**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) provide personal hygiene and provide timely assistance for 2 of 2 residents dependent on staff for incontinence care, Resident #21 and #147 and b.) provide nail care to Resident #280 who required assistance with ADL's care. This deficient practice was evidenced by the following: 1.) On 5/9/24 at 10:20 AM, the surveyor observed Resident #147 in bed, the head of the bed was elevated, and the resident was able to answer questions. Upon inquiry, the resident stated he/she had not been provided with incontinence care since last night. Resident #147 further stated that, I have asked the Certified Nursing Assistance (CNA) to change me in the morning, but they haven't. At 10:36 AM, the surveyor asked the Unit Manager (UM) to make incontinence rounds on this resident. Resident #147 was observed to have on 2 adult briefs with the inner brief saturated with urine and soiled with feces (stools). The UM closed the double briefs and told the resident, Let me call your CNA to provide you incontinence care. At 11:06 AM, the surveyor interviewed the Director of Nursing (DON) and UM, who stated, Incontinence rounds are done normally every 2 hours and the residents should not be double briefed. Due to the above observation, the surveyor and the UM continued incontinence care rounds which revealed the following: At 11:10 a.m., unsampled Resident #89 was wearing a brief and appeared to be wet. At 11:15 a.m., Resident #21 was wearing a double brief and was dry. At 11:21 a.m., unsampled Resident #65 was wearing a pull-up and was dry. At 11:25 a.m., unsampled Resident #123 was wearing a brief that did not appear to be wet but was soiled with feces. At 11:32 a.m., unsampled Resident #116 was wearing a brief and was dry. A review of the admission Summary revealed that Resident #147 was admitted to the facility with diagnoses which included but were not limited to Type 2 Diabetes Mellitus without complications, Urinary Tract infection, site not specified, and Depression. The quarterly Minimum Data Set (MDS), an assessment tool, dated 2/27/2024, revealed that Resident # 147's Brief Interview for Mental Status (BIMS) was 3 out of 15 which indicated the resident was severely cognitively impaired. Section GG of the MDS which referred to Activities of Daily Living (ADLs) revealed that Resident #147 was totally dependent on staff for toileting hygiene. Section H of the MDS which referred to Bladder and Bowel revealed that Resident #147 was always incontinent of urine and bowel. Section M of the MDS revealed that the resident had one unhealed Stage 3 pressure ulcer. Review of the Care Plan for Resident #147 initiated on 5/10/23 with revision date of 5/23/23, revealed a focus for [name redacted] has impaired functional status r/t (related to) recent hospitalization, muscle weakness, pain, deconditioning, high fall risk, impaired mobility. The goal was for Resident #147 will show improvement in functional status evidenced by increased self-participation in ADL's. The interventions included: Toileting hygiene: Dependent X 1: Helper does ALL of the activity; resident does none of the effort to complete the activity. Further review of the Care Plan, initiated on 5/10/23 with a revision date of 4/25/24 revealed a focus for [name redacted] is at risk for skin breakdown r/t fragile skin, impaired mobility, incontinence, Hx (history): skin problems; MASD (Moisture-associated skin damage [an inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus.]) bilateral (b/l) [both] thighs resolved 11/1/23 Pressure 3 wound on Sacrum-extending to Left buttocks. A review of the form CNA Task under Toileting Hygiene (GG), Toilet transfer (GG), Bladder Incontinence and Bowel Incontinence, which revealed the last time the resident received care was on 5/8/24 at 19:08 (7:08 PM). There was no other documentation that the resident received incontinence care between 5/8/24 at 7:08 PM and the time of the above observation. On 5/15/2024 at 12:41 PM, the above concerns were presented to the DON, the Licensed Nursing Home Administrator, and the Regional Nurse. 2.) On 5/9/23 at 11:15 AM, the UM checked Resident #21 for incontinence care. The surveyor and the UM observed resident in bed, who was wearing 2 adult briefs, the resident was dry. The UM acknowledged that the residents should not be double briefed. A review of the admission Summary revealed that Resident #21 was admitted to the facility with diagnoses which included but were not limited to Cerebral infarction, unspecified (a type of ischemic stroke that results from a blockage in the blood vessels supplying blood to the brain), Pressure ulcer of sacral region, Stage 3 (a full thickness skin loss that has progressed beyond the layers of skin and into the fatty tissue below ), and muscle weakness (generalized). The Annual MDS dated [DATE], revealed that Resident #21's BIMS was 14 out of 15, indicating the resident was cognitively intact. Section GG of the MDS which referred to ADLs revealed that Resident #21 was totally dependent on staff for toileting hygiene. Section H of the MDS which referred to Bladder and Bowel revealed that Resident #147 was always incontinent of urine and bowel. At 11:32 AM, the surveyors interviewed CNA #1 and CNA #2. They both acknowledged that they make incontinence rounds twice a shift, they check their residents in the morning and if the residents are dry then check them after breakfast. They further stated, if the resident asks them to change them, they will change the resident. CNA #1 and CNA #2 also stated that they put only one brief on the resident and would tell the nurse if they saw a resident in double briefs. On 5/15/2024 at 12:41 PM, the above concerns were presented to the DON, the Licensed Nursing Home Administrator, and the Regional Nurse. 3. Observation on 05/08/24 at 11:22 AM, revealed Resident #280 in bed, with nails long, jagged with a black coated substances underneath the fingernails. Observation on 05/09/24 at 08:41 AM, revealed the resident eating breakfast, the fingernails were long and jagged with black coated substance underneath the fingernails. Observation on 05/10/24 at 10:10 AM, after AM care had been provided, revealed the resident in bed, The nails were still long and jagged with black coated substances underneath the fingernails. When inquired regarding nails care, Resident #280 stated that she was visually impaired. Resident #280 stated that he/she was assisted with morning care but nail care was not done. She stated that she would like the nails to be trimmed and cleaned. On 05/10/24 at 10:13 AM, during an interview with CNA #3 who cared for Resident #280, she confirmed that Resident #280 was a total care. she further stated, I have to do everything for the resident. When inquired about nails care, CNA#3 stated that nail care was part of AM care. On 05/10/24 at 10:22 AM, the surveyor escorted the Registered Nurse (RN) to the room and we both observed the fingernails long and jagged with the coated black substance underneath the fingernails. The nurse stated, Oh yes the fingernails needed to be cleaned. The resident stated, If I could do it I will clean it, but I am visually impaired. In the presence of CNA #3, Resident #280 stated, I do not want them to be cut all way down but I want them to be cleaned. On 5/10/24 at 11:30 AM, during a second interview with the RN assigned to the resident's care, she stated that Resident #280 refused the nails to be cleaned. However, the surveyor returned to the room with CNA #3 and the resident stated in the presence of the CNA #3, I do not want the nails to be cut all way down but I want them to be cleaned. The RN could not provide a care plan or documentation of Resident #280's refusal of care. On 5/10/24 at 12:15 PM, the surveyor reviewed the Electronic Medical Record (EMR) which revealed that Resident #280 had diagnosis which included Alzheimer's disease, impaired vision related to glaucoma, and anxiety disorder. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/24 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating R# 280 had moderate cognitive impairment. Further review of the MDS revealed R# 280 required substantial maximum for hygiene. Review of the care plan had a focus for impaired functional status related to muscle weakness and recent hospitalization. The goal was for Resident #280 to show improvement by increased self-participation in Activities of Daily Living (ADL's). Interventions included: Assist as needed. Encourage self participation in ADL's as tolerated. Review of the facility policy titled, Activities of Daily Living Supporting, with revised date of 03/24, indicated, Residents will be provided with care and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's) The policy further stated that Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Under Policy Interpretation and Implementations: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: c. elimination (toileting). A review of the facility document titled, Job Description with Position: Certified Nursing Assistant, revealed Basic Function: To provide services that support the care delivered to patients/residents requiring long term or rehabilitative care. Under Duties and Responsibilities: 1.e.) Assistance is given with patient care, such as, bathing, dressing, positioning, monitoring temperature, feeding, making up beds, and toileting. k.) Familiar and able to perform all of the basic CNA skills. NJAC 8:39-27.1 (a), 27.2(d, g, h, j)

Based on observation, interview, and record review it was determined that the facility failed to consistently assess a resident's dialysis access site when returning from the dialysis clinic. The deficient practice was identified for 1 of 2 residents, Resident #4, reviewed for dialysis care and services and is evidenced by the following. On 5/9/24 at 10:15 AM, the surveyor observed the resident seated in a wheelchair in their room eating breakfast. The resident was alert but refused an interview. The resident told the surveyor that they had dialysis the previous day. The surveyor reviewed the medical record for Resident #4. The admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis(a complex process that involves the intrusiveness of renal dialysis, which can sustain life but doesn't cure or heal. Dialysis is a treatment that helps the body remove waste products and extra fluid from the blood when kidneys are unable to do so), major depressive disorder (a condition with a persistently low and depressed mood) and hypertension (a condition in which the force of blood against the artery walls is too high). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/19/24, reflected that the resident had a brief interview for mental status (BIMS) score of 9 out of 15, indicating that the resident was cognitively, moderately impaired. A review of the Dialysis Communication Sheets from 4/1/24 until 5/10/24 revealed that the resident's AV Fistula (Arterialvenous fistula; how patients are connected to a dialysis machine) was located on the resident's left arm and that the facility was checking the bruit/thrill (a thrill is a vibration felt when palpating a blood vessel. While a bruit is the auscultated equivalent of the thrill) pre-dialysis and at the dialysis center. The Dialysis Communication Sheets had no information showing that the bruit and thrill were being checked post-dialysis by the facility. The surveyor reviewed the facility progress notes from 4/1/24 through 5/10/24 which revealed no post-dialysis documentation. A review of the comprehensive care plan revealed a focus area of ESRD (end stage renal disease), receiving dialysis, potential for complications. A review of the interventions revealed the following interventions Monitor dialysis shunt for thrill & bruit every shift. Monitor site for s/s (sign and symptoms of) infection. If thrill or bruit not present or s/s infection are observed, notify MD (medical doctor) for prompt intervention. Monitor bleeding at site, if present, apply direct pressure with sterile gauze and notified MD. A review of the May 2024 Order Summary Report (OSR) revealed the following physician's order (PO) dated 3/12/24 to check blood pressure and pulse prior to leaving for dialysis and on return from dialysis. No BP (blood pressure) on left arm every shift Monday, Wednesday and Friday Pre and Post dialysis. A further review of the May 2024 OSR revealed no PO to check the AV fistula access site (bruit and thrill). A review of the April and May 2024 electronic medication administration record (EMAR) revealed no documentation showing that the AV fistula access site (bruit and thrill) was being checked every shift. On 5/13/24 at 11:40 AM, the surveyor interviewed the 2 South Registered Nurse/Unit Manager (RN/UM) who stated that a dialysis resident who had an AV access site,that it (bruit and thrill) should be checked every shift including post-dialysis. In the presence of the surveyor, the RN/UM reviewed Resident #4's medical record. The RN/UM reviewed the Dialysis Communication Sheets and acknowledge that the resident had an AV fistula on their left arm and that the bruit and thrill should be checked on every shift. The RN/UM acknowledge that they were no post-dialysis notes written on the Dialysis Communication Sheets and this documentation would have included the resident's vitals and that the resident's AV fistula access site (bruit and thrill) was checked. The RN/UM also reviewed the resident's progress notes, PO and EMAR and acknowledge that there was no documentation that showed that the resident's AV fistula site (bruit and thrill) was checked post-dialysis. The RN/UM then reviewed the resident's care plan and acknowledged that the resident's AV fistula access site (bruit/thrill) should be checked every shift. The RN/UM told the surveyor that he will try to find any additional information to show that the facility was checking the access site post-dialysis. On 5/14/24 at 11:30 AM, the surveyor interviewed the RN/UM, who had no additional information. The RN/UM stated that the resident should have had an order to check the AV fistula access site (bruit and thrill) every shift and he further stated that there was no documentation that he could provide which showed that the facility was checking the resident's bruit and thrill post-dialysis. On 5/14/24 at 12:35 PM, the surveyor presented the above concern to the administration team which included the License Nursing Home Administrator, Director of Nursing (DON) and the Regional Clinical Nurse (RCN). The RCN acknowledge that it was important to check the bruit and thrill to assure the wasn't any clotting. There was no additional information provided. A review of the facility's policy for Care of a Resident Receiving Dialysis revised on 1/5/2024, and was provided by the DON revealed the following: If a resident has an AV fistula (access site), nursing will access and palpate for thrill and auscultate for bruit every shift by a license nurse. This will be documented in the EHR (electronic health record). NJAC 8:39-27.1(a); 2.9

Complaint #: NJ00170376 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a resident received as needed (prn) narcotic (a controlled drug that produces pain relief) medication in accordance with the prescriber's orders and accepted professional standards. The deficient practice was identified for 1 of 6 residents (Resident #227) reviewed for medication management. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. A review of a closed medical record revealed a Progress Note (PN) dated 04/11/23 at 1409 (2:09 PM), identified that Resident #227 complained of getting both Oxycodone and Vicodin 10 minutes apart. The note revealed that both the Director of Nursing (DON) and Unit manager was made aware of the complaint. The surveyor reviewed the closed medical record for Resident #227. The admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (a complex process that involves the intrusiveness of renal dialysis, which can sustain life but doesn't cure or heal. Dialysis is a treatment that helps the body remove waste products and extra fluid from the blood when kidneys are unable to do so), encounter for orthopedic aftercare following surgical amputation, and hypertension (a condition in which the force of blood against the artery walls is too high). A review of the admission Minimum Data Set (MDS), an assessment tool, used to facilitate the management of care, dated 4/04/24, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident was cognitively intact. A review of the April 2023 Order Summary Report (OSR) revealed the following physician's order (PO) dated 4/4/23 for Oxycodone (pain) tablet 5 mg (milligrams) give 2 tablets by mouth every 6 hours as needed for moderate pain. 2 tablets (5MG) =10 MG. May cause drowsiness/dizziness. Avoid alcohol. A further review revealed a PO dated 4/4/23 for Vicodin (hydrocodone/acetaminophen) 5/300 mg give 1 tablet by mouth every 6 hours as needed for severe pain. A review of the April 2023 electronic medication administration record (EMAR) revealed that on 4/11/23 at 0455 (4:55AM), 2 tablets of Oxycodone 5 mg was documented as being administered to Resident #227 with a pain scale of 6 (moderate pain). The April 2023 EMAR also revealed that on 4/11/23 at 0456 (4:56AM) that 1 tablet of Vicodin 5/300 was documented as being administered with a documented pain scale of 7 (severe pain). A review of a facility Medication Error Report form dated 4/11/23, revealed the following: Under description of error the facility wrote that the resident was assess having a pain level of 6 and that the nurse should have administered per the physician's order 2 tablets of Oxycodone 5 mg tablets. The nurse should have waited a hour to assess the resident. Under reason for error the facility wrote the following: Failure to read order before administering medication. Pain management therapy should have been evaluated before considering a different medication. On 5/13/24 at 1:00PM, the surveyor attempted to interview the Registered Nurse (RN) but was informed by the Director of Nursing (DON) that the nurse no longer worked at the facility. On 5/14/24 at 12:35 PM, the surveyor presented the above concern to the administration team which included the License Nursing Home Administrator, Director of Nursing (DON) and the Regional Clinical Nurse (RCN). There was no additional information provided. A review of the facility's policy for Medication Preparation for Dispensing revised on 1/31/2024, and was provided by the DON revealed the following: G. Prior to Medication Administration: 1. Verify each medication preparation that the medication is the RIGHT DRUG, at the RIGHT DOSE, the RIGHT ROUTE, at the RIGHT RATE, at the RIGHT TIME, for the RIGHT CUSTOMER. 2. Verify that the MAR reflects the most recent medication order. 3. Check expiration date on medication label. J. Medication Administration: 3. Medications are administered in a timely fashion as specified by policy. 4. As specified by federal and state regulations, controlled substances are documented as given at the time of administration. K. After Medication Administration: 1. Document necessary medication administration/treatment information (e.g., when medications are administered, medication injection site, refused medications and reason, prn medications, etc.) on appropriate forms. NJAC 8:39-11.2(b), 29.2 (a)(d) ,

Based on interview and review of other facility documentation, it was determined that the facility Quality Assessment and Performance Improvement (QAPI) committee, that identified quality concerns, failed to utilize the Facility Performance Improvement Plan to follow the facility process to measure and utilize data acquired for frequency of physician visits. This deficient practice was evidenced by the following: On 05/16/24 at 9:40 AM, the surveyor reviewed the facility provided QAPI Plan Primary physicians' documentations compliance Effective Date: February 26, 2024 which revealed Design and Scope: Statements and Guiding Principles: PMD's (primary medical doctor)/NP's (Nurse Practitioner) Federal documentations compliance. Other Services Provided: Nursing and medical record staff will monitor physician visits compliance and informing the upper management. Feedback, Data Systems and Monitoring: Monitoring Process: Audit physicians and their NP's progress notes every other month for compliance x 6 months. Conduct meetings with the physician and and their NP's every time there's issues to address. Goal is 100% compliance 3 months. At 10:32 AM, during a meeting with the surveyor, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) regarding the results of the above mentioned QAPI Plan, the DON stated she presented the QAPI Plan at the April QAPI meeting. She stated audits were done but she was unable to provide the surveyor with an audit tool or evidence that the audits were being done according to the Monitoring Process of auditing physician and NP's progress notes every other month for compliance since being self-identified on 2/26/24 or that the audit results were presented at the QAPI meeting. She was also unable to show the surveyor that the facility was progressing toward the Goal of 100% compliance in 3 months. The DON stated she sent an email or a text to the physicians that were identified. The LNHA stated, the purpose (of a QAPI plan) was to show improvement, identify issues, how we are going to work on them and if they are working. Regarding the purpose of audits, the RNC stated, so we can identify if it is working. We continue with what is working if not we come up with a plan to change it. The LNHA and the DON both confirmed that they were unable to quantify the audits that were completed. Therefore, they were unable to show a monitoring system to show that their QAPI Plan was working. A review of the facility policy Performance Improvement-QA Committee last revised 1-2024, revealed: Policy: .The committee will implement quality assurance and performance improvement programs (PIP) for the facility . The committee .Any ongoing concerns will be discussed, and PIP will be started to rule out route cause. PIP will be revised and updated as schedule. Staff will be educated as needed. NJAC 8:39-33.1(a)(b)(c)(e)

Based on interview and review of pertinent facility documentation, the facility failed to ensure the required committee members, the Infection Preventionist (IP), was present for four of six Quality Assurance and Performance Improvement (QAPI) meetings and was evidenced by the following: On 05/16/24 at 9:53 AM, the surveyor reviewed the facility provided QAPI book, that included the quarterly sign in sheets for the QAPI meetings, which revealed: - Employee In-Service Education; Date: Jan (January) 2023; Subject: QAPI the IP did not sign in as being in attendance. - Daily Department Head Meeting; Date: 7/26/23; Subject: QAPI 2nd Quarter April-June 2023 the IP did not sign in as being in attendance. - Employee In-Service Education; Date: 10/17/23; Subject: QAPI the IP did not sign in as being in attendance. - Daily Department Head Meeting; Date: 1/31/24; Subject: QAPI 4th Quarter 2023 the IP did not sign in as being in attendance. On 05/16/24 at 10:08 AM, during a meeting with the surveyor, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Regional Nurse Consultant (RNC), the LNHA stated that the required members that should attend the QAPI meeting included but were not limited to; the Administrator, the DON, the medical director, department heads, and the Infection Preventionist. At 10:17 AM, in the presence of the surveyor, the LNHA, the DON, and the RNC reviewed the signatures on the January 2023 sign in sheet and were unable to determine who the IP was at that time or that the IP had attended the meeting. The LNHA reviewed the sign in sheets for July 2023, October 2023, and January 2024 and was unable to verify that the IP was in attendance. The LNHA stated, the purpose of the sign in sheets was to keep a record of who was there at that time. The RNC stated, the purpose of the IP attending was to review infection control, identify any trends or outbreaks we are having. A review of the facility policy Performance Improvement-QA Committee last revised 1-2024, revealed: Procedure: The Performance Improvement Committee shall be composed of, but not necessarily limited to the following personnel: -Administrator -Medical Director -Director of Nursing -Infection Preventionist NJAC 8:39-33.1(a)(b)

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure reference checks were completed for Ten (10) of Ten (10) newly hired staff reviewed. This deficient practice was evidenced by the following: On 05/14/24, the surveyor reviewed Ten (10) randomly new employee files which revealed the following: Staff #1-a Certified Nursing Assistant (CNA), with a hire date of 09/22/22, did not have a previous employee reference on file. Two (2) undated typed personal reference letters were on file. Staff #2-a CNA, with a hire date of 04/12/24, did not have a previous employee reference on file. An emailed personal reference letter dated 05/09/24 and an undated typed personal reference was on file. Staff #3 - a Registered Nurse (RN), with a hire date of 02/27/23, did not have a previous employee reference or any personal references on file. Staff #4- a Dietary staff, with a hire date of 05/15/23, did not have a previous employee reference on file. There were two (2) undated typed personal reference letters on file. Staff #5- a Maintenance Staff, with a hire date of 11/22/22, had an undated and unsigned employer verification on file. Staff #6-a CNA, with a hire date of 04/18/24, had an emailed previous employee reference letter dated 05/08/24. Staff #7-a RN, with a hire date of 07/24/23, did not have a previous employee reference on file. Staff #8- a Dietary staff, with a hire date of 01/18/24, did not have a previous employee reference on file. One (1) undated typed personal reference letter was on file. Staff #9 -a Licensed Practical Nurse (LPN), with a hire date of 04/11/24, did not have a previous employee reference on file. One (1) undated typed personal reference letter was on file. Staff #10-a LPN, with a hire date of 03/21/24, had a typed previous employee reference on file dated 05/10/24. One (1) undated typed personal reference letter was on file. On 05/14/24 at 12:24 PM, the surveyor interviewed the Human Resource Director (HR) who stated that he requests 2 reference letters form the employee and they could be from a relative or co-worker. The HR stated that he does not get the reference letters prior to hiring and that he asked the employees to provide the reference letters. When asked if references should be done prior to working, the HR stated, We try to do it, it looks better. On 05/14/24 at 12:50 PM, the surveyor interviewed the Administrator (LNHA), the Director of Nursing (DON) and the Regional Registered Nurse (RRN) regarding the hiring process. The LNHA stated that prior to hiring, an application, a background check, license verification, a physical and references should be done. The RRN stated that contacting previous employers to verify employment should be done prior to hiring. On 05/15/24 at 10:29 AM, during a follow up interview with the LNHA, DON and RNN, the LNHA stated that the references could be personal or from previous employers. The RRN stated that the employee can provide a personal reference, but the facility should call and verify that reference prior to employment. The RRN further stated that the facility should attempt to contact previous employers to verify employment prior to hiring. A review of the facility's policy titled Abuse and Neglect Policy and Procedure, reviewed 11/13/23, revealed that all prospective employees will be carefully screened using the following process to identify potential risk of abuse/neglect of any resident:1. Reference Check, 2. License check and background check. NJAC 8:39-9.3(b)

Based on obervations, interviews, record review, and pertinent facility documents it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents a.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission and b.) were seen by the attending physician or Nurse Practitioner (NP) every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 8 of 8 residents (Resident #4, #11, #23, #33, #77, #130, #135 and #147) reviewed for physician visits. This deficient practice was evidenced by the following: 1. On 5/9/24 at 12:25 PM, the surveyor observed Resident #77 sitting in her chair who stated, I have been here for almost 2 years, and I saw the doctor only 2 or 3 times. A review of Resident #77 admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but not limited to: Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified (nerve damage caused by diabetes that affects different parts of the body), Heart failure, unspecified (when the heart muscle doesn't pump blood as well as it should), Anemia in Chronic Kidney Disease (a gradual loss of kidney function), and Dependence on Renal dialysis (A blood purifying treatment given when kidney function is not optimum). A review of the progress notes in the Electronic Medical Records (EMR) revealed the attending physician saw the resident on 1/11/23, 2/3/23, 11/29/23, 1/2/24, and 3/28/24. Further review of the EMR revealed the NP saw the resident on 6/22/23, 8/29/23, 10/24/23, 12/22/23, 1/18/24, and 2/23/24. A review of the progress notes revealed that the resident was admitted to the facility in January 2023. Resident #77 was discharged and returned to the facility in December 2023 and January 2024. Further review of the progress notes, did not reveal that the physician saw the resident upon readmission in December 2023 or upon return in January 2024 or February 2024. A review of the EMR did not reveal a Progress Note (PN) from the attending physician or the attending NP in March 2023, April 2023, May 2023, July 2023, September 2023, and April 2024 or that the physician and NP were consistently alternating monthly visits. 2. A review of Resident #23s AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), Hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness caused by brain, spinal cord or nerve problems) following cerebral infarction (that occurs when blood flow to the brain is blocked or reduced) affecting left non-dominant side and Acute respiratory failure (when your lungs cannot deliver enough oxygen or remove enough carbon dioxide from your blood) with hypoxia (levels of oxygen in the blood are lower than normal). A review of the PN in the EMR revealed the attending physician saw the resident on 5/8/23, 9/29/23, 11/24/23, 1/29/24, 5/14/24. Further review of the EMR revealed the NP saw the resident on 1/11/23, 3/7/23, 4/4/23, 5/1/23, 6/16/23, 7/20/23, 10/18/23, 11/16/23, 12/20,23, 1/22/24, 2/8/24, 3/13/24, 4/1/24, and 5/8/24. A review of the PN revealed the resident was out of the facility in February 2024 and April 2024. Further review of the progress notes, did not reveal that the physician saw the resident upon readmission in February 2024, March 2024, or April 2024. A review of the EMR did not reveal a PN from the attending physician or the attending NP for February 2023 and August 2023 or that the physician and NP were consistently alternating monthly visits. 3. A review of Resident #33's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Paranoid Schizophrenia (kind of psychosis that makes you unreasonably suspicious of others), Major depression disorder, recurrent, unspecified, and Chronic obstructive pulmonary disease, unspecified (a common lung disease causing restricted airflow and breathing problems). A review of the PN in the EMR revealed the attending physician saw the resident on 1/23/23, 4/19/23, 7/13/23, 11/28/23, 2/5/24, and 4/4/24. Further review of the EMR revealed the NP saw the resident on 10/17/23, 1/3/24, 2/8/24, 3/22/24, and 4/10/24. A review of the PN revealed the resident was at the facility from January 2023. The resident was discharged and returned to the facility in December 2023. Further review of the progress notes, did not reveal that the physician saw the resident upon readmission in December 2023 and January 2024. A review of the EMR did not reveal a PN from the attending physician or the attending NP in February 2023, March 2023, May 2023, June 2023, August 2023, September 2023, or December 2023 or that the physician and NP were consistently alternating monthly visits. 4. A review of Resident #11's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Acute respiratory failure (when your lungs cannot deliver enough oxygen or remove enough carbon dioxide from your blood) with hypoxia (levels of oxygen in the blood are lower than normal), Chronic obstructive pulmonary disease, unspecified (a common lung disease causing restricted airflow and breathing problems), Pneumonia, unspecified organism (inflammation and fluid in your lungs caused by a bacterial, viral or fungal infection) and unspecified asthma, uncomplicated (a condition in which your airways narrow and swell and may produce extra mucus). A review of the PN in the EMR revealed the attending physician saw the resident on 3/10/24 and 5/5/24. Further review of the EMR revealed the NP saw the resident on 1/25/23, 3/13/23, 5/23/23, 7/19/23, 8/8/23, 9/15/23, 10/17/23, 11/8/23, 12/8/23, 1/3/24, 2/9/24, 4/23/24. A review of the PN revealed the resident was discharged and returned to the facility in August 2023. Further review of the progress notes, did not reveal that the physician saw the resident upon readmission in August 2023, September 2023 or October 2023. A review of the EMR did not reveal a PN from the attending physician or the attending NP for February 2023, April 2023, June 2023 or that the physician and NP were consistently alternating monthly visits. 5. A review of Resident #147's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Type 2 Diabetes mellitus without complications, Muscle weakness (generalized), Depression, and unspecified and pain in right knee. A review of the PN in the EMR revealed the resident was admitted to the facility in May 2023. A review of the PN in the EMR revealed the attending physician saw the resident on 5/26/23, 6/7/23, 7/7/23, 8/7/23, 11/29/23, 1/31/24, and 3/29/24. Further review of the EMR revealed the NP saw the resident on 9/21/23, 12/26/23, 2/22/24, and 4/25/24. A review of the EMR did not reveal a PN from the attending or the attending NP in October 2023. 6. A review of Resident #130's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Unspecified Dementia (affects memory, thinking and interferes with daily life), unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety and Alzheimer's disease, unspecified (caused memory loss and other cognitive impairment). A review of the progress notes in the EMR revealed the attending physician saw the resident on 1/30/23, 5/28/23, 9/29/23, 11/24/23, 1/26/24, and 3/22/24. Further review of the EMR revealed the Nurse Practitioner saw the resident on 3/13/23, 3/30/23, 4/5/23, 4/17/23, 4/18/23. A review of the progress notes revealed the resident was readmitted to the facility in March of 2024. Further review of the progress notes, did not reveal that the physician saw the resident upon readmission in March 2024 or April 2024. A review of the EMR did not reveal a progress note from the attending physician or the attending nurse practitioner in February 2023, June 2023, July 2023, August 2023, October 2023, December 2023, February 2024 or that the physician and NP were consistently alternating monthly visits. 7. A review of Resident #135's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Polyosteoarthritis (having arthritis in five or more joints at the same time) and type 2 diabetes (results from insufficient production of insulin, causing high blood sugar). A review of the progress notes in the EMR revealed the attending physician saw the resident on 1/3/23, 2/28/23, 3/30/23, 5/23/23, 6/27/23, 8/29/23, 10/9/23, 11/16/23, 1/15/24, and 3/28/24. Further review of the EMR revealed the Nurse Practitioner saw the resident on 12/11/23. A review of the EMR did not reveal a progress note from the attending physician or the attending nurse practitioner in April 2023, July 2023, September 2023, February 2024 or April 2024. 8. A review of Resident #4's AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to: end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (a complex process that involves the intrusiveness of renal dialysis, which can sustain life but doesn't cure or heal. Dialysis is a treatment that helps the body remove waste products and extra fluid from the blood when kidneys are unable to do so), major depressive disorder (a condition with a persistently low and depressed mood) and hypertension (a condition in which the force of blood against the artery walls is too high). A review of the progress notes in the EMR revealed the attending physician saw the resident on 1/8/24. Further review of the EMR revealed the Nurse Practitioner saw the resident on 1/13/23, 2/2/23, 2/23/23, 3/3/23, 3/13/23, 4/17/23, 5/1/23, 5/4/23, 5/12/23, 6/21/23, 6/30/23, 7/14/23, 7/24/23, 8/9/23, 8/28/23, 9/8/23, 10/4/23, 10/16/23, 10/31/23, 11/1/23, 11/3/23, 12/1/23, 12/11/23 ,12/26/23, 1/9/24,1/10/24, 1/12/24, 1/15/24, 1/17/24, 1/19/24, 1/22/24, 1/24/24, 2/1/24, 2/28/24, 3/6/24, 3/18/24, 4/17/24, 5/6/24, and 5/9/24. Further review of the EMR did not reveal that the physician and NP were consistently alternating monthly visits. On 05/14/24 at 11:30 AM, the surveyor interviewed the Registered Nures/Unit Manager, who stated, we inform the DON if we notice the attending has not seen the resident. He was unable to speak to the frequency of physician visits. On 05/14/24 at 12:45 PM, during a meeting with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Regional Nurse Consultant (RNC), the DON stated the attending physican for long term care alternated every 60 days. They should do the initial on admission then monthly for first 90 days, then can be seen by MD every 60 days, NP can see in between. The surveyor verified attending physician and/or the NP must see resident at least every 30 days. The LNHA, the DON, and the RNC were all in agreement. On 5/14/24 at 1:16 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager regarding physician visits, who stated, They document in the EMR every time they see a resident. The attendings are supposed to see the resident every 30 days. They have their schedule. Whenever we call them to see the resident or if the resident requests, they (the physician) come see them. A review of the facility policy Physician Visits reviewed December 2023 revealed: Policy Statement: The Attending Physician must make visits in accordance with applicable state and federal regulations. Policy Interpretation and Implementation: 1.The Attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. 2.The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and the at least every sixty (60) days thereafter. 4.After the first ninety (90) days, if the attending Physician determines that a resident need not be seen by him/her every thirty (30) days, and alternate schedule may be established, but not to exceed every sixty (60) days. A Physician Assistant or Nurse Practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted law or regulation. NJAC 8:39-23.2 (b)(d)

Based on observation, interview and document review it was determined that the facility failed to serve hot and cold food items at appropriate and appetizing temperature for 3 of 5 resident units (1 South, 2 North and 2 South), for 1 of 1 resident reviewed for food (Resident #165) and for 3 of 5 residents who attended a resident council meeting. The deficient practice was evidenced by the following: On 05/08/24, at 11:12 AM, the surveyor interviewed Resident #165 who stated the main concern was that the hot food was cold, along with the coffee for all three meals. On 05/09/24 at 9:46 AM, during a follow up interview with Resident #165, the resident stated the temperatures were off and the hot food was not hot, and the cold food was not cold. On 05/10/24 at 10:39 AM, a surveyor conducted a resident council meeting and 3/5 residents stated the food was not hot enough and the coffee could be cold at times. Two of the five residents stated that they requested cold cereal for breakfast because they knew the hot food would be cold. Two of five residents stated the lunch and dinner were also not hot enough. A resident stated, when the food comes up, the food stays there for a few minutes and it's not going to get to you, and it will be cold when I get it. On 05/10/24 at 8:10 AM, surveyor #1 conducted a meal observation on 2-North and observed the following: -8:13 AM the meal cart was brought to the unit. -8:18 AM, 5 minutes after the cart was brought to the unit, one staff removed a tray and brought it to a resident room. -8:22 AM, the 2nd meal tray was removed from the cart. -8:36 AM, the Licensed Nursing Home Administrator (LNHA) joined Surveyor #1 for the the observation. -8:37 AM, (25 minutes after the meal truck was delivered) the surveyor and the LNHA both checked meal temperatures of the last meal tray (Resident #280) and using separate thermometers. -Vegetable Frittata surveyor LNHA 93 degrees Farenheight (F) 94 F Hot Farina surveyor LNHA 128 130 F Whole Milk surveyor LNHA 50 F 47.7 F Orange juice surveyor LNHA 52 F 51.6 F Coffee surveyor LNHA 123 F 122 F On 05/10/24 at 8:47 AM, Surveyor #1, reviewed temperature logs in the kitchen with the [NAME] and Food Service Director (FSD) which revealed: Vegetable Fritatta 191 F Juice 38 F Farina 200 F At that time, the surveyor interviewed the FSD regarding what the hot food temperatures should be when they reach the resident and the FSD stated, ideally hot should be 140 F or above, and cold food should be 41 F or below which revealed the food temperatures in the kitchen were acceptable. On 05/09/24 at 8:05 AM, Surveyor #2 observed the meal cart arrive on the 1 South Unit (low side) and observed the first tray was passed at 8:09 AM. At 8:27 AM, an open meal cart arrived with the meal trays for the high side of the unit. At 8:31 AM, the staff initiated passing the trays. At 8:44 AM, the last meal tray was passed and the surveyor tested Resident #60's tray in the presence of the Unit Manager Liscened Practical Nurse, which revealed: Puree Fruit: 115.3 F Milk: 56.8 F Cheese Sauce for Farina: 109.6 F On 05/10/24 at 8:30 AM, Surveyor #3 observed the 2 South Sub-Acute, meal delivery and the meal truck arrived on the unit at 8:40 AM. The last tray was passed at 8:54 AM and the meal temperatures of an unsampled resident's meal tray were checked by the surveyor in the presence of a Recreation Aide which revealed: Eggs: 111.0 F Farina: 120.3 F Hot water for Tea: 115.9 F A Test Tray form provided by the LNHA on 05/10/24 at 9:00 AM revealed Acceptable Temperatures: Soup/Hot Cereal- 140 F or above; Milk/ Juice- 40- 50 F; Coffee 135-180 F; Breakfast Entree- 120 F, or above; Entree- 130 F or above. NJAC 8:39-17.4 (a)2

Based on observation, interviews and review of pertinent documentation, it was determined that the facility failed to a.) adhere to accepted standards of infection control practices for donning (put on) the required Personal Protective Equipment (PPE) prior to providing care to residents on isolation and Enhanced Barriers Precautions. (Resident #23 and #279) and b.) perform appropriate hand hygiene according to the Center for Disease Control (CDC) and the facility's policy. The deficient practice was evidenced by the following: 1. On 5/8/23 at 10:30 AM, during initial tour on unit 1 North, the surveyor observed a white signage posted at Resident #23's door. The door was closed and there was a PPE bin with yellow disposable gowns, outside the room. The surveyor observed the Contact Precautions signage which included but were not limited to; Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 5/9/23 at 12:34 PM, the surveyor observed a Certified Nursing Assistant (CNA) #1 take a lunch tray into Resident #23's room. CNA#1 did not don a yellow gown as the sign on the resident's door indicated before entering the room. Upon exiting Resident #23's room, The surveyor conducted an interview with the CNA. The CNA acknowledged that she did not have a gown on when entering the resident's room and she stated, I had gloves on and they didn't tell us to put a gown on before entering into this room when we are passing out trays. At 12:40 PM, the surveyor brought the Licensed Practical Nurse/Nurse Manager (LPN/UM) to the door of Resident #23 and asked what the Stop Contact Precautions signage meant. The LPN/UM stated that everything on the sign should be done before you enter the room. The LPN/UM stated that the resident was on contact isolation for Methicillin-resistant Staphyloccus Aureus (MRSA-a bacteria that causes infection) in the nares. She confirmed that CNA #1 should have donned a gown before entering the room. The LPN/UM stated that We need to gown up and put gloves on every time we go in this room because the staff is going to have contact with the patient the purpose of PPE was to prevent the spread of infection. The LPN/UM further explained to CNA #1, for contact isolation rooms, you need to put PPE for everything. The surveyor reviewed the medical records for Resident #23 which revealed the following: The admission Record (AR) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Methicillin Resistant Staphylococcus Aureus infection as the cause of diseases classified elsewhere and Metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). A review of the Order Summary Report indicated a physician order, dated from 5/7/24 to 5/10/24 and from 5/10/24 to 5/13/24 for Maintain Contact Precautions for MRSA every shift until 5/13/2024 15:00 (3:00 PM). A review of the May 2024 Treatment Administration Record (TAR) under Maintain contact precautions for MRSA every shift revealed that nursing had signed the TAR as completed for the Day, Eveni (evening) and Night shifts. A review of Nursing Progress Notes (PN) dated 5/8/24 at 00:22 (12:22 AM) revealed, on isolation precautions for unspecified MRSA. On 5/15/24 at 12:10 PM, during an interview with the Infection preventionist nurse (IPN), the IPN stated, Anyone going into contact isolation room, must have PPE and expectations from the staff are to do what the posted sign says. On 05/15/24 at 12:41 PM, the Director of Nursing(DON) , The Licensed Nursing Home Administrator (LNHA) and the Regional Nurse were informed of the above concerns. 4. On 05/09/24 at 11:32 AM, the surveyors entered an unsampled resident's room with CNA# 1 and CNA #3 for an incontinence care check. In the presence of the surveyors, CNA#1 performed hand washing as follows: she turned on the water, wet her hands, applied soap, lathered, and rubbed hands together for a total of 12 seconds outside of the running water, she rinsed her hands under the water, obtained a paper towel and dried her hands. CNA #3 walked over to the sink with the running water and performed hand washing as follows: she wet her hands, applied soap, lathered and rubbed hands together for a total of 11 seconds outside of the running water, she rinsed her hands under the water, obtained a paper towel, dried her hands and used a clean paper towel to turn off the water. Both CNA's donned gloves and proceeded with the incontinence check. 05/09/24 at 11:35 AM, after CNA# 1 and CNA# 3 exited the resident's, the surveyors interviewed them regarding hand washing. CNA#3 stated she sings the Happy Birthday song once while lathering her hands and then sings it again while rinsing her hands. She stated, It (lathering hands with soap) should be done for at least 20 seconds. CNA #1 agreed. CNA #3 stated, she counted in her head for 20 seconds while lathering. On 05/09/24 at 11:44 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who stated hand hygiene should be done before and after care, before and after medication administration and in between residents. She stated you turn on the water, wet hands, lather hands with soap for 30 seconds before rinsing. LPN#1 further stated you sing happy birthday 2 times while rubbing hands with soap, then rinse them, dry hands with a paper towel and take another paper towel to turn off the water. On 05/14/24 at 11:07 AM, the surveyor interviewed the Infection Preventionist Nurse (IPN) regarding hand washing. She stated, hand hygiene should be done before any care, after eating, and after touching soiled things. The IPN stated hand washing was done with soap and water as follows: turn on the water, rub hands for 20 seconds with the soap, rinse hands, dry and use a clean paper towel to turn off the water. She stated staff could sing happy birthday a couple of times and sing it again while rinsing your hands. On 05/14/24 at 12:42 PM, during a meeting with the DON, the RNC and the LNHA, the surveyor presented the above concerns. The DON stated, you handwash every time you touch the patient, during care, in between patients and when hands are soiled. She stated, you turn on the water, wet hands, apply soap, lather and rub hands for 20 seconds, rinse hands, use a paper towel to dry and get another one to turn off the faucet. A review of the facility provided Employee In-Service Education dated 4/18/24, Objective: Infection Control-Isolation Precautions + Hand Washing . revealed that CNA #1, CNA #2 and CNA #3 attended. A review of the facility provided annual Hand Hygiene Competency revealed a Yes under Competent for Hand Hygiene with Soap & Water .4. Vigorously rubs hands for at least 20 seconds including palms, back sides of hands between fingers, thumbs, and wrists for CNA #1, dated 6/6/23 and CNA #2, dated 6/5/23. On 05/16/24 at 8:15 AM, the Director of Nursing (DON) provided the policy for Enhanced Barrier Precautions. The following were noted: Purpose To outline the implementation of Enhanced Barrier Precautions to disrupt the potential spread of multidrug-resistant organisms. Procedure: EBP is used in conjunction with standards precautions and expand the use of PPE to don a gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Examples of high- contact resident care activities requiring gown and gloves use for Enhanced Barrier Precautions include: Dressing Providing hygiene Changing Linens . Indwelling medical devices examples include central lines, urinary catheters, feeding tubes and tracheostomies. EBP should be used for any residents who met the above criteria, wherever they reside in the facility . The policy was not being followed. A review of the facility's policy Handwashing/Hand Hygiene dated December 2023 revealed: Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Procedure: Washing hands 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) . Applying and removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. A review of the facility's provided policy un-titled with revised date April 2024 revealed: Contact Precautions- are a type of Transmission-Based Precaution that is intended to prevent transmission of infectious agents, that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of a gown and gloves on every entry into a resident's room. The resident is given dedicated equipment and is placed into a private room as available, cohorted, or grouped together. The facility will post clear signage on the door or wall outside of the resident room indicating the type of precautions and required person protective equipment (PPE), e.g., gown and gloves, along with the high-contact resident care activities requiring PPE. NJAC 8:39-19.4 (a) (1) (2) (5) 2. On 05/08/24 at 10:25 AM, the surveyor toured the Subacute Extension Unit (SAE) and observed signage posted at the door for enhanced barrier precautions which included but were not limited to; Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing. The surveyor observed an isolation bin containing gowns, gloves and surgical mask in the hallway at the door entrance. On 05/08/24 at 10:30 AM, the surveyor entered the room and observed Resident #279 in bed. The head of the bed was elevated and the resident was resting with the eyes closed. The resident had a Foley Catheter (medical device that helps drain urine from the bladder) contained in a dignity bag and hung on the bedrail. On 05/08/24 at 11:37 AM, the surveyor observed 2 staff members in the room assisting Resident #279 with care. One staff was changing the bed linen and the other staff was assisting the resident with dressing. Both staff were observed with mask and no gown on. During an interview with staff #1 at 10:45 AM, she identified herself as a CNA (#2) and informed the surveyor that staff #2 was an orientee Nursing Assistant (NA). The CNA stated that Resident #279 had a Foley catheter, wore a leg bag during the day. On 05/10/24 at 10:30 AM, the surveyor knocked at the door, and the staff prompted the surveyor to enter the room. The curtain was drawn and the surveyor observed the NA at the beside assisting Resident #279 with care. The NA had a mask and gloves on. The NA did not have a gown on as required by the signage posted at the door. On 05/10/24 at 10:45 AM, the surveyor interviewed the Registered Nurse/Unit Manager regarding the above observation. The RN/UM revealed that the NAs should not be working alone. They just came in, they should be working with another CNA. The UM further stated that all staff should have on the required PPE while providing care. On 05/10/24 at 11:30 AM, review of the electronic medical record (EMR) reflected that Resident #279 was admitted to the facility with diagnoses which included, but were not limited to; muscle weakness and urinary tract infection, site not specified. A review of the Order Summary Report for May 2024, revealed the following orders for Resident #279: Foley Catheter Care every shift. Maintain Enhanced Barrier Precautions related to: Foley Catheter Use every shift for Disrupt potential spread of MDROs ( Multi-drug Resistant Organisms.) On 05/15/24 at 08:53 AM, the surveyor interviewed CNA #2 who was observed in the room with the Orientee and not wearing the required PPE. The CNA stated that she was not aware that she had to have a gown on while changing the linen and could not provide the rationale for not wearing the required PPE while at the bedside providing care. On 05/15/24 at 1:15 PM, the facility was informed of the above concerns and requested the policy for Enhanced Barrier Precautions (EBP).

Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure: a) a consistent system for labeling and dating was implemented to ensure all potentially hazardous foods were labeled with a use by date, b) the kitchen environment, all equipment and dishware was maintained in a clean and sanitary manner and transported appropriately, and c) staff performed appropriate hand hygiene, to limit the potential for contamination, and the risk of potential foodborne illness. The deficient practice was evidenced by the following: On 05/08/24 at 9:26 AM through 10:40 AM, the surveyor conducted a tour of the kitchen with the Registered Dietitian (RD) and the Food Service Director (FSD) and observed the following: 1. The step garbage can next to hand washing sink did not open when the foot pedal was stepped on and this was confirmed by the RD. 2. The walk-in refrigeration unit contained the following: - A metal pan on the bottom shelf contained six cabbage heads with visible darkened areas/spots. The cabbage was not labeled and did not contain a use by date. The surveyor asked the RD if the cabbage was dated and she stated, I don't see one. - A plastic type bin of uncovered celery stalks, located on a bottom shelf, had a sticker affixed to the bin with 2/27/24. When asked about the date, the RD stated, they forgot to take the label off the bin and confirmed there was no use by date on the celery when she lifted the packages and was unable to locate a use by date. - A blue colored box that contained bags of red grapes had 4-26-24 written on the box. There was no use by date. - Two boxes of mushrooms, both uncovered, were also located on the shelf, one box was labeled Medium 10 lbs with a white sticker 4/18, and the second box was labeled 4/30. Neither box contained a use by date. -The grate covering the fan located in the refrigeration unit contained black spots and soiled areas and there was black splatter type debris on the ceiling, corner, and portions of the wall areas. 3. The walk-in refrigerator contained the following: - One ten-pound box of Fully Cooked Boneless, Skinless Chicken Meat, Diced Chicken was labeled in red handwriting, 4/30. The box was labeled, Keep Frozen, there was no indication when the product was defrosted or a use by date. - Three white boxes labeled ten pounds of Fully Cooked ½ Inch [NAME] Meat Chicken, two of the boxes had a date on the box 02/08/24 and there was no use by date, the third box had a handwritten date, 4/18/24 and did not contain a use by date. - A box that contained rolls of Turkey Bologna, that were not dated and the box was labeled Sell/Freeze by 11/24/23, Keep Refrigerated, another box of 19.76 pounds of Turkey Bologna rolls had a handwritten date of 11/29/23 with the same Sell/Freeze by 11/24/23 label. There was no use by dates on the items. Another Turkey Bologna roll had a printed label Date Received 1/23/24, partially over another label Sell/Freeze by 02/15/24, Keep Refrigerated. The surveyor asked the FSD what the product use by date should be. The FSD stated, seven days from the open date. The surveyor asked where the date was located on the boxes. The FSD stated, I don't see it. The surveyor asked if there should be a use by date on the products and the FSD stated, yes and he was unable to provide a use by date. -A package of opened parmesan cheese was wrapped and had a piece of paper with a handwritten date 11/28/24. There was no use by date, and the package was discarded by the FSD. -A five-pound opened container of Cottage Cheese had a sticker on it, Received 04/02/24, there was no use by date. The sell by sticker on the package indicated, 04/26/24. The surveyor asked about the use by date, the RD stated, I don't see a use by date. -Three cases of 4-ounce skim milk dated, May 7, 2024, and the surveyor asked the RD if the milk could be used and the RD stated, no. -14 cased of defrosted juices, STORE AT 0F printed on box in bold. The boxes did not contain use by dates 4. The walk-in freezer contained the folllowing: -The door gasket was ripped and pulling off door and the door curtain was ripped. -A box contained a plastic bag of breaded chicken patties which was not sealed and was open to air. The box was dated 04/16/24 and there was no use by date. -Three logs of frozen ground beef were stored on top of packages of various frozen meats. There were no use by dates. -There was a three pack of frozen turkey burgers and there was no use by date. 4. The dry storage room contained the following: a large, unsealed bin with stains on top of the bin. The bin had dark splatter type stains on the outside and in the inside of the bin. The top of the bin had Coconut Shredded, Open 05/01/24 written on the top of the lid. There was a white shredded product in the bin. The FSD confirmed that there was no use by date. -The floor in the dry storage room had debris in the corners of the room. The surveyor asked the FSD about a cleaning schedule for the kitchen and the FSD stated there was no schedule yet, as he was new to the facility and was working on it. -17 individual four-ounce containers of thickened cranberry juice cocktail were located on a shelf in the dry storage room. The juice had a best if used by date of 4/4/24. -Splatters of various colored debris were observed on the ceiling in the dry storage room. -A large fan inside the kitchen to the outside had a grate covered with dust like debris. -The can opener that was affixed to the metal table was very soiled with dark debris on the base and blade. The FSD confirmed as he observed that the base of the can opener was difficult to remove due to debris. On 05/10/24 at 8:52 AM, during a second kitchen observation conducted with the FSD, the surveyor observed the large slicer covered with plastic, which was identified as clean, and when the FSD removed the plastic there were several areas of food debris on the base and blade area. On 05/08/24 at 12:10 PM, during a lunch meal observation on the second floor, the surveyor observed the [NAME] transporting dishware and other supplies from the hallway into the dining room on a three tiered black cart. The bottom tier of the cart contained eight dishes, face up, that were uncovered during transit. 05/08/24 at 12:21 PM, during the same meal observation on the second floor, the [NAME] was observed using paper towels to wipe perspiration off of his head, then proceeded to place gloves on his hands without first performing hand hygiene, and proceeded to plate food on the uncovered dishes from the cart. The Handwashing/Hand Hygiene Policy, revised December 2023, revealed This facility considers hand hygiene the primary means to prevent the spread of infection. 6. Waterless alcohol products are preferred method for hand hygiene except for the following situations: a. When hands re visibly soiled . 8. Use an alcohol-based hand rub containing at least 62 % alcohol; or alternatively, soap and water for the following: . f. Before donning sterile gloves. The Storage Areas Policy, undated, revealed .Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate methods designed to prevent contamination or cross contamination. 4. All containers must be legible and accurately labeled and dated. 6. Schoops must be provided for bulk foods. Scoops are not to be stored in food or ice containers, but are kept covered in a protected area near the containers. 8. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. a. Old stock is always used first (first in-first out method). c. Food should be dated as it is placed on the shelves. Date marking top indicate the date or day by which a ready to eat, potentially hazardous food should be consumed, sold or discarded will be visible on all high risk food. 14. Refrigeratged Food Storage. a. All refrigerator units are kept clean and in good working condition at all times. f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. 15. Frozen Foods: d. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 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 act upon the Wound Doctor (WD) treatment recommendations according to professional standards of clinical practice for 2 of 2 residents reviewed for pressure ulcers, Resident #15 and #85. The deficient practice was evidenced by the following: 1. On 4/8/22 at 11:00 AM, the surveyor interviewed Resident #15 who stated, I have bedsore in my buttock area. The resident was receiving wound treatment daily. The surveyor reviewed Resident #15's hybrid (paper and electronic) medical records that revealed the following: According to the admission Record, Resident #15 had diagnoses that included but were not limited to Cerebral infarction (Stroke) with Right hemiplegia (severe loss of strength) and Morbid obesity. The admission Minimum Data Set (MDS) an assessment tool dated 1/6/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that cognition was intact. The MDS also reflected that the resident was at risk for pressure ulcer. The resident currently had a stage two pressure ulcer to the sacral area. The WD's Visit Reports dated 3/1/22, 3/8/22, 3/15/22, 3/22/22, and 4/6/22 indicated a wound treatment recommendation to cleanse the wound with saline, apply Xeroform (a non-adhering protective dressing), foam dressing BID (twice daily). The March and April 2022 Order Summary Report (OSR), reflected an order to cleanse the stage two pressure injury to the sacrum with NSS (normal saline), pat dry then apply Xeroform dressing to the wound bed, and cover with dry dressing every day. The WD Visit Report recommendations and the 3/29/22 Wound Description form indicated to perform the wound treatment BID, However, the treatment recommendation was not transcribed to the Electronic Medical Record (EMR) and the electronic Treatment Administration Record (eTAR). On 4/8/22 at 1:25 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that she was unaware of the wound treatment order of BID by the WD because the Licensed Practical Nurse/Wound Nurse (LPN/WN) would enter and update the treatment orders. The RN/UM acknowledged that the WD's treatment recommendation should have been transcribed in the eTAR. On 4/11/22 at 9:45 AM, the surveyor conducted a phone interview with the LPN/WN in the presence of the RN/UM. The LPN/WN stated that he made wound rounds with the WD weekly, and the WD would communicate the wound treatment order to him during rounds and email the report afterward. He would then transcribe the new wound treatment order into the EMR and transcribed it to the eTAR. At that time, the surveyor asked the LPN/WN to explain why the March and April 2022 OSR reflected an order for wound treatment and dressing to the sacrum once daily instead of twice daily as recommended by the WD. The LPN/WN stated that he was not aware of the wound treatment order and the WD recommendation discrepancy until the surveyor's inquiry. The LPN/WN further stated to the surveyor that he should have clarified the wound treatment order to the doctor. 2. On 4/7/22 at 10:40 AM, the surveyor observed Resident #85 in bed lying on an mattress. The surveyor reviewed the medical record for Resident #85 which revealed the following: According to the physician's progress notes dated 3/23/22, Resident #85 had a diagnosis that included a History of Cerebral vascular accident (Stroke). The Significant Change in Status Assessment MDS (SCSA/MDS) dated [DATE], indicated a BIMS score of 8, which reflected that the resident's cognition was moderately impaired. The SCSA/MDS indicated that the resident was determined to be at risk for developing pressure ulcers/injuries and had a stage three pressure ulcer to the sacral area. The WD Visit Report dated 3/15/22 indicated its wound treatment recommendation to cleanse the sacral wound with saline, apply Xeroform (used to cover and protect low to non-exudating wounds), and dry dressing daily. The WD visited the resident on 3/22/22 and updated the recommendation on the Visit Report to discontinue the treatment of Xeroform to sacral wound and start to cleanse with saline, apply skin prep (a protective wipe that form a barrier between skin and adhesives to prevent skin injury) every shift, and leave open to the air. The WD Visit Report dated 3/29/22 and 4/6/22 indicated a recommendation to continue to cleanse the sacral wound with saline, apply skin prep every shift and leave it open to the air. The April 2022 OSR reflected physician's orders Cleanse Stage-3 pressure injury to sacrum with NSS, pat dry then apply xeroform dressing to wound bed and cover with dry dressing everyday shift for WOUND CARE for 14 Day. On 4/11/22 at 1:00 PM, the License Practical Nurse Unit Manager (LPN/UM) informed the surveyor that the facility LPN/WN assisted the WD to do weekly wound assessments on residents. The LPN/UM stated that the LPN/WN would receive wound reports from the WD, which included wound treatment recommendations. She further stated that the LPN/WN would transcribe the wound treatment recommendations into the eTAR. The LPN/UM acknowledged to the surveyor that the WD treatment recommendation on 4/6/22 was not transcribed to the EMR and the eTAR. On 4/13/22 at 10:25 AM, the surveyor interviewed the LPN/WN concerning the 4/6/22 WD's Visit Report recommendations. The LPN/WN informed the surveyor that he assisted the WD to wound rounds every Wednesday. The LPN/WN stated that the WD would later provide him with written reports that included wound treatment recommendations. He further stated that the resident's Medical Doctor (MD) told him to follow the WD recommendations. The surveyor further asked the LPN/WN if the WD recommendations were all followed, and he stated no, it should have been followed. On 4/13/22 at 2:11 PM, the Administrator and Director of Nursing met with the survey team. No further information was provided. A review of policy titled Physician Services revised 2022, did not indicate how the consultant's recommendations should be executed by the nursing staff. NJAC 8:39-11.2 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/7/22 at 12:29 PM, the surveyor observed Resident #98 in bed, alert and oriented. The resident was receiving oxygen via a nasal cannula that was attached to an oxygen concentrator (an oxygen delivery system). The oxygen concentrator was set at 3.5 LPM. On 4/11/22 at 9:10 AM, the surveyor observed Resident #98 in bed, receiving oxygen via a nasal cannula. The oxygen concentrator was set at 3.5 LPM. The surveyor reviewed the EMR of Resident #98 which revealed the following: The resident's admission Record revealed that Resident #98 was admitted with diagnoses that included Pneumonia, and Acute Respiratory Failure (ARF). The Quarterly MDS dated [DATE], indicated that the facility assessed the resident's cognitive status using a BIMS. The resident scored a 15 out of 15 which indicated that the resident was cognitively intact. The April 2022 Order Summary Report revealed a physician's order, dated 12/2/21, that read: Administer Oxygen via N/C @ 2 LPM continuously. Monitor pulse ox [the oxygen level in the blood measured by placing a device on the finger] Q shift [every shift]. Notify MD if pulse ox less than or equal to 90% every shift for Oxygen Therapy. The April 2022 eTAR was initialed by nurses every shift from 4/1/22 to 4/12/22 to indicate the setting for the oxygen was at 2 LPM continuously. A care plan with the focus [The resident] has potential for respiratory complications r/t use of respiratory device (s) due to dx: ARF, SOB [Shortness of Breath], Hypoxia [lack of enough oxygen in the blood, tissues, and/or cells to maintain normal body function], Pneumonia; Patient is on BIPAP [a device that helps with breathing] and continuous oxygen. Under Interventions, an intervention listed read Monitor pulse ox as ordered, PRN. Provide oxygen as ordered. The date the care plan was initiated was 12/8/21 and the revision date was 3/5/22. On 4/12/22 at 9:41 AM, the surveyor asked LPN #2, assigned to care for the resident, how many LPM the resident's oxygen should be set at. LPN #2 said the resident wore oxygen continuously, she reviewed the EMR for the oxygen setting and said the resident's oxygen setting should have been set at 2 LPM. On 4/12/22 at 9:56 AM, the surveyor entered the resident's room with LPN #2. The surveyor observed the oxygen concentrator setting at 3 LPM. LPN #2 adjusted the setting to 2 LPM. LPN #2 said she checked the oxygen setting in the morning, it was at 2 LPM and thought it may have been changed while the Certified Nursing Assistant (CNA) was providing care to the resident. On 4/12/22 at 10:00 AM, the surveyor asked the assigned CNA if she adjusted the oxygen concentrator settings for Resident #98. The CNA said no. When asked if she had ever changed the oxygen concentrator settings for a resident, the CNA said no, she would call the nurse to check it. On 4/12/22 at 10:18 AM, the surveyor spoke with the Nurse Supervisor (NS) of the unit and asked about the resident's oxygen settings. The NS stated during morning rounds of the unit at 8 AM, he checked the resident's oxygen as part of his rounds, and he saw the oxygen setting at 2 LPM. The surveyor asked when he became aware of the issue with the resident's oxygen setting on the concentrator being different than what was ordered by the physician. The NS said LPN #2 just made him aware after the surveyor and LPN went into the resident's room. On 4/12/22 at 10:42 AM, the NS told the surveyor that the oxygen concentrator setting was just re-checked, and the oxygen setting was not at 2 LPM. The NS said they believed the oxygen concentrator was malfunctioning and the oxygen concentrator was replaced. On 4/12/22 at 12:21 PM, the surveyor spoke with LPN #2 and asked when she first noticed the oxygen settings were different than what was ordered by the physician. LPN #2 said since March. On 4/12/22 at 1:05 PM, the survey team met with the Administrator and the DON to discuss the concern of the resident not receiving oxygen at the setting the physician ordered. The surveyor requested a copy of the facility's policy and procedures for oxygen therapy. On 4/13/22 at 11:40 AM, the surveyor asked Resident #98 if the resident knew what their oxygen setting was. The resident replied, the staff said it should be set at two. The surveyor asked if the resident would ever adjust the oxygen concentrator settings on their own. The resident said they would never touch the oxygen machine or adjust the settings. On 4/13/22 at 1:10 PM, the DON provided the facility's policy and procedure titled Care of Oxygen Concentrators. with a revision date of 4/2022, Under Policy, it read To provide oxygen therapy in a safe and efficient manner and as ordered by the attending physician. Under Procedures 1 and 2 it read attach pre filled oxygen humidifier bottle filled with sterile distilled water, tubing and mask or cannula as ordered. And, Turn on concentrator to liters/minute (L/M) as offered . The surveyor reviewed another policy titled, Oxygen Tubing and Respiratory Products. The policy had a revision date of 2022. Under the procedure section it indicated that proper documentation on the Treatment Administration Record and Physician Order Sheet to ensure a current physician order. NJAC 8:39-27.1 (a) Based on observation, interview, and review of facility documentation, it was determined the facility failed to ensure two residents were receiving supplemental oxygen as prescribed by the physician. This was found for 2 of 3 residents reviewed for oxygen, Resident #53 and Resident #98, and was evidenced by the following: 1. On 04/07/22 at 10:32 AM, during the initial tour of the facility Resident #53 was out of the bed in a wheelchair. The resident had nasal cannula oxygen (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) on at the time of the observation that was connected to an oxygen concentrator (a medical device that provides extra oxygen). The resident's oxygen concentrator was set on four liters of oxygen. The surveyor reviewed the quarterly Minimum Data Set (MDS), an assessment tool dated 2/7/22. The MDS showed Resident #53 had a Brief Interview of Mental Status of 11, meaning the resident had moderate cognitive impairment. Under section O of the MDS, Special Procedures and Treatments, indicated that Resident #53 was oxygen dependent. Medical diagnoses included, but not limited to chronic obstructive pulmonary disease, anemia, heart failure, diabetes, and asthma. On 04/08/22 at 09:45 AM, the surveyor observed Resident #53 in the room sitting in the wheelchair. The resident was wearing the nasal cannula oxygen and the concentrator was set to 4 liters per minute (LPM). On 04/11/22 09:50 AM, the surveyor observed Resident #53 in the room in a wheelchair. The oxygen tubing that was attached to the oxygen concentrator. The concentrator was set on 4 LPM. On 04/11/22 at 10:33 AM, the surveyor reviewed the physician orders in the Electronic Medical Record (EMR) which showed the following order, administer oxygen via nasal cannula at 2 LPM continuously. On 04/11/22 at 10:42 AM, the surveyor reviewed the residents care plan which showed a respiratory focus including a potential for impaired respiratory status related to Chronic Obstructive Pulmonary Disease (a type of lung disease marked by permanent damage to tissues in the lungs making it hard to breathe) and interventions that included checking oxygen saturation and providing oxygen as ordered by the physician. On 04/11/22 at 10:55 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN #1) who was assigned to Resident #53. The surveyor asked how much oxygen the physician ordered for Resident #53 and LPN #1 said, 2 liters. At the same time, the surveyor asked the LPN #1 to go to the resident's room and check the oxygen. LPN #1 along with the surveyor entered the resident's room and looked at the oxygen concentrator which was set at 4 LPM. LPN #1 said, how did that get to four, and asked Resident #53 if they touched it. The resident said he/she would never touch something like that. LPN #1 could not speak to how the oxygen was set on four liters instead of the ordered two liters and proceeded to lower it to 2 LPM. The surveyor asked if the staff should be checking the settings and LPN #1 said, yes. On 04/14/2 at 10:12 AM, the surveyor reviewed the electronic Treatment Administration Record (eTAR) which showed the nursing staff signed administer oxygen via nasal cannula at 2 LPM continuously. This was signed by the nursing staff on day, evening, and night shifts daily for the month of April 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility's documentation, it was determined that the facility failed to maintain a safe, functional and sanitary environment involving 2 of 34 resident room hand sinks (Rooms #150 and #152) The deficient practice was evidenced by the following: On 4/7/22 at 11:40 AM, the surveyor observed, during the initial tour, in room [ROOM NUMBER] the hand sink had a yellowish-brownish color pooling of water and a sign taped to the mirror above the sink with the a message to not use the sink. On 4/11/22 at 10:30 AM, the surveyor observed, in room [ROOM NUMBER], the same sign taped to the mirror above the sink and the sink had yellowish-brownish water pooling in the sink. At 10:33 AM, the surveyor interviewed the certified nursing assistant (CNA) assigned to room [ROOM NUMBER] who informed the surveyor that the sink was clogged in both rooms #150 and #152 because the rooms shared a pipe for the sink in each room. The CNA stated that she filled the resident's basin with water at the sink to use for AM care and then disposed the water from the basin into the toilet in the bathrooms of room [ROOM NUMBER] and room [ROOM NUMBER]. At 10:34 AM, the surveyor and the Licensed Practical Nurse (LPN) assigned to room [ROOM NUMBER] observed the water pooling in the sink. The LPN stated the sink had been clogged for a week or more and that the sink in room [ROOM NUMBER] shared the same pipe and was clogged too. The LPN stated she wrote a note in the Maintenance log book. The LPN and surveyor reviewed the Maintenance log book. There was a note dated 4/2/22 that informed the Maintenance Director of a clogged sink and initialed by an LPN and the LPN confirmed that it was her initials. There was no room number listed but the LPN confirmed the entry was for room [ROOM NUMBER]. On 4/11/22 at 1:06 PM, the surveyor interviewed Maintenance Director (MD) in the presence of the Administrator and Director of Nursing. The surveyor asked the MD how often the Maintenance log book was checked. The MD responded that he checked it daily. He stated he was aware of the clogged sinks in rooms #150 and #152. He stated yes, that on 4/2/22 he snaked the pipe (a drain drilling tool but is nicknamed the snake due to its coiled shape). He further stated he saw that the water drained slowly because there was a clog further into the pipe that the snake couldn't go through and that it would require opening up the wall to fix it. The MD stated that he checked the sink in room [ROOM NUMBER] every morning and had not seen any pooling of water. The surveyor informed the MD that both the LPN and surveyor observed the pooling of water at 10:30 AM. The surveyor asked if he had a plan to fix the problem and he stated he didn't know. The MD also stated he did not inform the Administrator of the problem. On 4/12/22 at 10 AM, the Administrator provided a facility policy revised 2022 which indicated the following: Policy: It is the policy to ensure all maintenance concerns/issues must be logged into the Maintenance Log Record in the maintenance communication book located on each nursing unit. The concerns/issues will be properly handled to assure resident and employee safety. And under Procedure #3 The repairs are completed the day of request, if possible. If not possible, the repairs will be completed at the earliest possibility. NJAC 8:39-31.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/4/19 at 11:52 AM, the surveyor observed Resident #366 seated in the wheelchair watching television. The resident stated that he/she had a urinary catheter because he/she was unable to urinate on their own. The resident also reported that a urinary drainage bag was changed to a urinary leg bag during the day and was stored in the bathroom in a plastic bag. The resident stated that he/she thinks he/she had a UTI. The surveyor observed a urinary drainage bag stored in a plastic bag in the resident's bathroom and noted the tip of the catheter tubing was uncapped. The urinary drainage bag contained yellowish liquid inside. On 12/5/19 at 9:20 AM, the surveyor observed a urinary drainage bag stored in a plastic bag in the resident's bathroom the end of the tubing was capped. The bag contained a yellowish liquid inside. On 12/5/19 at 12:34 PM, the surveyor interviewed the CNA #2 assigned to Resident #366, who stated that the urinary drainage bag was removed when the resident gets OOB and a new urinary leg bag was attached. CNA #2 stated she would empty the urinary drainage bag and wipe the tip of tubing with soap and water before applying the cap. CNA #2 further stated that sometimes she would rinse the urinary drainage bag out but if there was a lot of urine left in the bag, she would discard the bag and provide the resident with a new one. CNA #2 observed in the presence of the surveyor, Resident #366's urinary drainage bag in the resident's bathroom. CNA #2 confirmed that the urinary drainage bag had yellowish liquid left inside. CNA #2 discarded the urinary drainage bag and stated that she would get a new one right away. On 12/5/19 at 1:01 PM, the surveyor interviewed CNA #3 that had been assigned to Resident #366 on 12/4/19, who stated that on 12/4/19 she rinsed out the urinary drainage bag and placed it in a bag in the bathroom, she stated she did not cap the tubing because she did not see a cap in the bathroom. CNA #3 stated she should have capped the end of the catheter tubing. The surveyor reviewed Resident #366's medical record that revealed the following: The admission Record for Resident #366 revealed that the resident was admitted to the facility on [DATE] with diagnoses that included Neuromuscular Dysfunction of the Bladder. According to the Annual MDS dated [DATE], revealed that Resident #366 scored a 15 out of 15 on the Brief Interview for Mental Status, which indicated no cognitive impairment. Resident #366's Care Plan dated 11/13/19, under Focus, revealed that the resident had a urinary catheter and the potential for UTI related to use of a urinary catheter. The Progress Note (PN) dated 12/2/19, revealed that the Nurse Practitioner (NP) examined Resident #366. The NP documented that the resident complained of suprapubic (lower abdominal area) tenderness and low urinary output. The NP documented that the resident's bladder was distention (swelling due to pressure inside) and had cloudy urine with sedimentation. The Urine Culture laboratory report dated 12/5/19, revealed that Resident #366 was positive for a UTI infection. On 12/5/19 at 1:18 PM, the surveyors discussed the above concerns with the Administrator and Director of Nursing (DON). The DON provided the policy regarding urinary catheter care. A review of the facility's policy titled, Urine Catheter Bag Care and Change under Procedure 3 d-e. revealed the following procedure when replacing the urinary drainage bag with a urinary leg bag: d. Detach the tubing of drainage bag from the catheter port, wipe with alcohol swab, remove the cap of the leg bag, then insert the valve of the leg bag into the catheter port. Clean the valve of the urinary drainage bag with alcohol swab and cap with the cap coming from the leg bag. Anchor the leg bag to the leg place the urinary drainage bag in plastic bag. e. Examine the urinary drainage bag if soiled, discard it even if it is capped. Under Procedure #4-a the following: Check if the urinary drainage bag and the cap was stored properly if not discard. N.J.A.C. 8:39-27.1 (a) Based on observation, interview and record review, it was determined that the facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTI) for 2 of 4 residents (Resident #54 and #366) reviewed for indwelling urinary catheters (a tube that allows a resident's urine to drain freely from the bladder into a urinary catheter bag). This deficient practice was evidenced by the following: 1. On 12/4/19 at 10:08 AM, the surveyor observed Resident #54 awake and seated in a wheelchair next to the bed. During the initial interview, the resident told the surveyor that they had a urinary catheter in place and wore a urinary leg bag when out of bed (OOB). The resident further stated they got OOB daily and returned back to bed on the the evening shift. On 12/4/19 at 10:20 AM, the surveyor went into Resident #54's bathroom and observed a urinary drainage bag and catheter tubing that was covered in a plastic bag. The tip of catheter tubing was not capped. On 12/5/19 at 8:20 AM, the surveyor observed Resident #54 seated in a wheelchair next to the bed. A Certified Nurse Assistant (CNA #1) was in the room making the resident's bed. The surveyor observed a urinary drainage bag attached to the metal base of the bed and covered in a privacy bag. The catheter tubing was laying on the floor and the tip of catheter was uncapped. After CNA #1 finished performing Resident #54's morning care, she told the resident she was leaving the room and would return later. When CNA #1 left the room, the catheter was still on the floor. On 12/05/19 at 8:35 AM, the surveyor went into Resident #54's room and observed that the catheter tubing was no longer on the floor. The surveyor went into the resident's bathroom and observed a urinary drainage bag in a plastic bag. The tip of the tubing was uncapped. The surveyor reviewed Resident #54's medical record and noted the following: According to the admission record, Resident #54 was admitted to the facility on [DATE] with diagnoses that included Chronic Inflammatory Demyelinating Polyneuritis (a rare neurotically disorder causing inflammation of nerve roots and peripheral nerves), Neuromuscular Dysfunction of Bladder and Neurogenic Bladder. The resident was admitted to the facility with a urinary catheter in place. The Quarterly Minimum Data Set (MDS) assessment tool dated 9/26/19, revealed the resident scored a 15 of 15 on the Brief Interview for Mental Status, which indicated no cognitive impairment. The December 2019 physician's Order Summary Report showed Resident #54 had a physician's orders dated 4/3/19, to apply a urinary leg bag to the thigh when OOB and to change the urinary catheter drainage bag every week and as needed. Resident #54 had a care plan for At risk for UTI related to catheter use for neurogenic bladder. The December 2019 Medication Administration Record revealed that the resident was currently receiving antibiotic treatment for five days for a diagnosis of a UTI. On 12/05/19 11:20 PM, the surveyor interviewed CNA #1 who was assigned to Resident #54 concerning the steps she took after she switched the resident's urinary drainage bag to a urinary leg bag. CNA #1 told the surveyor that she emptied, rinsed and stored the urinary drainage bag in a plastic bag in the resident's bathroom. CNA #1 further stated that the evening shift would remove the urinary leg bag and reattach the urinary drainage bag when the resident went to bed. The surveyor and CNA #1 went into the resident's bathroom. The surveyor asked CNA #1 if the urinary drainage bag that was in the bathroom was the same urinary catheter bag that she had removed from the resident earlier that morning. The CNA stated, Yes. The surveyor discussed with CNA #1 the observations that were made on 12/4/19 and 12/5/19 of the catheter tubing tip that was not capped while stored in the bathroom. The surveyor further discussed with CNA #1 the observation of the catheter tubing being left on the floor prior to her storing it in the bathroom. CNA #1 stated, I was very busy this morning. CNA #1 removed the catheter bag and said she was going to throw it out and tell the nurse. CNA #1 further stated that she wasn't aware that the tip of the catheter tubing needed to be capped when stored. On 12/05/19 11:30 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPNUM) about the above concerns. The LPNUM stated that CNA #1 should have discarded the urinary drainage system after it was found on the floor and then let a nurse that it needed to be replaced. The LPNUM further stated that the tip of the urinary catheter should always be capped when not in use to prevent an infection.