Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident and ensure that the side rail padding was in place. This deficient practice was identified for 1 of 19 residents reviewed for accommodation of needs (Resident #52), and was evidenced by the following: On 4/16/25 at 10:18 AM, the surveyor observed Resident #52 in bed, with his/her eyes open. Resident #52 did not respond to the surveyor's greeting. The surveyor observed that the resident's call bell (a bell used to summon staff for assistance) was not visible. The surveyor also observed that the resident's padding to the right upper half siderail was not placed correctly and was hanging down onto the floor. The surveyor reviewed the medical record for Resident #52. A review of the admission Record reflected that Resident #52 was admitted to the facility with diagnoses that included but were not limited to; epilepsy, diabetes mellitus, and cognitive communication deficit. A review of the Physician Order Summary revealed an active Physician's Order (PO) with a start date of 11/18/24 for seizure precautions every shift and an active PO with a start date of 11/18/24 for bilateral side rail seizure pads in place every shift. A review of Resident #52's quarterly Minimum Data Set (MDS), an assessment tool dated 2/24/25 revealed Resident #52 had a severe cognitive impairment. A review of Resident #52's Individualized Comprehensive Care Plan (CP) initiated on 11/19/24 reflected a focus area: activities of daily living (ADL) related to physical limitations with interventions that included but were not limited to; bed rails upper half to assist with mobility and independence, and right sided padding which was initiated on 3/24/25; a focus area: at risk for falls initiated 11/19/24 with interventions that included but were not limited to; have commonly used articles within easy reach. On 4/16/25 at 10:20 AM, the surveyor showed the Certified Nursing Assistant (CNA) assigned to Resident #52's care that the Resident's call bell was not observed and that the right upper siderail padding was not properly placed and hanging down onto the floor. The CNA stated that she had not checked to ensure that the resident had their call bell during her morning rounds nor did she check to ensure that the siderail padding was properly placed. At that time, the CNA observed the call bell was under the Resident's fitted bed sheet, and not within the resident's reach. The CNA confirmed that she should have made sure the resident's call bell was within their reach and that the siderail padding was in place. On 4/16/25 at 10:25 AM, the Licensed Practical Nurse assigned to Resident #52 confirmed that the call bell should be kept within the resident's reach and that she should have ensured that the side rail padding was in place for the resident's safety. On 4/16/25 at 10:30 AM, the surveyor showed the Licensed Nursing Home Administrator (LNHA) the siderail padding on the floor. The LNHA stated that it was an infection control and safety concern, and that the padding should be in place. A review of the facility's Answering the Call Light policy, revised 9/2022, reflected .the purpose of this procedure is to ensure timely responses to the resident's requests and needs .ensure that the call light is accessible to the resident when in bed . On 4/16/25 at 11:30 AM, the surveyor discussed the above observations and concerns with the LNHA and Director of Nursing. NJAC 8:39- 27.1(a); 31.8 (c)(9)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a safe, clean, and homelike environment. This deficient practice was identified for 2 of 19 residents (Resident # 18 and # 19) and was evidenced by the following: 1.On 4/15/25 at 11:35 AM, during an interview with the surveyor, Resident #18 stated his/her privacy curtain was soiled, and it was very upsetting as this was his/her home and that he/she liked things to be nice and clean. At that time, the surveyor observed that the privacy curtain was soiled with several brown stains. The surveyor reviewed the medical record for Resident #18. A review of the admission Record reflected Resident #18 was admitted to the facility with diagnoses that included but were not limited to; diabetes mellitus and repeated falls. The quarterly Minimum Data Set (MDS), an assessment tool, dated 1/19/25, reflected the resident had a brief interview for mental status score of 13 out of 15, which indicated that the resident's cognition was intact. On 4/15/25 at 11:40 AM, the Licensed Practical Nurse (LPN) assigned to Resident #18 confirmed that the privacy curtain was soiled and that she would contact the housekeeping department. On 4/15/25 at 11:41 AM, the surveyor showed the soiled privacy curtain to the Licensed Nursing Home Administrator, who acknowledged that the curtains should be clean to ensure a homelike environment. On 4/15/25 at 3:06 PM, during an interview with the surveyor, the Director of Housekeeping (DHK) stated that the privacy curtains were cleaned during the terminal cleaning of rooms, and when needed. The DHK confirmed that the curtains should be cleaned if they are soiled and that Resident #18's curtain should have been cleaned. 2. On 4/15/25 at 1:51 PM, during a tour on the first-floor high side, the surveyor observed Unsampled Resident #19's light switch pull cord, was about three (3-inch in length), which was located above their bed. Across was an unoccupied bed with a light switch pull cord that was about the same in length. On 4/15/25 at 1:57 PM, during an interview with the surveyor in Resident #19's room, the Licensed Practical Nurse (LPN) stated that the 3-inch light switch pull cords should not have been that short and that it probably broke. The LPN stated that there was a maintenance book at the nurse's station and that a report of the broken light switch pull cord was not reported in the book. On 4/15/29 at 1:59 PM, during an interview with the surveyor, the Maintenance Worker (MW) stated that the observed 3-inch light switch pull cords should have been longer. The MW stated that the light switches were checked but was not aware of a log to show how often they were checked. At that time, the MW stated that he would replace the 3-inch pull cords with longer cords, for the resident to be able to turn on, and turn off the light, at their discretion. On 4/16/25 at 11:31 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concern with Unsampled Resident #19's light pull cord switch that was observed to be about 3-inch in length, and did not allow for Resident #19 to turn their light on and off, at will, without assistance. On 4/16/25 at 1:45 PM, during a meeting with the survey team, the [NAME] President of Special Clinical Projects, and the DON, the LNHA stated that the light switches were checked as part of the maintenance weekly checklist and was last checked on the 4/9/24 (6 days prior to surveyor inquiry). The LNHA also stated that the maintenance weekly checklist was maintained by the Environmental Services Director. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.The surveyor reviewed the medical record for Resident #66. The resident was discharged from the facility, and according to the MDS, an assessment tool used to facilitate the management of care, dated 3/4/25, the resident was assessed as being discharged to the hospital. A review of Resident # 66's nursing progress notes dated 3/4/25 revealed the resident was discharged to a different skilled nursing facility as per the family's request. On 4/16/25 at 11:30 AM, the survey team met with the Licensed Nursing Home Administrator and Director of Nursing to discuss the above observations and concerns. On 4/16/25 at 12:57 PM, the surveyor interviewed the MDS Coordinator, who stated that the MDS dated [DATE] should have indicated discharged to another skilled nursing facility and that it was an error coded as discharged to the hospital. NJAC 8:39-11.2(e)1 Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 4 of 19 residents, (Resident #6, #14, #37 and #66). This deficient practice was by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 10/26/24, included the following. The CDC recommended administration of pneumococcal conjugate vaccine (PCV20 or PCV21) at least 1 year for all adults 50 years or older who have received PCV 13 only at any age. 1. On 4/13/25 at 11:07 AM, during the initial tour, the surveyor observed the resident in bed. The resident revealed to the surveyor that they had lived in the facility for about a year, felt depressed at times, and did not like to join activities. The surveyor reviewed Resident #14's medical record. The admission Record (AR, admission summary) reflected that Resident #14 was admitted to the facility with medical diagnoses which included but were not limited to: bipolar disorder (mental health condition that caused extreme mood swings with heightened energy and mood (mania or hypomania)) and cognitive communication deficit (communication difficulty caused by cognitive impairment). Resident #14's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 2/17/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out 15 which indicated the resident's cognition was intact. Section N - Medication reflected that the resident was taking an antipsychotic and the indication was noted. Under section N0450 A. Did the resident reflected receive antipsychotic medications since admission/entry or reentry or the prior assessment? The response was marked 0, which reflected, no antipsychotics were received A review of the electronic Medication Administration record for February 2025 reflected the resident received a daily dose of Risperidone (Risperdal; indication include treatment of acute manic or mixed episodes associated with bipolar 1 disorder in adults). Further review of the qMDS dated [DATE], under section O0300 A. Is the resident's Pneumococcal vaccine (PV) up to date? The response was marked 0, which reflected No. The reason was documented as not offered. A review of the immunization section of the electronic Medical Record (eMR) did not show a record that the pneumococcal vaccine was offered, education was given or the resident refused. A review of the facility provided Influenza and Pneumococcal Vaccine Consent and Tracking Form that was not in the eMR or the physical chart reflected that the pneumococcal vaccine was offered on 9/17/24, and the resident refused. 2. On 4/13/24 at 10-:52 AM, the surveyor heard an alarm from Resident #37's room, and observed two nurses enter the room. On 4/15/25 at 9:41 AM, the surveyor observed Resident #37 in bed, with oxygen infusing at 3 liters per minute (lpm) via a nasal cannula (a device used to deliver supplemental oxygen). The resident mentioned to the surveyor that they have not smoked for some time because she did not have any cigarettes. The surveyor reviewed the medical record for Resident #37. The admission Record (AR, admission summary) reflected that Resident #37 was admitted to the facility with medical diagnoses which included but were not limited to: chronic obstructive pulmonary disease (COPD; constriction of the airways making it difficult or uncomfortable to breathe) and diabetes mellitus (high blood sugar). Resident #37's admission Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care, dated 3/19/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out 15 which indicated the resident's cognition was moderately impaired. Further review of the AMDS, under section O0250 A. Did the resident receive the influenza vaccine? The response was marked 0, which reflected No; the reason indicated that the resident was not in the facility during that year's influenza vaccination season. A review of the facility provided Influenza and Pneumococcal Vaccine Consent and Tracking Form reflected that the influenza vaccine was offered on 3/13/25 and was signed not sure. No follow-up information was reflected on the form. On 4/16/25 at 11:31 AM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns with the inaccuracies with the MDS for: Resident #14's antipsychotic use and pneumococcal immunization status and the inaccurate, and Resident #37's influenza immunization status. The surveyor asked the DON what should the have been the correct documentation for Resident #37's MDS. The DON stated that Resident #37 was unsure, and did not answer the question. The DON acknowledged the MDS should have been coded accurately. On 4/16/25 at 11:50 AM, during an interview with the surveyors, the Registered Nurse/MDS-Coordinator (RN/MDSC) stated she worked in the facility once to three times a week. The RN/MDSC stated that the entry made on section N0450 that Resident #14 did not receive antipsychotic was probably an error. At that time, the RN/MDSC stated that the immunization information entered, into the MDS, was gathered from immunization record section of the eMR, progress notes, and the resident, when interviewable or the family/representative. The immunization information is dependent on nursing documentation on the eMR of acceptance, education and refusal. At that time, the surveyor discussed with the MDSC regarding the concern with the following MDS inaccuracies: Resident #14's pneumococcal immunization status and Resident #37's influenza immunization status. At that time, The MDSC stated that she would discuss the concern with the Regional MDS, provide education to the other MDS nurses and maybe a modification of the MDS. A review of the provided facility policy, Pneumococcal Vaccine, dated/revised 1/16/25, reflected that if refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination. A review of the provided facility policy, Influenza Vaccine, dated/revised 1/16/25, reflected that between October 1 and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. 3. The deficient practice was evidThe surveyor reviewed Resident #6 medical records. According to the Quarterly MDS dated [DATE], the resident was documented as receiving Hospice care. However, a review of the physician's orders dated 7/19/2024 indicated that Palliative Care services were ordered at that time, not Hospice care. The Quarterly MDS dated [DATE] accurately reflected that Hospice services were no longer in place. The Significant Change MDS dated [DATE] confirmed that the resident had been removed from Hospice services and was receiving Palliative Care services. Additionally, further review of the care plan dated 2/11/2025 stated that the resident required Palliative Care due to complex medical conditions and declined functional ability and cognition. On 4/15/2025 at 10:45 AM, the surveyor interviewed the Director of Nursing (DON), who confirmed that the resident is currently receiving Palliative Care services and is not on Hospice care. The DON acknowledged that the Quarterly MDS dated [DATE] incorrectly triggered Hospice care. The MDS Coordinator was interviewed on 4/16/24 at 1:05pm and acknowledged surveyors concern with the error.

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a.) provision of routine medication for administration (Resident #267) b.) accurate administration of medication for Resident #3, c.) documentation of removal of a controlled dangerous substance (narcotic; with high potential for drug diversion) medication from inventory, maintained accountability, and accurate reconciliation of Resident #43 and #50's narcotic medications, that was identified during the medication storage inspection of 2 of 2 medication carts. The deficient practice was evidenced by the following: On 4/14/25 at 8:13 AM, the surveyor observed Licensed Practical Nurse (LPN #1) begin to prepare 8 medications for Resident #267. The medications included a physician's order of 550 milligrams (mg) Rifamaxin (Xifaxan), give 1 tablet by mouth two (2) times a day for hepatic encephalopathy (a brain dysfunction caused by liver dysfunction). The order was started on 4/11/25 and was scheduled for administration at 9:00 AM and 5:00 PM. At that time, LPN #1 informed the surveyor that she did not have the Xifaxan in the medication cart, and that it was not packaged with the rest of Resident #267's medications for from the automatic dispensing machine (ADM; a computer-controlled machine that stores, dispenses, and tracks medications). At that time, LPN #1 called out to the Assistant Director of Nursing (ADON) who was seated at the nurses' station. LPN #1 asked the ADON to check if the Xifaxan was in stock within the electronic back-up machine (eBM; machine that stored routine and emergency medications). The surveyor reviewed the medical record for Resident #267. A review of the electronic Medication Administration Record (eMAR) for Resident #267 reflected the following: - On 4/11/25 at 5:00 PM, eMAR indicated 9 not administered. -On 4/12/25 at 9:00 AM, eMAR indicated 9 not administered. - On 4/13/25 at 9:00 AM, eMAR indicated 9 not administered. - On 4/13/25 at 5:00 PM, eMAR indicated 9 not administered. On 4/14/25 at 8:21 AM, the surveyor observed the ADON, give the Xifaxan 550 mg to LPN #1 for administration to Resident #267. A review of the eBM report, transaction by item reflected the following: -On 4/11/24 a quantity of 8 was available. -On 4/11/24 a quantity of 7 was available. -On 4/11/24 a quantity of 6 was available. On 4/14/2025 at 9:46 AM, the surveyor discussed the concerns with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) regarding the physician's order of Xifaxan 550 for Resident #267's that was not administered on 4/11/25 at 5:00 PM, 4/12/25 at 9:00 AM, 4/13/25 at 9:00 AM, and 4/13/25 at 5:00 PM. A review of the nurse practitioner progress note (NP), dated 4/14/25 at 4:18 PM, included that the resident was to continue their medications for hepatic encephalopathy (Xifaxan, Lactulose and Spironolactone) and monitor laboratory for sodium. A documentation that the NP was aware of the missed doses was not reflected in the PN. On 4/15/25 at 1:08 PM, during a meeting with the survey team, and the LNHA, the DON stated that the nurse who made the administration omission for all four (4) shifts/doses was the same nurse. The DON also stated that the new machine ADS arrived, and the nurse thought that all the stocked medications were transferred from the eBM to the ADS. The nurse went to retrieve the Xifaxan for Resident #267 from the ADS, and it was not there. The DON stated that she had educated the nurse that not all medications were transferred and that the nurse had called the pharmacy to inquire about the Xifaxan. A review of the facility provided correspondence from the pharmacy provider reflected that the pharmacy provided 24 hours a day, 7 days a week, 365 days emergency delivery service and have access to back-up pharmacies. 2. On 4/14/25 at 8:40 AM, the surveyor observed Licensed Practical Nurse (LPN #2) begin to prepare medications for Resident #3. The physician ordered medications included two (2) envelopes that were pre-packaged by the ADS. Envelope #1 contained: -Prednisone 2.5 mg, give 1 tablet one time a day for COPD (chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe). The order was started on 6/24/2020 and was scheduled for administration at 8:00 AM. The surveyor observed the Prednisone was packaged in a separate envelope from the rest of the medications. Envelope #2 contained the following: -Potassium Chloride Extended-Release tablet 20 milliequivalent (mEq) give 1 tablet by mouth one time a day for hypokalemia. The order was started on 8/27/24 and was scheduled for administration at 9:00 AM. - Amlodipine 5 mg, 1 tablet twice a day for hypertension. The order was started on 10/14/24 and was scheduled for administration at 9:00 AM and 5:00 PM. -Crestor 5 mg (Rosuvastatin) , give 1 tablet by mouth one time a day for hyperlipidemia. The order was started on 8/27/24 and was scheduled for administration at 9:00 PM. -Cymbalta Capsule Delayed Release Particles 30 mg, give 1 capsule by mouth one time a day for depression. The order was started on 3/23/23 and was scheduled for administration at 9:00 AM. At that time, LPN #2 stated that Crestor that was scheduled for 9:00 PM should not have been included in Envelope #2 and would remove the Crestor from the envelope, to exclude from the morning medication administration because the order was for a 9:00 PM administration. At that time, the surveyor and LPN #2 observed two (2) round white pills in envelope #2. The surveyor also observed LPN #2 clicked the images in the electronic Medication Administration Record (eMAR) to compare against the Amlodipine and Crestor in envelope #2; neither round white pill matched the images on the eMAR. LPN #2 stated that she would withhold both round white pills. LPN #2 informed the surveyor that the ADS usually printed out a list of Med Run report (MR; list of medications the ADS dispensed for the day that included images of the corresponding medication for the nurses to compare against the pills in pre-packaged envelope, and to ensure accuracy of the medications administered to the residents) but had difficulty with the printer that morning which was the reason why she did not have the MR. On 4/14/25 at 8:54 AM, LPN #2 confirmed that she was ready to administer the medications to Resident #3, poured water in a cup, locked the medication cart and entered the resident's door threshold. The surveyor stopped the medication pass and requested to speak with LPN #2 outside the resident's room. On 4/14/25 at 8:55 AM, LPN #2 and the surveyor reviewed the eMAR together against the Potassium and the Cymbalta contained in envelope #2. The eMAR revealed the following: -The Potassium on-hand had the same inscription as the eMAR. -The Cymbalta on-hand was a solid blue capsule with the inscription AP/DLX 30 while the eMAR had a blue and white capsule with the inscription of X 02. At that time, LPN #2 acknowledged that she should have had the MR and that she should have checked the Cymbalta, held it, until she was able to verify that the capsule contained in envelope #2 was correct. On 4/14/2025 at 9:46 AM, the surveyor discussed the concern with the LNHA and the DON regarding the medication administration for Resident #3 wherein LPN #2 who was unable to print the MR for accurate administration of medications and the failure to clarify the Cymbalta prior to the medication pass administration to Resident #3. At that time, LPN #2 informed the surveyor that she had printed the MR, after surveyor inquiry and was then available for the remainder of her medication pass administration. On 4/15/25 at 10:33 AM, in the presence of the survey team, the LNHA DON stated that LPN #2 should have had the MR prior to medication administration to residents. 3.) On 4/15/25 at 11:05 AM, the surveyor and LPN #3 began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart (narcotic box), located on the first-floor high side. At that time, in the presence of LPN #3, the surveyor observed Resident #43's Clonazepam 1 mg bingo card (a multidose card containing individually packaged medications) contained 18 tablets. A review of the Controlled Drug Administration Record (CDAR; a declining inventory log) for Resident #43's Clonazepam 1 mg indicated a count of 19 tablets remained and was not signed dispensed on 4/15/25. At that time, the surveyor and LPN #3 reviewed the controlled drug index (a shift-to-shift accountability log) for April 2025. The 4/15/25 shift-to shift log revealed signatures from LPN #3 who was on duty and the previous nurse that was on duty from 11:00 PM to 7:00 AM. LPN #3 stated that the signatures meant that the counts were completed, and no discrepancy was found. LPN #3 stated that it was her error, she missed the count that morning because it was chaotic during the change of shift. A review of Resident #43's eMAR reflected an order for Clonazepam 1 mg, to be given 1 tablet every 8 hours for seizure, and was administered on 4/15/25 at 6:00 AM, and the same administration was not reflected on the CDAR. 4.) On 4/15/25 at 11:49 AM, the surveyor and LPN #4 began the narcotic medication inspection, which was stored the narcotic box, located on the second-floor high side. At that time, in the presence of LPN #4, the surveyor observed Resident #50's Oxycodone 5 mg bingo card contained 8 tablets. A review of the CDAR for Resident #50's Oxycodone 5 mg indicated a count of 10 tablets remained and was not signed dispensed on 4/15/25. At that time, the surveyor and LPN #4 stated she forgot to sign the CDAR and acknowledged that she should have signed immediately after the removal of the two (2) Oxycodone 5 mg from inventory. A review of Resident #50's eMAR reflected an order for Oxycodone 5 mg, two tablets by mouth every 4 hours for as needed for severe pain, and was administered on 4/15/25 at 10:26 AM, and the same administration was not reflected on the CDAR. On 4/16/25 at 9:38 AM, during a meeting with the DON, the surveyor discussed the concerns found in two (2) medication carts wherein LPN #3 failed to identify the discrepancy in the narcotic count before taking responsibility of the medication cart. at the beginning of her shift, and LPN #4 who removed two (2) tablets of Oxycodone for administration and forgot to sign. At that time, the DON stated that the same nurses were given education in past and have been given education again after the medication storage observation. A review of the provided facility policy, Administering Medication dated/revised 1/16/25 reflected that medications are administered in a safe, and timely manner as prescribed. No further information was provided. NJAC 8:39-29.2(d), 29.4(b)2, 29.7(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to update one resident's (R)47) status by completing a significant change Minimum Data Set (MDS) assessment when R47 was admitted to hospice care on 01/05/24. This failure affected one of five residents reviewed for MDS assessment concerns, in a sample of 28 residents. Findings include: Review of R47's Face sheet found in the Profile tab of the Electronic Medical Record (EMR) revealed R47 was admitted to the facility on [DATE] with diagnosis of malignant cystic neoplasm (bladder cancer). Review of R47's quarterly MDS with an assessment reference date (ARD) of 2/18/23 documented that R47 had a Brief Interview for Mental Status score of 13 out of 15, which indicated mild cognitive impairment. Review of R47's EMR physician's order dated 01/03/24 revealed admit R47 to hospice care. Review of the hospice note dated 01/05/24 found in the MISC tab in the EMR revealed that on 01/05/24, hospice service was initiated by Ascend Hospice. Review of the EMR revealed that there was no updated MDS assessment to address R47's decline/change in condition and that resident was admitted to hospice services. Review of the facility policy titled Change in Resident Condition or Status, revised February 2021 revealed, .2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. b. impacts more than one area of the resident's health status. c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument (RAI). Interview with the MDS Coordinator on 01/25/24 at 3:50 PM revealed the facility policy was not followed because admission to hospice services would be a condition/status that would warrant a Significant Change MDS assessment. She further confirmed there had not been a timely Significant Change MDS completed for R47 when his status changed twenty days ago. NJAC 8:39-11.2(i)

Based on observation, record review, interviews, review of facility policy, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure three residents (Resident (R)4, R14, and R17) out of 28 sampled residents had an accurate Minimum Data Set (MDS) assessment. Findings include: 1. Observation on 01/24/24 at 4:00PM revealed R4 had a nephrostomy tube draining yellow urine in the right flank area. Review of R4's admission Record located in the electronic medical record (EMR) tab Profile revealed the resident was admitted to the facility with diagnoses that included calculus (stone) of the ureter and multiple sclerosis. Review of R4's Physician's Orders dated January 2024 located in the EMR tab Orders revealed right nephrostomy tube monitor site every shift. Review of R4's quarterly MDS with an Assessment Reference Date (ARD) 11/02/23 located in the resident's EMR tab MDS revealed the nephrostomy tube was not listed in the MDS section for appliances in bladder and bowel. 2. Review of R14's admission Record located in the EMR tab Profile revealed the resident was admitted to the facility with diagnoses that included unspecified psychosis, bipolar disease, major depressive disorder, and anxiety disorder. Review of R14's Physician Orders dated January 2024 located in the EMR tab Orders revealed the resident was to receive sertraline 50 milligrams (mg) and sertraline 100 mg for depression; trazadone 100 mg for depression; buspirone 30 mg for anxiety; and melatonin 5 mg for sleep (insomnia). Review of the R14's Quarterly MDS with an ARD 11/07/23 located in the resident's EMR tab MDS revealed it was documented the resident received an antipsychotic and antianxiety medications on daily basis. However, in section N0450 it was documented that the resident was not receiving antipsychotic medications. 3. Review of R17's admission Record located in the EMR tab Profile revealed the resident was admitted to the facility with diagnoses that included stage IV sacral region; stage 3 other region; and unspecified open wound lower back and pelvis without penetration into retroperitoneum. Review of R17's Wound Consultant Note dated 06/05/23 located in the EMR tab Miscellaneous revealed the resident had one stage IV sacral ulcer; and two stage III ulcers on the right thigh and left buttocks. Review of R17's quarterly MDS with an ARD of 06/09/23 revealed the resident was assessed to have one stage III ulcer and one stage IV ulcer: instead of two stage III ulcers and one stage IV ulcer. Interview on 01/25/24 at 2:30PM, the Minimum Data Set (MDS) Coordinator in the presence of the Director of Nursing revealed the MDS should reflect the resident's condition and the care the resident receives. The above residents were reviewed by the MDS Coordinator, and she agreed the MDS for these residents were inaccurate. Review of the facility's policy titled Quarterly MDS Assessment dated October 2023 revealed, Quarterly MDS assessments are conducted to track the resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored . Review of the RAI Manual, dated 10/01/19, indicated, . information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. NJAC 8:39-11.2(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revised/update care plans for two Residents (R )39 and R74 from a sample of 28 residents. The facility failed revised R39's care plan to reflect a fall with a significant injury and R74's care plan regarding tracheotomy care. Findings include: 1. Review of R39's admission Record located in the electronic medical record (EMR) Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included anoxic brain syndrome, cognitive communication deficit, dementia, major depressive disorder, and history of falls. Review of R39's Nursing Notes dated 03/02/23 located in the EMR Progress notes tab revealed the resident was readmitted to facility following surgical repair of femur fracture. Review of R39's Care Plan with a revision date of 02/20/23 located in the EMR Care Plan tab did not reflect the resident's fall with a hip fracture that required surgical intervention. Interview on 01/25/24 at 2:30PM, the Minimum Data Set (MDS) Coordinator confirmed that the resident's care plan was not revised to reflect the hip fracture from the fall, that required surgical intervention with wound care. 2. Review of R74's Face sheet found in the Profile tab of the EMR revealed R74 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia, cerebral infarction, cognitive and communication deficits following cerebral infarction. Review of R74 's admission MDS with an assessment reference date (ARD) of 01/30/22 revealed R74 was unable to communicate so the BIMS score was not completed. The MDS indicated that R74 was dependent on a tracheostomy (trach) collar when admitted . Review of R74's undated Order Summary Report found in the Order tab of the EMR revealed R74 was admitted on O2 [oxygen] via aerosolized tracheostomy (trach) mask at 35% and 10LPM (liters per minute) of oxygen every shift for TDRF (trach dependent respiratory failure). Keep an extra #8 Shiley [brand of tracheostomy tubes] and ambu bag [known as a manual resuscitator] with resident at all times. Review of Physician's Progress Note found in the Progress Note tab of the EMR and dated 02/08/22 revealed, resident had a behavior of reaching his trach and decannulating himself. He had done so three times on 02/08/22 and on the third decannulation the Nurse Practitioner (NP) was in the facility and assessed R74 he was breathing comfortably on a nasal cannula at 3-5 liters and was maintaining O2 sats of 95% or greater. R74's wife and the NP made a decision to . watch and see how he did on the nasal cannula since he could potentially do more harm to himself if he continued to decannulate himself without supervision/monitoring for adequate O2 support. Review of R74's care plan found in the EMR under the Care Plan tab revealed there was no documentation in the care plan to accurately reflect R74's oxygen delivery method, or changes in his care related to his respiratory status at all. Interview on 01/25/24 at 3:50 PM, the MDS Coordinator confirmed that R74's care plan should have been updated immediately when R74 went on a nasal cannula and off the trach collar. NJAC 8:39-11.2(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to update the physician's orders to accurately reflect the respiratory care and services for one resident (R)74 of three residents reviewed for respiratory care and services in the sample of 28 residents Findings include: Review of R74's Face sheet found in the Profile tab of the Electronic Medical Record (EMR) revealed R74 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia and cerebral infarction, Review of R74's admission Minimum Data Set (MDS) assessment revealed when he was admitted R74 was unable to communicate so there was no BIMS score for cognition and was dependent on a tracheostomy (trach) collar when admitted . Review of R74's undated Order Summary Report found in the Order tab of the EMR revealed R74 was admitted on O2 [oxygen] via aerosolized trach mask at 35% and 10LPM (liters per minute) of oxygen every shift for TDRF (trach dependent respiratory failure). Keep an extra #8 Shiley [brand of tracheostomy tubes] and ambu bag [known as a manual resuscitator] with resident at all times. Review of R74's Physician's Progress Note found in the Progress Note tab of the EMR and dated 2/08/22 revealed, the resident had a behavior of reaching his trach and decannulating himself. He had done so three times on 02/08/22 and on the third decannulation the Nurse Practitioner (NP) was in the facility and assessed R74. He was breathing comfortably on a nasal cannula at 3-5 liters and was maintaining O2 sats of 95% or greater. R74's wife and the NP made a decision to watch and see how he did on the nasal cannula since he could potentially do more harm to himself if he continued to decannulate himself without supervision/monitoring for adequate O2 support. The order changes were implemented as discussed with the wife and documented in the NP's progress notes. R74 was placed on O2 at 3-5 liters by nasal cannula. The orders to use the nasal cannula instead of the trach and use of OX at 3-5 liters per nasal cannula were never written as physician orders in the EMR Interview on 01/25/24 at 3:30PM, the Administrator stated that physician orders should have been transcribed immediately for R74 to receive proper respiratory management. The Administrator was unable to provide a facility policy prior to the survey team exiting the facility. NJAC 8:39-23.2(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to explain to residents the binding arbitration agreement and failed to inform the resident of the right to rescind the agreement within thirty calendar days for three (Resident (R) 224, R225, and R226) of three residents reviewed for arbitration agreement in a total sample of 28 residents. Findings include: Review of an undated copy of admission Agreement, provided to the survey team by the Administrator, with the following, Dispute Resolution and Arbitration embedded, indicated, Any controversy or claim arising out of or relating to this agreement and brought by the resident, his/her personal representative, heirs, attorneys or the responsible party shall be submitted to binding arbitration by a single arbitrator selected and administered pursuant to the commercial arbitration rules of the American Arbitration Association. A claim shall be waived and forever barred if, on the date the demand for arbitration is received, the claim (if asserted in a civil action) would be barred by the applicable state or federal statute of limitations. Any claimant contemplated by this paragraph hereby waives any and all rights to bring such claim or controversy in any manner not expressly set forth in this paragraph including, but not limited to, the right to a jury trial. During an interview on 01/25/24 at 4:46 PM, the Social Worker (SW) stated that the arbitration agreement was a part of the admission Agreement. The SW stated when she explained arbitration agreements to the residents, she would tell them that if they had any issues with the facility, they could reach out to the Administrator. Additionally, the SW stated she told the residents that they have a right to a jury trial. The SW was unable to state if the residents understood the binding arbitration agreement. The SW stated that she would sometimes leave a copy of the completed admission Agreement with the resident to read in their own time. During an interview on 01/25/24 at 5:36 PM, the Administrator stated the SSD was responsible for the arbitration agreements. Review of the Dispute Resolution and Arbitration which was embedded within the admission Agreement document revealed the absence of the resident's right to rescind the agreement within thirty calendar days. 1. Review of R225's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R225 was admitted on [DATE]. Review of R225's admission Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/15/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R225 was moderately cognitively intact. Review of R225's admission Agreement, provided by the Administrator, revealed R225 signed the arbitration agreement upon admission. Review of the Dispute Resolution and Arbitration revealed the absence of the resident's right to rescind the agreement within thirty calendar days. During an interview on 01/25/24 at 6:23 PM, R225 confirmed his signature on the Dispute Resolution and Arbitration portion of the admission Agreement. R225 stated that he may have previously heard of arbitration agreements. R225 stated the facility did not explain the binding arbitration agreement. 2. Review of R224's admission Record, located under the Profile tab of the EMR, revealed R224 was admitted on [DATE]. Review of R224's admission MDS, located in the EMR under the MDS tab with an ARD of 01/19/24, revealed the resident had a BIMS score of 15 out of 15, indicating R224 was cognitively intact. Review of R224's admission Agreement, provided by the Administrator, revealed R224 signed the arbitration agreement upon admission. Review of the Dispute Resolution and Arbitration revealed the absence of the resident's right to rescind the agreement within thirty calendar days. During an interview on 01/25/24 at 6:25 PM, R224 confirmed his signature on the Dispute Resolution and Arbitration portion of the admission Agreement. R224 stated he was unaware of the meaning of a binding arbitration agreement and that the facility did not explain the binding arbitration agreement. 3. Review of R226's admission Record, located under the Profile tab of the EMR, revealed R226 was admitted on [DATE]. Review of R226's admission MDS, located in the EMR under the MDS tab with an ARD of 01/08/24, revealed the resident had a BIMS score of 15 out of 15, indicating R226 was cognitively intact. Review of R226's admission Agreement, provided by the Administrator, revealed R226 signed the arbitration agreement upon admission. Review of the Dispute Resolution and Arbitration revealed the absence of the resident's right to rescind the agreement within thirty calendar days. During an interview on 01/25/24 at 6:27 PM, R226 confirmed his signature on the Dispute Resolution and Arbitration portion of the admission Agreement. R226 stated he was unaware of the meaning of a binding arbitration agreement and that the facility did not explain the binding arbitration agreement. During an interview on 01/25/24 at 6:31 PM, the Administrator stated the facility did not have an arbitration policy. NJAC 8:39-4.1(a)8 NJAC 8:39-13.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 09/01/21 at 9:01 AM, the surveyor and the first floor LPN/UM, were in Resident #52's room. Resident #52 was receiving O2 at 2 liters/min via nasal cannula attached to an oxygen concentrator with a humidification bottle. The surveyor observed that the O2 tubing and humidification bottle were not labeled or dated. The LPN/UM inspected the O2 equipment and acknowledged the tubing and humidification bottle were not labeled and dated. On 09/01/21 at 9:09 AM, the LPN/UM stated the oxygen tubing should be changed weekly and definitely should be dated so staff would know it was done and for infection control purposes. Review of Resident #52's EMR revealed the following: Resident #52 was admitted to the facility with diagnoses which included but were not limited to pneumonia due to coronavirus disease and hypertension (elevated blood pressure). The admission MDS, dated [DATE], revealed information which included but was not limited to the following: Resident #52 had moderately impaired cognition; was either totally dependent or required staff assistance for ADLs; had health conditions which included shortness of breath; and required oxygen therapy. The Care Plan revealed a focus area dated 08/12/21 that Resident #52 had cardiac disease related to arrhythmia, hyperlipidemia, hypertension and that one of the interventions was to administer oxygen as ordered. The POS indicated an order dated 08/19/21 to change all disposable oxygen supplies every week and as needed. Label and date all supplies. The Medication Administration Record (MAR) and TAR dated August 2021 revealed that the O2 supplies had been changed and label and dated only once on 8/16/21 and the MAR and TAR up to September 7, 2021 did not reflect the order to change, label and date the O2 supplies. On 09/01/21 at 10:09 AM, Resident #52's direct care LPN stated that any resident on oxygen should be monitored for oxygen saturation levels, shortness of breath, lung sounds and that the oxygen tubing and nasal cannula should be changed and dated to verify it was changed. The LPN stated it was important to change the tubing weekly to be sure it was sanitary and functioning properly. The LPN further stated it was her responsibility to check these things on morning rounds but that the LPN/UM had checked them this morning. On 09/01/21 at 11:33 AM, the acting DON stated that the nursing staff would do rounds together and should look at everything including oxygen tubing for dating. The facility policy titled. Departmental (Respiratory Therapy)-Prevention of Infection and dated 8/28/21, indicated that the purpose of this procedure is to guide prevention of infection associated with respiratory tasks and equipment, including ventilators, among the residents and staff. Under general guidelines the policy indicated that distilled water used in respiratory therapy must be dated and initialed when opened and discarded after twenty-four (24) hours. The steps in the procedure for infection control considerations related to oxygen administration indicated the following: -Change oxygen cannulae and tubing every (7) days or as needed. -Keep the oxygen cannulae and tubing used PRN (as Needed) in a plastic bag when not in use. The policy documentation included the following: -The date and time the respiratory therapy was performed. -The type of respiratory therapy performed. -The name and title of the individual (s) who performed the respiratory therapy. -The signature of title of the person recording the information. The facility policy titled, Oxygen Administration with an edited date of 4/2/2019, indicated that the purpose of this policy was to provide guidelines for safe oxygen administration. The policy indicated that the staff was to verify that there was a physician's order for this procedure and that the staff review the physician's order or facility protocol for oxygen administration. The policy indicated under documentation that after completing the oxygen setup or adjustment the following information should be recorded in the resident's medical record: - The date and time that the procedure was performed. -The name and title of the individual who performed the procedure. -The frequency and duration of the treatment. -The signature and title of the person recording the data. NJAC 8:39 - 19.4(a)(1); 27.1(a) Based on observation, interview and record review, it was determined that the facility failed to provide respiratory services, according to the physician orders and the facility policy for 3 of 5 residents (Resident #7, #18, #52) reviewed for respiratory services. The deficient practice was evidenced by the following: 1. On 8/30/21at 9:52 AM, during tour, two surveyors observed Resident # 7 in bed with the head of the bed up and O2 infusing at 4 liters/minute by way of (via) nasal cannula (nasal cannulas deliver supplemental oxygen to people who are using an oxygen supply to assist with their breathing). The surveyors observed that the O2 tubing and humidification (humidified breathable air) bottle were undated and unlabeled. The resident's electronic medical record (EMR) revealed the following information: The admission Record (AR) indicated that Resident #7 was admitted to the facility with the diagnoses which included but was not limited to: pulmonary fibrosis (lung tissue becomes damaged and scarred), chronic obstructive pulmonary disease (constriction of the airways and difficulty or discomfort in breathing), and heart failure. The quarterly Minimum Data Set (MDS) an assessment tool dated 06/23/21, indicated that the resident had severe cognitive difficulties, had no hallucinations or delusions, and did not exhibit any behaviors. The MDS also reflected that the resident required extensive assistance with activities of daily living (ADLs) and was on oxygen (O2). The physician order summary (POS) dated 09/17/21 indicated that the resident was ordered to have O2 at 4 liters/minute via nasal cannula for pulmonary fibrosis every shift. The POS dated 03/19/21 indicated that Resident #7 was to have all disposable O2 supplies, changed every week and as needed, and that all respiratory supplies were to be labeled and dated every night shift on Monday. The Treatment Administration Record (TAR) dated 08/01/21-8/31/21 reflected an order to change disposable O2 supplies every week and as needed and to label and date all supplies every night shift on Monday. There was a nurse's signature on the date of 08/30/21 that indicated that the O2 supplies were changed, labeled and dated however the O2 supplies including the O2 tubing, and humidification bottles were not labeled and dated as observed by the surveyors on 08/30/21 at 9:52 AM. On 08/31/21 at 11:21 PM, the surveyor had a second observation of Resident #7 lying in bed receiving O2 at 4 liters/minute via nasal cannula. The O2 tubing and humidification bottle were not labeled or dated. On 09/01/21 at 9:01 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the O2 tubing, and humidification bottle were changed on the 11 AM-7 PM shift on 09/01/21. She stated that she was not aware that the O2 tubing, or humidification bottle were not labeled or dated on 08/30/21 or 8/31/21 because she usually didn't look at that. She further added that it was the 11 PM-7AM nurses' responsibility to change, label and date the O2 tubing and humidification bottle. On 09/01/21 at 9:12 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) for sub-acute unit who stated that O2 tubing, and humidification bottles were to be changed, dated, and labeled weekly by the 11 PM-7 AM shift. She further added that this process was done for infection control measures and that dating the O2 tubing and humidification bottle to assure that the staff knew when it was done. She stated if it was not labeled or dated, then you would not know that it was changed. 09/01/21 11:33 AM, the surveyor interviewed the acting Director of Nursing (DON) who stated that staff should be making rounds in the morning and should make sure that O2 is placed on the resident and that O2 tubing, and humidification bottles are labeled with a date. 2. During the initial tour on 08/30/21 at 9:30 AM, the surveyor observed Resident #18 in bed, with oxygen in place. The Oxygen was connected to a device delivering humidified air via nasal cannula. The setting on the device was 2 liters. The humidifier bottle was almost empty and had a sticker dated 07/24/21. The connected tubing was not labeled or dated. On 08/31/21 at 7:40 AM the surveyor observed Resident #18 sitting in the room, Resident #18 told the surveyor that she had a bad night and had to use the oxygen almost all night. On 09/01/21 at 9:25 AM, the surveyor observed Resident #18 sitting in a chair in the room eating breakfast. The Oxygen tubing was noted on the bed underneath the pillows, not labeled or dated. The sticker on the humidifier bottle still dated 07/24/21. A review of Resident #18's clinical record revealed the following: Resident #18 was admitted to the facility with diagnoses which included shortness of breath, Acute kidney failure, diabetes mellitus and asthma. On the most recent Minimum Data Set (MDS) an admission assessment dated [DATE], Resident #18 was coded as being dependent on staff for some activities of daily living and coded as having received Oxygen therapy. Resident #18 was coded 12 for the Brief Interview for Mental Status (BIMS) which indicated the resident had a mild cognitive impairement. A physician order revealed Oxygen at 2 Liters/ minute Via Nasal Cannula as needed for shortness of breath- Start Date- 07/15/2021. A subsequent physician order revealed: Change all disposable oxygen supplies every week and as needed. Label and date all supplies every night shift every Monday Start Date- 07/19/2021. A review of Resident #18's comprehensive care plan dated 07/16/21 revealed the following: resident #18 has/at risk for respiratory impairment related to Chronic Obstructive Pulmonary Disease (COPD ). The intervention was as follows: Administer medications/ treatment per physician order. Administer Oxygen per physician order. On 09/01/21 at 9:25 AM, the surveyor verified with the Licensed Practical Nurse (LPN) the date on the humidifier bottle. The LPN stated that she was not sure about the facility protocol, she will ask the Unit Manager. On 09/01/21 at 10:19 AM the surveyor interviewed the Unit Manager Nurse (UMN) regarding the physician order for the oxygen. The UMN told the surveyor that all oxygen supplies were to be changed weekly on the 11:00 PM- to 07:00 AM shift. The surveyor accompanied the Unit Manager to Resident #18's bedside. When shown the 07/24/21 date on the humidifier bottle the UMN did not respond to the surveyor. On 09/07/21 at 12:45 PM, the Assistant Director of Nursing (ADON ), the Regional Director of Nursing and the Administrator were informed of these concerns and were asked what they would expect to occur if the 11:00 PM -07:00 AM shift failed to change the oxygen supplies. The ADON stated that the next shift should change the oxygen supplies.

Based on observation, interview and record review, it was determined the facility failed to ensure that medications received from residents, specifically a controlled schedule IV drug, were verified and accounted for daily by incoming and outgoing staff. This deficient practice was identified for 1 of the 3 medication carts reviewed and was evidenced by the following: During the Medication Pass Administration observation on 08/31/21 at 9:30 AM, the surveyor conducted a narcotic count with the Registered Nurse (RN ) responsible for the medication cart on the high side. The surveyor observed 2 bottles of medication stored in the locked narcotic compartment. The medication was labeled as Tramadol 50 milligrams (mg) and Klonopin 0.5 mg. The medication belonged to Resident #10 who still resided at the facility and were brought to the facility by the resident on admission. The declining inventory count was accurate for the Klonopin. The count was 25 and verified with the RN. The nurse had been using the Klonopin received from home when the Klonopin from the facility pharmacy had not arrived in time. The bottle of medication labeled as Tramadol was noted to have three different medications in the container. The nurse was unable to identify the other medications. The nurse told the surveyor that she did not verified that all the medications in the container labeled as Tramadol were Tramadol. The RN stated that she did not count the content of the container that morning. The above concern was brought to the team and discussed with the facility on 08/31/21 at 10:31 AM. The Assistant Director of Nursing (ADON ) told the team that she would investigate the above concern. On 08/31/21 at 9:30 AM, the surveyor interviewed the RN responsible for the medication cart. The RN stated that residents were not allowed to keep medications in their room. The RN stated that narcotic medications were kept in the narcotic compartment and should be checked daily. The RN further stated that prior to today, he was not aware that the Tramadol bottle contained other medications. On 09/03/21 at 10:47 AM, an interview with the ADON regarding the investigation for the Tramadol revealed the investigation was completed and the investigation revealed the admitting nurse was aware of the discrepancy. On 09/03/21 at 11:30 AM, during an interview with Resident #10 regarding medications brought from home, he/she indicated that he/she could not remember exactly what was in the medication container. On 09/03/21 at 10:30 AM, the facility provided a telephone statement from the nurse who initiated the narcotic count sheet for the Tramadol on 06/26/2021. The statement revealed that the Registered Nurse was aware there were some other medications in the Tramadol bottle and did not report the discrepancy to the Unit Manager nor seek guidance from the facility's dispensing pharmacy. On 09/08/21 at 9:00 AM, a telephone interview with the nurse who initiated the narcotic count sheet on 06/26/2021, revealed that she verified that 13 pills were in the bottle, there were three different types of tablets, and that she verified them with another nurse and documented the amount on the narcotic sheet and also on the resident's belonging sheet. The RN stated also that it was a busy night, she did not identify the other pills, and that they could have been from a different manufacturer. I just counted them, verified that 13 pills were in the bottle and I did not think to communicate the findings to the Unit Manager or the Director of Nursing. She further stated that residents are not allowed to keep medications at the bedside and all controlled substances were to be locked and kept secured in the narcotic compartment box and non-controlled medications were kept in the medication room. The surveyor asked the nurse what should have been done with the above situation. The nurse stated I should have separated the pills, looked on the medication website to identify the pills, separately counted and labeled them accordingly. The nurse further stated that I could have called the dispensing pharmacy for further guidance and that narcotic count was done daily with the incoming shift. On 09/08/21 at 9:26 AM, a telephone interview with the Consultant Pharmacist (CP) regarding the Tramadol discrepancy revealed that on a monthly basis she would visit the facility and generated a report regarding her findings. She stated she was aware of the Tramadol was being kept in the narcotic compartment box but did not verify the content of the medication bottle. The CP stated her responsibilities included to ensure processes were in place,which included checking that the medications were dated and to ensure that the narcotic count was done from shift to shift. She stated she also performed a unit inspection which included checking the medication carts. She further stated she inspected the medication rooms, completed a spot check, then forwarded the report via email to the DON/Administrator. The CP stated she did not physically do a narcotic count but would look at the declining inventory sheet and stated I do remember the Tramadol being in the narcotic compartment box and I spoke with the nurse responsible for the medication cart during the visit. She stated she did not provide any guidance and might have included that in the report but could not recall. The CP stated she understood that the nurses should abide by the facility policy and a narcotic count should be completed shift to shift. She stated the nurses were allowed to use medications from the dispensing pharmacy only, and if a medication was not available, the nurse should have retrieved the medication from the automated medication dispensing unit and that the nurses were not allowed to use medication from home unless it was an emergency medication that was not available. On 09/08/21 at 10:52 AM, the Administrator provided the facility policy titled, Medications brought to the facility by the resident/family dated 05/10/2017 and revealed the following: Medications brought into the facility by resident or responsible party are used only upon written order by the resident's attending physician, after the contents are verified and when appropriately packaged and labeled. Unauthorized medications are not accepted by the facility. Policy Interpretation and implementation revealed: The facility discourages the use of medications brought in from outside, and will inform residents and families of that practice as well as applicable laws and regulations. The medications have been ordered by the resident's attending physician, and documented on the physician's order sheet; The medication is appropriately packaged and labeled in accordance with established policies; when feasible a newly filled prescription in original packaging, as obtained from the dispensing pharmacy is preferred. The contents of each container have been verified by: consulting a medication identification reference ( e.g. Physician's Desk Reference ), or calling the dispensing pharmacy or provider pharmacy for a physical description of the medication. This verification may be completed by the nurse or consultant pharmacist. The nurse will document the receipt and verification of medication brought by the resident or family. Medications brought into the facility that are not approved for the resident's use shall be returned to the family. If the family does not pick up those medications within 30 days, the facility may destroy them in accordance with established policies. NJAC: 8-39-29.4 (a)(f)(g)

Based on observation, interview and review of medical records and other pertinent facility documentation, it was determined that the facility failed to: a.) initiate a timely and through investigation for two injuries of unknown origin, and b.) ensure the facility policy for Investigating Injuries and Abuse Investigation and Reporting 1 of 3 residents (Resident #7) reviewed for investigations. The deficient practice was evidenced by the following: On 08/30/21 at 9:48 AM, the surveyor observed Resident #7 lying in bed. The resident was alert and was confused. The surveyor observed a black-blue discoloration located on the left forehead. Upon surveyor interview, Resident # 7 was unable to describe how the black and blue discoloration occurred to his/her left forehead. The surveyor reviewed the resident's electronic medical record (EMR) which revealed the following: The admission Record (AR) indicated that Resident #7 was admitted to the facility with the diagnoses which included, but was not limited to, pulmonary fibrosis (a condition in which the lungs become scarred over time), chronic obstructive pulmonary disease, and heart failure. The quarterly Minimum Data Set (MDS), an assessment tool, dated 06/23/21, indicated that the resident had severe cognitive difficulties and had no hallucinations or delusions or exhibit any behaviors. The MDS also reflected that the resident required extensive assistance with activities of daily living (ADLs). The facility nursing clinical progress note (NCPN) dated 08/30/21 at 7:20 AM, indicated that Resident #7 had a blue-black discoloration on the forehead. The NCPN further revealed that the resident denied any pain or any discomfort when assessed by the nurse, and indicated that the resident was unable to explain how the blue-black discoloration occurred. Upon further review, a NCPN dated 08/23/21 at 23:10 (11:10 PM), revealed that there was a change in the resident's condition and that the resident had pain and swelling in the right knee. The NCPN indicated that the physician and family was notified, ice was applied to the right knee, and an x-ray was ordered. On 08/31/21 at 12:30 PM, the surveyor requested documentation from the Administrator (LNHA) regarding any incident/accident (I/A) reports, or investigations for Resident #7 for the prior six months. On 09/01/21 at 1:00 PM, the LNHA provided the surveyor with I/A reports and investigations for Resident #7 for the prior last six months. The surveyor reviewed the reports provided by the LNHA. The reports did not include any I/A or investigation for Resident #7's swelling and pain of the right knee or the black-blue discoloration on the resident left forehead. On 09/3/21 at 9:42 AM, the surveyor interviewed the Registered Nurse (RN) who documented 08/30/21 at 7:20 AM that Resident #7 had a bruise on the forehead. The surveyor asked the RN what she would do if she found any marks or discolorations on a resident. She stated that she would assess the resident and document the areas where the bruises were located, and if the resident was able to tell her what happened, she would document what the resident stated. She stated that she notified the nursing supervisor about the bruise and filled out an incident and accident report but did not document that in the NCPN. She also added that she would have the Certified Nursing Assistant (CNA) write a statement. She further revealed that the unit manager would then start an investigation. She stated that on 08/30/21 at 7:20 am, the CNA reported to her that Resident # 7 had a bruise on the left forehead. She stated that she assessed the resident and that the resident was unable to explain what happened. The RN stated that she did not document her assessment or finding in the resident's medical record. On 09/03/21 at 10:00 AM, the surveyor interviewed the CNA that provided care to Resident #7 who stated that she provided care to Resident #7 on 09/01/21. The CNA confirmed that she noticed that Resident #7 had a bruise on the left forehead and the CNA reported it to the nurse. The CNA stated that the nurse confirmed that Resident #7 had the bruise to the left forehead but she stated she was not sure what the nurse did about it. On 09/3/21 at 10:00 AM, the surveyor attempted to conduct a telephone interview with the hospice and was unable to reach a representative. A message was left. On 09/03/21 at 10:05 AM, the surveyor interviewed the hospice home health aide (HHA) who provided direct patient care to Resident #7 five days a week which included providing bed baths, assisting with meals, and reporting to the hospice service any findings such as a change in the resident's condition. The HHA stated that she observed that Resident #7 had complaints of pain in the right knee approximately 2 weeks ago, and she added that she reported Resident #7 had complaints of right knee pain to the nurse on duty and could not remember the nurse's name. She stated she also reported it to the nurse on duty and the hospice social worker (SW). The HHA added that she observed that the resident had a bruise or discoloration on the forehead a week ago and could not recall the exact date. The HHA stated she asked the resident what happened and the resident was unable to communicate what had occurred. The HHA further added that Resident #7 was very sweet and was never, ever combative with care. On 09/03/21 at 12:16 PM, the LNHA and acting Director of Nursing (DON), in the presence of the survey team, stated that when an incident or accident occurred with any resident in the facility, an investigation into the incident must occur immediately. Both the LNHA and DON stated that anytime an incident or accident occurred the nurse would initiate an incident report, the supervisor would be notified, and an investigation would be conducted immediately, and include statements from all employees involved for 72 hours prior to the incident. The nurse that discovered the incident or accident would perform a body check and assessment of the resident involved. In the presence of the survey team, the LNHA and DON stated that there was no investigation initiated into Resident # 7's swollen painful right knee, or the bruise on the resident's left forehead, according to the facility policy and procedure. On 09/07/21 at 8:55 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that the facility process for I/A was that the nurse who discovered the I/A would take the residents vital signs, notify the supervisor, perform the physical assessment and contact the physician and family. She further revealed that the nurse was responsible to complete a change of condition form in the computer program and fill out the incident accident report. She continued to explain that the supervisor would be responsible to initiate an investigation and the nurse would perform a head to toe assessment of the resident and inform the supervisor of the findings. She further revealed that she would assist in the investigation because she was responsible for the unit. The RN/UM then stated that when Resident #7 had a swollen knee she didn't remember if an incident or accident form was completed, or if an investigation was conducted. She further added that she was not notified about the bruise on the resident's forehead and that she found out about the bruise when she went to see the resident on 09/01/21. The RN/Unit manager stated that it would have been important for an investigation to be conducted immediately for the resident's swollen knee and bruise on the left forehead because the facility had to make sure the resident was safe and that there is no abuse. The RN/UM did not have an answer as to why an investigation was not conducted right away for the resident's swollen right knee or bruise on the forehead. On 9/07/21 at 12:17 PM, the surveyor interviewed the social worker (SW) who stated the LHNA was the facility abuse officer, and she was usually involved in any alleged abuse investigations or incidents regarding the residents. She stated that she was informed last week that Resident #7 had a bruise on the forhead, although she could not recall the exact date. She stated she was not asked to participate in the investigation or interview the resident because the DON informed her the family was involved already. On 09/07/21 at 12:53 PM, the survey team met with the LNHA, DON and Assistant Director of Nursing (ADON). During the meeting the LNHA stated she was the facility abuse officer and any allegations or investigations of abuse were her responsibility to ensure the facility policy for abuse was followed. The DON indicated that he primarily compiled the investigation into the edema of the right knee and the bruise on the left forehead after that was brought to the facility's attention after the surveyor inquiry, however, the investigation was incomplete. The LNHA and DON both agreed that they should have known about each incident when it occurred, and that the nursing supervisor should have initiated the investigation immediately after each incident and begin the interview process with the staff. The LNHA and DON stated that the SW would be involved in the investigation and her responsibility was to interview the resident and work with the nursing staff. When the survey team asked the DON why the supervisors did not initiate investigations into the residents swollen knee or bruise over the left forehead when it occurred, the DON stated that he just didn't ask them. The DON stated that he did not complete either investigation and staff statements were pending. On 09/08/21 at 1:30 PM, the DON stated to the life safety surveyor that he shredded the original statement that was written by the direct care per diem (per day employee) CNA who reported that the resident had a black-blue discoloration on the left forehead. The facility policy titled, Investigating Injuries and dated 2016, indicated that the Administrator will ensure that all injuries are investigated. The policy indicated the following: -The DON or designee will assess all injuries and document clinical findings in the clinical record. -If an incident /accident is suspected, a nurse or nurse supervisor will complete a facility-approved accident/incident form. The form will be disseminated to the appropriate individual for example the Administrator of DON. -Documentation shall include information relevant to risk factors and conditions that could cause or predispose someone to similar signs and symptoms (e.g., receiving anticoagulant, having osteoporosis, having a movement disorder that results in a thrashing movement, etc.) any descriptions in the medical record shall be objective and should not speculate about the cause. -The Medical Director or Attending Physician shall review and verify conclusion about the possibility of a medical or other cause of the findings. -With the help of the staff and management, the investigator will compile a list of all personnel, including consultants, contract employees, visitors, family members etc. who have had contact with the resident during the last 48 hours. The facility policy titled, Abuse Investigation and Reporting with a revised date of July 2017, indicated that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or unknown source shall be promptly reported to local, state, Federal agencies and thoroughly investigated by facility management. The policy indicated that the role of the Administrator: - Will assign the investigation to an appropriate individual. -The Administrator will provide any supporting documentation relative to the alleged incident to the person in charge of the investigation. The policy indicated that the role of the Investigator: -Review the completed documentation forms. -Review the resident's medical record to determine events leading up to the incident. -Interview the person (s) reporting the incident. -Interview any witnesses to the incident. -Interview the resident. -Interview the attending physician. -Interview staff members on all shifts who have had contact with the resident during the period of alleged incident. -Interview other residents to whom the accused employee provides care or services and review all events leading up to the alleged incident. -Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. The facility policy titled, Charting and Documentation with an edited date of 02/27/18, indicated all services provided to the resident, progress towards the care plan goals, or any changes in the residents medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy revealed that the following information is to be documented in the resident's medical record to include: -Changes in the resident's condition. -Events, incidents, or accidents involving the resident N.J.A.C 8:39-4.1(a), 5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 8/30/21 at 10:01 AM, during tour, the surveyor observed Resident #23 in bed with both feet raised on pillow. The surveyor observed that Resident # 23 had edema in both lower extremities. The surveyor observed that the resident was not wearing socks, stockings, or wrappings on bilateral feet. The resident was receiving therapy at this time and was not able to be interviewed. On 08/31/21 at 12:23 PM, the surveyor had a second observation of the ace wraps not on the resident's bilateral feet. The resident was not able to be interviewed because he/she was receiving therapy. The surveyor reviewed the resident's TAR which revealed a nurse's signature on 08/31/21 at 6:00 AM indicating that the ace wraps were in place, however the surveyor did not observe the wraps on the resident's legs. On 09/03/21 at 10:50 AM, the surveyor observed Resident #23 sitting up in a chair without a footrest on the bottom of the wheelchair (W/C), both feet were directly on the floor and he/she was wearing socks. The surveyor did not observe ace wraps on bilateral feet. The surveyor observed ace wraps on the windowsill in the room. The resident was interviewed at this time and stated that the nurses stopped applying the ace wraps to his/her bilateral lower legs approximately one week ago. He/she stated that he/she asked the nurses why, could not recall names, and was told he/she didn't need them anymore. The resident lifted his/her pants leg to show the surveyor his/her legs. The surveyor observed that the resident's bilateral legs were edematous (swollen). The resident's electronic medical records (EMR) revealed the following information: The admission Record (AR) indicated that Resident #23 had the diagnoses with included but were not limited to: compression fracture of the T11-T12 vertebra and epilepsy (seizure disorder). The admission MDS dated [DATE], indicated that the resident was cognitively intact and required extensive assistance with activities of daily living. The physician order summary (POS), dated 7/30/21, reflected an order for ace wraps to be applied in the AM (morning) and removed in the PM (evening) if the patient can tolerate. The surveyor reviewed the resident's TAR which revealed a nurse's signature on 08/30/21 at 6:00 AM indicating that the ace wraps were in place, however the surveyor did not observe the wraps on the resident's legs. On 09/03/21 at 11:04 AM, the surveyor interviewed the LPN (assigned to provide care to the resident) who stated that Resident # 23 was alert and oriented to person, place and time and was cognitively intact. She added that the resident did not have any treatments that she was aware of but wore a back brace. She further added that she did not usually do a full body assessment unless the resident complained of something but that when giving medications you could see if the resident had edema or any other issues. She stated that she was not aware that Resident #23 had bilateral lower leg edema. She stated that when she received report from the nurse that worked the previous shift and that nurse did not inform her that Resident #23 had edema. The LPN and the surveyor reviewed the TAR together and the LPN reviewed the physician's order for the ace wraps. The LPN then stated, I would not know that he was supposed to have ace wraps applied because they were ordered to be applied on a different shift. The LPN could not explain why the ace wraps were on the windowsill and not on the resident. On 09/03/21 at 11:32 AM, the surveyor interviewed the CNA who stated that when she cared for the resident, she did not see ace wraps on the resident's bilateral feet. On 09/03/21 at 11:33 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that if a resident had a treatment ordered then the nurse should be applying the treatment according to the physician's order. The RN/UM then added that after the treatment was performed the nurse would sign the plotted date on the TAR and that would indicate that the treatment was completed. If the resident refused the treatment, then the nurse would document the refusal in the residents' EMR. The RN/UM could not explain why the ace wraps were not applied to Resident #23's legs as indicated by the nurse's signature on the TAR. She stated that they should have been applied as ordered by the physician. The surveyor reviewed Resident #23's EMR and could not find documentation that the resident refused to have the ace wraps applied. On 09/03/21 at 11:45 AM, the surveyor attempted a telephone interview with the nurse that signed the TAR which indicated the ace wraps were applied. The facility Policy titled Charting and Documentation edited on 02/27/2018, indicated that all services provided to the resident, progress towards the care plan goals, or any changes in the residents medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy Interpretation and Implementation included the following: The following information is to be documented in the resident medical record: -Treatments and services performed. -Changes in the resident's condition. -Events, incidents, or accidents involving the resident. Documentation of procedures and treatments will include care-specific details, including: -The date and time the procedure/ treatment was provided. -The name and title of the individuals who provided the care. -Whether the resident refused the procedure/treatment. -The signature and title of the individual documenting. NJAC 8:39-27.1(a) Based on observation, interview and review of medical records, it was determined that the facility failed to provide physician ordered treatments, consistent with professional standards of clinical practice. This deficient practice was identified for 2 of 17 residents reviewed (Residents #34 and #23) and was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a licensed practical nurse is defined as performing task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 08/30/21 at 10:30 AM, the surveyor observed Resident #34 in bed, positioned on his/her back with their heels resting directly on the mattress. On 08/31/21 at 7:58 AM, the surveyor observed Resident #34 in bed with his/her feet rested directly on the mattress. Resident #34's lower extremities were reddened and swollen. On 09/01/21 at 9:20 AM, the surveyor observed Resident #34 in bed with their heels directly on the mattress. The surveyor reviewed the medical record which revealed the following: Resident #34 was admitted to the facility with diagnoses which included: Cellulitis of left lower limb, other abnormalities of gait and mobility, lymphedema not elsewhere classified, and local infection of the skin and other subcutaneous tissue. The admission Minimum Data Set (MDS) an assessment tool, dated 08/04/21, revealed that Resident #34 scored 15/15 on the Brief Interview for Mental Status ( BIMS ) which indicated intact cognition. Resident #34 had a Physician Order for: Offload bilateral heels on pillow while in bed every shift to prevent skin breakdown dated 07/29/2021. Resident #34 had a Care Plan initiated 08/14/21, with a focus area of Alteration in skin integrity related to impaired mobility/ actual wound left ischium and included an intervention to Suspend/ float heels as able. On 09/01/21 at 10:30 AM, an interview with the Unit Manager revealed that Resident #34 had an order for their heels to be off-loaded. The surveyor accompanied the UM to the residents room and observed that the resident's heels were not off-loaded. Resident #34 was lying on his/her back with their heels directly on the mattress. The surveyor and UM reviewed the order dated 08/12/21 and indicated the resident's heels to be elevated. The UM indicated that staff could have used pillows if the heel protectors were not available. The UM and Surveyor observed that Resident #34 had Prevalon Boots (pressure relieving heel boots) in the room and were in the original wrapper. On 09/01/21 at 10:46 AM, an interview with Resident #34 revealed that he/she would wear the heels protectors, but nobody put them on. He/she further stated, They are still in the package. The surveyor noted the Prevalon heel Protector boots on top of the receptacle bin in the resident's room, still wrapped. The surveyor observed Resident #34's heels were covered with layers of dry, flaky skin. On 09/01/21 at 11:11 AM, the surveyor interviewed the Certified Nursing Assistant ( CNA ) who cared for the resident. The CNA stated to the surveyor that she was not aware that Resident 34's heels were to be elevated. Upon request, the CNA provided to the surveyor the assignment sheet for the last 3 days. The assignment sheet did not contain information to off-load/suspend Resident #34's heels. On 09/01/21 at 11:30 AM, the surveyor interviewed the Licensed Practical Nurse (LPN ) and inquired about how the plan of care was communicated to the CNA. The LPN told the surveyor that the information was entered in the Electronic Plan of care (E-POC ) and the CNA would access the information on the computer. The LPN opened Resident #34's E-POC and reviewed the contents with the surveyor. Resident #34 E-POC contained information regarding turning and positioning and incontinence care. There was no provision for off-load/ float the heels. On 09/01/21 at 11:45 AM, the surveyor again interviewed the UM Nurse. The surveyor asked the UM Nurse what it meant to suspend/float heels. The UM Nurse replied heels should be elevated on a pillow or staff could have applied heel booties. A review of the Progress Notes from admission to 09/03/2021, did not include documentation that Resident #34 refused to have their heels elevated. On 09/01/21 at 12:30 PM, the surveyor and the UM Nurse reviewed the Treatment Administration Record (TAR) and observed that the nurses had signed that Resident #34's heels were off-loaded on the days the surveyor observed the heels rested directly on the mattress. On 09/07/21 at 1: 30 PM, the facility administrative staff was made aware of the above concerns. The Assistant Director of Nursing (ADON) acknowledged that if a resident had a physician's order to off-load heels, the order must be followed. On 09/08/21 at 9:30 AM, the Registered Nurse was interviewed regarding signing the TAR on the days that Resident #34 was observed with the heels rested directly on the mattress. He stated, I do not have a rationale to justify signing the TAR and that all nurses were to verify that a task was fully completed before signing the TAR/MAR. On 09/08/21 at 11:00 AM, the administrative staff provided the surveyor with an updated E-POC that included to Suspend/offload the heels as an FYI (for your information). The Regional Director of Nursing told the team that the nurse did not know how to access the E-POC. The ADON stated that the nurses were in-serviced on documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe environment to prevent the potential spread of infection by failing a.) to utilize the proper personal protective equipment (PPE) for residents on transmission-based precautions (TBP) for 4 of 5 (Resident #39, #210, #311, #29) resident reviewed for TBP, and b.) to adhere to infection control practices for hand hygiene to prevent the spread of infection during observation of a wound care treatment for 1 of 1 (Resident #29) reviewed. This deficient practice was evidenced by the following: A. 1.) On 08/30/21 at 9:24 AM, the facility informed the survey team that residents who were positive for COVID-19 were located on the first floor in a Red Zone area. The facility further stated the PPE required in the COVID-19 Red Zone were a reusable PPE gown, N95 mask with a surgical mask on top of it, and eye protection. On 08/30/21 at 10:08 AM, during tour, the surveyor observed the COVID-19 Red Zone. The surveyor observed Resident #311 in bed with signs posted outside of the room which included: Stop, Quarantine Droplet/Contact Precautions in addition to standard precautions only essential personnel should enter this room. Everyone Must: including visitors, doctors, and staff - clean hands when entering and exiting; gown prior to entering the room for any purpose, N95/KN95 respirator; eye protection (face shield or goggles); and gloves. Review of the admission Record (AR) revealed Resident #311 was admitted with diagnoses which included but were not limited to Chronic Obstructive Pulmonary Disease (disease characterized by persistent respiratory symptoms like progressive breathlessness and cough), and COVID-19. The admission Minimum Data Set (MDS) an assessment tool, dated 08/21/21, revealed the resident was cognitively impaired and had debility and cardiorespiratory conditions. The Resident Evaluation with COVID-19 Screen, dated 08/17/21, revealed the resident was positive for COVID-19. Resident #311's medical records included a Care Plan (CP), dated 08/17/21, which revealed a focus area of COVID-19 infection with interventions that included but were not limited to maintain droplet precautions. The Physician's Order Sheet (POS) revealed a physician order dated 08/17/21, for droplet precautions for COVID-19. On 08/30/21 at 12:17 PM, the surveyors observed a physician wearing a yellow reusable gown and a black cloth mask, and was not wearing eye protection. The physician started to unzip the barrier to enter the Red Zone. At that time, the surveyors interviewed her. The physician stated she had antibodies so she can't get it (COVID-19) and it doesn't bother her. The physician further stated she didn't need eye protection. The physician stated the Center for Disease Control and Prevention (CDC) would be concerned she could transmit it (COVID-19) but she believed she had a very low risk of transmission. The physician further stated she was sure the facility policy would want her to wear an N95 mask, that the residents who resided at the facility were vulnerable, and that she was at the facility daily. The physician walked away from the Red Zone. On 08/30/21 at 12:28 PM, the surveyors observed the same physician approach the Red Zone, unzip the barrier and enter the COVID-19 unit without donning (putting on) protective eye wear and without securing the back of her PPE gown. The MD was further observed not having a surgical mask over her N95 mask. The MD was in the COVID-19 secluded area for approximately two minutes-per surveyor time stamps. Upon exit, the MD stated that she was wearing her regular, personal use eyeglasses while in the COVID-19 area and had entered Resident #311's room to assess the resident. On 08/30/21 at 12:37 PM, the Assistant Director of Nursing Infection Preventionist (ADON/IP) stated that the physician just informed her about the error she made by wearing the incorrect PPE. The ADON/IP stated there was a barrier between the two areas of the COVID-19 unit which indicated where staff would don (put on) and doff (remove) PPE. The ADON/IP stated that prior to entry of the Red Zone, staff would need to wear an N95 mask, some form of eye protection, a reusable gown, and gloves prior to entering a resident's room. The ADON/IP further stated that personal eyeglasses would not be appropriate eye protection. The ADON/IP stated the purpose of wearing the eye protection was to prevent the spread of COVID-19, according to the CDC, to protect from respiratory droplets. The ADON/IP stated that the physician should have visited the non-ill residents first and then the COVID-19 positive residents should have been last. On 08/30/21 at 12:40 PM, the surveyor interviewed the physician. The physician acknowledged that she did not wear the proper mask or the proper goggles (eye protection) upon entering the COVID-19 unit. The physician stated she was never educated by the facility but had been on the COVID-19 unit before and she was knew what the Red Zone was. The physician stated she had made an error regarding her PPE. The facility provided, Employee Education Attendance Record, dated 03/22/21, topic of in-service: PPE use in Green, Yellow and Red Zones; Donning and Doffing (PPE), Handwashing and Cohorting, which revealed the physician had attended the educational in-service. The facility provided another Attendance Sheet, dated 08/04/21, topic infection control, cohort plan, screening, vaccination, PPE use (quarantine droplet/contact precautions), isolation (droplet/contact), [NAME] and Doff, and handwashing, which revealed the physician had attended the educational in-service. The educational material attached included but was not limited to the sign which hung on Resident #311's door and Donning PPE which included but was not limited to instruction to tie the back of the PPE gown. 2.) On 08/30/21 at 12:35 PM during the lunch observation, the surveyor observed an isolation caddy hanging on the door of Resident #39's room and contained PPE, such as isolation gowns and gloves. There was also a sign observed posted on the door which indicated that the resident in that room was on contact isolation and that gloves and gown should be worn while inside the room. On 08/30/21 at 12:40 PM, the surveyor observed a Certified Nursing Assistant (CNA) enter Resident #39's room to serve the resident a lunch tray. The CNA was observed without wearing an isolation gown, or gloves as instructed by the sign on the door. From outside of the resident's door, the surveyor observed the CNA, without wearing gloves or an isolation gown, proceeded to set up the resident's lunch tray and touch the resident's hands to wash them. The CNA was also in direct contact with the resident's environment, which included the bedside tray, at that time. When the CNA finished setting up the resident's tray, she then washed her hands and exited the room. The surveyor interviewed the CNA at that time and stated that Resident #39 required extensive assistance and had a diagnose of C-diff. She admitted that she did not wear an isolation gown or gloves while in the resident's and that she didn't have to because she was just serving the food tray. On 08/30/21 at 12:45 PM, the surveyor interviewed the primary care Registered Nurse (RN) who stated that Resident #39 was on contact isolation for the diagnoses of C-Diff (also known as Clostridioides difficile or C. difficile) and stated that no staff member should enter that room unless all PPE was applied, no exceptions. The surveyor reviewed the residents electronic medical records (EMR) which revealed the following information: The admission Record revealed that Resident #39 was admitted with the diagnoses of Enterocolitis clostridium difficile (bacterium that causes severe diarrhea) and colitis (an inflammation of the colon). The admission MDS, dated [DATE], reflected that Resident #39 was cognitively intact and required extensive assistance with all aspects of activities of daily living (ADL's). The Physician Order Sheet (POS) dated 08/16/21, reflected a physician's order for contact isolation for diagnoses of C-diff. The POS indicated that Resident #39 was on Vancomycin 50 mg/ml 2.5 ml every 6 hours for C-diff for 4 weeks. Medication end date was 09/12/21. The Care Plan dated 08/3/21, reflected that Resident #39 had an infection of the gastrointestinal tract which was C-diff and that the resident was on contact isolation. On 08/31/21 at 11:11 AM, the surveyor interviewed the Physical Therapy Assistant (PTA) who stated that Resident #39 was deconditioned and received skilled physical therapy (PT) for gait training and strengthening. The PTA added that the resident was on contact isolation precautions and had C-diff and that PPE (gown and gloves) were to be worn in Resident #39's room at all times. The PTA stated that PPE was to be worn while in the resident's room and when performing care to prevent the spread of infection. On 09/01/21 at 11:30 AM, the surveyor interviewed the ADON/IP who stated that staff was trained on the application of PPE for any resident that was on TBP and which included residents that had C-diff. She added that all staff should be wearing the appropriate PPE in resident rooms and there was no exception to this. She confirmed that all staff should be following the proper infection control procedures for residents on TBP to prevent the spread of infection. 3.) On 08/30/21 at 12:57 PM, the surveyor observed that there were signs posted in the hallway that identified the unit as the yellow zone and a sign posted on Resident #210's door that the resident was on quarantine for droplet/contact precautions. There was an isolation caddy hanging on the door which contained isolation gowns and gloves. The signs posted on the door indicated that before entering the room the staff was supposed to wear PPE which included, an isolation gown, gloves, eye protection (goggles and/or face shield) and an N95 mask. From outside of the resident's door, the surveyor observed a CNA in the resident's room wearing an N95 mask and protective eye wear. The surveyor observed the CNA set up the resident's food tray without wearing gloves or an isolation gown. The CNA then exited the resident's room and the surveyor interviewed the CNA. The CNA stated that she has been employed by the facility for the last 7 years and had been educated regarding PPE and transmission based precautions (TBP). She stated that the signs on the resident's door indicated that the resident was on isolation precautions and that prior to entry to the resident's room you were required to wear an N95 mask, isolation gown, gloves, and eye protection. The surveyor inquired to the CNA why she was not wearing an isolation gown or gloves while inside the resident's room. The CNA stated that she was only taking the resident to the bathroom and serving the resident lunch, and she did not need to wear a isolation gown or gloves. She also stated that she only had to wear the isolation gown and gloves when she provided direct resident care. The CNA further stated that she assisted the resident with toileting and stated she did not wear an isolation gown at that time. The surveyor reviewed Resident #210's medical record which revealed the following: The admission Record indicated that Resident #210 was admitted with the diagnoses which included but was not limited to: pneumonia unspecified organism, acute respiratory failure and malignant neoplasm of the lung. The admission MDS, dated [DATE], indicated that Resident #210 was cognitively intact and required limited assistance with all aspects of activities of daily living. The Physician Order Sheet, reflected an order dated 08/26/21, that Resident #210 was on droplet precautions every shift. The nursing progress note (NPN) dated 08/30/21 at 21:22 (9:21 PM), indicated that Resident #210 was swabbed for a COVID-19 antigen test and the results were negative. The Care Plan did not reflect that the resident was on droplet/contact precautions. On 08/31/21 at 9:29 AM, the surveyor conducted an interview with the CNA who stated that the facility provided her with education regarding residents on isolation in the Yellow Zone (Persons under investigation-PUI.) She stated that the residents on the yellow zone were resident's that were exposed to COVID-19 and might have been exposed while they were in the hospital. She stated that when an employee entered the resident's room that were PUI, that full PPE which included use of N95 mask, protective eye equipment, isolation gown and gloves were requires. She added that she also received education on handwashing which included washing hands for 20 seconds and stated that wearing PPE prevented the spread of infection. She admitted to not wearing the correct PPE such as gown and gloves in the resident's room on 08/30/21 and stated that she just forgot. On 08/31/21 at 10:35 AM, the surveyor interviewed the primary care Registered Nurse (RN) who had been employed in the facility for 4 years. The RN stated that the facility educated the staff on the following information: handwashing with competencies, PPE application and removal and to what PPE was to worn in different zones. The RN stated that the red zone was the COVID-19 positive unit, and that staff should wear full PPE such as isolation gown, gloves, goggles (eye protection), N95 mask. The RN stated that the yellow zone contained residents that were under investigation (PUI) for COVID-19 due to being unvaccinated or exposed from the hospital and that PPE worn in yellow zone should be full PPE such as N95, isolation gown, gloves, and eye protection. He confirmed that staff must adhere to the signs that are posted on the door as to what PPE was to be worn and there was no exception to the rule that he was aware of and stated Wearing the appropriate PPE helped prevent the spread of infection. On 08/31/21 at 10:57 AM, the surveyor interviewed a second CNA who had been employed for 3 years in the facility. The second CNA stated that when she worked on the yellow zone (PUI) the staff had to wear full PPE when entering the rooms and there were no exceptions. She confirmed that wearing full PPE prevented the spread of infection. On 08/31/21 at 11:22 AM, the surveyor interviewed the Occupational Therapist (OT) who provided occupational therapy to Resident #210. The OT explained that Resident #210 was in the yellow zone (PUI) because he/she was on a two-week quarantine from coming in from the hospital. The OT added that when a resident was on quarantine the resident stayed in the room and received OT services in the room. She also confirmed that staff was to wear N95, face shield, gloves, and gown while in the room to protect the staff and other residents from spreading the COVID-19 infection. On 09/01/21 at 10:43 AM, the surveyor interviewed the ADON/IP who stated that all staff were educated on different cohorts (Red, Green, Yellow), proper PPE that should be worn in those areas, and application and removal process for PPE. She confirmed that all staff should be wearing the appropriate PPE in all cohorts and that there was no reason that a staff member should breech infection control procedure by failing to wear the appropriate PPE in resident rooms that were on TPB. On 09/07/21 at 9:16 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM.) The RN/UM stated that when residents were on TPB, signs were posted on the doors to inform staff that the resident was on TPB and directed what PPE should be worn when inside those rooms. The RN/UM stated that wearing the appropriate PPE prevented the spread of infection. She further added that there would be no exception to wearing the appropriate PPE while inside resident rooms that were on TBP. B.) On 09/7/21 at 9:50 AM, the surveyor observed a Registered Nurse (RN) perform a wound care treatment to Resident #29's coccyx wound. Prior to the treatment observation, the surveyors observed the RN wash the table with a bleach disinfectant wipe and set up a clean field and placed the antibiotic solution bottle and dressings on the clean field. The surveyor observed the RN wash her hands for 20 seconds according to the CDC guidelines and applied a pair of non-sterile clean gloves. The RN then removed the resident's disposable brief. The resident was observed to have had a bowel movement (bm). The RN then proceeded to clean the bm while wearing the same gloves and then removed the packing (soiled wound dressing) from the resident's wound. After cleaning the bm and removing the packing from the resident's wound, and while wearing the same gloves (without removing the gloves and washing her hands) the RN proceeded to touch the antibiotic solution bottle, the clean dressings and proceeded to then clean the residents wound. The RN then removed the gloves, washed her hands, put on another pair of clean, non-sterile gloves and packed the wound using a clean sterile Q-tip applicator. The RN then applied a dressing over the wound, took her gloves off and then proceeded to wash her hands. At that time, the surveyor inquired to the RN regarding hand hygiene after cleaning bm. The RN stated she should have washed her hands after she cleaned the resident's bm and after she removed the wound packing from the residents wound. The RN stated that she should have removed her gloves, washed her hands and applied new gloves before touching the bottle of antibiotic solution and the clean dressings. The surveyor reviewed Resident #29's medical record which revealed the following: According to the admission Record, Resident #29 was admitted to the facility with diagnoses which included but was not limited to: nontraumatic intracerebral hemorrhage (brain bleed), aphasia (difficulty speaking or understanding language), and pressure ulcer of the sacral region. The annual MDS dated [DATE], indicated that Resident #29 was unable to speak and was not able to be interviewed. The MDS also indicated that the resident required complete care with all aspect of ADL's and had a stage three pressure ulcer on the sacral area. According to the Physician Order Sheet dated 06/30/21 there was a physician order to irrigate the wound at the coccyx region with triple antibiotic solution (Polymixin, Clindimycin and Gentamyxin) then pack with ¼ packing strip and cover with optifoam daily. On 09/8/21 at 1:00 PM the ADON/IP stated that the nurse should have removed her gloves after changing the resident and removing the soiled dressing and then washed her hands and applied new gloves. Policies: The facility provided, Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents policy, edited 01/27/21, included but was not limited to: residents will be identified and isolated to help control the spread of infection to other residents, staff and visitors and that dedicated units must be able to adhere to strict infection control practices. The facility provided, Isolation-Categories of Transmission-Based Precautions policy, reviewed 04/18/19, included but was not limited to: when a resident is placed on TBP, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC precaution (s), instructions for use of PPE, and/or instructions to see a nurse before entering the room; Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the environmental surfaces or resident-care items in the resident's environment. The policy reflected the following for contact isolation: -Staff and visitors will wear gloves (clean,nn-sterile) when entering the room. -While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal matter and wound drainage) -Gloves will be removed and hand hygiene will be performed before leaving the room. -staff and visitors will wear a disposable gown upon entering the room. Droplet Precautions may be implemented for an individual documented or suspected to be infected with micororganisms transmitted by droplets (large particle droplets(larger then 5 microns in size) that can be generated by the individual coughing, sneezing, talking, or the performance of procedures - Masks will be worn when entering the room, gloves, gown and goggles should be worn if there is a risk of spraying respiratory secretions. -Gloves, gown and goggles would be worn if there is risk of spraying respiratory secretions. The facility policy titled, Clean Dressing Change with a revised date of 04/29/2016, indicated that clean wound dressing change technique will be used as clinically appropriate and to promote wound healing; prevent infection; assess the healing process; and protect the wound from mechanical trauma. The policy specified that after removal of the soiled dressing that hand hygiene was to be performed according to the local requirements and then clean gloves were to be donned (applied). The facility policy titled, Handwashing/Hand Hygiene with an edited date of 04/12/21 indicated that the facility considers hand hygiene the primary means to prevent the spread of infection. The policy indicated that following information and implementation of the policy: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: -Before performing and any non-surgical invasive procedures. -Before handling clean or soiled dressings or gauze pads, ect. -After contact with a resident's intact skin. -After contact with blood and bodily fluids. -After handling use dressings, contaminated equipment. -before and after direct contact with residents. The Center for Disease Control (CDC) guidelines for hand hygiene if healthcare facilities indicated the following: The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: · Immediately before touching a patient · Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices · Before moving from work on a soiled body site to a clean body site on the same patient · After touching a patient or the patient ' s immediate environment · After contact with blood, body fluids, or contaminated surfaces · Immediately after glove removal Healthcare facilities should: · Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations · Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled · Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands. Reference: The Center for Disease Control (CDC); Guidelines for Hand Hygiene in Health-Care Setting, Vol [volume]. 51/No. RR-16 (dated 10/25/02). Recommendations included but were not limited to the following: 1. Indications for hand washing and hand antiseptics: A). When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-microbial soap and water or an antimicrobial soap and water. C). Decontaminate hands before having direct contact with the patient. I.) Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. J.) Decontaminate hands after removing gloves. NJAC 8:39-27.1 (a); NJAC 8:39-19.4 (a)(b)(c)(d)