Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) maintain infection control to reduce the risk of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice during a wound care treatment and b.) ensure a treatment was administered in accordance with a physician order. This deficient practice was identified for 1 of 3 residents reviewed for pressure ulcer (Resident #46), and was evidenced by the following: Reference: CDC Recommendations for Hand Hygiene, updated 2/27/24, Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; after contact with blood, body fluids, or contaminated surfaces; immediately after glove removal. https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html#cdc_clinical_safety_best_practices_recomm-recommendations On 3/23/25 at 10:34 AM, the surveyor observed Resident #46 lying in bed on an air mattress. The Registered Nurse (RN) on duty stated that the resident had a sacral (the back) pressure ulcer (PU). On 3/24/25 at 12:31 PM, the surveyor observed the Licensed Practical Nurse (LPN) perform the PU treatment for the resident's sacral wound assisted by the Certified Nursing Assistant (CNA #1) and observed the following: During the wound care observation, the surveyor observed the LPN and CNA #1 wearing surgical masks, gowns, and gloves. The LPN's gown was observed untied on the top part. The resident was positioned on their left side lying on top of the soiled unfastened incontinence brief which was on top of a clean chuck pad. While the LPN was cleansing the resident's wound with a gauze pad and normal saline solution, the nurse's loose gown sleeve touch the soiled incontinence brief and clean chuck pad. Then the LPN dropped the gauze pad she was cleaning with onto the soiled incontinence brief, picked it up, and proceeded to use that pad to clean around the wound cavity. Then the LPN without changing her gloves or performing hand hygiene, removed a tube of zinc oxide from the treatment cart in the hallway, squeezed the cream onto her right hand, and applied it to the reddish skin around the wound. The LPN then changed her gloves and performed hand hygiene, and then used her gloved hands to remove a treatment tube from the treatment cart. The LPN then with the same gloved hands opened a package of collagen sprinkles (powder for wound care) and applied the powder directly to the wound and the edges of the packet were observed touching the wound bed. Without changing gloves and performing hand hygiene, the LPN took an unlabeled tube of honey wound gel, squeezed a dollop of gel onto a cotton-tipped applicator and applied the gel to the wound. The LPN used the same cotton-tipped applicator that was blood-stained from touching the wound bed, and applied more gel to the applicator. The contaminated tip of the applicator touched the tip of the treatment tube. The LPN then took a new cotton-tipped applicator and calcium alginate packing strips (wound dressing for drainage), and the LPN tried to apply the long packing strips inside the wound cavity using their left hand and the applicator. Parts of the packing strips were observed touching the soiled incontinence brief the resident was lying down on. The LPN picked up the parts of the strips that touched the soiled incontinence brief with the applicator. After a bundle of strips fell to the soiled incontinence brief, the LPN picked up those strips with her left gloved hand and placed the packing strips inside of the wound cavity with her gloved hand. Without changing gloves or performing hand hygiene, the LPN covered the packed wound with an ABD pad (a sterile dressing used for wound care). The resident was then turned to their back with the ABD pad underneath them and on top of the soiled brief. The LPN then removed her gloves, but did not perform hand hygiene. The LPN took a sanitizing wipe from the treatment cart and wiped down the scissors, honey wound gel tube, and zinc oxide cream tube with the same wipe. The LPN then cleaned the overbed table with the same sanitizing wipe used to clean the treatment tubes and scissors. The LPN discarded the sanitizing wipe, treatment table liner, gown, and gloves, and proceeded to wash hands. The LPN returned the unlabeled zinc oxide and honey wound gel tubes to first drawer of the treatment cart. After wound care was completed, the resident was turned to their right side and the soiled brief was rolled beneath them and thrown on the trash can by CNA #1. CNA #1 removed their gloves and washed their hands appropriately. CNA #1 put on a new pair of gloves and applied a new incontinence brief on top of the chuck pad used earlier for wound dressing. On 3/24/25 at 1:05 PM, the surveyor discussed their observed concerns from the wound care treatment with the LPN. The LPN stated that they should have changed gloves and performed hand hygiene between clean and unclean procedures. The LPN stated that they instructed CNA #1 to remove the soiled incontinence brief prior to the treatment, but the CNA did not remove it. The LPN stated that they tried not to touch the tip of the treatment tube with the blood-stained applicator, and she should have disposed it and used a new one. The LPN stated that she would label the gel tube and proceeded to write resident's name on the gel tube and returned it to the cart. The LPN stated that acetic solution 0.25% should have been used to cleanse the area around the wound prior to the application of other treatments as ordered. The LPN stated to the surveyor that they think they failed the test. On 3/24/25 at 1:09 PM, the surveyor discussed the wound treatment observation concerns with the Licensed Practical Nurse/Unit Manager (LPN/UM), who acknowledged that there were several lapses in terms of infection control that warranted the treatment to be redone. The LPN/UM stated that the soiled incontinence brief should have been disposed prior to the treatment to avoid cross contamination. The LPN/UM also stated that gloves should have been changed between clean and unclean procedures and that hand hygiene should have been performed before and after changing the gloves. The LPN/UM stated that acetic solution (acetic acid diluted in water to kill bacteria and promote healing of wounds) should have been applied after cleansing with saline solution. On 3/24/25 at 1:30 PM, the surveyor reviewed the medical record for Resident #46. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; pressure ulcer of the sacral region stage 4 (loss of full thickness of the skin exposing underlying structures like muscle, tendon, ligament, or bone) and paralytic syndrome following cerebral infarction (stroke with paralysis). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/31/24, revealed that the resident had a stage 4 PU and that the resident received PU care. A review of the Order Summary Report dated active as of 3/26/25, included a physician's order to cleanse the area of the sacrum with acetic solution 0.25%, apply zinc oxide cream to the periwound area, apply collagen sprinkles, apply medical grade honey gel, pack with calcium alginate, cover with ABD pad every day shift for sacral ulcer stage 4. A review of the March 2025 Treatment Administration Record (TAR) reflected that the ordered treatment was administered by the LPN on the day shift of 3/24/25. A review of the comprehensive individual care plan (ICCP) dated revised on 2/29/24, included a focus for enhanced barrier precautions because of wound with the goal for the resident not to have symptoms of infection. Interventions include that the wound care consultant recommended to continue treatment as ordered; on 8/1/23, the wound care consultant recommended to cleanse the sacral wound with normal saline solution (NSS), do not scrub or use excessive force; pat dry, apply collagen sprinkles then calcium alginate and ABD pad; cover with ABD pad daily, do not put tape directly to the skin, pressure ulcer improving. During an interview with the surveyor on 3/26/25 at 12:37 PM, the Director of Nursing (DON) stated that hand hygiene should be performed before and after gloves changes and gloves should be changed between clean and unclean procedures to prevent cross contamination and infection. A review of facility's Wound Treatment Management policy dated 9/1/24, included Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders . A review of facility's Personal Protective Equipment policy dated 9/1/24, included Policy Explanation and Compliance Guidelines: .4.a.iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn; .4.b.ii. Gowns should fully cover torso from neck to knees, arms to end of wrist, and wrap around the back. Fasten in back at neck and waist . NJAC 8:39 - 27.1(a)(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the facility admission Record face sheet for Resident #25 reflected that the resident was admitted to the facility with the diagnoses that included but were not limited to; end stage renal disease. A review of the comprehensive MDS dated [DATE], reflected that Resident #25 was cognitively intact and required maximum with activities of daily living. The MDS also reflected that the resident received dialysis. On 3/23/25 at 10:54 AM, during initial facility tour, the surveyor observed Resident #25 lying in bed. The resident was pleasant and stated that they had a central catheter for dialysis on the left side of their chest. The resident explained that they went out for hemodialysis on Tuesday, Thursday and Saturday. The surveyor observed a central catheter with dressing intact to the resident's left side of the chest. A review of the physician's order summary reflected a physician's order dated 1/7/25, for the resident to go out for hemodialysis on Tuesday, Thursday, and Saturday. A review of the ICCP reflected that the resident required dialysis with interventions that included: to monitor/document/report and signs or symptoms of infection to access site, monitor labs and report to doctor as needed and that the resident received dialysis on Tuesday, Thursday, and Saturday. On 3/24/25 at 11:43 AM, the surveyor attempted to review the resident dialysis communication book (communicate the information including the resident's status with the dialysis facility prior to and post dialysis). LPN/UM #2 was not able to locate the dialysis communication book. The surveyor interviewed the resident at that time, who stated that they usually took paperwork to the dialysis center for them to fill out and then the communication sheet went back to the nurses. The resident stated, They are always losing the communication book. On 2/24/25 at 12:00 PM, the surveyor interviewed the facility's Regional Clinical Nurse (RCN), who was also not able to locate the dialysis communication book and was only able to provide two dialysis communication sheets since January 2025, dated 1/1/25 and 1/14/25. On 3/27/25 at 10:14 AM, the surveyor interviewed the DON, who stated that the dialysis communication forms were an important form that was utilized as a form of communication between the dialysis center and the facility. The DON stated that the forms were an important part of the resident's clinical record and included vital signs, weighs and any procedures that were performed at the dialysis center. The DON stated that the nurse should assure that the forms in the dialysis book were kept as part of the resident's medical record. A review of the facility's Hemodialysis policy dated 9/1/24, included 5. the licensed nurse will communicate to the dialysis facility via telephone communication or written format, such as a dialysis communication form or other form . NJAC 8:39-27.1(a) Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure dialysis communication forms between the facility and the contracted dialysis facility were consistently completed. This deficient practice was identified for 2 of 2 residents reviewed for dialysis (Resident #25 and Resident #45), and was evidenced by the following: 1. On 3/23/25 at 10:32 AM, during initial tour of the facility, the surveyor observed Resident #45 seated in their wheelchair in the hallway. Resident #45 stated that they go to dialysis three times a week. On 3/24/25 at 12:52 PM, the surveyor reviewed the medical record for Resident #45. A review of the Transfer/Discharge Report face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but were not limited to; end stage renal disease (kidneys have permanently lost their ability to function), dependence on renal dialysis (relies on dialysis machine to filter their blood), and type two diabetes mellitus (body does not use insulin properly). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/28/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated a severe impairment cognition. A further review included the resident received dialysis while at the facility. A review of the Order Summary Report included a physician's order (PO) dated 3/20/25, for dialysis at [dialysis center name] on Tuesday, Thursday, and Saturday; seating time 6:00 AM. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 7/31/24, that the resident needed hemodialysis related to renal failure. Interventions included but were not limited to; encourage resident to go for scheduled dialysis appointments; resident receives dialysis (Tuesdays/Thursdays/Saturdays), monitor labs and report to the doctor as needed, and do not draw blood or take blood pressure in the arm with the graft. On 3/24/25 at 12:52 PM, the surveyor reviewed Resident #45's dialysis communication record that was sent with the resident on dialysis treatment days. The communication forms were reviewed for February and March 2025. The following dialysis communication forms were not completed by the facility's nurse upon return from dialysis: 2/14/25, 2/15/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25, 3/15/25, and 3/20/25. On 3/25/25 at 10:35 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated the dialysis communication form was completed by the nurse prior to departure and it was sent to dialysis with the resident. LPN #1 also stated that when the resident returned from dialysis, the nurse obtained vital signs, checked the bruit and thrill, reviewed the dialysis communication form and signed the bottom of the form indicating the nurse reviewed it. LPN #1 further stated the nurse reviewed the information from the dialysis center for medication changes, new orders, and the resident's weight. LPN #1 stated the purpose of the dialysis communication form was to have communication between the facility and the dialysis center. LPN #1 acknowledged that the dialysis communication forms should not have any blank sections, and the nurse should sign it upon the resident's return. On 3/25/25 at 11:23 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated when the resident was sent out to dialysis, their communication book went with them. LPN/UM #1 also stated that the nurse was responsible to review and sign the dialysis communication form when the resident returned from dialysis. LPN/UM #1 further stated that the purpose of the dialysis communication form was to see if there were any changes with the resident's medication, weight, and vital signs. LPN/UM #1 acknowledged that the dialysis communication forms should not have blanks and that the nurse should have signed the form upon return. On 3/26/25 at 11:20 AM, the surveyor interviewed the Director of Nursing (DON), who stated the purpose of the dialysis communication form was to ensure proper coordination of care for the resident. The DON further stated that when a resident went out to dialysis, the nurse was responsible to complete the Information from sending facility section with vital signs, and upon the resident's return, the nurse reviewed the form and signed the bottom of the form. The DON also stated if there were any new orders the nurse followed up with the physician. The DON acknowledged that the dialysis communication forms were not filled out completely on the following dates: 2/14/25, 2/15/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25, 3/15/25, and 3/20/25. On 3/27/25 at 10:14 AM, the DON, in the presence of the Licensed Nursing Home Administer (LNHA), Regional Administrator, [NAME] President of Clinical Services, and the survey team, stated dialysis communication forms should be reviewed and signed by the nurse upon the resident's return from dialysis. The DON acknowledged that the dialysis communication forms were not filled out completely.

Based on observation, interview, and review of pertinent records, it was determined that the facility failed to a.) ensure the accountability of the narcotic shift count logs were completed and b.) accurately account for and document the administration of controlled medications. This deficient practice was identified on 2 of 3 medication carts (Rosewood #1 and #4) reviewed and was evidenced by the following: On 3/25/25 at 10:20 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN), reviewed the Rosewood nursing unit's medication cart #1. The following was observed when the narcotic logbook was reviewed: The nurse's signature for the going off duty was missing on: 3/8/25 the 3:00 PM to 11:00 PM (evening) shift; 3/13/25 the 7:00 AM to 3:00 PM (day) shift; and 3/19/25 the evening shift. The nurse's signature for the coming on duty was missing on the 3/8/25 night shift. A further review of the declining inventory logs indicated that Resident #56 should have had 30 tablets of phenobarbital 32.4 milligram (mg) (a controlled medication used to treat seizures), but only 29 tablets were on hand. The LPN at that time, stated she administered the medication during the morning medication pass and failed to sign it out. The LPN further stated that controlled medications should be signed out immediately for each dose administered so that the narcotics were accounted for. On 3/25/25 at 11:35 AM, the surveyor, accompanied by the Registered Nurse (RN), reviewed the Rosewood nursing unit's medication cart #4. The following was observed when the narcotic logbook was reviewed: The nurse's signature for the incoming and outgoing nurse was blank for the 3/10/25 evening shift. A further review of the declining inventory logs indicated the following controlled medication doses that were administered and not signed out when compared to their corresponding Medication Administration Records (MAR): Resident #3: tramadol hydrochloride (hcl) 25 mg tablet (medication used to treat pain). Resident #17: lacosamide 200 mg tablet (medication used to treat seizures). Resident #33: pregabalin 25 mg capsule (medication used to treat seizures and nerve pain). Resident #42: lacosamide 50 mg tablet. Resident #46: oxycodone-acetaminophen 5-325 mg tabled (medication used to treat pain). Resident #397: oxycodone 5 mg tablet. At that time, the RN stated to the surveyor that the narcotic shift-to-shift accountability logs should not have any missing signatures and that the declining inventory logs should have been updated for each dose administered at the time of administration. The RN stated the reason was to maintain narcotic accountability, but it's time consuming to fill out narcotic declining inventory logs for each medication at the time of administration. On 3/25/25 at 12:15 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the expectation was that the shift-to-shift logs were completed and signed by the incoming nurse and outgoing nurse at the time of medication cart hand off, whether it be at shift change or otherwise. The DON stated that the requirement was that two licensed nurses completed the narcotic count together and signed the log which indicated that the count was completed and accurate. The DON stated that there should never be any missing signatures. The DON further stated that the declining inventory logs were used to keep accountability of narcotics administered and that each sheet should be filled out for each dose administered in real time, and that nurses were not to wait to sign out the dose later. A review of the facility's Controlled Substance Administration and Accountability policy with a revised date of 3/17/25, included in all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the medication administration record (MAR), controlled drug record, or other facility specified form and placed in the patient's medical record .nursing staff (2) must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services . NJAC 8:39-29.7(c)

Based on observation, interview, and review of facility policy, it was determined that the facility failed to properly store and secure medications. This deficient practice was observed in 1 of 3 medication carts reviewed (Rosewood #4), and was evidenced as follows: On 3/25/25 at 11:35 AM, the surveyor observed the Rosewood nursing unit's medication cart #4. The medication cart was next to the nurse's station and was unattended by any nursing staff. The cart was observed to be unlocked and had a bottle of acidophilus with pectin (a probiotic medication used to treat diarrhea) left unattended on top of the cart. At that time, the surveyor requested that the nurse assigned to the cart to be paged to come to the cart. The Registered Nurse (RN) assigned to the cart came out of a resident's room down the hall and approached the surveyor at the cart. The surveyor interviewed the RN who stated that medication should not have been left unattended and unsecured. The RN also confirmed that the medication cart should have been secured since it was left unattended. The RN further stated that she had worked at facilities where residents have tried to access medications. The surveyor did not observe any residents ambulating independently near the medication cart. On 3/25/25 at 12:15 PM, the surveyor interviewed the Director of Nursing (DON), who stated medications and medication carts should never be left unsecured and medications should not have been left on top of the medication cart when unattended. The DON stated medications should only be accessible to licensed nurses to ensure that residents and others cannot access medications. A review of the facility's Medication Storage policy with an implemented date of 9/1/24, included all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . NJAC 8:39-29.4(h)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 3/23/25 at 9:23 AM, during initial tour of the kitchen, the surveyor accompanied by the Head Chef, and observed the following: An opened container of bulk beef base. The beef base was not labeled with a use by date and contained a coffee mug that was used as a scooper in the beef base. A large, opened container of flour that contained a coffee mug left inside the flour to be used as a scooper. On 3/23/25 at 10:05 AM, the surveyor interviewed the Assistant Food Service Director (AFSD), who stated that the bulk beef base should have had a use by date on the container and the coffee mugs should not be used as scoopers. The AFSD acknowledged that scoopers should not be left in the flour or beef base for infection control purposes. On 3/27/25 at 10:13 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, acknowledged that the coffee mugs should not have been used and left in the flour and bulk beef base for infection control purposes. A review of the facility's provided and undated Dry Food policy did not include the proper use and storage of scoopers used in the kitchen to scoop out and measure dry ingredients. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of medical records, it was determined that the facility failed to provide necessary treatment services, consistent with professional standards of clinical practice by not a.) securing medications during medication administration observation for 1 of 3 nurses; b.) notifying a physician regarding a resident's refusal of medication for 1 of 1 residents (Resident #31); c.) applying skin protective devices as ordered by a physician for 1 of 2 residents (Resident #8) reviewed for pressure ulcers; and d.) destroying unused medication properly during medication observation for 1 of 3 nurses. Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, 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 task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. This deficient practice was identified by the following: 1. A review of the admission Record face sheet (admission summary) indicated that Resident #31 was admitted to the facility with the diagnoses which included but were not limited to; displaced intertrochanteric fracture of the left femur. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated [DATE], reflected that the resident was cognitively intact and required maximum assistance with activities of daily living. On [DATE] at 9:10 AM, during medication administration observation for Resident #31, the surveyor observed Resident #31 lying in bed. The surveyor observed the Licensed Practical Nurse (LPN #1) offer Resident #31 the medication Lovenox injection (anticoagulant that thins the blood for the prevention of blood clots). The resident refused the injection. LPN #1 placed the medication, unsecured, on top of the medication cart and went into the resident's room and bathroom while the medication was out of the LPN's view. The surveyor interviewed LPN #1 and asked her if all medications should be secured in the cart and the LPN confirmed that all medications should be secured in the cart. The surveyor then asked LPN #1 why she left the Lovenox injection on the top of the medication cart and did not secure it in the cart, and the LPN admitted that she should have locked the medication in the medication cart because another resident could have taken it from on top of the cart. A review of the Physicians Orders (PO) dated [DATE], reflected an order for Lovenox injection solution prefilled syringe 40 milligrams per 0.4 milliliters (40 mg/0.4 mL); inject 0.4 ml subcutaneously one time a day for left femur (thigh bone) fracture prophylactic. A review of the [DATE] Medication Administration Record (MAR) revealed that Resident #31 had refused the Lovenox subcutaneous injections 19 out of 24 days in [DATE]. The medication was refused on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The surveyor reviewed Resident #31's Progress Notes (PN) and there was documentation that the resident's primary care physician (PCC) was notified one time on [DATE] at 9:59 AM, regarding the resident's refusal of the medication, however there was no documentation regarding the physician's response to the refusal. There was also documentation in the PN on [DATE] at 10:34 AM, that the resident refused the medication, however the note did not indicate that the physician was made aware. The surveyor reviewed the Physician Progress Notes (PPN) for [DATE], which included notes documented on [DATE], [DATE], [DATE], [DATE], and [DATE]. The notes did not include documentation that the physician was aware that the resident was refusing the anticoagulant medication Lovenox. A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated [DATE], that the resident was on anticoagulant therapy related to (r/t) post-surgery. Interventions included to: administer anticoagulant medications as ordered by physician and monitor for side effects and effectiveness every shift; and to monitor/document/report as needed (PRN) adverse reactions of anticoagulant therapy which included; blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. The ICCP did not indicate that the resident had behaviors of non-compliance with mediation usage. On [DATE] at 11:55 AM, the surveyor interviewed LPN #1, who stated that if a resident refused a medication on consecutive days, the assigned nurse was expected to call and notify the physician. LPN #1 stated that if the resident consistently refused the medication by day three, the nurse was responsible to call the physician to obtain an alternate medication or to get a discontinuation order for the medication. On [DATE] at 1:38 PM, the surveyor interviewed the Director of Nursing (DON), who stated that if the resident refused a medication after three days, the physician should have been notified to find out if an alternative could be ordered or to see if the medication could be discontinued. The DON continued to explain that there should have been documentation in the progress notes that the resident had been refusing Lovenox for multiple days in March, and there also should have been documentation that the physician was made aware and what the physician wanted to do about the refusals. On [DATE] at 11:53 AM, the surveyor interviewed the PCC, who stated that Resident #31 was high risk for deep vein thrombosis (DVT). The PCC stated that she knew that while the resident was in the acute care hospital that the resident was non-complaint with treatments, however she could not remember if she was notified that the resident refused the Lovenox at this facility. The PCC stated that if she was notified, she could have recommended an alternative such as compression stocking, because you cannot force resident to take something that they did not want to. On [DATE] at 9:29 AM, the surveyor interviewed the Pharmacy Consultant (PC), who stated that when she conducted the medical record review (MRR), she reviewed the MAR, physician orders, checked parameters and documented any discrepancies. The PC stated that she conducted an MRR review for Resident #31 and sent a separate report to the PCC on [DATE], regarding the resident missing doses of Lovenox. The PC stated that she did not know why the PCC stated that she was not aware the resident refused the medication. A review of the Pharmacy Consultant Report (PCR) dated [DATE], included the PC's recommendations: This resident has been refusing Lovenox. Please consider switching to an oral anticoagulant. On [DATE] at 10:14 AM, the DON stated that the facility reviewed and acted upon the PC's recommendations on [DATE], however they did not see the second page which contained the recommendations regarding the resident's refusal of the Lovenox, which was acted upon on [DATE], after surveyor inquiry. The DON stated that the PCC switched the medication to oral anticoagulant medication. 2. The admission Record face sheet indicated that Resident #81 was admitted to the facility with the diagnoses which included but were not limited to; cerebral infarction (stroke) and contracture of the knee. The comprehensive MDS dated [DATE], reflected that Resident #81 had moderate cognitive impairment and was dependent on staff for activities of daily living (ADLs). The MDS also indicated that the resident had a pressure ulcer and was at risk for development of pressure ulcers. A review of the PO dated [DATE], reflected an order for heel boots to be applied bilaterally and to maintain and check for placement every shift. The boots were to be removed for care every shift for prophylaxis to check for redness. On [DATE] at 11:52 AM, the surveyor observed the resident lying in bed and was not wearing heel boots. On [DATE] at 11:30 AM, the surveyor observed Resident #81 lying in bed. The resident was interviewed at that time and stated that they were not wearing any heel boots on the feet. The resident lifted the blankets and showed the surveyor. A review of the resident's ICCP included a focus area dated [DATE], that the resident had actual skin breakdown. A review of the intervention dated [DATE], included that the resident was to wear bilateral heel boots while in bed and check placement every shift. On [DATE] at 11:44 AM, the surveyor interviewed the resident's Certified Nursing Assistant (CNA #1), who stated that Resident #81 was alert and oriented and able to answer questions appropriately. CNA #1 stated that the resident required total care for washing and dressing, had a wound on their left hip, utilized an air mattress, and wore no devices. A review of the Treatment Administration Record (TAR) dated [DATE], indicated that the nurse had signed that the heel boots were in place on the resident. On [DATE] at 11:45 AM, the surveyor observed Resident #81 not wearing bilateral heel boots as ordered by the physician. The surveyor interviewed the Registered Nurse (RN #1), who accompanied the surveyor to the resident's room, and RN #1 stated that the boots must be in the laundry. RN #1 then went to a closet in the hallway and obtained the boots. RN #1 had no explanation as to why she had signed in the TAR that the resident's bilateral heel boots were in place when they were not on. On [DATE] at 10:14 AM, the surveyor interviewed the DON, who stated that the heel boots should be applied as ordered by the physician and that if the resident refused to wear them, it should be documented in the PN. 3. On [DATE] at 9:10 AM, the surveyor conducted a medication observation on the Evergreen Unit with LPN #1. The surveyor observed a resident refuse a Senna laxative medication. After the resident's refusal, LPN #1 returned to the medication cart and threw the medication in the trash can. The surveyor asked LPN #1 what the process was for proper disposal of medication, and the LPN stated that she should have disposed the medication into the drug buster (used for pill disposal, destroys prescription medications safely, and safe disposal of medications). When asked why she threw the medication in the trash can, LPN #1 stated that she improperly disposed of the medication because she was nervous. On [DATE] at 10:14 AM, the surveyor interviewed the DON, who stated that medication should have been disposed in the drug buster not the trash can. A review of the facility's Medication Storage policy dated [DATE], included that during medication pass, medications must be under the direct observation of the person administering the medications and locked in the medication storage area/cart. A review if the facility's Resident Rights Regarding Treatment and Advance Directives policy dated [DATE], included that should a resident refuse treatment of any kind, the facility would document the following in the resident's chart: what the resident refused; the reason for the refusal; how the resident was educated regarding the consequences of the refusal; the offering of alternative treatments; the continuation of providing all other services; that the physician was notified of the refusal and the resident's response to education/offering of alternatives . A review of the facility's Use of Assistive Device policy dated [DATE], included that use of assistive device will be based on the resident's comprehensive care plan and that the nurse with responsibility for the resident would monitor for consistent use of the device. Refusals of use would be documented in the resident's medical record . A review of the facility's Destruction of Unused Drugs dated [DATE], included all unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations (refer to any state-specific requirements). 1. Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements .3. Prescription drugs may not be flushed down the toilet in accordance with EPA regulations. 4. Our facility utilizes Drug Busters to destroy unused, non-returnable medications . NJAC 8:39-11.2(b); 27.1(a); 29.4(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ175184, NJ176084, NJ179637 Based on observations, interviews, and review of pertinent facility documents, the facility failed to ensure residents who required assistance with their daily activities of living (ADLs) a.) received incontinence care and b.) staff answered resident call systems to provide care and services. This deficient practice was identified for 1 of 4 residents reviewed for bowel and bladder (Resident #65); 2 of 8 residents observed during incontinence rounds (Resident # 29 and Resident #63); and on 1 of 2 nursing units (Rosewood). The evidence was as follows: 1. On 3/23/25 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated the unit today had five certified Nurse Aides (CNA) for 48 residents. On 3/23/25 at 10:26 AM, during the initial tour of the unit, the surveyor interviewed Resident #65 who was lying in their bed. The resident stated that they were saturated and had not been changed yet that morning. Resident #65 stated that they had to use incontinence briefs due to a stroke. The resident then showed the surveyor the brief that was soiled with urine. The resident then stated that they had not been changed all night. A review of Resident #65's most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/27/24, revealed that the resident had a brief interview for mental status (BIMS) score or 15 out of 15, which indicated a fully intact cognition. The MDS further revealed that the resident was incontinent of bowel and bladder and dependent on staff for toileting. On 3/24/25 at 9:45 AM, the surveyor observed Resident #65 lying in bed in their room. The resident stated, Thank you, I was changed this morning. The resident then stated that they were not changed until later in the afternoon yesterday (3/23/25). On 3/25/25 10:30 AM, the surveyor interviewed CNA #1, who stated that residents' incontinence briefs were changed every two hours. CNA #1 further stated that it was importance to change the resident every two hours to prevent skin breakdown and for skin integrity. On 3/26/25 at 11:20 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the schedule to change residents' incontinence briefs was specific to each resident and their needs. The DON also stated that they do not have specific time frames to change the resident's incontinence brief. On 3/27/25 at 10:14 AM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Administrator, [NAME] President of Clinical Services (VPCS), and the survey team, acknowledged that CNAs needed to ensure timely incontinence rounds were being completed. 2. On 3/23/25 at 10:34 AM, the surveyor observed the call device for Resident room [ROOM NUMBER] on at 10:34 AM. The nurse call device system at the nurse's station revealed it was activated for three minutes at 10:34 AM. The surveyor observed LPN/UM #1 enter the room at 10:41 AM. The nurse call device system present at the nurse's station revealed that Resident room [ROOM NUMBER]'s call device was activated for ten minutes when attended to at 10:41 AM. On 3/24/25 at 9:13 AM, the surveyor observed the call device for Resident room [ROOM NUMBER] on at 9:13 AM. The nurse call device system at the nurse's station revealed that the call device at 9:19 AM, had been activated for fourteen minutes at that time. During the surveyor observation, it was observed that multiple staff walked past the resident's room during the call device being activated. At 9:22 AM, the surveyor observed a staff member enter the room to assist the resident and turned the call device off. The call device was activated for seventeen minutes. On 3/24/25 at 9:29 AM, the surveyor observed the call device for Resident room [ROOM NUMBER]B was triggered on at 9:29 AM. The surveyor observed two staff walk by the resident's room on three occasions. At 9:40 AM, the surveyor observed a staff member enter the room to assist the resident and turned off the call device. On 3/27/25 at 10:14 AM, the LNHA, in the presence of the DON, Regional Administrator, VPCS, and the survey team, stated that call device response times were very serious. The LNHA further stated that weekly audits for call devices have been completed and the longest weight time was ten minutes. The LNHA further stated that no staff should walk by a call device light without seeing the need of the resident. A review of the facility's Call Lights: Accessibility and Timely Response policy with an implemented date of 9/1/24, included .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow resident to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response .10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 11. Process for responding to call lights: a. turn off the signal light in the resident's room .c. listen to the resident's request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel. d. inform the appropriate personnel of the resident's need . 3. On 3/24/25 at 9:10 AM, the surveyor conducted with LPN/UM #1 an incontinence tour and observed the following: On 3/24/25 at 9:23 AM, the surveyor and LPN/UM #1 observed Resident #63 in bed. LPN/UM #1 exposed the resident's incontinence brief. The surveyor observed the incontinence brief was saturated with urine and had a strong urine odor. There was also moderate amount of formed and grayish substance on the brief that LPN/UM #1 acknowledged was a bowel movement. LPN/UM #1 stated that the resident needed to be changed. On 3/24/25 at 9:27 AM, the surveyor and LPN/UM #1 observed Resident #29 in bed. LPN/UM #1 exposed the resident's incontinence brief. The surveyor observed the incontinence brief to be saturated with urine. There was also large amount of formed brownish substance that the LPN/UM acknowledged was a bowel movement. The surveyor observed the skin around the resident's buttocks area was reddened. The resident stated that nobody changed them since the night before. LPN/UM #1 stated that the resident would be changed immediately. On 3/26/25 at 10:38 AM, the surveyor interviewed CNA #2, who stated that they changed the residents' incontinence briefs every two hours or as needed because the residents could develop urinary tract infections if they were not changed when they needed to. CNA #2 also stated that as soon as they started their shift at 7:00 AM, the CNAs did rounds with the CNAs from the 11:00 PM to 7:00 AM (night) shift and received reports. CNA #2 confirmed that the 7:00 AM to 3:00 PM (day) shift CNAs do the morning rounds and that the night shift CNAs did their last rounds at 5:00 AM. On 3/26/25 at 10:40 AM, the surveyor interviewed CNA #3, who stated that they checked the residents' incontinence briefs every two hours or more depending on how often the resident voided. On 3/26/25 at 10:42 AM, the surveyor interviewed CNA #1, who stated that they checked the residents every two hours. A review of the facility's Incontinence policy with an implemented date of 9/1/24, included .based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible . A review of the facility's Activities of Daily Living (ADLs) policy with an implemented date of 9/1/24, included .Care and services will be provided for the following activities of daily living: .3. Toileting .Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . A review of the facility's Nursing Services and Sufficient Staff policy dated implemented on 3/3/25, included .1. The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and other pertinent facility documentation it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection by ensuring a.) proper use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP) for 2 of 2 residents reviewed for EBP (Resident #81 and #397), b.) label and date piston syringe irrigation kit (a device intended for medical purposes that consists of a calibrated hollow barrel and a movable plunger) in a manner to prevent contamination for infection control identified for 1 of 1 resident reviewed for tube feeding (Resident #64), and c.) respiratory device tubing and mouthpiece/ mask were stored in protective covering identified for 1 of 2 residents (Resident #17) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. A review of the admission Record (AR) face sheet (admission summary) indicated that Resident #81 was admitted to the facility with the diagnoses which included but were not limited to; cerebral infarction (stroke) and contracture of the knee. A review of the Minimum Data Set (MDS), an assessment tool dated 2/14/25, reflected that Resident #81 had moderate cognitive impairment and was dependent on staff for activities of daily living (ADLs). The MDS also indicated that the resident had a pressure ulcer and was at risk for development of pressure ulcers. On 3/23/25 at 10:57 AM, during initial tour, the surveyor observed a sign on the resident's door which indicated that Resident #81 was on enhanced barrier precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes). The signage indicated that staff were to wear personal protective equipment (PPE) such as an isolation gown and gloves. The surveyor observed PPE in a cart in front of the resident's door that contained gowns and gloves. The surveyor observed a Certified Nursing Assistant (CNA #1) providing direct resident care (bathing the resident in bed) wearing only gloves and not an isolation gown. At that time, the Licensed Practical Nurse/Unit Manager (LPN/UM #1) walked by the resident's room and was notified by the surveyor the breech in infection control. LPN/UM #1 then entered the resident's room. LPN/UM #1 also observed the CNA #1 not wearing the appropriate PPE while performing direct resident care. LPN/UM #1 stated that CNA #1 did not realize the resident was on EBP even though there was a visible sign on the door that specified what type of PPE to be applied when providing direct resident care. LPN/UM #1 confirmed that CNA #1 should have been wearing the appropriate PPE such as gown and gloves when caring for Resident #81. A review of the physician's order (PO) dated 2/19/25, reflected an order to maintain EBP related to a history of methicillin resistant staphylococcus aureus (MRSA). A review of the individual comprehensive care plan (ICCP) dated 2/7/24, indicated that the resident had actual skin breakdown with a goal to avoid infection and resolve wounds. A review of the facility's Enhanced Barrier Precautions policy dated 9/1/24, included that EBP refer to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities .initiation of EBP would be obtained for any resident who had wounds or indwelling medical devices . 4. On 3/23/25 at 10:40 AM, during the initial tour of the facility, the surveyor observed Resident #64 sleeping in their bed. The surveyor observed a piston syringe irrigation kit in a bag located on the resident's nightstand. On 3/24/25 at 12:07 PM, the surveyor observed LPN #1 administer Resident #64's tube feeding as per physician orders. The surveyor observed the piston syringe irrigation kit that LPN #1 used to administer the tube feeding was not labeled or dated. After LPN #1 completed the administration of the tube feeding, the surveyor interviewed LPN #1 who stated the piston irrigation kits were changed daily. LPN #1 stated the piston syringe bottle and container should have a date on it to indicate when it was opened. LPN #1 acknowledged that there was no date on the piston syringe bottle or the container it comes in. LPN #1 then stated it should be dated so we know when it was opened for infection control purposes. On 3/23/25 at 12:58 PM, the surveyor reviewed the medical record for Resident #64. A review of the AR face sheet reflected the resident was admitted to the facility with diagnoses which included but ere not limited to; dysphagia (difficulty swallowing), gastrotomy status (presence of gastrotomy feeding tube), and unspecified severe protein calorie malnutrition (consumes inadequate amounts of protein and calories). A review of the most recent quarterly MDS 1/6/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severe impairment cognition. A further review included the resident had a feeding tube while at the facility. A review of the Order Summary Report included a physician's order (PO) dated 4/10/24, for NPO (nothing by mouth) diet. A further review revealed a physician's order dated 4/25/24, for enteral tube feeding four times a day, Two Cal HN 237 ml bolus (single dose) via peg tube (flexible tube inserted through the skin and into the stomach) for a total volume of 948 ml. There was also a physician's order dated 4/1/24, to change piston syringe every night shift. On 3/25/25 at 10:35 AM, the surveyor interviewed LPN #2, who stated that the piston syringe irrigation kits should be changed every day. LPN #2 also stated that the bottle and the container were labeled with the resident's room number and dated. LPN #2 further stated it was important to label and date the irrigation kits, so the nurse knew when it had been opened and to make sure we were not using old dirty ones. On 3/25/25 at 11:23 AM, the surveyor interviewed LPN/UM #2, who stated the piston syringe irrigation kits were changed daily on the 11:00 PM to 7:00 AM shift. LPN/UM #2 stated that when the irrigation kits were opened by the nurse, they were to be dated. LPN/UM #2 further stated that the importance of dating the irrigation kits was to ensure the nurse did not use an old one and for contamination reasons. On 3/26/25 at 11:20 AM, the surveyor interviewed the DON, who stated that piston syringe irrigation kits were changed daily, every 24 hours, or if needed sooner. The DON stated that the 11: 00 PM to 7:00 AM nurse discarded the old irrigation kit and replaced it with a new one. The DON also dated that the irrigation kit once it was opened to ensure it was not being used over 24 hours. The DON stated that it should not be used over 24 hours due to infection control purposes. On 3/27/25 at 10:14 AM, the DON, in the presence of the Licensed Nursing Home Administrator, Regional Administrator, [NAME] President of Clinical Services, and the survey team, acknowledged that piston syringe irrigation kits should be dated when opened for infection control purposes. The DON stated that if a nurse saw an irrigation kit not dated, they were to discard it and get a new one. A review of the facility's Care and Treatment of Feeding Tubes policy date implemented 9/1/24 did not address piston syringe irrigation kits. NJAC 8:39-19.1; 19.4(a); 27.1(a)(e) 2. During the initial tour of the facility on 3/23/25 at 10:50 AM, the surveyor observed a sign by Resident #397's door which indicated that the resident was on EBP. The surveyor observed CNA #2 changing Resident #397 in bed. CNA #2 wore gloves with no gown. The surveyor asked CNA #2 what PPE they should be wearing when changing a resident with the EBP sign on the door. CNA #2 stated that they should have worn a gown and gloves. On 3/24/25 at 8:00 AM, the surveyor reviewed the medical record for Resident #397. A review of the AR face sheet indicated the resident was admitted to the facility with diagnoses including but were not limited to; acute kidney failure and dermatitis (skin irritation and rashes caused by genetic factors and others). A review of the most current quarterly MDS dated [DATE], reflected that the resident did not have any wounds but was at risk for developing pressure injuries. A review of the Order Summary Report dated active as of 3/23/25, included the following physician's orders (PO): A PO dated 10/17/24, that the resident required EBP for wound status every shift per protocol. A PO dated 3/21/25, to cleanse distal left lower leg ulcer with normal saline, cover with abdominal pad, then ACE wrap (an elastic bandage) every 72 hours for left leg ulcer. A review of the ICCP included a focus area revised on 8/27/24, that the resident required EBP related to a wound. Interventions included to post of signage outside resident's room indicating required PPE and high-contact activities that require the use of PPE. During an interview with the surveyor on 3/25/25 at 10:01 AM, LPN/UM #2 stated that if a resident was on EBP, staff had to wash their hands, and put on gloves, a gown, and a mask. LPN/UM #2 stated that prior to exiting the room, the staff had to remove the PPE and wash their hands again. During an interview with the surveyor on 3/25/25 at 11:18 AM, the Director of Nursing (DON) stated that EBP was utilized by staff during high contact activities such as changing residents with wounds. 3. During the initial tour of the facility on 3/23/25 at 10:17 AM, the surveyor observed Resident #17 sitting in their wheelchair in their room. On top of the resident's side table was a nebulizer (a device used to administer medication in the form of mist inhaled into the lungs), and the handheld mouthpiece attached was unlabeled, unbagged, and exposed to air. The tubing connecting the mouthpiece to the nebulizer was observed touching the plastic liner of the trash can in front of the side table. On 3/24/25 at 12:19 PM, the surveyor observed the resident's nebulizer on top of the side table with the handheld mouthpiece unlabeled, unbagged and touching the content of a plastic container. On 3/24/25 at 12:10 PM, the surveyor reviewed the medical record for Resident #17. A review of the AR face sheet indicated the resident was admitted to the facility with diagnoses including but were not limited to; acute respiratory failure with hypoxia (low level of oxygen in the body) and dementia (symptoms affecting thinking and social abilities). A review of the most current quarterly MDS dated [DATE], revealed the resident had a moderately impaired cognition. A further review of the MDS indicated the resident had not received any respiratory therapy during a seven day look back period. A review of the Order Summary Report dated active as of 3/26/25, included the following physician's order (PO): A PO dated 12/26/24, for ipratropium-albuterol solution 0.5-2.5 (3) milligram per 3 milliliters (3 mg/3 ml); inhale 3 ml orally via nebulizer every six hours for chronic obstructed pulmonary disease (COPD, a lung disease causing restricted airflow). During an interview with the surveyor on 3/25/25 at 10:01 AM, LPN/UM #2 stated that nebulizer masks/handheld device should be dated, labeled with the name of the resident, and stored in a plastic bag. During an interview with the surveyor on 3/26/25 at 12:37 PM, the DON stated that nebulizer masks/handheld device should be bagged with date and name of resident. A review of facility's Oxygen Safety policy dated implemented on 9/1/24, did not include the care and storage of nebulizers.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop and implement a baseline person-centered care plan to meet a resident's medical needs and b.) implement a focus and interventions that are specific to the resident's respiratory needs for 1 of 1 (Resident #148) investigated for respiratory care. The deficient practice was evidenced by the following: On 05/01/24 at 11:02 AM, during the initial tour, the surveyor observed Resident #148 lying in bed asleep receiving oxygen (O2) at two (2) liters per minute (lpm) via nasal cannula. On 05/02/24 at 11:03 AM, the surveyor observed Resident #148 lying in bed awake receiving oxygen at 2 lpm via nasal cannula. At that time, the surveyor interviewed the resident who stated that she received oxygen most the time. The surveyor reviewed the medical record for Resident #148. According to the admission Record, Resident #148 was admitted to the facility with diagnoses that included, but were not limited to, congestive heart failure (heart muscle does not pump blood as well as it should), pulmonary hypertension (high blood pressure that affects the blood vessels in the lungs), and chronic kidney disease (kidneys are damaged and cannot filter the blood). According to the Entry Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, dated 04/24/24, Resident #148 had a Brief Interview for Mental Status Score (BIMS) of 15 out of 15, indicating he/she was cognitively intact. Section I of the MDS revealed that Resident #148's primary reason for admission was due to debility cardiorespiratory conditions (range of conditions that affect the heart and lungs). According to Section O: Special Treatments, Procedures and Programs reflected the resident received intermittent oxygen therapy on admission and while a resident. A review of Resident #148's Baseline Care Plan, initiated 04/29/2023, revealed that it did not address oxygen therapy as an intervention for the resident's respiratory needs. On 05/07/2024 at 10:22 AM, the surveyor interviewed the Licensed Practical Nurse/ Unit Manager (LPN/UM). The LPN/UM stated that the unit manager completed the baseline care plan upon admission and updated it as needed. The LPN/UM further stated that each department would complete their section of the care plan. When asked which areas should be included on the care plan, the LPN/UM stated we include skin care, falls, pain, and ADL's [Activities of Daily Living]. She then stated she would review the resident's medications and diagnosis and would add pertinent things to the care plan. The surveyor then asked if oxygen therapy should be on the care plan and the LPN/UM replied yes, if the resident was on oxygen there should be a care plan for it. The LPN/UM verified that oxygen therapy was not on resident #148's baseline care plan. On 05/07/2024 at 11:55 AM, the surveyor interviewed the Director of Nursing (DON) regarding the care plan process. The DON stated, the interdisciplinary team along with the social worker, risk management, physical therapy, and the dietician work together to create the care plans. Baseline care plan areas include falls, admitting diagnosis, medications, skin care, and pain. The surveyor then asked if oxygen therapy be included on the baseline care plan? The DON stated yes, if they are receiving oxygen or if they have a respiratory diagnosis. The DON confirmed that resident #148 should have a base line care plan for oxygen therapy. On 05/10/2024 at 09:28 AM, during a follow up interview the surveyor asked if resident #148 was receiving oxygen on admission if it should be on the baseline care plan and the DON stated, Yes, it should have been on the baseline care plan. The surveyor reviewed the facility policy titled, Care Plans - Baseline, updated 1/2024. The following was revealed under Policy Statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The following was revealed under Policy Interpretation and Implementation: 2. The Interdisciplinary Team will review the healthcare practitioners orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the residents immediate care needs including but not limited to: a. Initial goals base on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable. N.J.A.C. 8:39-11.2 (e)2

Based on observation, interview, and medical record review, the facility failed to follow professional standards of clinical practice with respect to a.) obtaining a physician's order for the application of a treatment device utilized to manage a resident's edema, and b.) update the care plan to reflect a device utilized to manage edema for 1 of 22 residents reviewed (Resident #64). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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. According to the admission Record (AR), Resident #64 was admitted to the facility with the diagnoses which included but was not limited to; diabetes mellitus, cellulitis (infection of the skin) and edema (swelling). The admission Minimum Data Set (MDS) and assessment tool that facilitates a resident's care, indicated that the resident was cognitively intact and required maximum assistance with activities of daily living (ADLs). On 05/01/24 at 11:49 AM, the surveyor observed Resident #64 lying in bed and was observed with edema to the bilateral lower extremities. The surveyor observed that the resident was wearing ace bandages to bilateral lower extremities. The surveyor reviewed Resident #64's physician Order Summary Report (OSR) dated 04/26/24, which indicated that the resident was to have a compression stocking applied to the right leg in the morning and to be removed in the evening. The Treatment Administration Record (TAR) dated 04/26/24, contained a physician orders indicating that the resident was to have a compression stocking applied to the right leg in the morning and to be removed in the evening. There were no physician orders for the resident to have ace wraps applied to the bilateral lower extremities. The surveyor reviewed the resident's Care Plan (CP) which also did not indicate that the resident was to wear ace wrap bandages to the bilateral lower extremities to manage lower extremity edema. On 05/02/24 at 01:55 PM, the surveyor interviewed Resident #64 who stated that he/she had a history of bilateral lower extremity edema. Resident #64 stated that he/she was supposed to wear a compression stocking on the right lower leg and an ace wrap on the left lower leg. The resident stated that he/she had a wound on the left foot and had it wrapped in an ace wrap instead of a compression stocking. The resident then revealed that the staff had been wrapping both lower extremities with an ace wrap and that he/she had not been wearing a compression stocking to the right lower extremity. On 05/02/24 at 02:01 PM, the surveyor observed that the nurses were documenting in the TAR that they had applied and removed a compression stocking to the right lower extremity, however the resident was wearing ace wraps bandages to the bilateral lower extremities. The surveyor also observed that there was not a physician's order for the resident to be wearing ace wrap bandages to the bilateral lower extremities to manage the resident's edema. On 05/02/24 at 02:05 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who documented in the TAR that the resident refused to have the compression stocking applied to the resident's right lower extremity. The LPN then stated that the order should have been written for the ace wraps to be applied to the bilateral lower extremities and that she would get the ordered clarified to reflect the accurate devices that should have been applied. On 05/07/24 at 09:30 AM, the surveyor observed that the resident was lying in bed wearing bilateral ace bandage wraps to the lower extremities. The resident stated that he/she did not wear compression stockings to his right or left lower extremity. The surveyor reviewed the physician orders and the order still reflected that the resident was to have a compression stocking applied to the right lower extremity. There was not a physician's order to apply ace wraps bandages to the bilateral lower extremities. On 05/07/24 at 09:40 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that the nurses applied the ace wraps to the bilateral lower extremities and that she had not seen the resident wearing compression stockings. On 05/07/24 at 09:48 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated that she had been employed in the facility for approximately 1 (one) year. The LPN UM reviewed Resident #64's physicians orders in the presence of the surveyor and confirmed that the physicians order written was to apply a compression stocking to the right lower extremity in the morning and to remove the compression stocking in the evening. The LPN/UM stated that the resident had not been wearing the compression stockings and had been wearing ace wraps to the bilateral lower extremities to manage edema. The LPN/UM stated that the order should have been clarified to reflect that the resident was wearing ace wraps to the bilateral lower extremities. She also stated that the nurses should not be signing the TAR that they were applying and removing the compression device when the resident did not utilize it. The LPN/UM then stated that she would get the physician order clarified to reflect the appropriate devices that should be worn. The LPN/UM revealed that the resident had been wearing the ace wrap bandages to the lower extremities and that there should have been a physician's order to reflect the use of these ace bandages. On 05/07/24 at 09:54 AM, the surveyor interviewed the Director of Nursing (DON) who confirmed that if the resident was not utilizing the compression stocking to the right lower extremity, then the nurses should not have been documenting that they were applying and removing the compression stocking. She stated that any application of any devices or treatments need to have a physician's order and if the resident was wearing ace wraps to the bilateral lower extremities, then a physician's order should reflect the use of the device. The DON also stated that the use of ace wraps to the bilateral lower extremity to manage bilateral lower extremity edema should have been reflected in the resident's care plan. On 05/10/24 at 09:24 AM, the survey team met with the DON. The DON stated that the nurses should have notified the physician regarding the resident's refusal to wear the compression stocking to the right lower extremity and a physician's order should have been obtained for the application of ace wraps bandages to be applied to the resident's bilateral lower extremities. The facility policy titled, Medication Orders dated 01/2024 indicated that when recording treatment orders, specify treatment, frequency, and duration of the treatment. The facility policy titled; Physician Orders dated 03/2024 indicated that all medications and treatments orders are received from a credentialed practitioner before implementing. The policy also indicated that the physician's order must be written on the appropriate physician's order sheet and interim plan of care. The facility policy titled, Care Plans, Comprehensive Person-Centered dated 01/2024 indicated that that CP would contain services that were furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. NJAC 8:39-27.1(a)

Complaint #: NJ 166493 Based on interview, record review, and review of facility documents, it was determined that the facility failed to thoroughly investigate a facility acquired pressure ulcer for 1 of 3 residents (Resident #146) reviewed for pressure ulcers. This deficient practice was evidenced by the following: The surveyor reviewed the closed record for Resident #146. According to the admission Record, Resident #146 was admitted with diagnoses which included, but were not limited to, COVID-19, major depressive disorder, severe protein-calorie malnutrition, and unspecified dementia. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/02/23, included the resident had a Brief Interview for Mental Status score of 06, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident did not have any unhealed pressure ulcers upon admission to the facility. Review of a progress note, dated 07/04/23, revealed, opened area to left buttock noted . new treatment of Santyl [topical cream to remove dead tissue] and foam border gauze noted. Review of the care plan, revised 08/03/23, included a focus of potential for skin breakdown r/t [related to] a recent surgery and immobility. Left buttocks unstageable pressure ulcer, and an intervention, dated 07/04/23, for treatments and dressings as ordered per physician. Review of the Wound Care Consultant report, dated 07/10/23, included recommendations for the Left Buttock wound to include, daily wound care with normal saline cleanse, apply Santyl, cover with silicone foam dressing. On 05/08/24 at 1:00 PM, the surveyor requested all incident/accident reports with complete investigations for Resident #146 for July 2023. During an interview with the surveyor on 05/09/24 at 9:00 AM, the Licensed Nursing Home Administrator (LNHA) stated the facility did not have any incident/accident reports for Resident #146. During an interview with the surveyor on 05/09/24 at 9:26 AM, the Certified Nursing Assistant (CNA) stated that if a resident obtained a facility acquired pressure ulcer, she would report it to the nurse. The CNA further stated that she would be required to write a statement including any details of the skin injury. The CNA explained it was important for the facility to investigate facility acquired pressure ulcers because they need to know how it was obtained. During an interview with the surveyor on 05/09/24 at 9:30 AM, the Licensed Practical Nurse (LPN) stated that if a resident obtained a facility acquired pressure ulcer, the nurse would report it to the supervisor. The LPN further explained that it would be important for the facility to investigate all facility acquired pressure ulcers so that the appropriate interventions could be implemented. During an interview with the surveyor on 05/09/24 at 9:37 AM, the LPN/Unit Manager (LPN/UM) stated if a resident obtained a facility acquired pressure ulcer, the nurse would have to complete an investigation to determine how the wound developed and to initiate interventions. During an interview with the surveyor on 05/09/24 at 11:15 AM, the Director of Nursing (DON) stated that if a resident obtained a facility acquired pressure ulcer, the wound team would be alerted. The DON further stated that the nurse would complete an incident report and obtain statements from staff. The DON explained that it was important to investigate facility acquired pressure ulcers to determine the cause of the wound. When asked about the missing incident/accident report for Resident #146, the DON verified that the nurse who discovered the facility acquired pressure ulcer should have initiated the incident report. Review of the facility's Accidents and Incidents - Investigating and Reporting policy, updated 01/2024, included, The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident, and, The following data, as applicable, shall be included on the Report of Incident/Accident form: the nature of the injury/illness (e.g. bruise, fall, nausea, etc.). NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order for oxygen therapy. This deficient practice was identified for 1 of 1 resident (Resident #148) reviewed for respiratory care. This deficient practice was evidenced by the following: On 05/01/24 at 11:02 AM, during the initial tour the surveyor observed Resident #148 lying in bed sleeping receiving oxygen (O2) at two (2) liters per minute (lpm) via nasal cannula. On 05/02/24 at 11:03 AM, the surveyor observed Resident #148 lying in bed awake receiving oxygen at 2 lpm via nasal cannula. At that time, the surveyor interviewed the resident who stated that she received oxygen most the time. The surveyor reviewed the medical record for Resident #148. According to the admission Record, Resident #148 was admitted to the facility with the following but not limited to diagnoses: congestive heart failure (heart muscle does not pump blood as well as it should), pulmonary hypertension (high blood pressure that affects the blood vessels in the lungs), and chronic kidney disease (kidneys are damaged and cannot filter the blood). According to the Entry Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, dated 4/24/24, Resident #148 had a Brief Interview for Mental Status Score (BIMS) of 15 out of 15, indicating they were cognitively intact. Section I of the MDS revealed Resident #148 had an active diagnosis of congestive heart failure, pulmonary hypertension, and chronic kidney disease. Section I also revealed that Resident #148's primary reason for admission was due to debility cardiorespiratory conditions (range of conditions that affect the heart and lungs). According to section O: Special Treatments, Procedures and Programs reflected the resident received intermittent oxygen therapy on admission and while a resident. A review of Resident #148's April 2024 Physician Order Summary Report (POS) located in the electronic medical record (EMR) did not include any orders for oxygen therapy. On 05/07/2024 at 10:22 AM the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated there should be a physician's order for anyone receiving oxygen because it was considered a treatment. The surveyor and LPN/UM reviewed the physician's orders in the EMR. The LPN/UM confirmed that a physician's order for oxygen 2 lpm via nasal cannula every 24 hours as needed for SOB[shortness of breath]/wheeze (a high-pitched whistling sound made while breathing) was written on 05/02/2024. The LPN/UM further stated that there should have been an physician's order written for the oxygen on 04/24/2024. On 05/07/24 at 11:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated any resident that needed oxygen therapy needed to have a physician's order. The DON confirmed that on 04/24/2024 resident #148 was receiving oxygen at 2 lpm via nasal cannula and did not have a physician's order on that date. The DON further stated there should have been a physician's order written on that date for the oxygen. On 05/10/2024 at 09:28 AM, the Director of Nursing stated in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team, if a resident is on oxygen therapy there needs to be a physicians order. The DON confirmed that resident #148 did not have a physician's order for oxygen therapy. A review of the facility's Oxygen Administration policy, dated updated 10/2019, included, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. N.J.A.C. 8:39-11.2 (e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to label, date, and store potentially hazardous foods appropriately to prevent food borne illness. This deficient practice was evidenced by the following: On 05/01/24 at 10:24 AM, the surveyor in the presence of the Food Service Director (FSD), toured the kitchen and observed the following in the dry storage pantry: 1. Two (2) packs of 12 bread that was identified as hamburger buns, had a used by date of 4/25/24. 2. A bag of [NAME] couscous toasted pasta was opened and not dated. 3. A bag of instant nonfat dry milk was opened with a used by date of 4/27/24. On 05/08/24 at 11:08 AM, the surveyor interviewed the FSD who stated that everything should have an opened date, used by date, and received by date on it. He stated that anything that came into the kitchen should have a sticker with the date it was received on it, a sticker for when it was opened and a used by date sticker. He explained anything opened and was a bulk item such as the couscous had a six (6) months expiration. The FSD confirmed there should be an opened date sticker on the couscous, to show when it was opened and when to use it by. He then confirmed that the 2 packs of 12 hamburger buns dated 4/25/24 and the instant nonfat dry milked dated 4/27/24 should have been discarded. The FSD concluded that the items were discarded on 5/1/24. On 05/10/24 at 09:31 AM, the Licensed Nursing Home Administrator (LNHA) stated in the presence of the Director of Nursing (DON), the Regional LNHA, the Infection Preventionist (IP) and the survey team that the FSD generally conducted a walk through on Wednesdays to check for all expired items and that everything would have been discarded and labeled by then. A review of the facility's Food Storage policy, undated, included All foods will be properly stored in a safe, sanitary manner. Dry Storage 2. Plastic containers with tight-fitting covers will be used for storing products such as grains, sugar, dried vegetables and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. 4. All foods will be stored either wrapped or in closed storage containers and be clearly dated and labeled. A review of the facility's Dry Food policy, undated, included 2. Immediately after delivery all products will be dated for proper rotation. A review of the facility's Dating and Labeling policy, undated, included All foods are to be labeled and dated appropriately to ensure food safety regulations are followed. 1. Upon receiving and storing, all items must be labeled with the name of food and received date. Once opened, the label must be updated with the current date and a use by date of 3 days (including date opened) unless indicated on labeling and dating protocol. 3. All items with an expired use by date must be discarded immediately. NJAC 8:39-17.2(g)

2.) The surveyor reviewed the closed medical record for Resident #147. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included, cognitive communication deficit, dementia with other behavioral disturbance, anxiety disorder and major depressive disorder. A review of the quarterly Minimum Data Sheet (MDS), an assessment tool, dated 1/18/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 05 out of 15, which indicated the resident had severe cognitive impairment. A review of the Facility Reportable Event (FRE) indicated an incident occurred on 2/22/24 between Resident #147 and Resident #245. It reflected the residents were immediately separated, assessed and no injuries were noted. It further reflected there were descriptions from the nurse and both residents of the incident as well as the written statements from staff with the incident reports. A review of the February 2024 Progress Notes (PN) revealed there were no documentation in the PNs related to the incident that occurred on 2/22/24. A further review reflected a PN on 2/22/24 at 20:58 (8:58 PM) that the psychiatrist conducted rounds and to follow up as needed. 3.) The surveyor reviewed the closed medical record for Resident #245. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included, Down Syndrome, anxiety disorder, dysphagia (difficulty swallowing), and Attention-Deficit Hyperactivity Disorder (ADHD - may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active.) A review of the quarterly Minimum Data Sheet (MDS), an assessment tool, dated 12/29/23, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had an intact cognition. A review of the February 2024 Progress Notes (PN) revealed there were no PN on 2/22/24 or any documentation in the PN related to the incident that occurred on 2/22/24. On 05/08/24 at 01:14 PM, the surveyor interviewed the Registered Nurse (RN) who stated that after an incident they documented in the electronic medical record (EMR). She explained they documented what occurred, the assessment, and that the physician and the family were notified. She further explained they completed an incident report and wrote a PN. The RN stated it was important to write a PN in the EMR, so everyone was aware of what occurred with the resident. She further stated that the staff generally did not go into the incident section of the EMR and that was the importance of writing PNs. On 05/09/24 at 09:31 AM, the surveyor interviewed the Director of Nursing (DON) who stated that there should be progress notes in the EMR related to any incident, but staff have not been consistence with documenting in the PN. On 05/09/24 at 09:47 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #2) who stated that after an incident occurred, they assessed the resident and obtained witness statements from any staff that witnessed the incident. He then explained if it was unwitnessed then they would obtain statements from the Certified Nursing Assistant (CNA) and any other staff members that may have cared for the resident to document what the resident was doing the last time they were observed. LPN #2 stated that they completed a paper handwritten incident report and then document in the PN in the EMR on what occurred and what they did. He stated the importance of PN were to inform the next nurse and other staff that had access to the EMR what occurred. He stated the PN allowed them to coordinated care and allowed everyone to be aware on how to monitor the resident the next few days. LPN #2 stated that if there was a resident-to-resident incident then there should be a progress note in the EMR, so the staff was aware of what occurred and ensure the residents were safe and secure. On 05/09/24 at 09:56 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that after an incident occurred and the resident was assessed, they obtained written statements right away from staff that was around. She stated that they completed an incident report form to investigate what happened, how it occurred, and the next steps needed. The LPN/UM stated that they documented in the EMR under the risk management tab and in the progress notes which were separate. She stated that PN were important because the PN allowed them to follow up with the resident after the incident. The LPN/UM stated that if there was a resident-to-resident incident that occurred then it should be documented in the PN so they could follow up with the residents and see if any additional interventions should be put into place. On 05/09/24 at 11:35 AM, the DON stated in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team that a lot of times the nurses would document on the incident report in the nursing description section and not in the PN. The DON confirmed that staff should be documenting in the PN and that after they completed an incident report it should be followed by a PN in the EMR. The DON stated that a progress note was a description of the occurrence and that it was a communication tool for all clinicians and staff to be aware of what occurred with the resident. The DON acknowledged that there should be progress notes for both Resident #147 and #245 in addition to the incident report from 2/22/24. On 05/10/24 at 09:29 AM, the DON acknowledged in the presence of the LNHA, the Regional LNHA, the Infection Preventionist (IP) and the survey team that there was no PN in the EMR and that it was an over site. A review of the facility's Charting and Documentation policy, updated 01/2022, included All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: e. events, incidents, or accidents involving the resident. NJAC 8:39-35.2 (d) Complaint #: NJ 166943 Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to accurately document in the medical records for 3 of 26 residents (Resident #146, #147, and #245) medical records reviewed. This deficient practice was evidenced by the following: 1.) The surveyor reviewed the closed record for Resident #146. According to the admission Record, Resident #146 was admitted with diagnoses which included, but were not limited to, COVID-19, major depressive disorder, severe protein-calorie malnutrition, and unspecified dementia. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/02/23, included the resident had a Brief Interview for Mental Status score of 06, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident did not have any unhealed pressure ulcers upon admission to the facility. Review of a progress note, dated 07/04/23, revealed, opened area to left buttock noted . new treatment of Santyl [topical cream to remove dead tissue] and foam border gauze noted. Review of the care plan, revised 08/03/23, included a focus of potential for skin breakdown r/t [related to] a recent surgery and immobility. Left buttocks unstageable pressure ulcer, and an intervention, dated 07/04/23, for treatments and dressings as ordered per physician. Review of the Wound Care Consultant report, dated 07/10/23, included recommendations for the Left Buttock wound to include, daily wound care with normal saline cleanse, apply Santyl, cover with silicone foam dressing. Review of the Treatment Administration Record (TAR) for July 2023, included a physician's order, dated 07/04/23, to apply Santyl ointment to left buttock daily. Further review of the TAR revealed the treatment was not signed out as completed and was left blank on 07/05/23 or 07/15/23. During an interview with the surveyor on 05/09/24 at 9:26 AM, the Certified Nursing Assistant (CNA) stated that when a resident obtained a facility acquired pressure ulcer, she would report it to the nurse. During an interview with the surveyor on 05/09/24 at 9:30 AM, the Licensed Practical Nurse (LPN #1) stated that when a resident obtained a facility acquired pressure ulcer, the nurse would obtain a treatment order. LPN #1 further stated that when a treatment was completed, the nurse would sign off on the TAR. If the resident was unavailable or refused the treatment, LPN #1 explained that the nurse would use the corresponding code when signing the treatment off on the TAR. LPN #1 added that it was important not to leave the TAR blank, to let everyone know that the treatment was done or not. During an interview with the surveyor on 05/09/24 at 9:37 AM, the LPN/Unit Manager (LPN/UM) stated that nurses knew which treatments to complete because they checked the TAR. The LPN/UM further stated that when the treatment was completed (or not due to unavailability or refusals) the nurse would sign off on the TAR. The LPN/UM explained that it was important to sign the treatments on the TAR so that staff could follow-up on the treatments. During an interview with the surveyor on 05/09/24 at 11:15 AM, the Director of Nursing (DON) stated that when a resident obtained a facility acquired pressure ulcer, the nurse would notify the physician for a treatment order. The DON further stated that the nurses reviewed the TAR for current treatment orders and signed off the treatments when they were completed. The DON explained that if there was a blank on the TAR, it would appear the treatment wasn't done, and that the nurse should make sure to sign the TAR, to take credit for what they did. At that time, the surveyor notified the DON of the blanks on Resident #146's July 2023 TAR and the DON verified that the nurse should have documented if they did the treatment or if the resident was unavailable or refused the treatment. Review of the facility's Pressure Ulcers/Skin Breakdown policy, updated 01/2024, included, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents.

Based on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to ensure that the infection control practices for residents on transmission-based precautions (TBP) were followed to prevent the potential spread of infection by not utilizing contact precautions in accordance with facility policy and accepted national standards for 1 (one) of 2 (two) resident (Resident #79) reviewed for TBP and was evidenced by the following: According to the admission Record, Resident #79 was admitted to the facility with the diagnoses that included but was not limited to C-diff (infection of the large intestine (colon) caused by the bacteria Clostridium difficile) and MRSA (methicillin-resistant Staphylococcus aureus, a type of bacteria that is resistant to several antibiotics). A review of the quarterly Minimum Data Set (MDS) an assessment tool that facilitated a resident's care dated 02/22/24 indicated that the resident was cognitively intact. On 05/01/24 at 10:28 AM, the surveyor observed a sign posted on Resident #79's door indicating that the resident was on enhanced barrier precautions (EBP). There were also signs posted to indicate what type of personal protective equipment (PPE) must be worn when caring for the resident. There was an isolation cart in front of the resident's door containing necessary PPE such as gloves and isolation gowns. The surveyor did not observed signs posted on the resident's door that the resident was on contact isolation. The resident was observed sitting in the wheelchair in his/her room. The resident was interviewed at this time and the resident stated that the staff only utilized the PPE such as gowns and gloves when they took direct care of her/him. Resident #79 stated that they were not aware of any infection that she/he had at this time. On 05/02/24 at 08:57 AM, the surveyor reviewed Resident #79's medical record which revealed the following information: The physician Order Summary Report (OSR) dated 02/21/24, indicated that Resident #79 was on Contact Isolation Precautions because the resident was positive for the infection c-diff (stool infection) and MRSA (methicillin-resistant Staphylococcus aureus, a type of bacteria that is resistant to several antibiotics) of wound. The OSR dated 02/21/24, indicated that Resident #79 required Enhanced Barrier Precautions for a diagnosis of ESBL (Extended Spectrum Beta-Lactamase (ESBL)-producing Bacteria) and MRSA every shift. The resident's Care Plan (CP) indicated that Resident #79 was on enhanced barrier precautions related to a wound, indwelling medical device and infection or colonization. The CP was initiated on 11/16/2023. Interventions included: -Clear signage must be posted on the door or wall outside of the resident room. indicating the type of precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high contact. resident care activities that require the usage of gown and gloves. Date Initiated: 11/16/2023. - EBP will in place for the duration of a residents stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Date Initiated: 11/16/2023. The CP also indicated that the resident was on Contact Isolation for the diagnoses of urinary tract infection and ESBL of the urine. The CP indicated that contact isolation was discontinued on 01/02/24, however there was still an active physician's order for the resident to be on contact isolation. The surveyor reviewed the Medication Administration Record (MAR) which contained a physician's order dated 02/21/24, for Resident #79 to be on contact isolation for c-diff and MRSA of the wound. The surveyor also observed that there were nurses' signatures documented on the MAR from April 2024 till present, which indicated that the staff were maintaining contact isolation for Resident #79. On 05/02/24 09:12 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that she had been employed in the facility for 22 years. CNA #1 stated that she was very familiar with Resident #79. She stated that Resident #79 required limited to extensive assistance with activities of daily living (ADLs). She stated that the resident was alert and oriented to person, place, and time. She stated that the resident was on EBP for MRSA in a foot wound. She stated that the resident had no bacteria in her urine and that personal protective equipment (PPE) only had to be worn during direct resident care only. She explained that a gown and gloves had to be worn only when in direct contact with the resident. She stated that it was important to wear PPE to prevent the spread of infection or protect the resident from acquiring an infection from the staff. On 05/02/24 at 09:15 AM, the surveyor was standing outside Resident #79's room and observed CNA#2 providing direct resident care (toileting) for Resident #79 in the resident's room. The CNA was only wearing a surgical mask and a pair of gloves. The surveyor did not observe the CNA wearing an isolation gown when providing direct resident care for Resident #79. On 05/02/24 at 09:20 AM, the surveyor interviewed CNA #2 who stated that she had been employed through the agency. CNA #2 stated that Resident #79 required limited assistance with ADLs. The surveyor asked the CNA why she was in the resident's room providing care and not wearing an isolation gown? CNA #2 stated that she was only wearing a glove and a mask. CNA #2 stated that she was not aware that the resident had an infection of any kind. The CNA accompanied the surveyor to Resident #79's room and CNA #2 stated that she did not notice the sign that was posted on the resident's door which indicated that the resident was on enhanced barrier precautions and that gloves and a gown were required when providing direct patient care. CNA #2 confirmed that she was not wearing an isolation gown when providing direct resident care for Resident #79 and added that she should have read the sign that was posted on the resident's door. On 05/02/24 at 09:27 AM, the surveyor interviewed the primary care Licensed Practical Nurse (LPN) who stated that she had been employed in the facility since July 2023. The LPN explained to the surveyor the difference of Enhanced barrier precautions and Contact precautions. She stated that Enhanced barrier precautions were provided to any resident with any access to the body such as tubes, wounds, IVs [intravenous], tracheostomy's etc. She stated that when a resident was on EBP, gown and gloves were to be worn only when providing direct resident care. She stated that when a resident was on contact precautions that meant the staff must wear the required PPE (gown and gloves) when entering the room, when in contact with the resident and when in contact with the resident's environment. She stated that it was important to adhere to what type of transmission-based precaution (TBP) a resident was on to prevent the spread of infection. The LPN then added that if Resident #79 had an order to be on contact isolation, then the sign on the resident's door should have specified that. The LPN confirmed that the precaution sign on the resident's door should have indicated that the resident was on contact isolation instead of enhanced barrier precautions. The LPN admitted that she did sign the MAR indicating that the resident was on contact precautions, however there was no sign on the resident's door nor were the staff following contact precautions when entering the residents room. On 05/02/24 at 09:38 AM, the surveyor interviewed the Licensed Practical Nurse/Infectionist Preventionist (LPN/IP) who stated that she had been employed in the facility for 30 years. The LPN/IP explained that EBP were required to protect residents with any kind of inner body access such as tubes, wounds, catheters, and IVs ect. She explained that application of PPE such as gowns and gloves were required when providing direct patient care. She stated then when a resident was on EBP, PPE would not have to be applied if only delivering a food tray or just going in to talk to the resident or to administer medications. She stated that when a resident was on contact isolation the staff were required to wear PPE prior to entering the room, when in direct contact with the resident and the resident's environment. She stated that when a resident was on contact precautions the resident had an active infection and it was important to wear the appropriate PPE to prevent the spread of infection. She stated that Resident #79 did not have an active infection. The surveyor asked the LPN/IP why the resident had a physician's order for contact precautions and she stated that that order should have been discontinued. She then added that if the order was not discontinued then Resident #79 should have still been on contact isolation and the sign posted on the resident's door should have indicated as such. She also stated that when CNA#2 was providing resident care this morning she should have been wearing a gown and gloves when providing direct resident care. She also added that the LPN should have questioned the physicians for contact precautions in the MAR and should not have signed the MAR that contact precautions were being done if she was not following the order. On 05/02/24 at 09:50 AM, the surveyor interviewed the Director of Nursing (DON) who stated that EBP were for residents with access to their external fluids. She explained that PPE such as gown and gloves were required for direct resident care to prevent transmission of infection to the resident. She stated that EBP was instituted to protect the resident from infection that could be transmitted from the staff. The DON then explained what contact precautions meant. She stated that contact isolation was required for specific microorganisms the resident had and that PPE such as gowns and gloves were required when in contact with the resident and the resident's environment. She stated that there was a confusion related to what type of TBP Resident #79 was on because there was an order for the resident to be on contact isolation as well as enhanced barrier precautions. She stated that if the resident had an order for contact precautions, then the sign posted on the resident's should have been posted on the resident's door should have reflected that. She also stated that if the nurses were signing the MAR that the resident was on contact precautions then the nurses should have been adhering to the order. She confirmed that when CNA #2 was providing direct resident care to Resident #79 she should have worn a gown and gloves. On 05/10/24 at 09:29 AM, the surveyor interviewed the LPN/IP who stated that the resident had a history of c-diff which was resolved on 2/27/24. The LPN/IP confirmed that the staff should have obtained a physician's order to discontinue the contact isolation. She stated that the resident's MRSA in the wound was colonized so there was no need for contact isolation. The LPN/IP continued to add that if there was no order to discontinue contact isolation and the nurses were documenting in the MAR that they were adhering to contact isolation, then nurses should continue to follow the order until the order was discontinued. The order for the resident to be on contact isolation was discontinued after surveyor inquiry. The facility policy titled, Enhanced Barrier Precautions dated 04/2024, indicated that the implementation of EBP will reduce transmission of resistant organisms by employing targeted use of gown and glove use during high contact resident care activities. The policy indicated that high-contact care activities included: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care and wound care. The Policy also described Contact Isolation which indicated that this type of TPB was used when pathogen transmission was not completely interrupted by standard precaution alone. Contact precautions were intended to prevent the transmission of infectious agents and gloves and gowns were required on entry to the resident's room. The policy indicated that gloves and gowns were to be applied before entry to the resident room and removed before exiting the resident's room. The facility policy titled, Categories of Transmission-Based Precautions dated 03/2021, indicated that Contact Precautions was implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the environmental surfaces or resident care items in the resident's environment. The policy also indicated that gowns, gloves, and handwashing was to be utilized while caring for resident or indirect contact with the residents environmental surfaces or resident care items in the resident's environment. NJAC 8:39-19.4 (m)(n), 27.1 (a)

Based on observation, interview and review of other facility documentation, it was determined that the facility failed to ensure the the call bell was within reach of the residents. The deficient practice was identified for 4 of 7 residents (Residents #63, Resident #28, Resident #11, and Resident #70) reviewed for the Environmental Task. The deficient practice was evidenced by the following: On 4/20/22 at 10:08 AM during the initial tour, surveyor #1 observed Resident #63 lying in bed. At that time, the surveyor observed the call bell on the ground behind the bed headboard out of reach from the resident. On 4/20/22 at 10:37 AM during the initial tour, surveyor #1 observed Resident #28 lying in bed. At that time the surveyor observed the call bell behind the bed headboard out of reach from the resident. On the same date and time, surveyor #1 observed Resident #11 lying in bed. At that time, the surveyor on observed the resident's call bell attached to the call bell wall input out of reach from the resident. On 4/21/22 at 12:02 PM, surveyor #2 observed Resident #70's call bell on the floor under the bed. On 4/22/22 at 11:46 AM, surveyor #2 observed Resident #70's call bell on the floor behind the headboard of the bed. On 4/25/22 at 11:16 AM, surveyor #2 observed Resident #70's call bell hanging over the top of the oxygen concentrator. During an interview with the surveyor on 4/27/22 at 9:41 AM, the Charge Nurse said that when the staff provided care to Resident #63 and Resident #11, they forgot to attach the call bells in reach of the residents. During an interview with the surveyor on the same date at 9:46 AM, the Certified Nursing Assistant assigned to Resident #63 and Resident #11 said she did not touch the call bells yet. A review of the facility policy titled, Call Lights updated 1/2022, revealed under, Procedures number 6., Always position call light conveniently for use and within the reach of the resident. NJAC 8:39-31.8(c)

Based on observation, interview and record review, it was determined that the facility failed to maintain professional standards of nursing practice by not following a physician's order for 1 of 19 sampled residents, (Resident #52). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the admission record, Resident #52 was admitted to the facility with diagnoses including, but not limited to, periprosthetic fracture (fracture associated with implant) around internal prosthetic right hip joint and Cerebral Infarction. A review of the most recent Minimum Data Set (MDS) an assessment tool, dated 3/1/2022, identified the resident as having a Brief Interview for Mental Status of 14/15, indicating that the resident cognitively intact. During an interview with the surveyor on 4/25/2022 at 11:24 AM, Resident #52 revealed that they were to start bending his/her knee; however, the resident voiced, I don't want to do it without anyone there. No one comes in to watch me. A review of the resident's physician orders, revealed an order dated 3/31/2022 at 1:33 PM, may start gentle Range of Motion (ROM) to right knee in 2 weeks on 4/14/22 and may start right hip active/full ROM. A review of Resident #52's care plan, medication administration record (MAR), and treatment administration record (TAR) did not include the physician's order for the range of motion interventions. During an interview with the surveyor on 04/25/2022 at 1:35 PM, the Rehabilitation Director (RD) said they are made aware of potential for therapy services by nursing. When asked if Resident #52 is currently receiving services, the RD said they are not receiving range of motion or restorative nursing services because they are non-weight bearing and not using their legs. During an interview with the surveyor on 4/25/2022 at 1:55 PM, Unit Manager #1 (UM #1) stated for therapy consultations they (the nurses) will complete a paper therapy screen or therapy will initiate therapy, through an electronic task. The Surveyor asked how therapy is initiated upon direct request from a physician and UM #1 responded, Honestly, I have to ask. I don't know if I ever had that happen. The Surveyor requested UM #1 to review physician order dated 3/31/22 at 1:33 PM UM #1 confirmed therapy should have received the order. UM #1 also confirmed that nursing is responsible to ensure orders are fulfilled. During an interview with the surveyor on 4/28/2022 at 12:41 PM, the Director of Nursing (DON) said there are no policies in place for reconciliation of physician's orders. The DON explained the procedure is 11pm to 7am staff will print out the orders from the day and given to the unit managers in the AM. The unit manager will then review the orders to make sure they are all completed. NJAC 8:39-11.2(B)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that it was free of a medication error rate of five percent or greater by failing to ensure three medications were given within sixty minutes before or after the scheduled administration time. The deficient practice was observed for 1 of 7 residents (Resident #5) during the Medication Administration Task. The deficient practice was evidenced by the following: On 4/25/22 at 9:34 AM on the Rosewood Unit, the surveyor observed Licensed Practical Nurse (LPN) #1 prepare Resident #5's medication for administration. At that time, LPN #1, removed one Exelon capsule (Cognition-enhancing medication), one Metformin tablet (used to treat high blood-sugar) and one Carvedilol tablet (used to treat high blood pressure) and place them in the medication cup. At that time, the surveyor observed the Electronic Medical Administration Record (EMAR) on the medication cart computer with LPN #1. The EMAR revealed that the Exelon capsule was scheduled to be given at 7:30 AM, the Metformin tablet was scheduled to be given at 8:00 AM and the Carvedilol was scheduled to be given at 8:00 AM. LPN #1 then crushed the medications and added pudding to the medication cup. During an interview with the surveyor at that time, LPN #1 revealed that she started her shift at 8:00 AM after acknowledging the scheduled medication times. LPN #1 then entered the resident room and administered the medications using a spoon into Resident #5's mouth. During an interview with the surveyor on 4/28/22 at 1:32 PM, the Director of Nursing (DON) confirmed that the Excelon capsule, Meformin and Carvedilol tablets were given outside of the administration time. A review of the EMAR Administration History revealed that the Exelon capsule was scheduled for 7:30 AM and the administration was documented on 4/27/22 at 9:37 AM. The EMAR Administration History further revealed that the Carvedilol tablet and Metformin tablet were both scheduled for 8:00 AM and the administration was documented on 4/27/22 at 9:37 AM. A review of a facility policy titled, Administering Medications, updated on 10/2021, revealed under Policy Interpretation and Implementation number 3., Medication must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The policy further revealed under number 5., The individual administering the medication must check the label against the Physician's order to verify the right resident, right medication, right dosage, right time . N.J.A.C.8:39-29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 4/25/2022, at 3:15 PM, the Surveyor observed the following in the Rosewood Nourishment Room: 1. On the refrigerator door, located on the bottom shelf, one opened 24 ounce (oz) jar of kosher pickles was observed with resident's name and room number identified on lid. No use by date observed. Located on the same shelf, one opened 8 oz jar of sliced olives with resident's name and room number. No use by date observed. Throughout the bottom of the shelf, dried liquid was observed. 2. On the refrigerator door, located in the beverage hold, one TwoCal HN 8 oz Vanilla Carton, opened with no date identified, and One [NAME] Ready Care 8 oz carton, opened with no date identified. 3. On the bottom of the refrigerator, located under the crisper bins, of dried liquid was observed. 4. Coffee machine was observed to have coffee splatter behind dispensers. The grate above the drainage area was observed to have dried coffee residue. 5. Juice machine was observed to have spatter behind the dispensers and significant amount of thickened juice under the grate in the drain area. 6. Located in the top left cabinet, 4 individual (Name) cereal containers with expiration date of 2/10/2022. In the same area, 4 individual (Name) cereal containers with expiration date of 4/3/2022. During an interview with the surveyor on 4/26/2022 at 3:33 PM, the Food Service Director (FSD) confirmed the opened items are to be dated and contents are to be used within three days. The FSD advised that Food Services are responsible for the maintenance, cleaning, and inspection of cabinets and refrigerator. The FSD further stated that housekeeping or nursing is responsible for the juice machine. The FSD confirmed the following: 1. Ready Mildly Thickened Lemon Flavored was opened and was undated and should be dated. 2. Ready Moderately Thickened Lemon Flavored that was opened with date of 4/20/2022. The FSD said should be discarded since it was opened for more than three days. 3. Opened jar of kosher pickles should be discarded as it does not have an opened date. 4. Opened jar of sliced olives should be discarded as it does not have an opened date. 5. TwoCal HN 8oz Vanilla, should be discarded as it does not have an opened date. 6. Ready Care 8oz, should be discarded as it does not have an opened date. A review of a facility policy titled Foods Brought by Family/Visitors, version 2.0, revealed the following under Policy Statement; 7b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. 8. The nursing staff will discard perishable foods on or before the use by date. 9. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger for example, mold growth, foul odor, past due package expiration dates). During an interview with the surveyor on 4/28/2022, at 1:45 PM, the Administration and Director of Nursing (DON) confirmed that housekeeping is responsible for cleaning the coffee or juice machine. NJAC 8:39-17.2(g)

C.) According to electronic medical records, Resident #46 had a medical history consisting of, but not limited to, gross hematuria (blood in urine), benign prostatic hyperplasia (Age-associated prostate gland enlargement that can cause urination difficulty), and suprapubic catheter (which drains urine from the bladder through a cut in the abdomen) for drainage. On 4/25/2011 at 12:23 PM, surveyor #2 observed the Resident #46 in the dining room independently eating lunch. Resident #46 was dressed in sweatpants and a leg bag was not visible; however, the sweatpants had no wetness or soilage observed. During an interview with surveyor #2 on 4/26/2022 at 11:14 AM, Licensed Practical Nurse #3 (LPN) confirmed that Resident #46 had physician's orders for a leg bag during the day and urinary drainage bag at night. LPN #3 stated that the policy is for the leg bag to be changed once weekly but can be changed as needed if soiled and/or malfunction. On 4/27/2022 at 11:32 AM, surveyor #2 obtained an unopened facility leg bag package. Surveyor #2 reviewed the manufacturer instructions which revealed under number 4, To keep leg bag clean, rinse daily with 3 parts water and two parts white vinegar when not in use. During an interview with surveyor #2 on 4/27/2022 at 1:08 PM, the Director of Nursing (DON) was questioned about cleaning the leg bag. The DON responded, They can rinse the bag and ensure to clean the tip. Surveyor #2 asked if the bag is cleaned with product and the DON said no. Surveyor #2 requested that DON read #4 of the Manufacturer Instructions. Upon reading the instructions, the DON stated, I see what you are saying. When asked if the facility is following the Manufacturer Instructions, the DON responded, As you can see with me just reading it, I was unaware. I have always just rinsed it. A review of a facility policies titled Urinary Leg Drainage Bags, and Emptying a Urinary Drainage Bag and did not include instructions regarding cleaning of urinary or leg bags. N.J.A.C. 8:39-19.4(n) N.J.A.C. 8:39-19.3(a) N.J.A.C. 8:39-19.4(l) Based on observation, interview, record review and other pertinent facility documents, it was determined that the facility failed to ensure that A.) staff implemented appropriate hand hygiene after direct patient care by not performing hand hygiene for a minimum of 20 seconds, B.) failed to ensure medical waste was properly disposed of by staff leaving a used surgical drain on a resident's (Resident #426) bedside table and C.) failed to ensure a urinary drainage leg bag was properly cleaned for reuse according to the manufacturer's instructions. The deficient practice was identified for two residents (Resident #374 and Resident #426) during the Medication Administration Task and 1 of 2 residents (Resident #46) investigated for Catheters. The deficient practice was evidenced by the following: A.) On 4/25/22 at 8:28 AM, after medication was administered to Resident #374, surveyor #1 observed Licensed Practice Nurse (LPN) #2 prepare to perform hand hygiene using soap and water in the resident room bathroom. At that time, surveyor #1 started an electronic timer to verify that a minimum of 20 seconds was used to lather the hands with soap, prior to rinsing. LPN #2 began to rinse her hands with water at 14 seconds. On the same date at 9:13 AM, LPN #2 removed her gloves and prepared to perform hand hygiene using soap and water in the resident room bathroom. At that time, surveyor #1 started an electronic timer to verify that a minimum of 20 seconds was used to lather the hands with soap, prior to rinsing. LPN #2 began to rinse soap off her hands at 2 seconds. The handwashing process performed including lathering with soap and rinsing totaled 17 seconds. B.) On 4/25/22 at 9:21 AM, in Resident #426's room, surveyor #1 observed a Jackson Pratt drain (used to help empty excess fluid from the body after surgery) on the bedside table adjacent to hard candies. The drain contained yellow-colored matter inside the drain bulb. After administering medication to Resident #426, LPN #2 disposed of the drain into a clear, plastic bag. LPN #2 tied the bag and placed it into the resident's trash can next to the bed. During an interview with surveyor #1 on 4/25/22 at 9:25 AM, LPN #2 said during hand hygiene she counts a full thirty seconds and then rinses her hands in water. During an interview with surveyor #1 on 4/26/22 at 12:14, the Infection Prevention Nurse (IPN) said leaving the Jackson Pratt drain on the bedside table was incorrect and considered medical waste that should have been disposed of in a red bag. A review of a facility policy titled, Handwashing/Hand Hygiene revised on 1/2019, revealed under Policy Interpretation and Implementation subsection, Washing Hands number 1., Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds. A review of a facility policy titled, Waste Disposal revised on 1/2019 revealed under Policy Interpretation and Implementation number 1, subsection b. revealed, Disposal of all infectious and regulated waste shall be in accordance with applicable federal, state, and local regulations.

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure equipment was in good repair by A.) providing fall mats (safety mats that are placed on the floor along the side of the bed) that had rips along the seams exposing the foam interior and B.) failed to ensure medication carts and Emergency carts were free of dust and debris on the wheels and shelves. The deficient practice was identified for 2 out of 7 residents (Residents #63 and #73), 3 medication carts, and 2 emergency carts reviewed for the Environmental Task. The deficient practice was evidenced by the following: On 4/20/22 at 10:09 AM during the initial tour of the facility, surveyor #1 observed Resident #63 in bed. At this time, the surveyor observed a fall mat next to Resident #63's bed. The fall mat had a rip along the seam exposing the foam interior. On the other side of the bed was another fall mat. Surveyor #1 observed dried, yellow matter and stains on the surface of the mat. On 4/28/22 at 10:04 AM, surveyor #1 observed Resident #73 in bed. At this time, the surveyor observed a fall mat next to Resident #73's bed. The fall mat had a rip along the seam exposing the foam interior. On the same date at 10:07 AM, surveyor #1 observed Resident #63 in bed. The fall mat was folded against the wall. The fall mat had ripped corners and a piece of the exterior partially detached from the fabric surface. During an interview with the surveyor on 4/28/22 at 12:47 PM, the Director of Nursing said there is no facility policy on broken equipment. During an interview with the surveyor on 4/28/22 at 1:32 PM, the Administrator confirmed that fall mats should not have rips and should not be folded against the wall when a resident is in bed. A review of facility policy titled, Falls and Fall Risk, Managing updated on 10/2019 did not specifically address fall mats. B.) On 04/22/22 at 11:11 AM, surveyor #2 observed the following: 1. Medication cart #3 on Rosewood Unit had hair and thread/fabric strands wrapped around the wheels of the cart 2. Medication cart #4 on Rosewood Unit had hair and thread/fabric wrapped around the wheels of the cart. 3. Medication cart #2 on the Evergreen Unit had hair and thread/fabric wrapped around the wheels. 4. The Emergency Cart on the Evergreen Unit had an accumulation of dust on the second shelf support bracket. There was also as debris accumulated in the corner of the 2nd shelf. 5. The Emergency Cart on the Rosewood Unit had with debris and brown stain on top shelf and accumulation of dust debris on support brace on the 2nd shelf. During an interview with the surveyor on 04/28/22 at 1:42 PM, the Administrator said that absolutely the Emergency Carts should be cleaned by housekeeping. She also said they were looking to get new carts. The Administrator went on to say that Housekeeping cleans outside of medication carts and maintenance periodically looks at the wheels for anything stuck and are on a cleaning schedule. NJAC 8:39-31.4(a)