above. The LHNA indicated that her expectations would be that staff would follow up immediately with any order. A review of the facility's policy titled, Medication Administration dated September 2002 last revised January 2019, included but was not limited to the following under procedure: 1. All medications of the resident will be in the medication cart except the injectable, the medications that need to be refrigerated and any overflow medications. 7. When a regularly scheduled dose of medication is not administered or the resident refused the medicine, the licensed nurse will circle the time and initial on the MAR and document reason for the omission or refusal at the back side of the MAR. The physician must be notified of repeated occurrence. The LHNA also provided, Rules of Medication Pass, which included but was not limited to the following: # 7 Rule. If medication is not available- It is not acceptable to borrow. After your med pass is over (unless medication is time sensitive) check the next dose machine for availability. If medication not available you must call the pharmacy, obtain a time when medication should arrive, call the prescriber, obtain order for next dose, write order and document contact with prescriber in nursing notes. (The facility'policy was not followed, the prescriber was not contacted, and the pharmacy was not called until 12/08/21, 6 days after the Metoprolol was ordered on 12/02/21) NJAC 8:39-29.2 (d); 29.3 (a)6; 29.8; 33.2 (c)4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/07/21 at 12:21 PM, during observations conducted in the [NAME] hallway of the first floor unit, two surveyors observed an unattended medication cart with the lock mechanism pushed out. There was no staff present and further observations revealed a nurse was observed two resident rooms down from the medication cart. The nurse was standing in a doorway facing a resident with her back against the hallway and out of view of the medication cart. The surveyor confirmed the medication cart was unlocked by easily opening the top drawer in the presence of the other surveyor. At that time, a nurse appeared at the medication cart and the surveyor inquired if the medication cart was locked. The nurse who identified herself as a Licensed Practical Nurse (LPN) stated its not locked and she apologized and stated there was no reason it was not locked. There were no residents in the vicinity of the medication cart during the observation. The following facility provided documents revealed the following: Review of the Medications, Storage of Policy, Effective Jan. 2004, Revised Jan. 2018 revealed Policy: All medications at [NAME] Hall will be stored within the guidelines of all State and Federal regulations governing the storage of medications at medial facilities. Procedure, 4 [NAME] Hall shall provide a medication storage area/medication cart of sufficient size for the storage of all medications of the residents, and shall assure that: b. The storage area/medication cart shall be kept locked when not in use. According to the Medication Cart Policy, Revised 2019 and a copy of a blank [NAME] Hall Nursing Shift Responsibilities and [NAME] Hall Medication Cart Q.A. (quality assurance) Checklist, provided on 12/09/21 by the LHNA, revealed the following : It is the policy of [NAME] Hall that medication carts are checked to ensure cleanliness, proper infection control and proper medication storage according to storage policy. Procedure: 1. Each Nurse is responsible for their medication care during their assigned shift. East and [NAME] Medication Nurse: Weekly Q.A. Infection Control check on med. cart. Double check all expiration dates. (Monday). Medication Cart Q.A. Checklist: 4. Cart is locked when unattended, 5. No expired meds (medications). NJAC 8:39-29.4 (g) Based on observation, staff interviews, record review and document review, it was determined that the facility failed to ensure: a) that biological drugs were removed from the medication cart when expired for 1 of 4 medication carts observed during a medication pass observation , and b) a medication cart was locked when not in use for 1 of 8 resident care units observed (1st floor - Main building). The deficient practice was evidenced by the following: 1. The surveyor observed the following during a medication pass observation on 12/08/21: Resident # 23 was admitted to the facility with diagnoses of Diabetes Mellitus. Resident #23 had a physician order for Accu-Chek [point of care glucose testing] used to measure blood glucose] x 2 (twice) daily 6:30 AM and 4:30 PM BID [twice daily ] with an order to administer Insulin Lispro (substitute for Humalog ) (Injectable medication used to treat diabetes). The nurses were to administer Insulin based on the following blood glucose readings: 0-199= zero units 200-249= 3 Units. 250-299=5 Units 300-349=7 Units. 350-399=9 Units Call Nurse Practitioner for blood sugar 400 and above. The order specified to store opened insulin pen at room temperature and discard 28 days after. On 12/08/21 at 9:30 AM, the surveyor inspected the [NAME] Hall medication cart with the Licensed Practical Nurse (LPN ) and observed an insulin pen stored in the medication cart with an expiration date of 11/18/21. The LPN stated the date written on the insulin pen indicated the insulin pen was removed from the refrigerator on 10/21/21. The surveyor inquired about the expiration date on the Insulin Pen and the LPN informed the nurse that the Insulin Pen should have been discarded. The LPN could not provide the rationale for the expired Insulin Pen being in use. The LPN further stated that she would discard the Insulin Pen and get a new Insulin Pen from the refrigerator. On 12/08/21 at 10:30 AM the surveyor reviewed Resident #23's clinical record and noted that the Insulin Pen had been administered for 2 administrations from the expired date: 11/28 at 4:30 PM and 12/04/21 at 6:30 AM and was available for administration to Resident #23. On 11/28/21 at 4:30 PM, Resident #23's blood glucose level was 223 milligrams per deciliter (mg/dl ) and he/she received 3 Units of Humalog on 12/04/21 at 6:30 AM, Resident #23 blood glucose level was 218 mg/dl and received 3 Units of Humalog for coverage. According to manufacture specification's Humalog Insulin should be discarded 28 days from the opening date. On 12/08/21 at 12:30 PM the DON provided the surveyor with a copy of the form titled, Expiration Dates from Opened Medications dated 2014, which indicated the following: Humalog (Insulin Lispro ) discard after 28 days.** Date removed from the refrigerator. (According to the date written on the insulin pen, the insulin pen was removed from the refrigerator on 10/22/21 and should have been removed from the medication cart on 11/18/21) On 12/09/21 at 9:30 AM the surveyor interviewed the regular LPN assigned to the [NAME] Hall where the expired insulin pen was located. The LPN stated that she could not explain why she failed to remove the expired insulin pen from the medication cart. On 12/09/21 at 02:28 PM the surveyor informed the Administrator (LHNA) that an expired insulin Pen had been in use and stored in the medication cart. The surveyor requested a policy related to medication storage. On 12/09/21 the LHNA provided a policy titled, Disposal of Unused and Expired Medication dated September 2002 last revised June 2019. The policy indicated the following: Policy: All used and expired medications that cannot be returned to the pharmacy must be disposed properly according to EPA ( Environmental Protection Agency ) and RCRA (Resource Conservation and Recovery Act ). The policy was not being followed.

Based on observation, interview and document review it was determine that the facility failed to maintain food service equipment in a clean and sanitary manner to limit the development of microbial growth. The deficient practice was evidenced by the following: On 12/08/21 at 11:08 AM, two surveyors observed the following during the tray line production was in progress. A rack of insulated tray lid covers that were being utilized for the lunch meal and were double stacked in the slots of the cart and adjacent to the tray line which was in progress. At that time, Surveyor #1 asked the Executive Chef (EC) to remove the double stacked lids which were nested together and the interior of the lids was visible wet. The EC stated the lids should not have been wet. At 11:15 AM the surveyors observed an additional rack of insulated lids located by the dish machine. The lids were double stacked in the slots of the rack, and the surveyor inquired to a dietary staff member if the lids were clean and the staff replies yes. At that time the Operation Manager (OM) was interviewed about the lids and asked to remove the double stacked lids from the rack. The OM showed the surveyor the interior of the lids. Twenty-seven of twenty-seven lids were double stacked and the interior of the lids were wet. On 12/08/21 at 11:27 AM the surveyor observed two covered dish dollies by the food preparation area. The OM stated both were clean. One dish dolly had four wells and contained 5 glass plates. There was debris in several areas and in all of the wells. The second dolly did not contain dishes and contained debris inside the wells. A review of the undated Kitchen Sanitation After Dishmachine Use Policy revealed 3. All lids and domes must be separated individually into the drying rack. Air dry afterwards. Keep them dry for the next meal time use. NJAC 8:39 17.2 (g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and a review of facility documentation, it was determined that the facility failed to follow infection control standards and procedures to limit the risk of transmission of infection by failing to follow appropriate contact tracing protocols when an employee alerted the facility of symptoms of a potential COVID-19 infection in accordance with the Centers for Disease Control (CDC) Guidance, New Jersey Department of Health (NJDOH) guidance and per facility policy, to prevent the spread of COVID-19. The deficient practice was identified for 1 of 1 staff reviewed for contact tracing and was evidenced by the following: Reference: CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated September 10, 2021. Healthcare facilities should have a plan for how SARS-CoV-2 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. Reference: CDC Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes Updated September 10, 2021. Key Points: Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as SARS-CoV-2, A strong infection prevention and control program is critical to protect residents and healthcare personnel Reference: COVID-19 Exposure Risk Assessment Template for Patients in Post-acute Care Settings, New Jersey Communicable Disease Service, November 17, 2021. On 12/14/21 at 8:10 AM, the facility Administrator (LHNA) informed the survey team that an employee who worked in Cottage #6 tested COVID-19 positive. At that time the surveyor requested the facility line listing and NY contact tracing that was completed to identify any close contacts. On 12/14/21 at 8:30 AM, the LNHA provided the surveyor with copies of three email communications between the Director of Nursing/Infection Preventionist (DON/IP) and the Local Health Department (LHD) and the current facility line listing. The line listing revealed CNA #1 worked in Cottage #6, called out of work sick on 12/10/21 and had symptoms that included chills, cough and congestion. CNA #1 had worked the 3-11 PM shift on 12/09/21, and had a positive COVID-19 test result on 12/11/21. The CNA #1 subsequently alerted the management team of the positive test result on 12/12/21. The emails revealed the following: -To: LHD, 12/13/21 at 2:22 PM, Subject: Contact Tracing, From: DON/IP, The DON/IP was notified late last night that one of the full time, 3-11 shift, employees (CNA #1) in House #6 tested positive for COVID and the employees last date of work was 12/09/21 on the 3-11 shift. The staff stated she rendered care for 7 residents and all of the residents were rapid tested today and the results were negative with no reports of any ill symptoms. The staff member stated she was compliant with her PPE. The staff also stated there is one other employee that she worked with who may have potentially been exposed and she will be tested today. A subsequent email from the DON/IP to LHD, dated the same day and timed at 2:24 PM revealed the 7 residents were fully vaccinated. An email dated 12/13/21 at 3:27 PM from the LHD to the DON/IP Subject: Contact Tracing revealed the LHD asked the DON/IP Do you need immediate guidance or the LHD questioned if the email was just for notification. The LHD copied the health department nurses and requested to the DON/IP to copy the nurses with correspondence so someone would be available to assist the DON/IP as needed. (The emails did not contain contact tracing regarding the potentially exposed staff member). On 12/14/21 at 9:01 AM the surveyor interviewed the LHNA regarding the contact tracing emails. The LHNA stated the emails were the documentation that the facility completed for contact the tracing and she will have the DON/IP clarify along with the infection preventionist (IP) from the adjacent facility who was helping out. On 12/14/21 at 9:21 AM, the surveyor interviewed the DON/IP regarding the notification received regarding the CNA who was positive for COVID-19 and the start of the CNA's symptoms. The DON/IP stated she was made aware by the employee that she tested positive for COVID-19. The DON/IP stated, I believe it was that day, and stated for contact tracing you would go back 48 hours from the CNA #1's symptoms. The surveyor reviewed the line listing with the DON/IP regarding the symptomatic CNA who called out sick from work on 12/10/21. The DON/IP stated she was not aware that the CNA's symptoms started on 12/10/21 as documented on the line listing. The DON/IP stated that the LHNA had completed the line listing and the DON/IP stated she had completed the contact tracing. The DON/IP stated she received the information about the COVID-19 positive employee on 12/13/21 via a group text message around 8-9:00 PM. The DON/IP stated when an employee called out sick to the supervisor, that she was supposed to be informed, along with the employee health nurse. The DON/IP was unaware that the CNA #1 first developed symptoms on 12/10/21, and stated it was the first time she had completed contact tracing. At 9:28 AM, the LHNA joined the interview. The LHNA stated that the DON/IP completed the contact tracing with assistance from the Infection Preventionist (IP) from the sister facility. The LHNA stated that the DON/IP completed the contact tracing and confirmed the line listing was accurate. The LHNA stated the staff would call out sick to the supervisor and the supervisor would ask the questions. The LHNA stated she was not sure who received the 12/10/21 call out message. The surveyor inquired as to any guidance received regarding contact tracing from the LHD and the LHNA stated nothing. On 12/14/21 at 10:49 AM, the adjacent facility IP was interviewed by the survey team. The IP stated she provided the DON/IP information on how to complete contact tracing and she was not involved in the contact tracing for the facility. On 12/14/21 at 10:56 AM, the surveyor conducted a phone interview with the LHD and a Nurse from the LHD. The LHD stated the facility was offered guidance and they refused. The LHD stated contact tracing should have been completed to identify all close contacts and it should have been documented. On 12/14/21 at 11:45 AM, the surveyor conducted a subsequent interview with the LHNA and DON/IP regarding the contact tracing and the emails provided to the LHD that were identified as the facility contact tracing. Both the LHNA and DON/IP confirmed there was no additional documentation or investigation related to CNA #1. The surveyor inquired about contact tracing completed regarding the potential exposure to an additional employee (CNA #2). The DON/IP stated she was unaware what day CNA #2 worked with the CNA #1, and stated the other employee spoke with the employee health nurse on 12/13/21 (This was three days after the symptomatic employee called out sick and two days after the employee tested COVID-19 positive). The LHNA provided the surveyor with a Time Detail for CNA #2 that was identified as the potentially exposed employee on the December 13, 2021 email to the LHD which revealed . there is one other employee that she works with who may have potentially been exposed and she will be tested today. The Time Detail revealed the potentially exposed employee worked on 12/09/21 from 2:55 PM to 11/19 PM, 12/10/2021 from 3:03 PM to 11:20 PM and also on 12/11/21 from 3:03 PM to 7:21 AM (16.5 hours). (The CNA #2 worked on 12/11/21 after the facility was alerted on 12/10/21 of a symptomatic employee. The failure to conduct contact tracing did not identify the potential exposure to a COVID-19 positive employee on 12/09/21). The LHNA provided the surveyor with a COVID-19 Exposure Risk Assessment Template for Patients in Post-acute Care Settings, New Jersey Communicable Disease Service, November 17, 2021. The blank Risk Assessment Template Decision Tree was identified as the latest guidelines for contact tracing. The document revealed Rapid identification of patients/residents who may have been exposed to a case of COVID-19 is an important control measure in post-acute care settings. On 12/14/21 at 12:50 PM the LHNA provided the surveyor with a COVID-19 Contact Tracing Form dated and signed by the DON/IP on 12/13/21. The LHNA stated the form was completed on 12/14/21 and dated 12/13/21 because the survey team requested documented contact tracing and that is when the investigation was completed. The document revealed: CNA #1 Staff Confirmed Positive, Date the sample was taken for the confirmed positive 12/11/21, Day and times worked in the 48 hours prior to the positive test: day 12/9/21 time, 3-11 shift, Close contact with confirmed positive, (CNA # 1), Last date of Exposure to Close Contact: 12/9/21, Date employee was notified of Close Contact: 12/12/21, Testing date 12/12/21- Negative, Employee is showing the following symptoms (Circle): Fever or Chills, Cough and Congesting or Runny Nose was circled on the document and return to work date: 10 days/ symptom free. The document further revealed that CNA #2 was not informed immediately upon CNA # 1 calling out sick with symptoms on 12/10/21 and after CNA #1 tested positive for COVID-19 on 12/11/21, CNA #2 worked on 12/11/21. Date employee was notified of close contact: 12/12/21. The facility document titled, [NAME] Hall Covid-19 Contact Tracing Policy and Procedure, Date Implemented: 11/2020, Date Reviewed/Revised, (blank), Revealed it is the policy of [NAME] Hall to conduct contact tracing on any COVID-19 positive resident or staff member. Purpose: To maintain the safety of the residents and staff of [NAME] Hall. Procedure:1. Rapid notification of exposure, a. A close contact as defined by the CDC/NJDOH will be notified of their exposure as soon as possible, 2. Contact Interview, a. Every effort will be made to interview the close contact, 3. Quarantine/Isolation Instructions and Testing per the NJDOH guidelines will be reviewed with the close contact, 4. Review of COVID-19 symptoms will be reviewed with the close contact so they know what to look out for, 5. The close contact will be closed out: w. When the person remains asymptomatic for 14 days, 6. Close contact who develop symptoms but test negative are instructed to continue to self-quarantine and follow all recommendations for the public health authorities. The facility document titled, [NAME] Hall Pandemic Response Plan (incl. COVID-19), Date Implemented: 8/20, Date Reviewed/Revised 8/20, Purpose: To control and prevent further disease and to identify factors contributing to an outbreak in order to develop and implement measures to prevent similar outbreaks in the future. Review: Triennially or as needed. 1. Responsibility: Employees should promptly notify the nursing supervisor and/or designee whenever there is a known or suspected communicable disease, exposure to a communicable disease, or with an unusual outbreak of illness identified in employees, patients, or visitors . a. For COVID-19, employees should promptly notify the physician as well as the Nursing supervisor and/or Infection Practitioner if a patient exhibits any signs or symptoms compatible with COVID-19: fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle/body aches, headache, new loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting or diarrhea, 2. Nursing Supervisor: Nursing Supervisor and/or designee notifies the Infection Control Practitioner and/or designee is responsible, under the direction of the Infection Control Committee Chair, to accept all reports of the outbreak and exposure, coordinate the investigation, notify Employee Health Nurse of exposed employees, consolidate date, communicate needs and immediate control measure as is the focal point to who and from which information flows. NJAC 8:39-19.4(a)(b)(f)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a pneumococcal vaccine. This deficient practice was identified for Resident # 71, 1 of 5 residents reviewed for immunization status. The deficient practice was evidenced by the following: The surveyor reviewed Resident #71'a medical record which revealed the following information: Review of the admission Record revealed that Resident # 71 had been admitted to the facility with diagnoses which included but were not limited to heart failure, adult failure to thrive, hypertension (high blood pressure), and dementia. Review of Resident #71's Care Plan (CP) revealed a focus updated revised 10/21/20 area at risk to decline medically and physically due to multiple medical conditions and interventions which included to encourage to take medications; and a focus updated 10/13/21 area of a tendency to be resistive to care and interventions which included to please allow me to make decisions about treatment regimen and please educate me/family/caregivers of the possible outcome(s) of not complying with treatment or care. Review of the most recent comprehensive Minimum Data Set (MDS - an assessment tool), dated 10/8/21, revealed a Brief Interview for Mental Status (BIMS) of 00 which indicated the resident was severely cognitively impaired; and under section O, O0300 Pneumococcal Vaccine revealed 3 not offered. Review of Resident #71's, Immunization Report date range 10/01/19 to 12/31/21, revealed no Pneumococcal vaccine administered but the resident was administered Influenza vaccine two separate year; Mantoux skin test upon admission; two step COVID-19 vaccination; and a COVID-19 booster. On 12/14/21, the concern regarding Resident #71 not receiving, no documentation of a refusal, no documentation of the vaccine being offered, or education related to the Pneumococcal vaccine, was brought to the attention of the Licensed Nursing Home Administrator and the Director of Nursing (DON) and any additional information was requested. On 12/16/21 at 12:12 PM, the DON stated she was not sure why there was no documentation about the Pneumococcal vaccine being offered, no documentation of a refusal, or the resident or representative being educated. The facility was unable to produce any additional information. Review of the facility provided, Pneumococcal Polysaccharide Vaccine policy and procedure, revised 1/28/10, included but was not limited to the following: Policy: To prevent and control transmission of Pneumococcal Pneumonia. Procedure: 1) families will be offered to complete immunization during the pre-admission process; 2) administer pneumovax vaccine to all persons over [AGE] years old but contraindicated with severe anaphylactic reaction or resident refused the vaccine; 3) revaccination should be considered for persons who received the vaccine prior to the age of 65; and 4) Pneumovax vaccination will be offered to all accepting resident who have not received this immunization prior to or on admission. NJAC 8:39-19.4(h), (i), (j)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) consistently document the size and appearance of a pressure ulcer (PU) weekly to determine the effectiveness of a wound treatment, b.) perform appropriate handwashing during a PU treatment, c.) maintain infection control practices to reduce the risk of infection during a PU treatment, and d.) perform a PU treatment in accordance with a physician's order for 1 of 2 residents reviewed for PU (Resident #101). This deficient practice was evidenced by the following: 1. On 12/07/21 at 9:49 AM, the surveyor observed Resident #101 seated in a wheelchair at the entrance of his/her room. Resident #101 stated that he/she had a pressure ulcer on his/her backside and that he/she was not sure if it developed at the facility. On 12/08/21 at 10:45 AM, the surveyor reviewed Resident #101's medical record. A review of the Entry Minimum Data Set (MDS), an assessment tool, dated 10/26/21 and the admission MDS, dated [DATE], indicated that Resident #101 was readmitted to the facility from the hospital on [DATE] with a sacral pressure ulcer that was acquired during the hospital stay. On 12/10/21 at 9:00 AM, the surveyor reviewed the Wound Care Assessment forms for Resident #101's sacral PU which included the following: Under the sections titled measurement and progress- -10/14/21 red blanchable area 2 X 2 area -10/21/21 red no change -10/28/21 red no change -110/1/21 red deteriorated -12/02/21 4 X 3.2 -12/06/21 4 X 3.2 no change. The facility could not provide the surveyor additional wound care assessment forms that included any dates between 11/01/21 and 12/02/21. At 12/10/21 at 9:10 AM, the surveyor interviewed the second floor Unit Manager (UM) who stated that the nurse was responsible to measure wounds on Mondays if the resident was not being followed by the wound consultant. She further stated that the attending physician would decide if a resident's wound needed to be seen by the wound consultant. She further stated that Resident #101 was followed by the wound consultant and that the wound consultant would document the measurements and appearance of the wound on a weekly basis on Wednesdays. The surveyor then requested the wound consultant weekly documentation. On 12/10/21 at 10:20 AM, the surveyor reviewed the facility provided wound consultant's Wound Care and Vascular Assessment Note(s) which included the following: -10/27/21 WOUND #4; LOCATION: sacrum; TYPE: pressure injury unstageable; DATE OF ONSET: 10-2021; .MEASUREMENTS: 6 cm (centimeters) length X 6 cm width X 0.3 cm depth; .WOUND BED: color yellow and pink, tissue: slough and granular 50% .TUNNELING: 0 cm .ULCERS STATUS: new to me . -11/03/21 WOUND #4; LOCATION: sacrum; TYPE: pressure injury revealed stage 4; DATE OF ONSET: 10-2021; .MEASUREMENTS: 5 cm length X 5 cm width X 0.3 cm depth; .WOUND BED: color yellow and pink, tissue: slough and granular 50% . TUNNELING: 0 cm .ULCERS STATUS: not healed . -11/05/21 WOUND #4; LOCATION: sacrum; TYPE: pressure injury revealed stage 4; DATE OF ONSET: 10-2021; .MEASUREMENTS: 5 cm length X 5 cm width X 0.3 cm depth; .WOUND BED: color yellow and pink, tissue: slough and granular 50% . TUNNELING: 0 cm .ULCERS STATUS: not healed . -11/10/21 WOUND #4; LOCATION: sacrum; TYPE: pressure injury revealed stage 4; DATE OF ONSET: 10-2021; .MEASUREMENTS: 3 cm length X 4 cm width X 0.3 cm depth; .WOUND BED: color yellow and pink, tissue: slough and granular 50% . TUNNELING: 0 cm .ULCERS STATUS: not healed . -11/17/21 WOUND #4 Unable to see 11/17/21: sitting in chair, unable to get to bed . -12/01/21 WOUND #4; LOCATION: sacrum; TYPE: pressure injury revealed stage 4; DATE OF ONSET: 10-2021; .MEASUREMENTS: 3 cm length X 3 cm width X 0.3 cm depth; .WOUND BED: color yellow and pink, tissue: slough and granular 50% . TUNNELING: 0 cm .ULCERS STATUS: not healed . The facility could not provide any additional wound consultant notes. On 12/10/21 at 10:24 AM, the UM stated to the surveyor that the wound consultant was unable to visit the week of Thanksgiving [11/25/21] and that the wound consultant was unable to visit on Wednesday [12/08/21]. She then stated that the wound consultant would be visiting the resident today [12/10/21]. The surveyor inquired to the UM if the facility would be able to assess if Resident #101's wound was improving or getting worse if there were no measurements completed by the wound consultant consistently. The UM stated that the attending physician visited the resident on 11/29/21. At approximately 10:29 AM, the UM provided the surveyor with the attending physician's Progress Note dated 11/29/21 which included the following: -Sacral stage 4 wound-worsening. There was no documentation of the sacral wound measurements or appearance. At approximately 10:35 AM, the UM provided the surveyor with the Infectious Disease Consultant Request and Report dated 12/3/21 which included the following: -Chronic stage IV (4) sacral decub [decubitus- wound] 4 X 3.2 X 1 tunneling. Slough 80%. R/O osteomyelitis/slough. On 12/10/21 at 11:11 AM, the surveyor interviewed the UM regarding the incomplete Wound Care Assessment forms with noted the sacrum was red and no measurements for 10/28/21 and 11/01/21 and the wound consultant notes had a measurable sacral PU [pressure ulcer] for 10/27/21 and 11/03/21. The UM stated that the Wound Care Assessment form should not have been completed. She then stated that if the resident was seen by the wound consultant then the Wound Care Assessment form did not have to be completed. The surveyor then asked the UM how a treatment for a wound would be assessed to see if it was effective if the wound measurements and appearance were not consistently documented weekly. The UM explained to the surveyor that if the nurses were performing the treatment daily then the nurses would know if the wound had worsened. She further stated that the nurses could compare the wound with their eyes. The surveyor then asked the UM what the process would be if the wound consultant did not come to evaluate wounds on a weekly basis. The UM stated that the nurses were responsible to complete weekly wound rounds and to document the findings. On 12/10/21 at 11:37 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding the missing consistent weekly documentation of the measurements and appearance of Resident #101's sacral wound. The ADON stated that the initial assessment was done by the nurse and the interdisciplinary team would decide if the resident would be followed by the wound consultant. She then stated if the resident was followed by the wound consultant then it was then the responsibility of the wound consultant to document the wound measurements and appearance and to recommend a treatment. The surveyor then asked the ADON what the process was if the wound consultant was not be able to visit the resident or observe the wound. The ADON then stated that the nurse would document the appearance of the wound. She further stated that the size of the wound was important to know but then added that assessing the appearance was the most important factor in assessing for improvement of a wound. At that time the ADON provided the surveyor with Nursing Progress Notes which included the following Health Status Notes: -10/26/21 19:36 arrived from .hospital .wound to sacrum 5.5 X 3.5 cm, blackish to the center of the wound . -11/17/21 12:37 The sacrum measures 2 cm X 2.5 cm X 0.5 cm depth with slough and granulating tissue observed. -11/19/21 13:37 Wound care done noted sacral wound slightly wider and depth increased by 1 cm and width 5.5 cm Dr [physician] and aware tx [treatment] done as ordered. -11/26/21 10:43 wound care to sacral area done 5 cm wide depth 1 cm some yellow drainage . -11/29/21 14:55 return to bed for dr to check sacral area right wound noted to have some tunneling .wound care changed to Bactroban and santyl cover with bordered cushion gauze daily. On 12/10/21 at 9:27 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform Resident #101's wound treatments. Prior to the start of the sacral wound treatment, the surveyor observed the LPN perform handwash for the appropriate amount of time. The LPN then took two paper towels and dried her hands. She then turned off the faucet with the used wet paper towels. Throughout the entire wound treatment, each time the LPN performed handwashing, she turned off the faucet with the used wet paper towels. She did not obtain a new dry paper towel to turn off the faucet. The LPN donned (put on) a new pair of gloves and removed the dressing from Resident #101's sacral PU. The LPN then performed handwashing and donned a new pair of gloves. The LPN held the bottle of wound cleanser in her right hand and sprayed the wound cleanser on the wound. She wiped the wound with a 4 x 4 dressing with her left hand. The LPN did not change her gloves or perform hand hygiene and proceeded to then grasp the Santyl ointment tube in her left hand and squeezed some ointment onto a cotton tipped applicator that she had in her right hand. She then applied the Santyl ointment that was on the cotton tipped applicator onto the sacral wound. She discarded the cotton tipped applicator into the garbage can. She then again grasped the Santyl ointment tube in her left hand and squeezed some ointment onto a new cotton tipped applicator that she had in her right hand. She then applied the Santyl ointment that was on the cotton tipped applicator onto the sacral wound. She discarded the cotton tipped applicator into the garbage can. The LPN, wearing the same gloves and without performing hand hygiene, proceeded to take the bordered gauze dressing that she had previously opened onto the clean barrier on top of the bedside table and applied it to the sacral wound. The LPN then removed her gloves and did not perform hand hygiene by either handwashing or utilizing an alcohol-based hand rub. The LPN then placed her hand in her pocket and removed a pen and then dated the bordered gauze dressing that was already in place on Resident #101's sacral area. The LPN did not date the bordered gauze dressing prior to placement on the resident. At 9:50 AM, after the LPN completed the sacral wound treatment, she performed handwashing and started the wound treatments to Resident #101's bilateral heels. After she donned a new pair of gloves, she lifted the resident's left foot out of the heel bootie. She removed the dressing to the left heel and placed the resident's left foot down onto the heel bootie. The surveyor observed that the left heel had a large closed blackened area with a small open reddened area which had drainage visible on the dressing that was removed. The LPN then lifted the resident's right foot out of the heel bootie. She removed the dressing to the right heel and placed the resident's right foot down directly onto the heel bootie. The right heel had a closed blackened area. The LPN then performed handwashing and dried her hands with the paper towel. She took an additional paper towel and wrapped it around the wet paper towels she used to dry her hands and then used the wet paper towels to turn off the faucet. She did not use a new dry paper towel to turn off the faucet. After the LPN donned a new pair of gloves, she lifted the left foot out of the heel bootie and sprayed wound cleanser on a 4 x 4 dressing and wiped the left heel with the 4 X 4 dressing. She then placed the left foot directly back onto the heel bootie. She then took the bordered foam dressing that she had previously opened onto the clean barrier on the bedside table and after she lifted the left foot out of the heel bootie, applied the dressing to the left heel wound. The LPN then removed her gloves and performed handwashing and used the wet paper towel to turn off the faucet. After the LPN donned a new pair of gloves, she lifted the right foot out of the heel bootie, and she sprayed wound cleanser on a 4 x 4 dressing and wiped the right heel. She then placed the right foot back onto the heel bootie. She then took the bordered foam dressing that she had previously opened onto the clean barrier on the bedside table and after she lifted the right foot out of the heel bootie, applied the dressing to the right heel wound. She then removed her gloves and failed to perform hand hygiene prior to using her pen to date the bordered foam dressing that was already placed on Resident #101's left heel. The LPN did not date the bordered foam dressings prior to placement on the resident. At 10:05 AM, the surveyor reviewed Resident 101's Treatment Administration Record which included the following orders: Apply bordered foam dressing to R (right) heel daily x (times) 14 days. Apply bordered foam dressing to L (left) heel daily x (times) 14 days. (The LPN failed to follow the physicians order for the wound treatment for Resident #101's right and left heel) At 10:09 AM, during surveyor interview, the LPN stated that she should use a new dry paper towel to turn off the faucet but that there was no garbage can available to throw out the used paper towel into. She then stated that she did not change her gloves after cleaning the sacral wound because she used a cotton tipped applicator to apply the Santyl ointment. The LPN confirmed that she should perform some sort of hand hygiene after she removed her gloves. She then stated that she usually dated the dressing prior to placement on the resident but that she was nervous and forgot. She further stated that she used wound cleanser because there was drainage. At 11:55 AM, the surveyor interviewed the second floor Unit Manager (UM) and the Assistant Director of Nursing (ADON) regarding the observed wound treatment. The UM and ADON stated that staff should perform hand hygiene every time they removed their gloves. The UM stated that staff should change their gloves before they applied ointment to a wound during a wound treatment. The UM and ADON stated that there needs to be a physician's order for the use of a wound cleanser during a wound treatment. On 12/14/21 at 1:40 PM, in the presence of the survey team and the LHNA, the surveyor interviewed the DON regarding the observed wound treatment. The DON stated that the LPN should have used a new paper towel to turn off the faucet. She then stated that the LPN should have prepared the supplies which included placement of the Santyl ointment into a medicine cup, with clean gloves, and dated the dressing prior to the start of the wound treatment. She then stated that the LPN should have performed some sort of hand hygiene when she removed her gloves. She further stated that the use of wound cleanser requires an order from the physician. A review of the facility provided policy titled, Wound Care Management with a revised date of 2019 included the following: Procedure: 12. Weekly Wound Rounds will be done by the Unit Manager/designee to evaluate the response to the treatment and if needed with the wound care specialist . 14. An initial description of the wound will be documented by the charge nurse. 15. The Unit Manager/designee with the wound care specialist, if needed will document the stage of the pressure ulcer . Documentation: 1. Initial observation to include measurement in centimeters (longest point of the L [length] X W [width]) a. Should be noted in the IDC notes 2. To complete on weekly wound rounds: a. Location b. Size: length, width, depth (longest point of the L X W) c. Exudate: color, odor, and amount d. Appearance of wound base e. Surrounding skin condition f. Sinus tract, undermining or tunneling g. Signs of infection h. Current treatment i. Presence of pain . A review of the facility provided policy titled, Handwashing with a reviewed date of 9/2019, included the following: Introduction: 1. Wash Hands: a. Before and after using gloves . Procedure: . 4. Dry hands thoroughly with paper towel. Discard paper towel. 5. Turn off faucets with a clean, dry paper towel. A review of the facility provided policy titled, Dressing, Dry/Clean, with a revised date of December 2021, included the following: Preparation: 1. Verify that there is a physician order for this procedure . Steps in the Procedure . 10. Label tape or dressing with date, time, and initials. Place on clean field . 17. Apply the ordered dressing . 19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. N.J.A.C 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and review of facility documentation, it was determined that the facility failed to a.) test unvaccinated (not fully vaccinated with the COVID-19 vaccination) staff for COVID-19 at a frequency based on the county COVID-19 level of community transmission in accordance with the U. S. Centers for Disease Control and Prevention (CDC) recommendations and b.) have procedures to mitigate possible transmission of COVID-19 to residents for unvaccinated staff who refused COVID-19 testing. This deficient practice was evidenced by the following: Reference: CDC's guideline titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes with an updated date of Sept. 10, 2021, included the following: Create a Plan for Testing Residents and HCP for SARS-CoV-2 . Expanded screening testing of asymptomatic HCP should be as follows: Fully vaccinated HCP may be exempt from expanded screening testing. In nursing homes, unvaccinated HCP should continue expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, unvaccinated HCP should have a viral test twice a week. If unvaccinated HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). Centers for Medicare and Medicaid Services (CMS) QSO-20-38-NH Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, with a revised date of 9/10/21 included the following: Routine testing of unvaccinated staff should be based on the extent of the virus in the community .Facilities should use their community transmission level as the trigger for staff testing frequency. Reports of COVID-19 level of community transmission are available on the CDC COVID-19 Integrated County View site: https://covid.cdc.gov/covid-data-tracker/#county-view. Please see the COVID-19 Testing section on the CMS COVID-19 Nursing Home Data webpage: https://data.cms.gov/covid-19/covid-19-nursing-home-data for information on how to obtain current and historic levels of community transmission on the CDC website. Routine Testing Intervals by County COVID-19 Level of Community Transmission: Low (blue) testing frequency: not recommended; Moderate (yellow) testing frequency: once a week; Substantial (orange) testing frequency: twice a week; and high (red) testing frequency: twice a week. On 12/9/21 at 11:38 AM, the surveyor interviewed the Director of Nursing/Infection Preventionist (DON/IP). The DON/IP stated that she had just recently taken on the role of IP after the prior IP resigned. The surveyor asked the DON/IP how often the facility was testing their staff. The DON/IP stated that unvaccinated staff were expected to be tested two times a week. She stated that if the staff only work on the weekend then they would just be tested on e time a week. The surveyor requested to view the last three weeks of testing logs. The surveyor then asked the DON/IP what reference she used to base the frequency of testing performed on the staff. The DON/IP stated that she used the COVID-19 Activity Level Report ([NAME]) score and that the [NAME] score was high. On 12/14/21 at 12:45 PM, the DON/IP provided the surveyor with a form titled Unvaccinated Staff Weekly COVID testing with the dates of 12/8/21, 12/10/21, 12/15/21 and 12/17/21 listed on the form, which included the following information: 30 staff members [typed] from various departments were listed. (There were additional handwritten staff members that were from a different facility and were not included in the information below) 11 of the 30 staff members were tested 2 times during the week of 12/6/21. 11 of the 30 staff members were tested 1 time during the week of 12/6/21. 8 of the 30 staff members were not tested during the week of 12/6/21. On 12/14/21 at 1:02 PM, the surveyor, in the presence of the survey team, interviewed the Employee Health Nurse/Educator ([NAME]/E) via phone call placed on speaker, regarding the COVID-19 testing of staff. The [NAME]/E stated that she kept a list of unvaccinated staff that are supposed to be tested two times a week. She stated that she is available to test staff on Mondays, Wednesdays and Fridays and that staff are aware that they need to come to the Employee Health Office to be tested two times a week. She stated that staff sign the consent log sheet prior to testing and that there is a small form they fill out and that the test result is put on the form and then she will track the testing on her log sheet that is dated for a two week period. She then stated that some staff refuse to come and get tested and that if that happened she would try and call them and that if they still refused they would get written up. The surveyor then asked the [NAME]/E if the staff that refused to test are still allowed to work. The [NAME]/E stated that the staff still work. The surveyor requested the prior four weeks of testing logs. On 12/14/21 at 1:18 PM, the DON/IP provided the surveyor testing log sheets labeled with the dates of 11/10/21, 11/12/21, 11/17/21 and 11/19/21 on one log sheet and 11/24/21, 11/26/21, 12/1/21 and 12/3/21 on the other log sheet. A review of the testing log sheet for the week of 11/8/21 included the following information: 31 staff members [typed] from various departments were listed. (There were additional handwritten staff members that were from a different facility and were not included in the information below). 7 of the 31 staff members were tested 2 times during the week of 11/8/21. 8 of the 31 staff members were tested 1 time during the week of 11/8/21. 16 of the 31 staff members were not tested during the week of 11/8/21. A review of the testing log sheet for the week of 11/15/21 included the following information: 31 staff members from various departments were listed. (There were additional handwritten staff members that were from a different facility and were not included in the information below) 4 of the 31 staff members were tested 2 times during the week of 11/15/21. 13 of the 31 staff members were tested 1 time during the week of 11/15/21. 14 of the 31 staff members were not tested during the week of 11/15/21. A review of the testing log sheet for the week of 11/22/21 included the following information: 31 staff members from various departments were listed. (There were additional handwritten staff members that were from a different facility and were not included in the information below) 3 of the 31 staff members were tested 2 times during the week of 11/22/21. 10 of the 31 staff members were tested 1 time during the week of 11/22/21. 18 of the 31 staff members were not tested during the week of 11/22/21. A review of the testing log sheet for the week of 11/29/21 included the following information: 31 staff members from various departments were listed. (There were additional handwritten staff members that were from a different facility and were not included in the information below) 15 of the 31 staff members were tested 2 times during the week of 11/29/21. 9 of the 31 staff members were tested 1 time during the week of 11/29/21. 7 of the 31 staff members were not tested during the week of 11/292/21. On 12/15/21 at 8:45 AM, the LNHA provided the surveyor ten Disciplinary Notice (DN) forms for nine staff members that were dated 12/6/21 and one staff member that was dated 12/13/21. One DN form was for CNA #1 and included the following: Failed to report to Employee health for COVID testing twice a week per guidelines for the week of 11/29/21. She only came once on 12/3/21. There was a checkmark next to 1st warning and dated 12/6/21. The facility did not provide a DN form for CNA #2. At 10:26 AM, the DON/IP provided the surveyor 13 DN forms for seven staff members that were dated 12/15/21. There were 3 forms for CNA #1 which included the following: DN #1 dated 12/15/21-above employee failed to report to Employee Health for COVID testing. Employee must report 2x/week as per COVID guidelines for non-vaccinated staff. Employee failed to report twice on week of 11/21-11/27/21. There was no checkmark that indicated if this were 1st Warning, 2nd Warning, Final Warning or Employee's employment was terminated. DN #2 dated 12/15/21-above employee failed to report to Employee Health for COVID testing. Employee must report 2x/week as per COVID guidelines for non-vaccinated staff. Employee failed to report twice on week of 11/28-12/4/21. There was no checkmark that indicated if this were 1st Warning, 2nd Warning, Final Warning or Employee's employment was terminated. DN #3 dated 12/15/21-above employee failed to report to Employee Health for COVID testing. Employee must report 2x/week as per COVID guidelines for non-vaccinated staff. Employee failed to report twice on week of 12/5-12/11/21. There was no checkmark that indicated if this were 1st Warning, 2nd Warning, Final Warning or Employee's employment was terminated. The facility did not provide a DN form for CNA #2. At 10:03 AM, the surveyor interviewed the [NAME]/E regarding the testing logs and the DN forms. The [NAME]/E confirmed that the slashes listed under the date and next to the staff member's name, indicated that the staff member did not have a COVID-19 test for that date (or the couple of dates before or after the date listed). She then stated that all the unvaccinated staff knew that they had to be tested two times a week. The surveyor then asked the [NAME]/E what the procedure was when an unvaccinated staff member refused to be tested. The [NAME]/E stated that if the staff member refused, they first would receive a verbal warning and then they would receive written warnings. She then stated that after the third written warning they would get fired. She further stated that we could not fire them because then we would not have enough staff. The surveyor then asked the [NAME]/E what the purpose of COVID-19 testing of unvaccinated staff were. The [NAME]/E stated that the purpose of the testing were to make sure COVID-19 did not come into the building by the way of an employee. She then stated that the facility screened the employees for signs and symptoms of COVID-19 by by taking their temperature and asking questions when they entered the building. The surveyor then asked the [NAME]/E if a person who did not exhibit any signs or symptoms of COVID-19 (asymptomatic) could still be COVID-19 positive and potentially spread the virus. The [NAME]/E stated that a person could be COVID-19 positive and not have any signs or symptoms. The surveyor asked the [NAME]/E why she did not provide any DN forms for CNA #2. The [NAME]/E stated that CNA #2 was not working that day and was not able to give CNA #2 the write up yet. At 10:26 AM, the surveyor, in the presence of another surveyor, interviewed CNA #1, who was unvaccinated, regarding COVID-19 testing. CNA #1 stated that COVID-19 testing should be done two times a week but that she missed a couple of tests because she forgot to go. The surveyor then asked what the facility did if she did not get tested two times a week. CNA #1 stated that she would get a verbal or written warning. She then stated that she had received one verbal and one written warning by the facility. CNA #1 did not say that she had been restricted from caring for residents. A review of CNA #1's Time Detail Report indicated CNA #1 worked on 11/10/21, 11/11/21, 11/12/21, 11/13/12, 11/14/21, 11/16/21, 11/17/21,11/18/21, 11/19/21, 11/22/21, 11/23/21, 11/26/21, 11/27/21, 11/28/21,11/30/21, 12/1/21, 12/3/21, 12/4/21, 12/6/21, 12/7/21, 12/9/21, 12/10/21, 12/11/21 and 12/12/21. CNA # 1 was tested for COVID-19 via rapid antigen on 12/3/21. The facility could not provide any documented evidence that CNA #1 was tested on any other date from 11/10/21 to 12/12/21. A review of CNA #2's Time Detail Report indicated CNA #2 worked on 11/10/21, 11/12/21, 11/13/12, 11/14/21, 11/16/21, 11/17/21, 11/19/21, 11/21/21, 11/22/21, 11/23/21, 11/24/21, 11/27/21, 11/28/21, 12/1/21, 12/2/21, 12/3/21, 12/4/21, 12/5/21, 12/6/21, 12/7/21 and 12/8/21. CNA #2 was tested for COVID-19 via rapid antigen on 12/1/21 and 12/8/21. The facility could not provide any documented evidence that CNA #2 was tested on any other date from 11/10/21 to 12/8/21. At 11:07 AM, the surveyor interviewed the DON/IP regarding the COVID-19 testing of unvaccinated staff members. The DON/IP stated that staff are tested two times a week prior to the start of their shift. She then stated that if the staff did not come to get tested that someone would call the staff member. The surveyor then asked the DON/IP what was done if a staff member did not get tested. The DON/IP stated that they gave the staff member the benefit of the doubt to come later that day or the next day. She then stated that first we would give a reminder with education and then they would be 'written up' [DN]. She added that it was a struggle. The surveyor then asked the DON/IP what the purpose of COVID-19 testing of unvaccinated staff members were. The DON/IP stated that it would be to make sure the staff members did not have COVID-19. She added that staff were screened when they entered the facility to see if they had signs or symptoms of COVID-19. The surveyor then asked the DON/IP if she were aware that a person could test positive for COVID-19 and not have any signs or symptoms of COVID-19. The DON stated that she was aware that a person could be positive without symptoms. On 12/16/21 at 9:00 AM, the surveyor, in the presence of the survey team, interviewed CNA #2, who was unvaccinated, regarding COVID-19 testing. CNA #2 stated that she would be going to get vaccinated and that if she did not get tested that the [NAME]/E would hunt her down. The surveyor then asked CNA #2 what the facility did if she did not get tested two times a week. CNA #2 stated that she had received a verbal warning. CNA #2 did not say that she had been restricted from caring for residents. At 9:15 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the COVID-19 testing of unvaccinated staff members. The LNHA stated that the unvaccinated staff would get tested depending on the [NAME] or county positivity rate. She then stated that currently the frequency of testing was two times a week. The surveyor then asked the LNHA what the facility would do if the unvaccinated staff member did not get tested the appropriate amount of times during the week. The LNHA stated that the staff member would have progressive discipline which meant that it would start with a verbal warning with education and then several write ups would follow if the staff continued to refuse to be tested. She then added that after going through the entire progressive disciplinary process and the staff members final refusal would result in the staff member termination (fired) . The surveyor than asked the LNHA how soon after the staff member refused to be tested would the verbal or written warning be given to the staff member. The LNHA stated that the [NAME]/E or any supervisor would give the verbal or written warning in a reasonable amount of time. The surveyor then asked the LNHA if she could define how long that amount of time was and if that meant that day, a few days or a week or more later. The LNHA could not define what a reasonable amount of time. The surveyor then asked the LNHA what the purpose of COVID-19 testing two times a week was. The LNHA stated that she did not know what the purpose for testing two times a week was, but that people are tested to find out if they have COVID-19. She then added that testing is only one of the ways to screen them for COVID-19 but that you can tell if someone has signs and symptoms [of COVID-19] by other ways of screening them. The surveyor then asked the LNHA if she were aware that a person could test positive for COVID-19 and not have any signs or symptoms of COVID-19. The LNHA stated that she was sure some people that are COVID-19 positive were asymptomatic (did not exhibit symptoms). On 12/16/21 at 9:45 AM, the Administrator provided the surveyor the CALl Report for the week ending November 27, 2021 and the week ending December 4, 2021 which included the following: Central [NAME] Region's Current Activity Level was high for both weeks. Upon exit of the survey, the facility did not provide documented evidence that the staff on the unvaccinated list were fully vaccinated against COVID-19. The facility also did not provide documented evidence that the unvaccinated staff that refused to be tested for COVID-19 were restricted from direct resident care when they refused to be tested. A review of facility provided policy titled, COVID-19 Testing Policy with a reviewed/revised date of 9/20, included the following: Routine Testing of Staff/Patients 1. The facility will test staff and residents according to the most current NJDOH guidelines/requirements . Refusal of Testing 2. Staff that refuse routine testing will be reported to their Department Director, Staff will be re-educated as to the reason for testing. A final refusal will result in employee termination . Documentation of Testing 1. The facility will demonstrate compliance with the testing requirements by doing the following: a. For staff routine testing, document: i. The corresponsing testing frequency indicated ii. Date(s) that testing was performed for all staff iii. results of each test b. Document the facility's procedures for addressing residents and staff that refuse testing or unable to be tested, and document any staff or residents who refused or were unable to be tested and how the facility addressed those cases. N.J.A.C. 8:39-19.4(a)

**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 an accurate accountability and reconciliation for receipt, administration and documentation of controlled medications for 1 of 1 back-up controlled medication storage area. This deficient practice was evidenced by the following: On [DATE] at 10:30 AM, the Assistant Director of Nursing (ADON) provided the Drug Enforcement Administration (DEA) 222 forms (a form used for ordering controlled substances) and supporting documentation for the following DEA 222 forms, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. 1. Review of the DEA 222 form, #192309960 dated [DATE], and the Delivery Sheets received at the facility on [DATE] revealed an order on line number 1 for two packages of 1.25 milliliters (ml) of Roxanol (Morphine Sulfate, a liquid narcotic pain medication) 20 milligrams (mg) per ml. Line number two revealed one package of Duragesic Patches (a narcotic pain patch) 12 micrograms (mcg) that contained five patches. The order was checked by the ADON on [DATE] at 2:00 PM. The portion of the form designated to be completed by the purchaser (facility) upon delivery from the pharmacy indicated that three packages of Roxanol 1.25 ml were received by the facility (instead of two packages as ordered per the form). On [DATE] at 10:52 AM, the surveyor interviewed the ADON regarding the discrepancy with the amount of Roxanol received on [DATE]. She stated that according to the Delivery Sheet (invoice from pharmacy), dated [DATE], three packages of Roxanol 20 mg/ml were received and it should have been two. She stated that it was a transcription error as she accidentally wrote that three packages of Roxanol were received instead of two. 2. Review of the DEA 222 form #192309961 dated [DATE], and the Delivery Sheets received at the facility on [DATE], revealed an order on line number 1 for one package of 1.25 ml of Roxanol 20 mg per ml. The portion of the form completed by the facility indicated that one package was received as ordered. Review of the Delivery Sheet from the pharmacy specified that two packages of Roxanol (2.50 ml) were delivered to the facility instead of one package of 1.25 ml. The order was signed as checked by two Registered Nurses (RN #1 and RN #2) on [DATE] at 2:15 PM. During an interview on [DATE] at 10:52 AM, the ADON reviewed the Delivery Sheet with the surveyor and stated that, while she was designated as the responsible party to receive controlled medications from the pharmacy along with another nurse, she did not sign for the receipt of the order dated [DATE]. She further stated that she and the Medical Director were the only two that saw the DEA 222 forms and that the Consultant Pharmacist (CP) reviewed them but not every month. On [DATE] at 12:51 PM, the surveyor interviewed the Risk Management Nurse (RMN) who stated that, while the ADON was designated to receive back-up controlled medications, she sometimes received them in the ADON's absence. The RMN stated that she and another nurse were responsible to compare the packing slip (Delivery Sheet) and the declining inventory sheet (form used to record controlled drug administration) to the delivery received. If a discrepancy was noted on the packing slip, the order should be rejected, and a call should be placed to the pharmacy to clarify the discrepancy. On [DATE] at 8:32 AM, during an interview with the ADON, she stated she spoke with the pharmacy and it was determined that an error on the Delivery Sheet originated in the pharmacy. She further stated that a pharmacist inputted a quantity of 2.50 ml from a prior order in the computer system when the order for 1.25 ml was dispensed. The ADON provided the surveyor with written documentation from the pharmacy that confirmed that they were responsible for the transcription error on the Delivery Sheet and furnished the facility with 1.25 ml of Roxanol as requested instead of 2.50 ml as printed on the form. On [DATE] at 9:53 AM, the surveyor interviewed the CP who stated that she reviewed the facility's DEA 222 forms and noted that the date and quantity received were not always completed by the ADON. She stated that she provided the ADON with oral information on form completion and storage and possibly provided a hand out, but she wasn't sure. The ADON was unable to provide the surveyor with documented evidence that the facility had a policy in place that referenced controlled drug acquisition. The surveyor reviewed the Controlled Substance Record (form used to track each controlled substance from the manufacture to final dispensing to the patient or disposal) that was furnished by the ADON and corresponded to Roxanol 1.25 ml where each individual dose was 0.25 ml or 5 mg per dosage. The surveyor reviewed the Controlled Drug Record which revealed that the pharmacy allotted space on the form for five doses of Roxanol to be signed out by the facility staff. The following volumes of the drug were pre-printed on the form and were signed out as follows: Line 1: 1.25 ML, Line 2: 1.00 ML, Line 3: 0.75 ML, Line 4: 0.50 ML and Line 5: 0.25 ML. The form did not provide space for accurate documentation of the dosage obtained for the administration of a single dose on four of the lines provided for nursing staff to sign out Roxanol 0.25 ml or 5 mg except for the last line on the page. The ADON clarified that the pharmacy prepared the Roxanol in batches of five individual syringes each of which contained 0.25 ml=5 mg. She further stated that the total volume of 1.25 ml for all five syringes was the first line available to sign out for the first syringe administered and the remaining lines were in descending order (1.25 ml, 1.00 ml, 0.75 ml, 0.50 ml, 0.25 ml). Further review of the Controlled Drug Record revealed that a facility Licensed Practical Nurse (LPN) #1 signed out three dosages of Roxanol on the Controlled Drug Record on [DATE] at 1:30 AM and 3:30 AM to an (unsampled resident). On [DATE] at 5:00 AM, LPN #1 signed out one dosage of Roxanol and did not document the name of the resident that the drug was administered to. On [DATE] at 10:00 AM, a nurse, whose signature was illegible and could not be identified by the ADON, signed out a dosage of Roxanol and there was no documentation of the name of the recipient. On [DATE] at 8:59 AM, the ADON stated that both she and the Director of Nursing (DON) wasted 0.25 ml of Roxanol because she didn't want to leave an extra one in the back-up controlled medication box because the par level was five. The ADON acknowledged that both she and the DON should have signed the last line on the form represented by 0.25 ml and documented wasted on that line instead of in the disposition of medical waste box located on the left-hand corner of the form. She further stated that the Controlled Drug Record was unclear and did not give a true depiction that only 0.25 ml of Roxanol was administered within each syringe except for the last line allotted on the form. The ADON further stated that LPN #1 and the nurse whose signature was illegible were required to enter the name of the resident that they intended to administer the drug to at the time it was removed from the back up controlled drug inventory. On [DATE] at 10:06 AM, the CP stated that two nurses were required to sign and date all wasted controlled drugs to indicate that it was wasted and must specify the amount that was wasted on the Controlled Drug Form. The CP further stated that nursing was responsible to document the exact amount removed from the controlled drug inventory if it was different than what was printed on the form. On [DATE] at 12:35 PM, the surveyor interviewed the DON who stated all nurses were required to sign on the same line of the drug that was to be wasted and specify amount wasted and indicate disposition of drug. The DON further stated that nursing was required to enter the name of the resident that a controlled drug was signed out for on the line allotted for removal and nurse signature. The DON stated that the ADON was solely responsible for oversight of the DEA 222. The ADON provided the surveyor with the facility policy, Emergency Medication, Crash Cart & Narcotic Back-up Box (Reviewed 2019) which revealed, The Pharmacy Consultant is responsible for reviewing the emergency medications for compliance as part of their monthly report. The surveyor reviewed a second policy, Disposal of Unused Expired Medication (Reviewed 2019) provided by the ADON, which revealed, Two nurses will destroy expired or discontinued controlled substances. Documentation of the destruction requires the signature of theses [sic] nurses. NJAC 8:39-29.7(c)

Based on observation, interview and document review, it was determined that the facility failed to ensure staff consistently covered hair to minimize the potential for contamination. This deficient practice was evidenced by the following: On 01/02/20 at 9:21 AM, the surveyor completed an initial tour of the kitchen with the Executive Chef (EC) and Director of Operations (DO). The DO was observed wearing a facial hair cover that was not covering the exposed facial hair around and above his mouth. At 9:24 AM, the surveyor, in the presence of the EC, observed a female Dietary Worker (DW#1) scraping and loading racks of soiled items. She then placed the racks through the dish machine to be cleaned. DW#1 wore a black hair net that did not cover all of her hair. The exposed hair was hanging outside of the hair net and was touching her right shoulder. On 01/07/20 at 12:50 PM, the surveyor toured the kitchen in the presence of the EC, DO and General Manager (GM). The DO was observed wearing a facial hair cover that was not covering the exposed facial hair around his mouth. A [NAME] (Cook #1) was observed in the cooking battery area. [NAME] #1 had a mustache that was not covered. At that time, the surveyor interviewed the GM regarding the policy for covering exposed facial hair. The GM stated the policy was to cover the perimeter of the beard and not the mustache. Review of an undated SLRC Policy #3.32- Dietary Department Uniform Policy Addendum B revealed, Black, plain caps or hairnets are worn as hair restraints. [NAME] Guards are required around the perimeter if applicable. NJAC 8:39-17.2(g)