Every finding on record at Alliance Care Rehabilitation and Nursing Center

Based on record review, interview, and policy review, the facility failed to ensure an allegation involving an injury of unknown origin was reported as required for one out of one sampled resident (Resident (R)12) reviewed for reporting requirements. Specifically, R12 was discovered on 06/14/26 with an unwitnessed head injury after being observed attempting to climb back into bed. The facility's failure to report an injury of unknown origin had the potential to delay regulatory review and intervention, which could allow abuse, neglect, mistreatment, or exploitation to go unidentified and unaddressed, placing residents at risk for further harm.Findings include: Review of R12's Face Sheet located in the Electronic Medical Record (EMR) under the Profile tab revealed an initial admission date of 09/22/25 and the most admission date of 04/21/26. With the following diagnoses: included traumatic subdural hemorrhage without loss of consciousness (subsequent encounter), Parkinson's disease, Type 2 diabetes mellitus, and dementia. Review of the Quarterly Minimum Data Set (MDS) assessment located in the EMR under the MDS tab with an Assessment Reference Date of 04/27/26 revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, indicating moderate cognitive impairment. Review of previous MDS assessments did not indicate a significant decline in cognition. Review of the Progress Notes located in the EMR under the Progress Note tab revealed that on 06/14/26, R12 sustained an unwitnessed injury in his/her room. Certified Nurse Aide (CNA)12 observed the resident attempting to climb back into bed and noted dried blood on the floor and on the left side of the resident's head. The facility's fall protocol was initiated, and the resident was transferred to the local hospital for evaluation. Review of the facility's internal investigation revealed the allegation that staff negligence caused the injury was determined to be unsubstantiated. The investigation documented a hematoma measuring approximately 4 cm x 3.6 cm on the left side of the resident's head and concluded the most likely scenario was an unwitnessed, self-initiated attempt by the resident to get out of bed and subsequently re-enter the bed independently, resulting in a loss of balance and head injury. The facility's root cause analysis identified the most probable cause as an unwitnessed attempt by the resident to independently re-enter bed during an unsupervised interval. Due to the unwitnessed nature of the event and the residents' inability to provide a reliable history, the exact sequence of events could not be determined. The investigation did not identify evidence that staff failed to provide required supervision or care. Interview and observation on 06/27/26 at 12:54 PM, observation of R12 revealed the resident seated in a wheelchair during mealtime receiving assistance with lunch. The resident was observed wearing non-slip socks. No environmental hazards were identified in the room. The bed was in the lowest position with a fall mat positioned beside the bed. R12 communicated primarily in Creole and required interpretation assistance from CNA12. Through interpretation, the resident indicated he had previously experienced falls, denied pain, and reported feeling safe in the facility. The residents did not demonstrate fear or hesitation toward CNA12. CNA12 was the staff who reported R12's injury and his account of the incident was consistent with facility documentation and the internal investigation findings. Interview on 06/30/26 at 03:52 PM, with Licensed Practical Nurse (LPN) 5 revealed he/she responded after being notified by CNA12. LPN5 stated that he/she did not witness the incident but observed the resident with an injury to the left side of the head while holding an ice pack. LPN5 reported the wound had already been cleaned and that the resident could not explain how the injury occurred. This surveyor inquired if the incident was considered a reportable incident LPN5 shared he/she did not feel that this incident was abused and needed to be reported. Interview on 06/30/26 at 02:45 PM with the Director of Nursing (DON) revealed the facility did not report the incident involving R12 the facility determined the unwitnessed fall, which resulted in a hematoma to the left side of the resident's head, was not related to abuse and therefore was not considered a reportable event. The DON stated the facility concluded the injury was the result of an unwitnessed fall and did not identify the incident as an injury of unknown origin requiring notification to the State Agency. Review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy dated 12/01/25 read, in pertinent part, . (The facility) will ensure that allegations/violations involving abuse, neglect, exploitation or mistreatment, including injuries from an unknown source .are reported immediately but not later than 2 hours after the injury has been reported. NJAC 8:39-9.4(f)

Based on observation, interview, record review, and policy review, the facility failed to ensure a medication error rate of less than five percent. A total of two errors occurred out of 25 opportunities for a medication error rate of 8%. This error affected one of six residents (Resident (R) 141) who were observed for medication administration. Findings include: Review of the Physician's Orders in the electronic medical record (EMR) under the Orders tab revealed R141 had an order for Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) dated 01/31/26. The instructions were to Instill 1 drop in left eye three times a day for Glaucoma Review of the physician's orders in the EMR under the Orders tab revealed Cosopt Ophthalmic Solution 2-0.5 % (Dorzolamide HCl-Timolol Maleate) Instill 1 drop in left eye two times a day for Glaucoma -Start Date 01/31/2026. Observation of Charge Nurse (CN) 4 on 06/30/26 at 8:38 AM revealed CN4 instilled one drop of Brimonidine tartrate ophthalmic solution 0.2% in R141's right eye and instilled one drop of Brimonidine tartrate ophthalmic solution 0.2% in R141's left eye. Observation of CN4 on 06/30/26 at 8:46 AM revealed CN4 instilled one drop of Cosopt Ophthalmic Solution 2-0.5 % in R141's right eye and instilled one drop of Cosopt Ophthalmic Solution 2-0.5 % in R141's left eye. Interview with CN4 on 06/30/26 at 9:15 AM revealed I put it in both eyes. Record review of the facility's policy, Eye Drops Administration, revealed .prior to administration.verify the provider's order. NJAC 8:39-29.2(d)

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

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

Based on interview, record review, and facility policy review, the facility failed to thoroughly investigate resident-to-resident abuse incidents for three residents (Residents (R)54, R210, and R411) reviewed for abuse out of a sample size of 31. This failure has the potential for further resident-to-resident abuse occurring and not being investigated so interventions can be put in place. Refer to F600 Findings include: 1. Review of the Census tab located in the electronic medical record (EMR) revealed Resident (R)411 was admitted to the facility on [DATE]. Review of the Med Diag [Medical Diagnoses] tab located in the EMR revealed R411 had diagnoses including dementia, bipolar disorder, and dementia with agitation. Review of the Census tab located in the EMR revealed R54 was admitted to the facility on [DATE].Review of the Med Diag tab located in the EMR revealed R54 had diagnoses including end-stage renal disease, vascular dementia, and previous stroke. Review of a Reportable Event Record/Report dated 03/27/23 and supplied by the Director of Nursing (DON) revealed staff had reported to them on 03/25/23 at around 1pm that on 03/24/23 at around 7pm R411 had been hit by another resident. The facility informed the appropriate authorities, reported the incident within the correct timeframe, and performed an investigation The facility questioned R54 at which time he admitted to pushing R411to get him [R411] out of his [R54] room and hitting him [R411] on the back. R54 stated he did not report anything to staff because R411 left the area. The facility educated R54 on reporting issues. X-rays were taken of R411 showing no injury. The facility investigation indicated the DON, law enforcement, the family, and the physician were notified. Skin checks and care plan updates were completed. The investigation stated staff education related to abuse/timeline abuse allegation was completed. The facility investigation did not contain staff education or resident interviews aside from R54 and R411. Review of the Alliance Incident List provided by the DON revealed R54 had not been involved in a resident-to-resident incident since 03/24/23. In an interview on 10/17/24 at 11:30 AM the DON stated the only investigation information related to the R54 and R411 incident was in the file supplied. The DON stated she started earlier this year, inherited the reported event, and has no more information to provide. She verified the investigation did not contain staff interviews, resident interviews, or staff education related to R54 hitting R411 in the back. 2. Review of R210's electronic medical record (EMR) revealed per the Census tab resident was admitted on [DATE] and discharged on [DATE]. Review of the facility's Incident list provided by the Regional Nurse indicated on 03/08/24 at 4:00PM, R210 was identified on the document with allegation of abuse. The investigative file provided by the Regional Nurse on 10/17/24 at 11:58 AM, contained a narrative that indicated that the alleged physical abuse occurred on 03/08/24 at approximately 3:00PM, in which R210 stated that the previous Social Service Director (SSD) pushed R210 out of his wheelchair and twisted his arm. The narrative indicated, Social Worker served patient with discharge notice. He became agitated and started screaming at her that he was not going to leave. Resident stood in between the elevator doors and continued to scream at staff members. Social worker was about eight feet from him and never made physical contact with the patient. The narrative contained a witness statement from the Director of Rehab who stated, .previous SSD was six to eight feet away from R210 and the previous SSD did not touch resident. The narrative indicated that Licensed Practical Nurse (LPN)1 witnessed the incident but the narrative nor the investigative file contained LPN1's statement. The investigative file did not include a statement from the previous SSD. Interview with the Regional Nurse on 10/17/24 11:58 AM, she confirmed that everything that was in the investigative file was all the information she could find for this allegation of abuse investigation. Review of the facility's policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident's Property dated 01/11/24 indicated, .Section V-Investigation 17. Upon receipt of the resident's accident/incident report .The investigation shall include a. statement from all parties involved including but limited to the resident involved, family members and other residents and staff . 46592 NJAC 8:39-9.4(f)

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

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

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

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

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

Based on observation, interview, and record review, it was determined that the facility failed to ensure: a.) there was no delay in implementing recommendations made by the consulting wound care Nurse Practitioner (NP), b.) care planned interventions to promote wound healing were implemented for a resident who was identified at risk for developing a pressure ulcer (PU) and developed a Stage 2 sacral PU, and c.) a thorough assessment for (PU) risk factors was completed. This deficient practice was identified for 1 of 5 residents reviewed (Resident #49) for PU, who developed a new PU on 10/27/22, and was evidenced by the following: On 11/07/22 at 10:15 AM, the surveyor toured the 300's Unit of the facility and observed Resident #49 in bed with the head of the bed elevated, facing the door, the feet rested on the mattress, and the eyes were closed. When inquired about the resident's status, the Certified Nursing Assistant (CNA) observed in the room stated, All he/she does is sleep all day. On 11/07/22 at 11:30 AM, the surveyor returned to the room and observed Resident #49 in bed, the same position as observed at 10:15 AM, facing the door and his/her eyes were closed. On 11/07/22 at 11:45 AM, the surveyor returned to the 300's Unit to observe the lunch meal. The lunch cart arrived on the floor at 11:50 AM. Resident #49 was not in the dining room. Resident #49 was observed still in bed and in the same position as the surveyor's prior two observations. The surveyor returned to the room at 12:05 PM, to find Resident #49 was still sleeping. The Unit Manager followed the surveyor into the room and stated that the resident could feed his/herself after being set up. However, Resident #49 was observed in bed and the lunch tray was left behind the door and inaccessible to the resident. On 11/07/22 at 12:15 PM, the surveyor observed Resident #49 in bed. His/her lunch tray was observed on the bedside table behind the door. The tray was untouched, and Resident #49 could not access the lunch tray. On 11/07/22 at 12:49 PM, the surveyor observed a CNA enter the room and then assisted Resident #49 with the lunch meal (approximately one-hour after the meal truck arrived on the unit). Resident #49 consumed 25% of the lunch meal. On 11/09/22 at 11:30 AM, the surveyor reviewed Resident #49's electronic medical record. According to the Admission Face Sheet, Resident #49 had diagnoses which included, but were not limited to, vascular dementia, unspecified severity, without behavioral disturbances, mood disturbance, visual disturbances, and anxiety. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed that Resident #49 was severely cognitively impaired for daily decision making as indicated by the score of 99 on the Brief Interview for Mental Status, and required assistance with most activities of daily living, including incontinence care and transfers. Section G of the MDS which addressed Functional Status, revealed that Resident #49 required supervision with setup help only for eating. Review of the Quarterly MDS dated [DATE], revealed that Resident #49 was assessed as required extensive assistance with one person assist for eating. Review of the Order Summary Report dated 11/18/22, reflected a Physician Order Sheet with an original date of 05/22/19, for Skin Assessment every shift every Monday and Thursday, To check for skin impairment document using the following codes: 0- no skin impairments 1-previous skin impairment present 2-Newly identified skin impairment. If you respond with a 2, further documentation in progress notes was required. Review of Resident #49's facility provided Care Plan revealed an undated Focus for potential skin breakdown secondary to impaired bed mobility. Two undated Goals revealed the Ressident will have care needs met as evidenced by no skin breakdown and the sacral wound will heal while at the facility. The interventions included: Keep skin clean and dry, sheets as wrinkle free as possible. Notify physician of any changes in skin integrity. Observe skin during bathing, turning, and incontinence care for early signs of breakdown. Pressure relieving devices on bed and wheelchair. Turn and reposition every 2 hours and as needed. Use proper positioning, transferring, and turning techniques to minimize skin injury due to friction and shear forces (There were no updated goals or indterventions related to the sacral wound identified on 10/27/22). Review of the Braden Scale for predicting Pressure Sores Risk dated 06/21/22, revealed that Resident #49 was assessed to be at high risk for pressure sores. Resident #49 had a score of 11 which indicated being at high risk. On 11/09/22 at 11:30 AM, the surveyor interviewed the CNA responsible for taking care of Resident #49 during the 7:00 AM to 3:00 PM shift. The CNA stated that Resident #49 had been unable to feed him/herself, and could not turn and reposition him/herself. The CNA stated that Resident #49 was totally dependent on staff and required extensive assistance with most activities of daily living. Resident #49 was unable to ambulate. The CNA further stated, Resident #49 had an open area to the sacrum cared for by the nurse. On 11/10/22 at 9:15 AM, the surveyor observed Resident #49 in bed laying on his/her backside. Resident #49 had remained in bed in the same position during the morning shift. At 11:30 AM, the surveyor asked the CNA to come to the room to check Resident #49. At that time the surveyor had observed that Resident #49's incontinent brief was saturated with urine and inquired to the CNA about the care she had provided to the resident. The CNA stated that she had not provided any care to the resident yet. On 11/14/22 at 9:02 AM, the surveyor observed Resident #49 in their room sitting in a wheelchair. Resident #49 was awake and more alert than previous observations. The surveyor remained on the unit at the nursing station, from 9:30 AM until 1:10 PM (over three hours) and observed Resident #49 remained in the dayroom sitting, in the wheelchair and had not been assisted with toileting or having their incontinent brief changed. On 11/14/22 at 12:52 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who cared for Resident #49. The LPN stated that Resident #49 had a wound which was cared for weekly by the Wound Care Specialist, and that the facility's staff would perform wound care daily. The LPN stated that documentation for wound care could be viewed on the computer under the Assessment Task. On 11/14/22 at 1:15 PM, the surveyor reviewed the electronic medical record and noted the following under the Assessment Task: Visit Report for Resident #49 on 10/27/22. Chief Complaint 10/27/22: left gluteal wound resolved. New Sacral stage 2 was noted. Diagnoses: Pressure Ulcer of sacral region, stage 2. Progress Note Details: Resident was seen today for evaluation and management of the sacral wound as requested by nursing staff. Staff reports that the wound was noted recently. Current treatment includes Silvadene cream and Peri guard. Wound Assessment: Wound #4 is a Partial Thickness Skin Tear and has received a status of Not Healed. Subsequent wound encounter measurements are 0.5 centimeters (cm) length, x 0.5 cm width x 0.1 cm depth, with an area of 0.25 square centimeter and a volume of 0.025 cubic centimeter. No tunneling has been noted . Integumentary system: Sacral ulcer noted. Wound Orders. Pressure Relief/Offloading Facility Pressure Ulcer Prevention Protocol. Pressure Redistribution Mattress per facility protocol. Wheelchair Pressure Redistribution Cushion per Facility Protocol. Cleanse wound with Normal Saline. Apply: Zinc, Cover wound with: keep open to air. Additional Orders: Plan of Care discussed with Facility Staff. The surveyor reviewed the electronic Progress Notes, there was no documentation prior to 10/27/22, regarding any redness or open area to the sacrum that had been identified by the facility. Visit Report for Resident #49 on 11/03/22. Progress Note Details: Resident was seen today for evaluation and management of the sacral wound as requested by nursing staff. Staff reports that the wound was noted recently. Current treatment includes Silvadene cream and Peri guard. Wound Assessment: Wound #4 Sacral is a stage 2 Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 4 cm length x 2 cm width x 0.1 cm depth, with an area of 8 square cm and a volume of 0.8 cubic cm. No tunneling has been noted . The peri wound skin exhibited: Maceration, Erythema. No signs of infection, weight 142 lbs [pounds]. Wound Orders: Pressure Relief/Offloading, Facility Pressure Ulcer Prevention Protocol. Pressure Redistribution Mattress per facility protocol. Wheelchair Pressure Redistribution Cushion per Facility Protocol. Other, Cleanse wound with Normal Saline. Apply: Silvadene to wound and Peri guard to surrounding area. Cover wound with dry protective dressing. Change Daily and as needed for soiling, saturation, or accidental removal. Additional Orders, Plan of Care discussed with Facility Staff. Visit Report for Resident #49 on 11/10/22. Progress Note Details: Resident was seen today for evaluation and management of the sacral wound as requested by nursing staff. Staff reports that the wound was noted recently. Current treatment includes Silvadene cream and Peri guard. Wound Assessment: Wound #4 Sacral is a Partial Thickness Skin Tear and has received a status of Not Healed. Subsequent wound encounter measurements are 4 cm length x 2 cm width x 0.1 cm depth, with an area of 8 square cm and a volume of 0.8 cubic cm. There is small amount of sero-sanguineous drainage noted which has no odor. Wound has 1-25% slough, 76-100% granulation; no eschar and no epitheliazation present. Wound Orders: Pressure Relief/Offloading, Facility Pressure Ulcer Prevention Protocol. Pressure Redistribution Mattress per facility protocol. Wheelchair Pressure Redistribution Cushion per Facility Protocol. Skin Tear, Cleanse wound with Normal Saline. Apply: Peri guard and Silvadene. Cover wound with dry protective dressing. Change Daily and as needed for soiling, saturation, or accidental removal. Additional Orders, Plan of Care discussed with Facility Staff. (There was no documentation in the electronic Progress notes to indicate that direct care staff were made aware of the action plan. There was no note in the dietary section to indicate that the dietitian was made aware of a new wound on 10/27/22. The care plan was not revised. The care plan did not include revised interventions to prevent further breakdown) On 11/15/22 at 11:47 AM, the surveyor observed that Resident #49, in the resident's room, and was out of the bed. An observation of the mattress revealed that the mattress was stained and without pressure, or elasticity. The mattress was observed as deflated in the middle. On 11/15/22 at 11:52 AM, the surveyor interviewed the Unit Manager (UM) who stated that Resident #49 had a pressure relief mattress. The surveyor accompanied the UM to the room where both observed the mattress completely deflated in the middle. The UM confirmed that the mattress was deflated and could not provide pressure relief. The UM stated that the mattress was not suitable for a resident who had a pressure ulcer injury. The UM stated that direct care staff did not report that the mattress needed to be changed. On 11/15/22 at 1:25 PM, the surveyor interviewed the UM regarding Resident #49 sitting in the chair all day. The UM stated she attempted to shift the resident today. However, the surveyor observed Resident #49 sitting in the wheelchair from 8:55 AM-1:30 PM. Resident #49 had not been escorted to the room to be changed for over four hours, which included, before the lunch meal. The surveyor asked to view the Task tab on the computer where direct care staff documented the care provided, no documentation was available for review (The Care Plan did not provide interventions related to the amount of time sitting was appropriate for Resident #49). The Visit Report for Resident #49, dated 11/17/22, revealed: Progress Note Details: Resident was seen today for evaluation and management of the sacral wound as requested by nursing staff. Staff reports that the wound was noted recently. Current topical treatment includes Silvadene cream and Peri guard. Wound Assessment: Wound #4 Sacral is a stage 2 Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 6.5 cm length x 5.5 cm width x 0.2 cm depth, with an area of 37.75 square cm and a volume of 7.15 cubic cm. No tunneling has been noted . There is a small amount of sero-sanguineous drainage noted, no odor. No slough, no eschar . The peri wound skin texture is normal (The wound increased in size from the 11/10/22 report), Wound Orders: Pressure Relief/Offloading Facility Pressure Ulcer Prevention Protocol. Pressure Redistribution Mattress per facility protocol. Wheelchair Pressure Redistribution Cushion per Facility Protocol. Other, Cleanse wound with Normal Saline. Apply: Zinc, Cover wound with keep open to air. Change Daily and as needed for soiling, saturation, or accidental removal. Additional Orders, Plan of Care discussed with Facility Staff. Treatment Goals: Staging Care. Staging of care will be required due to poor wound progression. Short Term Goals: Patient /Caregiver will have understanding to care for wound and will improve and maintain without exacerbation or deterioration. The wound base will be 25% cleaner. Long Term Goals: Patient /Caregiver will understand need for continued care when health problems are identified. A Nursing Progress Note dated 11/17/2022 at 10:56 read: Awake, alert and responsive, confused. Resident was seen by wound team today. Wound change from IAD (Incontinence Associated Dermatitis) to pressure stage 2. New recommendation were to change treatment to zinc oxide cream every shift, LAL (low air loss) mattress. NP (Nurse Practitioner) informed recommendation approved and carried out. On 11/18/22 at 11:10 AM, the surveyor observed the LPN performed wound care to the sacral wound. Scattered wound noted on the sacral and coccyx area. During the wound care, the LPN acknowledged that the wound had worsened. A new open area was noted on the right hip and the LPN cleansed the new open area and did not measure the wound. On 11/18/22 at 11:59 AM, the surveyor interviewed the LPN who performed the wound care. The LPN stated that she had been off for the weekend. She performed wound care on 11/14/22, and noticed that the wound had worsened. She further stated that she informed the Unit Manager of the wound condition on 11/14/22. The LPN stated that she also had a conversation with the CNA who cared for the resident and the CNA stated that she did not report the wound condition because she thought that other staff were aware of the condition of the wound since wound care were being done daily. The LPN stated that she continued with the same treatment orders. She attempted to notify the Nurse Practitioner, but she was unable to leave a message. On 11/18/22 at 12:11 PM, the surveyor asked the LPN for documentation of the wound observation she made on 11/14/22, during wound care. The LPN stated that she did not document her findings. When asked if she informed the physician, revised the care plan, or checked the mattress condition, the LPN stated that she did not (The UM was aware and verified the condition of the mattress on 11/16/22, and failed to notify the physician and address the concern with the Wound Care Coordinator. Resident #49 remained on the worn and deflated mattress until 11/18/22). On 11/18/22 at 12:25 PM, the surveyor reviewed the electronic Progress Notes with the UM and the LPN assigned to the 300's unit high side and could not find any documentation regarding the wound. Although aware of a change in condition since 11/14/22, both the LPN and the UM failed to notify the physician, involve the dietitian, or implement interventions to promote wound healing. The skin assessment signed by the LPN on 11/14/22 did not reflect that the wound had increased in size. The care plan had not been revised. On 11/18/22 at 12:30 PM, the UM confirmed that she was made aware of the change in the wound condition on 11/14/22, by the LPN. She could not comment on the interventions implemented after she was informed. The UM entered a note in the clinical record that she had informed all involved parties in the resident's care on 11/18/22. On 11/18/22 at 1:15 PM, the LPN stated that she should have documented her findings. The LPN stated, I reported the condition of the wound to the Unit Manager. I continued the treatment since I knew that Resident #49 was going to be seen on 11/17/22, by the Wound Care Specialist. On 11/19/22 at 10:30 AM, the surveyor reviewed again the electronic clinical record and there was no entry from the dietitian regarding the wound and the weight loss. On 11/19/22 at 15:44 PM (3:44 PM), the following entry was noted and revealed: Nutrition Note (SPN) Note Text: Wound note of 11/17/22; Resident #49 sacral pressure injury is a Stage II 6.5 x 6.5 x 0.2. He/she is receiving MVI/min [multi vitamin with minerals] and ascorbic acid [vitamin C] daily to promote wound healing. There are no recent labs to assess. RD [Dietitian] will recommend for CBC/CMP/pre-alb [complete blood count/comprehensive metabolic profile/ pre-albumin]. CBW [current body weight] 135#-BMI [body mass index] 26.4-wnr [within normal range] for age. He/she has gained 1# [pound] x 1 month. He/she has had no significant weight changes x 1-3-6 months although he/she is having a gradual weight loss. He/she continues a Regular diet with mechanical soft consistency, consuming approximately 50-75% of meals served. He/she does need assistance from staff during meals. Will assess further once lab results are available. On 11/21/22 at 8:42 AM, the surveyor interviewed the dietitian who confirmed that she was not made aware of Resident #49's wound until 11/18/22. She stated that she added a note in the electronic medical record and will formulate a plan. On 11/21/22 at 11:45 AM, the surveyor asked the dietitian if she would assist to obtain Resident #49's weight. The dietitian accompanied the surveyor to the 300's Unit and assisted staff with the weight. Resident 49's weight was 128.5 in the presence of the UM, Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The last weight taken on 11/01/22 was 134.5. This was a six pound (4% weight loss) in less than one month. The facility was not aware that Resident #49 decreased intake and had been unable to feed him/herself, was losing weight, and did not notify the Dietitian. On 11/22/22 at 9:21 AM, the surveyor interviewed the ADON regarding his role as the Wound Care Coordinator. The ADON stated he had just taken on the role and had not assessed fully what needed to be done. The surveyor then asked the ADON to elaborate on the skin assessment performed weekly by the facility. The ADON stated that Skin Assessment entailed checking the whole body on shower day. Resident prone to pressure sore should have random skin check. Findings should be reported to the Wound Care Coordinator and discussed with the Wound Care Specialist. The ADON added he had not had the opportunity to review yet the recommendations dated 11/10/22, and 11/17/22, regarding Resident #49's wound. On 11/22/22 at 9:33 AM, the surveyor accompanied the ADON to Resident #49's room, where both observed Resident #49 in bed, the feet rested directly on the mattress. Resident #49 had no heel protectors on. Resident #49's feet were dry and scaly. The right heel was discolored and reddened. The ADON stated that Resident #49 should have had heel protectors on. Resident #49 had an order to offload the heels dated 07/22. The Care Plan failed to address the recommendation to offload the heels. On 11/16/22, Resident #49 was referred to Occupational Therapy for evaluation. The Occupational Therapy notes dated 11/23/22, documented the following: Resident #49 assessed for her/his ability to feed herself/himself. Due to severe limitation in shoulder ROM (Range of Motion ) left hand contracture, generalized weakness and severe cognitive impairment /impaired following commands, Resident #49 requires hand over hand assist for hand to mouth movements, Resident #49 can spontaneously grasp utensils and cup at times, but other times requires hand over hand assist. Due to severe deficit in self-feeding, Resident #49 requires 100% staff assist for meals. Allow Resident #49 to participate as much as she can and allow him/her to spontaneously hold utensils/cup if he/she desires. Risk Factors: Due to the documented physical impairment and associated functional deficits, Resident #49 is at risk for : Compromised health. Resident #49 was not assessed for a change in condition. The facility did not initiate a significant change although Resident #49 had a gradual weight loss started 08/08/22, and develop a new pressure ulcer on 10/27/22, and had some functional deficits as reported by the direct care staff. Resident #49's care plan was not revised to include interventions such as, limited sitting while out of bed, intake monitoring during meals, and frequent incontinence care to prevent skin breakdown and promote healing of the sacral wound. Staff was not in- serviced to reflect understanding of the policy regarding change in condition and preventive measures to promote wound healing. Resident #49 was not provided with a Low Air Loss mattress until 11/18/22. The UM was aware and confirmed on 11/16/22, that the mattress was deflated in the middle and was not suitable for a resident with a stage 2 pressure ulcer. The Wound Care Coordinator was not aware of the recommendations made by the Wound Care Specialist. There was no evidence that the IDCP (Interdisciplinary Care Team) discussed measures needed to be implemented since the sacral wound was identified on 10/27/22, to ensure that preventive measures were in place. The dietitian was not informed of the pressure Ulcer Injury until 11/18/22. The facility did not identify the causal factor and implement meaningful interventions to prevent the pressure ulcer from worsening, and the above concerns was discussed with the facility on 11/22/22 at 2:00 PM. On 11/23/22 at 9:42 AM, the DON and the Regional Nurse both stated there was a discrepancy in the wound documentation. They both acknowledged there was no system in place to review wound care. They stated they would provide the wound tracking form with their investigation of the wound. On 11/23/22 at 11:33 AM, the DON provided the following report: She acknowledged that a stage 2 sacral wound was identified on 10/27/22, which measured 0.5 cm length x 0.5 cm width and 0.1 cm depth. 11/03/22, Sacral stage 2 had increased in size related to maceration (skin is broken down by moisture) and Erythema (skin reddening) on the peri wound. 11/10/22, Sacral stage wound increased in size but continue to have maceration and Erythema on the peri wound and documented Resident is incontinent. The document further indicated that Resident #49 was assessed by Occupational Therapy on 11/16/22, and it was determined that Resident #49 needed extensive assistance of one for feeding. The resident was weighed yesterday, and recent weight loss was identified. The dietitian was made aware and new interventions were put in place. An Interdisciplinary Team meeting will be scheduled for the resident to ensure all interventions are in place to prevent further weight loss and deterioration of the wound. As of 10/27/22 the new ADON was in charge of the wound care tracking at the facility, and the ADON will ensure all policies and procedures would be followed. According to the DON, Resident #49 had a new stage 2 wound to the sacrum that was not identified by the nurse who had been provided daily wound care. She admitted that there was no documentation in the clinical record that the Physician was made aware of the wound and no documentation of any redness before the wound was identified by the Wound Care Specialist. The Wound Care Specialist indicated in the Progress Notes of 10/27/22, that staff reports the wound was noted recently. The facility could not provide documentation regarding when the wound was identified and what interventions were implemented. A review of the facility's policy titled, Skin and Wound Management/Skin Risk assessment dated [DATE], last revised 07/21/22, revealed: Policy: A skin risk assessment will be conducted on each resident to identify the resident's level and nature of risk for developing pressure ulcers. This assessment will be done on admission, readmission then quarterly, annually, significant changes in condition and as deemed appropriately. Purpose: To identify the individual residents at risk for developing pressure ulcers; as well as identifying and evaluating risk factors and changes in the resident's condition, in an attempt to stabilize, reduce or remove underlying factors that place the resident at risk. Procedure: Licensed Nurse: Assesses the resident's risk for impaired Skin Integrity, using the Braden Scale Pressure Ulcer Risk Assessment at the time of admission, readmission then quarterly assessment and comprehensive annual assessment, significant change in condition or as deemed appropriate. Implement preventative measures and or actual measures determined to be appropriate for each individual resident. Dietitian: will assess resident to evaluate caloric needs and determine if supplements or dietary changes are indicated. will communicate recommendations to physician. Nurse Manager: Oversees the assessment process for all new residents ensuring the care plan and interventions address the risk factors and skin care needs taking into consideration causes and potentialities. The facility's Policy titled, Change in condition dated 10/16/20, with a revised date of 06/07/22, revealed, It is the facility policy to identify and communicate changes in condition to the physician and other team members to implement interventions to prevent further deterioration and possibly prevent hospitalization . Purpose: To provide prompt and appropriate interventions to promote resident's health and well-being and positive outcomes. General Information: All staff are encouraged to promptly report changes in condition to the charge nurse, supervisor or DON/ADON or designee immediately. A complete assessment will be conducted of all systems. The nurse will contact the physician or Nurse Practitioner, discuss findings, and formulate a plan. Entries will be made each shift to monitor condition. The resident will be placed on the 24 hours report. The resident will be monitored until condition significantly improved. The facility failed to follow their own policies. The facility did not notify the physician, did not reassess the resident, revise the care plan, the resident, involved the Interdisciplinary Team to develop interventions to prevent the pressure Ulcer Injury from worsening. A review of the Comprehensive Care Planning Policy, Effective 05/29/20, revealed, it is the policy of the [facility name] to develop and implement a comprehensive person-centered care plan to each resident consistent with rights set forth .that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Procedure: Interdisciplinary team, 4. Updated care plan as needed with changes in treatment, needs, and condition. NJAC 8:39-27.1 (a)

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

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

Complaint #NJ00158982 Refer to F882 Based on observations, interviews, medical record review, and review of other facility documentation, it was determined that the facility failed to minimize the spread of infection during a Candida Auris (C. Auris, an emerging fungus that presents a serious global health threat) Outbreak by failing to ensure: a) staff donned (put on) the required Personal Protective Equipment (PPE, garments or equipment used to protect the body from infection) prior to room entry of residents on transmission based precautions (isolation protocol) and performed hand hygiene when indicated b) housekeeping staff utilized cleaning products that were effective against C. Auris c) maintained ongoing communication with the on-site dialysis (kidney treatment) center regarding the status of residents who required transmission based precautions (isolation) during dialysis treatment due to C. Auris d) the facility assessment was updated to include staff roles and responsibilities related to the care of residents diagnosed with C. Auris at the facility. This deficient practice was identified for (three) 3 of 5 (five) residents (Residents #113, #115 and an unsampled resident) reviewed for transmission based precautions on 1 of 1 nursing unit, First Floor Ventilator and Tracheostomy Unit, in accordance with acceptable standards of infection control practice and was evidenced by the following: Surveyor A 1. On 11/10/22 at 10:53 AM, the surveyor observed Resident #113 lying in bed talking on the telephone. There was signage on the outside of the resident's door which indicated that the resident was on transmission based precautions (TBP) and droplet precautions were in place and instructed that everyone who entered must: Clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, remove face protection before room exit. A second sign cautioned that Contact Precautions were also in place and everyone must: Clean their hands, including before and after entering the room. It further instructed providers and staff to: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . On 11/10/22 at 12:16 PM, the surveyor observed the Certified Nursing Assistant (CNA) who wore only a surgical mask and did not perform hand hygiene with the alcohol based hand rub (ABHR) that was present on top of the fully stocked PPE cart that was outside of the resident's room as she prepared to don her PPE. The CNA donned a gown and did not don gloves prior to entering Resident #113's room before she picked up the resident's meal tray with her bare hands and carried it out to the food cart that was outside of the resident's room. The CNA then proceeded to doff her gown and surgical mask and placed it in the trash can inside the resident's room. The CNA came out of the resident's room, obtained a new surgical mask which she donned without first performing hand hygiene. When interviewed, the CNA stated that Resident #113 had C. Auris and was on contact isolation. The CNA stated that gloves, eye protection and hand hygiene were not required if direct care was not provided to the resident. The CNA acknowledged that she failed to perform hand hygiene after she doffed her gown and surgical mask and exited the resident's room. The CNA stated that she also failed to perform hand hygiene before she obtained a new surgical mask from the PPE cart and donned it, because the surveyor wanted to speak with her. The CNA stated that she received an in-service related to contact precautions which required that she must wear full PPE as indicated on the signage to enter the room, doff the PPE in the room and wash her hands when she came out of the room. Review of Resident #113's Admission Record, an admission summary, revealed that the resident was admitted to the facility in May of 2022 with diagnoses which included but were not limited to: Candidiasis (fungal infection caused by Candida), Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterium with antibiotic resistance), acute respiratory failure, tracheostomy and chronic kidney disease. Review of Resident #113's quarterly Minimum Data Set (MDS), an assessment tool dated 08/12/22, revealed that the resident's Brief Interview for Mental Status (BIMS) score was 13/15, which indicated that the resident was cognitively intact. Further review of the assessment revealed that the resident required total dependence of two persons for bed mobility and transfers to the wheelchair and required limited assistance of one person for eating. Active diagnoses included Candidiasis, unspecified. On 11/10/22 at 12:33 PM, the surveyor interviewed the Assistant Director of Nursing Uncertified Appointed Infection Preventionist (ADONUAIP) in the presence of the survey team, who stated that the staff on the Ventilator Unit were in-serviced and informed that a gown, N95 mask (respirator that filters 95% of particles), gloves and face shield were required to be worn to enter resident rooms who had C. Auris and hand hygiene was required to be performed both before entry and prior to exiting the room. The ADONUAIP stated that ABHR was preferred over handwashing. When the surveyor informed the ADONUAIP of the observation of the CNA who entered Resident #113's room she stated, That was a big No, No for the aides to go into the isolation rooms without gloves on and a failure to perform hand hygiene. The ADONUAIP stated, She did not know if the staff did not understand or if they just did not want to listen to us. The ADONUAIP explained that an N95 was required to enter the resident's room, though she did not know why, as that was what she had learned. The ADONUAIP further stated, staff may wear a surgical mask in the hallway and when they entered the resident's room they must then wear full PPE as directed to prevent the further spread of infection. On 11/10/22 at 10:23 AM, the surveyor interviewed the Director of Respiratory Therapy ([NAME]) who stated that Resident #115 was on both Contact and Droplet Precautions due to C. Auris and indicated that full PPE which included an N95 respirator mask was required in order to enter the resident's room. There was signage posted on the outside of the resident's room which provided full instruction for PPE usage and hand hygiene. At 10:25 AM, the surveyor entered Resident #115's room and observed that the resident was ventilator dependent and was unable to speak due to tracheostomy. The resident was able to make his/her needs known by silently mouthing words. Review of Resident #115's Admission Record revealed that the resident was admitted to the facility in June of 2022 with diagnoses which included but were not limited to: Acute respiratory failure, chronic obstructive pulmonary disease (condition involving constriction of the airways), pseudomonas (gram-negative bacteria), resistance to multiple antibiotics, ventilator dependence, and dependence on renal dialysis. Review of Resident #115's quarterly MDS, dated [DATE], revealed that the resident's BIMS score was 0/15, which indicated that the resident was severely, cognitively impaired. Further review of the MDS revealed that the resident required total dependence of two persons for bed mobility and transfers. Active diagnoses included Candidiasis, and resistance to multiple antibiotics. On 11/15/22 at 12:27 PM, the surveyor observed the Housekeeper (HK) outside of Resident #115's room. When interviewed, the HK stated she had worked at the facility for one month and filled in for the full-time HK who was off that day and did not normally work on the unit. The HK stated that she used Clorox bleach wipes to wipe the mop and broom handles and used Virex II to wipe down all other room surfaces, and Stride Citrus to mop the floors. On 11/15/22 at 12:42 PM, the surveyor observed the HK as she prepared to enter Resident #115's room. When interviewed, she stated that a face mask, goggles, gown and gloves were required to enter the resident's room. The HK then proceeded to don gloves, then donned a gown and left the gown untied in the back and the arms of the gown hung down past her gloved hands. The HK then doffed (removed) her surgical mask and donned an N95 mask and face shield. The HK entered the resident's room and emptied the resident's trash and swept up a glove that was on the resident's floor into a dust pan. The HK then doffed her gown and gloves and lifted the lid of the trash can with her bare hands in order to dispose of her gown and gloves. The HK then doffed her N95 mask and lifted the lid of the trash can a second time with her bare hands and disposed of the N95 mask. The CNA then came out of the room and failed to perform hand hygiene before she accessed the PPE bin and obtained a new surgical mask which she donned beneath her face shield. When interviewed, the HK stated that she forgot to tie her gown in the back and was unsure of the order that she was supposed to don her PPE and whether her gloves or gown were to be donned first. The HK stated that she put her gown on first which left the gown to hang down over her hands. The HK stated that when she touched the lid to the trash can with her bare hands and then doffed her N95 mask without first performing hand hygiene there was a chance that she was exposed to germs. When asked why she did not use the ABHR that was on top of the PPE bin the HK stated that she normally carried her own personal hand sanitizer in her pocket but she forgot it today. The surveyor noted that there was a reference guide posted on the wall outside of the room which provided instruction for the sequence to don PPE. The HK then proceeded to review the signage that she reportedly had not noticed prior to the observation. On 11/15/22 at 1:16 PM, the surveyor interviewed the Manager of Housekeeping ([NAME]) in the presence of the survey team. The [NAME] stated that the facility used Clorox Bleach Wipes and Virex II for cleaning. The [NAME] confirmed that Virex II did not kill C. Auris, but that bleach did. The [NAME] stated that bleach wipes were required to clean room surfaces and diluted bleach was required to be used to mop the floors in order to be effective against C. Auris. The [NAME] stated that staff were required to wear PPE according to the signage posted outside of the resident's room. The [NAME] stated that if the HK donned her gloves first the band of the gown would be opened. The [NAME] stated that if you donned the gown first and then the gloves, the band of the gown would remain closed to protect clothing. The [NAME] stated that the gown should have been tied in the back so that nothing gets on your clothes. The [NAME] stated if the gown were left open, that would be an infection control problem. The [NAME] stated it was also an infection control problem if the HK did not perform hand hygiene after she doffed her PPE, touched the trash can lid and before she donned a new surgical mask. The [NAME] stated that the HK staff should not have used her own hand sanitizer as staff were required to use the hand sanitizer that was provided on their housekeeping carts. The [NAME] explained that the HK staff did an AM tour, spot cleaned the floors and cleaned the C. Auris rooms last after their AM tour, so the room was already cleaned this morning prior to the surveyor's observation. The [NAME] stated that she would provide the HK with an in-service right now because they should not have cleaned Candida Auris with Virex II or Stride Citrus and should have donned/doffed PPE correctly to prevent the further spread of C. Auris. 2. On 11/10/22 at 11:15 AM, the surveyor reviewed both Resident #113's and Resident #115's Dialysis Communication Binders which contained Dialysis Communication Logs (DCL) that were dated 11/2/22, 11/4/22, 11/7/22, and 11/9/22 and failed to contain documented evidence that the residents required ongoing transmission based precautions due to a diagnosis C. Auris. On 11/14/22 at 11:50 AM, the surveyor reviewed both Resident #113's and Resident #115's DCLs and noted that on 11/11/22, the DCL failed to inform the receiving dialysis center that both residents had C. Auris and required transmission based precautions. On 11/14/22 at 12:36 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to the First Floor Ventilator/Tracheostomy Unit regarding Resident #113's and Resident #115's DCL. The LPN stated that the dialysis center was informed verbally in report that the residents were positive for C. Auris prior to dialysis treatment. The LPN stated that the dialysis center had a list of residents who were positive for C. Auris and also had access to the facility's electronic health record (EHR). The LPN stated that the DCLs were completed by the sending facility nurse and communicated the resident's medications and vital signs but maintained that the diagnosis of C. Auris was not required to be documented on the forms because it was in the EHR. The LPN stated that she did not document that she provided verbal report to the receiving dialysis center in the nursing progress notes contained within the EHR. On 11/14/22 at 1:02 PM, the surveyor interviewed the ADONUAIP in the presence of the survey team, who reported that she had filled in for the facility Infection Preventionist Nurse who was on vacation since the middle of October and was unsure when she would return. The ADONUAIP stated that before a resident was scheduled for dialysis treatment, the diagnosis of C. Auris was communicated so that staff were fully aware. The ADONUAIP explained that nursing called the dialysis center over the phone and she would have expected that nursing would have documented a diagnoses of C. Auris on the DCLs as well. The ADONUAIP stated that she was unsure if the dialysis center had access to the facility's EHR. The surveyor showed the ADONUAIP both Resident #113's and Resident #115's DCLs and the ADONUAIP stated that she did not see that C. Auris status written on the forms as required. The ADONUAIP stated that, We are going to start doing that. The ADONUAIP stated that she would emphasize that this was a C. Auris positive resident. The ADONUAIP provided the surveyor with the contact information for the Nurse Manager (NM) at the dialysis center. The surveyor phoned the NM at 1:20 PM, and provided direct contact information on the voicemail to return the surveyor's phone call. On 11/16/22 at 12:13 PM, the surveyor interviewed the NM at the on-site, non-affiliated dialysis center, who stated that there was an endorsement Dialysis Communication Log that listed several residents who were positive for C. Auris. The NM stated that the LPN from the long term care facility came to the dialysis center today and informed her verbally that Resident #113 was positive for C. Auris. The NM stated that the dialysis was not notified via the DCLs and was not made aware prior to today. The NM stated that she learned of other positive cases of C. Auris at the facility via review of the hospital discharge summary. The NM maintained that Resident #113 was the only resident who was positive for C. Auris that the dialysis center was unaware of. The NM stated that the sending facility nurse should have told the dialysis staff the resident had C. Auris. The NM further stated that the dialysis nurses wore a gown, face shield, mask and gloves during the care of the resident who received dialysis treatments. The NM further stated that since the resident was not on isolation to our knowledge, the nurse would have worn the same gown to treat all assigned residents and only changed his/her gloves between residents. The NM stated that if isolation was required the resident would have been put on the dialysis machine at the end of the room and double disinfected and cleaned the dialysis machines and chairs more thoroughly with bleach. The NM stated that the dialysis center was unable to assign designated staff due to short staffing. The NM stated that the nursing staff were also told not to wear the same gown to care for other residents that they have worn to care for a resident known to have C. Auris to prevent transmission. The surveyor asked the NM to provide a list of all residents at the long-term care facility who received dialysis at the center and were known to have a diagnoses of C. Auris. 11/16/22 12:49 PM, the surveyor interviewed the LPN who stated that she did not speak to anyone at the dialysis center about Resident #113. The LPN stated that she was informed by the facility after she spoke with the surveyor, that the diagnoses of C. Auris was required to have been documented on the DCLs. The LPN maintained that the dialysis center had the same EHR and the dialysis center staff should have reviewed the computer system to confirm that the resident did not have C. Auris prior to treatments. The LPN further stated that she informed the NM of Resident #113's diagnoses of C. Auris along with several others. The surveyor noted that Resident #115 was not identified in the list that the LPN provided orally to the surveyor. The LPN stated that, Some of the residents at the facility were not admitted with a confirmed diagnoses of C. Auris and developed it here because we test the residents monthly. The LPN stated that if she had a new resident, she would not jump to provide care and would instead review the resident's history first to see if the resident had an infection or not. The LPN stated that we do not document that the resident had C. Auris on the DCLs and if it were not documented, it was not done. The LPN further stated that the spread of infection were a problem if the dialysis center was not informed of the resident's diagnoses of C. Auris prior to treatment due to the need to isolate the resident. The LPN stated that the NM asked her today which residents had C. Auris, and she insisted that they did not have a conversation about it. On 11/16/22 at 1:29 PM, two surveyors went to the dialysis center and interviewed the NM who stated that she was unable to demonstrate her view of the facility's EHR, because it was not working right now. The NM instead referred the surveyors to the dialysis Renal Dietician (RD) who demonstrated the EHR view for Resident #113's EHR and stated that they probably forgot to write it on the Dialysis Communication Record. The RD reviewed the Progress Notes and Medical Diagnoses sections with the surveyors. The NM stated that someone should have endorsed the resident's diagnoses of C. Auris to her. The NM stated, I do not remember seeing isolation in the EHR. The RD replied, That is because you do not have access to the EHR. The NM then proceeded to provide the surveyor with a list of residents at the facility for whom she had a confirmed diagnoses of C. Auris that was provided by the facility LPN. The surveyor reviewed the list and noted that Resident #115 was not on the list. When the surveyor asked why the resident was not on the list she stated. Nobody told us that Resident #115 had C. Auris. The NM stated when we received the list today, resident #115 had already had a treatment done earlier that morning. The NM confirmed that there was only one isolation room in the dialysis center and it was not equipped for ventilator residents. So the ventilator residents who have isolation needs were placed at the end of the dialysis unit. On 11/16/22 at 1:39 PM, the NM took the two surveyors to the dialysis unit and the surveyors observed that Resident #113 was in the only available isolation room. The NM stated that the nurse who was assigned to her was at lunch and was unable to be interviewed. The NM stated that the dialysis nurses only changed their gowns between residents if a resident was known to be on isolation. Otherwise the same gown was worn between residents. The NM stated that a 1:100 bleach concentration was used to disinfect the dialysis machines (filters waste products from blood which are passed into the dialysate fluid) and chairs for non-isolation residents and a 1:10 bleach concentration was used to disinfect the dialysis machines and chairs for known isolation residents. On 11/16/17 at 1:47 PM, in a later interview with the NM she stated, Moving forward Resident #115 would now need to be isolated now that we know the resident has C. Auris. On 11/16/22 at 3:06 PM, the surveyor interviewed the LNHA who stated that the facility liaison provided the dialysis center NM with an electronic referral prior to admission for approval of hemodialysis insurance coverage etc. The LNHA stated that the clinical paper was reviewed by the facility and it was determined that the facility had indeed informed the facility prior to acceptance that Resident #113 did have a diagnoses of C. Auris. The LNHA also maintained that the NM also had access to the EHR and could have reviewed the system and determined that the resident was on isolation precautions. The LNHA stated that she could not speak to why the facility nurses had not documented that Resident #113 and #115 had a diagnoses of C. Auris on their DCLs to maintain ongoing communication with the dialysis center as required. The LNHA stated that we told them verbally. The LNHA acknowledged that, If you did not document it, you did not do it. The LNHA stated that the NM did not tell her that she was not aware that Resident #115 had C. Auris. On 11/16/22 at 3:34 PM, the LNHA and the DON were called to the conference room to join the survey team and were informed of the findings that were a public health concern related to the critical information regarding C. Auris that there was not an ongoing communication between the facility and the dialysis center to ensure that the residents were properly placed on TBP. On 11/18/22 at 11:29 AM, two surveyors interviewed the NM and the Regional Coordinator (RC). The RC stated that we received referrals from the sending facility and the NM printed it out and reviewed it. The NM stated she checked COVID-19 status, Hepatitis B antigen (test to detect a contagious liver infection transmitted by blood and body fluids), history and physical (H & P), and a chest x-ray result within the past 30 days. The NM stated that she also reviewed the diagnoses and prescription of the dialysis treatment. The NM stated that the diagnoses of a multi-drug resistant organism was not in those records. The NM stated that she provided the facility with a statement that she received the clinical record and it was an oversight on her part because when she reviewed the Progress Notes and H & P and the present assessment she did not see the diagnoses. The NM further stated that she had not realized that she had forgotten to date the statement. The NM acknowledged that she only learned of Resident #115's need for isolation precautions last Wednesday based on surveyor inquiry. The NM further stated that she overlooked the isolation status in the initial clinical referrals sent by the facility for both Residents #113 and 115. The NM stated that she never spoke to the nurses at the facility prior to treatments as oral report was not given. The NM stated that the Charge Nurse was off and could not be reached. The NM stated that the Charge Nurse did not document having received oral report from the facility prior to resident transfer. The NM stated they just brought the residents over and provided the Dialysis Communication Book for review. The NM stated that the facility Nurse and CNA accompany the dialysis staff to hook up the resident to the dialysis machine for treatment. The RC stated that if there were a new case of C. Auris it should have been documented in the Dialysis Communication Book. The RC stated that the staff reviewed the DCSs to ensure the resident was stable prior to treatment. 3. On 11/18/22 at 12:23 PM, the surveyor interviewed the ADONUAIP and the DON in the presence of the survey team regarding the status of the residents on the First Floor Ventilator/Tracheostomy Unit with diagnoses of C. Auris. On 11/10/22, the LNHA provided the surveyor with a list of ten residents who were diagnosed with C. Auris. The DON stated that it was her understanding that there was no indication that the residents tested positive at the facility and agreed to provide the survey team with data to demonstrate that. At that time, the ADONUAIP stated that if a resident were tested at the hospital and were determined have been colonized (presence of a bacteria on a body surface without causing disease in the person) with C. Auris, it meant that the resident was already tested and treated with antibiotics. The ADONUAIP stated that though she had no formalized training in infection control, she had covered for the IP since she was out. The ADONUAIP stated that the Department of Health (DOH) had just issued an E# (tracking number for a confirmed outbreak) to the facility which indicated that the facility had an active outbreak related to C. Auris. The ADONUAIP stated that she completed case reports for eight residents who had C. Auris, and that two of the ten residents who were on the list provided to the surveyor on 11/10/22, were hospitalized and she only scanned eight of the case reports to the DOH for review. The ADONUAIP stated she conferred with the resident's regular physicians when she had questions related to C. Auris, as she, Just found out last month that there was an Infectious Disease Doctor (IDD) on staff at the facility. On 11/21/22 at 12:46 PM, the surveyor interviewed the ADONUAIP in the presence of the survey team as she reviewed hospital records provided by the Regional Nurse (RN) in the presence of the survey team. The ADONUAIP stated when the residents tested positive in the hospital we have to accept them and isolate them for 10 days because we do the swabbing here at the facility. The ADONUAIP stated that if the resident was positive for C. Auris upon transfer from the hospital, we tested the resident here and notified the DOH of the result. The ADONUAIP acknowledged that an unsampled resident may have gotten C. Auris here at the facility. The ADONUAIP stated that since we tested the resident here, the positive test result was attributed to our facility. The ADONUAIP stated that her submission of testing to the DOH was sometimes delayed because of the start of the onset of C. Auris, so she did not send the case reports until she had all of the information. On 11/22/22 at 9:33 AM, the DON and the RN presented the surveyor with four C. Auris Case Report Forms for four unsampled residents that were completed and returned to the DOH, and lab specimen results for a fifth unsampled resident. The RN stated that four case reports were sent for four unsampled residents. The surveyor asked why a Case Report was not completed for the fifth unsampled resident and she responded because the resident was only here at the facility for a couple of days and was not determined to have tested positive for C. Auris at the facility. The DON maintained that upon receipt of the case studies the DOH issued an E# over the phone verbally. The DON maintained that, While the E# was issued by the DOH, there was no determination that the C. Auris infections for those five unsampled residents originated at the facility and it was still under investigation. On 11/22/22 at 10:13 AM, the surveyor phoned the Medical Director (MD) in the presence of the survey team via speakerphone (with permission) who stated that he had been the MD for a year or so. The MD stated that if a resident were to be determined to have been colonized with C. Auris, it was an infection, and was not treated. The MD stated that some of the residents who were diagnosed with C. Auris may have been positive prior to admission to the hospital. The MD stated that once C. Auris was detected via lab specimen the resident was required to be placed on isolation. The MD stated that he would not know if C. Auris was discussed at the Quality Assurance Meetings that he attended every three months. The MD stated that he did not know who the IDD was or the IP at the facility was as they changed sometimes. The MD stated that there was now PPE located outside of isolation rooms and he felt that the staff were doing more about C. Auris than they used to. On 11/18/22 at 10:23 AM, the surveyor requested a copy of the Facility Assessment (Intent, For the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require) and the IP's employee file and proof of her last day worked. Review of the Facility Assessment revealed that it failed to contain any mention of C. Auris under the Infectious Disease section. Further review of the Facility Assessment revealed that Infection Prevention and Control were provided directly by the facility and was not a contracted services. Also contained within the Facility Assessment was the contact information for the Infection Control Medical Doctor who was assigned to the facility. On 11/22/22 at 12:54 PM, the surveyor interviewed the RLNHA in the presence of the survey team who stated that the purpose of the Facility Assessment was to communicate the needs of the facility and it was required to be updated yearly. Review of the Facility Assessment indicated that it was updated in 2022, the month and day were not specified. When the surveyor asked the RLNHA if C. Auris should have been included in the Facility Assessment the RLNHA stated that all of the needs of the facility should have been in the Facility Assessment as we have to care for the residents. The facility failed to provide the surveyor with the employee file or time card punches to validate the last day the Infection Preventionist worked at the facility. 41858 Surveyor B 4. On 11/10/22 at 11:39 AM, the surveyor observed a staff member (who was later identified as a Licensed Practical Nurse Apprentice (LPNA)) wearing an N95 mask, glasses (not protective goggles or face shield) and gloves, deliver a lunch tray to Resident #92. She placed the lunch tray on the bed side table and moved the table over to the side of the resident's bed. The LPNA removed her gloves and exited the room. She then used hand sanitizer donned a gown and gloves and went back into room and assisted the resident with his/her meal. The surveyor observed signage on the outside of the resident's room: a STOP, Must See Nurse sign, a Droplet Precautions Everyone Must: .Make sure their eyes, nose and mouth are fully covered before room entry sign, and a Contact Precautions Everyone Must: .Put on gown before room entry. Discard gown before room exit sign. There was a stocked PPE bin located outside of the room which contained hand sanitizer, gloves, gowns, and masks. A review of the Admission Record revealed Resident #92 was admitted to the facility with diagnoses that included, but were not limited to; Osteomyelitis (an inflammation or swelling that occurs in the bone) and Methicillin Resistant Staphylococcus Aureus Infection (a type of bacteria that could be fatal or cause serious infections). Review of Resident #92's Physician Orders revealed two active orders for Contact Precautions for Candida Auris (C. Auris) on Skin, dated 12/30/2021 and 3/29/2022. On 11/10/22 at 11:47 AM, the surveyor interviewed the LPNA when she exited the room. The surveyor pointed to the signs and asked the LPNA what the signage for droplet and contact precautions meant. She stated that before entering the room you must follow the signage requirements. She stated, I did not put on a gown before I dropped the tray, but I shouldn't of gone in the room without a gown. The surveyor asked her about the glasses she was wearing, she stated she was wearing eye glasses and that it was not OK to go in the room without eye protection. She further stated that she should have found a face shield before entering the room. The LPNA stated the resident had C. Auris, which was contagious, and she should have had a gown on to prevent getting into contact with anything in the room because it was an infection barrier, to protect you and the resident. On 11/10/22 at 11:52 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN), assigned to Resident #92, reviewed the Contact an [TRUNCATED]

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

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

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

Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to provide appropriate care for resident's who were dependent on staff to provide Activity of Daily Living (ADL) care. This deficient practice occurred for 4 of 4 dependent residents (Resident #49, #34 and #101 and #114) and on two of four resident care units (3rd and 4th floor) reviewed for ADL care and was evidenced by the following: 1. On 11/07/22 at 10:15 AM, the surveyor toured the 300's Unit of the facility and observed Resident #49 in bed with the head of the bed elevated, and was facing the door, and both feet rested directly on the mattress, and eyes were closed. The fingernails were observed as long and jagged, and contained a black coated substance underneath all of the fingernails. The upper lip and chin were covered with facial hair. When inquired about the resident's status to the Certified Nursing Assistant (CNA) observed in the resident's room at the time, the CNA stated, All [he/she] does was sleeping all day. On 11/07/22 at 11:30 AM, the surveyor returned to the room and observed Resident #49 in bed and was facing the door and his/her eyes were closed. The nails remained long and jagged with a black substance and the facial hair was still present. On 11/07/22 at 11:45 AM the surveyor returned to the 300's unit and observed the lunch meal. The lunch cart arrived on the floor at 11:50 AM. Resident #49 remained in bed in the same position as the surveyor observed one and one-half hours later. The surveyor went to the room at 12:05 PM, and Resident #49 was still sleeping in the same position. Observations on 11/07/22 at 12:15 PM, revealed Resident #49 was in bed. His/her lunch tray was behind the door on the bedside table, and the meal tray was not set up and Resident #49 could not access the tray. On 11/07/22 at 2:03 PM, Resident #49 was still in bed, ADL (Including, but not limited to the following self care activities: Bathing, Dressing, Eating, Transferring, Toileting, Bed Mobility, Nail Care and Foot Care) care was not provided, facial hair remained and nails remained long and jagged. Black coated substance was still present underneath all fingernails. On 11/09/22 at 11:30 AM, the surveyor reviewed Resident #49's electronic medical record. According to the admission Face Sheet, Resident #49 had diagnoses which included, but were not limited to, vascular dementia, unspecified severity, without behavioral disturbances, mood disturbance, visual disturbances and anxiety. Review of the most recent Annual Minimum Data Set (an assessment tool), dated 02/04/22, revealed that Resident #49 was severely cognitively impaired for daily decision making and required assistance with most activities of daily living. Review of Resident #49's Care Plan (CP) dated 05/2019 revealed he/she was care planned for ADL/self care performance deficit related to dementia. The goal was for Resident #49 to improve current level of function in mobility, transfers, eating, dressing, toilet use and personal hygiene. The interventions included the resident required staff participation to use toilet, requires staff participation with transfers, oral hygiene and personal care. Required supervision to turn and reposition, required setup and assistance with meals. On 11/09/22 at 11:30 AM, the surveyor interviewed the CNA responsible for providing care to Resident #49 during the 7:00 AM to 3:00 PM shift. The CNA stated that Resident #49 was totally dependent on staff for care, had not been able to feed self and could not ambulate. The CNA further stated Resident #49 had an open area to the sacrum that had been cared for by the nurse. Resident #49's nails were not trimmed or cleaned. Facial hair remained present on the upper lips, and the chin area after morning care was completed. On 11/10/22 at 9:15 AM, the surveyor observed Resident #49 in bed laying on the backside. Resident #49 had remained in bed in the same position during the morning shift. The surveyor asked the CNA to check Resident #49's brief, the brief was saturated with urine. The CNA stated that she had not provided care yet to the resident. On 11/10/22 at 11:10 AM, the surveyor interviewed the Licensed Practical Nurse /Unit Manager regarding ADL care for dependent residents. The UM stated that nail care was completed every Monday and there was a reminder on the daily assignment to complete nail care. The surveyor reviewed the daily assignment with the UM, there was no notation regarding nail care. The surveyor then asked the UM how she supervised the care provided by the staff to the residents. The UM stated she knew the staff and she trusted them. The surveyor then accompanied the UM to Resident #49, #34 and 101's Room, where we both the surveyor and UM observed that nail care had not been provided. The resident's nails were long, jagged and had a black coated substance embedded from 1/2 to 1 inch underneath the fingernails. On 11/10/22 at 12:15 PM, the UM stated she attempted to shave the resident on 11/09/22 but the resident refused. The surveyor asked the UM to provide the documentation where Resident #49 refused care. She could not provide the surveyor with any documented evidence to support the resident's refusal. On 11/10/22 at 1:30 PM, the UM provided a note dated 11/10/22, that she confirmed she had as a late entry after the surveyor's inquiry. The Progress Notes revealed: Attempted to remove facial hair, resident was resistive with care. The surveyor accompanied the UM and the Regional Nurse to Resident #49's room where we all observed that Resident #49's face remained un-shaven. 2. Resident #34 was admitted to the facility with diagnoses which included, but were not limited to, unspecified dementia, Type 2 diabetes mellitus, muscle weakness, hemiplegia and hemiparesis. On 11/07/22 at 10:25 AM, the surveyor observed Resident #34 lying in bed with the eyes closed. The head of the bed was elevated. The nails were noted to be long and jagged. On 11/09/22 at 09:50 AM, the surveyor observed Resident #34 in bed with the head of the bed elevated. The nails were long, jagged with a dark coated substance underneath the fingernails. The fingers of the right hand were curled into the palm of the right hand. The surveyor observed a hand roll placed to the left hand. On 11/10/22 at 09:30 AM, the surveyor observed Resident #34 in a recliner chair by the bed, eyes closed, Resident #49 did not initiate conversation and did not respond to the surveyor's greetings. On 11/10/22 at 11:00 AM, the surveyor interviewed the CNA who cared for Resident #34. The CNA stated that Resident #34 was non verbal and was totally dependent on staff for all activities of daily living. The CNA also stated that Resident #34 got out of the bed daily. The surveyor asked the CNA to open Resident #34's right hand, the nails were long and jagged, and a sour odor was noted when the right hand was opened. On 11/10/22 at 11:50 AM, the surveyor accompanied the UM to Resident #34's room where we both observed all of Resident #34's nails were long and jagged, and there was a black substance underneath the fingernails. On 11/10/22 at 12:30 PM, review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed that Resident #34 was severely cognitively impaired. Resident #34 scored 00/15 on the Brief Interview for Mental Status (BIMS ). Section G of the MDS which referred to Activities of daily living, Resident #34 was coded as 4:3 indicative of total assistance with 2 persons physical assist. Review of Resident #34's care plan dated 06/01/21 revealed that Resident #34 was not care planned for activities of daily living. Resident #34's care plan addressed the following concern: Resident #34 has a behavior problem of pulling out his/her incontinent brief and scratching himself related to disrobing. The goal was for Resident #34 will have fewer episodes of that behavior by review date (not specified). The interventions included to anticipate and meet needs. Document behaviors, and resident response to interventions. Trimmed his/her nails on a daily basis. The surveyor observed Resident #34 on 11/07/22 10:25 AM, 11/09/22 at 9:50, and 11/10/22 at 9:30 AM. During all three observations, the surveyor observed the nails were all long and jagged. On 11/14/22 at 12:50 PM, the surveyor again interviewed the UM regarding care for dependent residents. The UM stated that the CNA and nurses were to check the nails during shower day and a general assessment was to be completed. The surveyor requested the shower log for review. On 11/14/22 at 1:15 PM, the lead CNA provided the shower log for review, and the surveyor observed that the shower log had not been filled out consistently. Resident #34 most recently completed shower log, which included the daily skin assessment, for November was not completed. The Treatment Administration Record (TAR) was signed off and indicated that the skin assessment was performed every Tuesday on the 7:00 AM-3:00 PM shift. The UM did not have any comment. 3. On 11/07/22 at 11:10 AM, the surveyor observed Resident #101 in bed. The head of the bed was slightly elevated. Resident #101 did not initiate conversation but smile when asked questions. Resident #101 was noted with facial hair around upper lip and chin. The nails were observed as long and jagged. On 11/09/22 at 8:41 AM, the surveyor observed Resident #101 in bed eating breakfast, the nails were long and jagged. 11/09/22 at 10:46 AM, the surveyor returned to the room after care was provided and observed the nails remained long, jagged with a dark coated substance underneath the fingernails. On 11/09/22 at 11:30 AM, the surveyor reviewed Resident #101's electronic medical record. The Admission Face Sheet reflected that Resident #101 had diagnoses which included, but were not limited to, other Alzheimer's disease and essential hypertension. Review of the the most Quarterly Minimum Data Set (MDS) dated [DATE], revealed that Resident #101 was severely cognitively impaired. Resident #101 received a score of 99/15 on the Brief Interview for Mental Status ( BIMS ) indicative of severe cognition. Section E 0008 of the MDS which addressed rejection of care was coded with a zero value, indicative of compliance with care. Review of Resident #101's undated Care Plan provided by the facility revealed a care plan for ADL self care performance deficit related to decrease mobility. The goal was for Resident #101 to improve current level of function in bed mobility, transfers eating, dressing, toilet use and personal hygiene. The interventions included praise all efforts at self care. Encourage to participate to the fullest extent possible with each interaction. Monitor, document report to MD PRN [physician as needed] any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. On 11/10/22 at 11:45 AM, the surveyor accompanied the UM to the room where we both observed that nails care had not been addressed. Resident #101's nails were not trimmed/cleaned. Resident #101 did not have a skin assessment completed in the shower log to indicate the last time skin assessment included nails care were last performed. The UM informed the surveyor that resident's care was documented on the Kiosk (Computer system located in the hallway for direct care staff to document care) . On 11/10/22 at 2:00 PM, the Regional nurse accompanied the surveyor and the CNA to the computer to view the care performed for the resident. In the presence of the Regional Nurse, the CNA was unable to show where she documented the care for Resident #101. On 11/14/22 at 12:00 PM, the surveyor observed Resident #101 out of the bed for the first time during the survey. An interview with the CNA who cared for Resident #101 revealed that Resident #101 was dependent on staff for care, and had no behavior. On 11/14/22 at 12:15 PM, the surveyor reviewed the Physician Progress notes and noted an order for skin assessment on the day shift for Tuesday and Friday. Also noted was an order for transfer with [a brand name mechanical lift]( frequency not specified.) The surveyor observed Resident #101 in bed on 11/07, 11/09 and 11/10/22. The surveyor observed Resident #101 out of the bed for the first time on 11/14/22. On 11/14/22 at 12:50 PM, An interview with the UM regarding Resident #101's care revealed that the CNA and nurses were to check the skin and nails, and performed a general assessment on shower day. The surveyor then asked the UM to elaborate on her day. The UM stated, she made rounds, greeted the residents, took care of appointments, checked the assignment, reviewed 24 report, checked the medication carts, attending meeting and made any follow up. The UM did not include following up on resident care to be provided by the staff and she was not aware that nails care had not been provided during her rounds. On 11/15/22 at 1:30 PM, the surveyor interviewed the CNA who cared for Resident #101 on 11/7, 11/09 and 11/10/22. The CNA stated that Resident #101's [brand name mechanical lift] pad was soiled and had to be sent to the laundry for cleaning. The CNA stated that Resident #101 had only one [brand name mechanical lift] pad, and she was unable to get Resident #101 out of the bed. On 11/21/22 at 11:03 AM, the surveyor observed Resident #101 sitting in the room. Facial hair noted on 11/07/22 was still visible. The surveyor informed the UM and she replied that she was not aware that Resident #101 was unshaven. On 11/22/22 at 09:02 AM the surveyor interview a random CNA assigned to the 300's Unit high side. The CNA stated it was not on the assignment to provide shaving care for residents. 31654 On 11/07/22 at 11:45 AM, the surveyor observed Resident #114 in a wheelchair in their room watching television on the roommate's side of the room. The surveyor observed there was no call bell in the resident's reach. The surveyor asked the resident about using the call bell and Resident #114 stated, I don't even know if it works, and when they come, they come, and I cannot say on time. The surveyor reviewed the electronic medical record for Resident #114 which revealed: The Admission Record revealed diagnoses which included, but were not limited to, cerebral infarction, unspecified and type 2 diabetes mellitus. The quarterly Minimum Data Set, dated dated [DATE], revealed the resident scored 10/15 on the Brief Interview for Mental Status which indicated a moderately impaired cognition. The Functional Status, G revealed the resident was totally dependent on one person for toileting. Section H revealed the resident was always incontinent of bowel and bladder. The resident had a Care Plan focus for bowel and bladder incontinent, Initiated 02/11/22, with a goal to have less than two incontinence episodes per day, Date initiated: 02/11/22 with a Target Date: 11/11/22. The resident had an ADL self-care performance deficit due to generalized weakness status post hospitalization care plan. The Goal was to improve current level of function in .toilet use .Target Date: 11/11/22, Interventions included Toilet Use: totally dependent on staff for toilet use. On 11/16/22 at 7:59 AM, the surveyor observed Resident #114 awake in bed, the call bell was not attached to the wall. The Certified Nurse Aide (CNA) assigned to Resident #114 was in the room and asked about the call bell and he stated, it is not there. The surveyor inquired to the CNA how many briefs should be used on residents, and he stated one. When asked if he had ever found two briefs on residents, he confirmed he has. On 11/16/22 at 8:06 AM, the surveyor asked Resident #114 how many briefs the staff had put on him/her and the Resident stated, I think they have two on me, at that time the CNA stated he was looking for the linen. On 11/16/22, at 8:14 AM, the CNA went to the room to complete incontinence care on Resident #114. The surveyor inquired to the CNA to confirm how many briefs the resident was wearing. The CNA proceeded to show the surveyor the corners of two green colored briefs and confirmed resident #114 was wearing two briefs. On 11/16/22 at 8:22 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who was overseeing the unit at that time, regarding how many briefs should be on a resident. The ADON stated one, the ADON accompanied the surveyor to Resident #114's room and asked the CNA how many briefs were on the resident. The CNA stated two. The surveyor also inquired about the resident's call light and stated, oh yeah, and confirmed there was no call light attached to the wall. On 11/16/22 at 8:31 AM, the surveyor requested the ADL policy, and any training related to how many briefs should be used on a resident. The ADON stated, I know the night staff is doing it (using double briefs). On 11/16/22 at 12:00 PM, the Director of Nursing provided a copy of an ADL inservice Dated 07/05/22. The summary of Presentation revealed: all CNA's when doing incontinence care and resident wearing diaper should follow the protocol to do changing. Diaper every two hours or as needed. Note: No Double Diapers Application at all, this is strictly a must!! On 11/22/22 the surveyor reviewed the facility's ADLs policy dated 07/09/07 and last revised 08/14/22. The policy read, It it the policy of the facility to provide ADL care to all residents based on assessment of needs. ADL care consist of but it is not limited to: Bathing Dressing Eating Transfers Toileting Bed Mobility Nail Care Foot care. Purpose: To ensure all resident's needs are met. Responsibility Licensed Nurse : Assesses resident to determine ADL needs. Completes instructions to reflect residents needs for all aspects of ADL care. CNA reviews nursing instructions for each resident before providing care. Provides care and assistance with care in accordance with the nursing instructions (plan of care ) Reviews the shower schedule to ensure that shower is given on designated day as scheduled. On 11/22/22 at 1:30 PM, during the pre-exit conference the DON stated it was her expectation that dependent residents be provided with ADL,s care. NJAC 8:39-27.2 (g)

Based on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to: a.) ensure that medications were administered in accordance with the physician order for 6 residents reviewed (Resident #3, #14, #24, #42, #92, #102) for two days (11/15/22 and 11/16/22), and b.) implement physician ordered interventions for 1 of 1 resident (Resident #105) reviewed for skin concerns. This deficient practice was evidenced by the following: a.) Surveyor #1 conducted a medication Pass Observation on 11/16/22 on the 300's Unit of the facility and observed that some of the medications were not available for administration. Resident #3 had diagnoses of essential hypertension and edema. Resident #3 had an order for Lasix (a loop diuretic) to be administered daily for edema. The documentation found on the Medication Administration Record (MAR) reflected that Resident #3 did not receive the Lasix on 11/15/22 and 11/16/22. Resident #14 had diagnoses of unspecified atrial fibrillation, hyperlipidemia, and cerebrovascular accident. The Physician Order sheet dated, 11/22, revealed orders for Diltiazem (medication to reduce blood pressure) 120 mg (milligrams) daily, Neurontin 100 mg twice daily for neuropathy, Lasix 20 mg daily for edema, and Naltrexone 0.5 mg daily for alcoholism. Resident 14's medications were not available for administration on 11/15/22 and 11/16/22. Resident #24 had diagnoses of essential hypertension and heart failure. Resident #24 did not receive the following medications for 2 days: Plavix (a blood thinner) 75 mg daily, Lasix 20 mg daily, and Metoprolol Succinate Extended Release (medication to reduce blood pressure) 25 mg daily. Resident #42 had diagnoses of cerebral infarction and unspecified chronic obstructive pulmonary disease. Resident #42 had an order for Eliquis (a blood thinner) 2.5 mg to be administered twice daily and Metoprolol 75 mg to be administered every 12 hours for hypertension. Resident #42 did not receive the Eliquis and the Metoprolol on 11/15/22 and 11/16/22. Resident #94 had diagnoses of hypertension, aphasia, and diabetes. Resident #94 had a physician order for Lisinopril 40 mg to be administered daily for hypertension. Resident #94 did not receive the medication on 11/15/22. Resident #102 had diagnoses of Parkinson disease and essential hypertension. Resident #102 had a Physician Order for Lisinopril 30 mg to be administered daily for hypertension and Amlodipine 10 mg daily for hypertension. Resident #102 did not receive these medications on 11/15/22 and 11/16/22. Further review of the Progress Notes revealed that there was no documentation to show that the resident's Physicians were notified that the medications were not available to be administered to the residents. On 11/16/22 at 11:30 AM, Surveyor #1 interviewed the Unit Manager Licensed Practical Nurse (LPN/UM) who administered medications on the low side of the 300's Unit on 11/14/22. The LPN/UM stated that she was aware that some of the medications were not available. She further stated that the pharmacy was informed. She was unable to comment on the facility's process to reorder medications. On 11/16/22 at 2:30 PM, Surveyor #1 discussed the above issues with the Director of Nursing (DON). The DON stated that she was made aware that only the medication Midodrine was missing and was not administered. The DON stated that medications should be reordered when 8 doses of medications were left on the Bingo (a medication delivery system) card. The DON stated that she was unsure if all staff were aware of the process. On 11/16/22 at 2:45 PM, the surveyor reviewed the Delivery Order Form from the pharmacy and confirmed with the nurse that the medications were not available to be administered. The Bingo card received from pharmacy after 1:30 PM was untouched. On 11/21/22 at 9:02 AM, during an interview with the DON, who stated that residents were to receive medications according to the a Physician order. The surveyor reviewed the facility's policy titled, Medication Reordering dated 04/01/17 last revised 09/15/22. The policy revealed: It is the policy of the facility to reorder medications when supply is running low (2 days prior), Purpose: To ensure that all meds [medications] are available in sufficient quantity to fulfill MD [Physician orders]. Procedure: Individual: Physician/NP 1. Orders medication in the electronic clinical record. Pharmacy: Delivers a 28-day supply of all medications unless ordered for a specific amount of time. Licensed Nurse: Receives medications and verifies appropriate medication. If medication is not received in a timely manner, recalls the pharmacy to obtain estimated delivery time. Notifies nursing supervisor or manager. Responsibility: Licensed Nurse: If medication is not available for the specific medication, notifies MD/NP to obtain hold order or substitute medication which may be available in emergency stock. Reorders medication from the pharmacy. (The process was not being followed. There was no documented evidence that the physicians were made aware that the above residents did not receive their prescribed medications on 11/15/22 and 11/16/22) 38079 b.) On 11/15/22 at 9:04 AM, Surveyor #2 observed Resident #105 lying in bed on his/her left side. The surveyor observed visibly soiled gauze dressings on both feet, the bottom of the left foot had a lollipop stick stuck to it, and both feet were in direct contact with the bed. The surveyor observed there were no heel protectors on the resident, and there was no offloading of the resident's heels/feet observed. At that time, Resident #105 stated he/she was not in pain at that time and that his/her dressings had been changed yesterday. A review of Resident #105's medical records revealed the following: An Admission Record revealed he/she was admitted with diagnoses which included but were not limited to peripheral vascular disease (PVD - disease affecting the blood vessels), cellulitis (bacterial skin infection causing swelling and pain), unspecified open wound left foot, and type 2 Diabetes Mellitus with foot ulcer. An Order Summary Report which included the following orders: dated 09/14/21 to apply ACE (elastic bandage) wrap to left lower extremity from foot to knee in the morning and remove at bedtime; dated 10/14/21 to elevate legs above heart level while at rest every shift; dated 09/14/21 heel protectors every shift check placement; dated 10/14/21 no pressure to heels float heels when in bed every shift; dated 09/14/21 offload left foot/heel every shift; and dated 09/14/21 [redacted] boot on when in bed every shift. The ongoing Care Plan (CP) revealed a focus area dated 08/11/21, actual blister with open area to left lateral foot (diabetic wound) related to PVD and Diabetes Mellitus. The goal revealed resident's wound will improve and heal as evidenced by closure within the next review date, and the diabetic foot ulcers will improve and heal as evidence by closure. Interventions included but were not limited to position resident off affected area and [redacted] boot when in bed. Another focus area undated, potential for skin breakdown secondary to Diabetes Mellitus, decreased mobility, and PVD. The goal revealed Resident #105 would have care needs met as evidenced by no skin breakdown. Interventions included but were not limited to pressure relieving devices on bed and wheelchair. The quarterly Minimum Data Set, an assessment tool, dated 10/14/22, revealed Resident #105 had a Brief Interview for Mental Status (BIMS) of 10 out of 15 indicating the resident was mildly cognitively impaired. Section E, Behavior, indicated the resident has not exhibited any behaviors of rejection of care. Section G, Functional Status, indicated Resident #105 required extensive assistance of at least one staff member for dressing which included putting on and removing items. Section M, Skin Conditions, revealed diabetic foot ulcer(s), skin tears, pressure reducing device for bed in use and application of dressings to feet. On 11/15/22 at 9:09 AM, during an interview with Surveyor #2, the Certified Nursing Aide (CNA) #1 stated she had been caring for Resident #105 for at least a few months. CNA #1 stated the resident was alert, takes care of most of his/her own activities of daily living (ADL-bathing, dressing, eating, etc), and that she would need to offer to him/her a shower. CNA #1 further stated the wounds on the resident's feet were better and that the nurse would apply cream to his/her legs. CNA #1 stated there was nothing she was responsible to do for Resident #105's wounds. CNA #1 stated she would get a report in the morning from the nurses, and at that time she would be told if pillows or booties were required for any resident. On 11/15/22 at 9:21 AM, during an interview with Surveyor #2, Resident #105 was asked about the wounds on his/her feet and if he/she had ever been provided with special boots or pillows. Resident #105 stated that the staff never put any boots on him/her, or a pillow for under his/her feet. Resident #105 asked the surveyor what was meant by boots for his/her feet. On 11/16/22 at 8:00 AM, during an interview with Surveyor #2, LPN #2 who was caring for the resident, stated the resident would be seen by wound care weekly. LPN #2 stated the nurses would do daily dressing changes. When asked about any other interventions required for Resident #105's wounds, the LPN stated there was nothing else to be done for the wounds on his/her feet. LPN #2 stated that all orders would show up on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) in the electronic medical records in the computer. On 11/16/22 at 8:31 AM, during an interview with Surveyor #2, the Assistant Director of Nursing (ADON) #1, stated that if a resident had an order to off load their heels or use heel booties, the information would be documented in a book on the unit for the nurses and CNAs to review daily. At that time, CNA #1 was present and stated there was no book and that the nurses would tell them (CNA) and the task would be listed in kiosk (electronic medical computer). On 11/16/22 at 10:03 AM, Surveyor #2 observed Resident #105 sleeping in bed. The surveyor observed no Ace wraps had been applied, no heel boots were applied, and the heels were not off loaded. Resident #105's feet were lying directly on the bed. Surveyor #2 observed there were no heel boots in the room and no extra pillow available for offloading the heels. On 11/18/22 at 10:10 AM, Surveyor #2 observed Resident #105 in bed with his/her feet dangling on the side of the bed. The surveyor observed there were no heel boots, or Ace bandages on the resident. Again, the surveyor observed there were no heel boots, or an extra pillow available for offloading the heels. On 11/18/22 at 11:27 AM, Surveyor #2 reviewed the CNA tasks in the electronic medical system. There were no interventions listed for the CNAs to apply the heel boots or to offload the resident's heels/feet. On 11/18/22 at 12:02 PM, during an interview with Surveyor #2, the Director of Nursing (DON) stated the resident should always have offloading or heel boots applied while in bed. The DON stated that the application of the heel boots and the offloading of the heels would be documented in the MAR. The DON further stated if the resident refused, she would expect to see that documentation in the MAR or TAR as well as documentation that the doctor was notified of any refusal of treatment or medication. On 11/18/22 at 12:40 PM, Surveyor #2 observed Resident #105 awake lying in bed with both feet directly on the bed with no heel boots, no offloading of the heels/feet, and no Ace wraps applied. The surveyor asked Resident #105 if he/she had any boots that were put on his/her feet or a pillow to keep his/her feet off the mattress. Resident #105 stated, nobody ever gives me anything like that. The surveyor observed the resident's room and did not see any heel boots. Resident #105 stated that he/she didn't have any. On 11/21/11 at 9:22 AM, during an interview with Surveyor #2, CNA #2 stated the care she would provide to Resident #105 would be to give him/her clean clothes and towels. CNA #2 stated the resident had wounds, but the nurses would take care of all that. CNA #2 stated she would know what care to provide because the nurses would give report in the morning. On 11/21/22 at 9:24 AM, Surveyor #2 observed Resident #105 sitting on the side of the bed with his/her feet dangling over the side of the bed by the floor. The surveyor observed dressings on both feet, but no heel boots or ACE wraps. On 11/21/22 at 11:01 AM, Surveyor #2 observed Resident #105 lying in bed asleep with his/her feet directly on the bed. The resident did not have Ace wraps or heel boots applied and his/her heels/feet were not offloaded. Surveyor #2 observed the room and could not locate any heel boots or extra pillows. On 11/21/22 at 11:04 AM, Surveyor #2 asked LPN #2 to access Resident #105's orders. Surveyor #2 and LPN #2 reviewed the orders, and LPN #2 acknowledged the order for [redacted] heel boot, Ace wraps, and to offload heels. LPN #2 and Surveyor #2 went to Resident #105's room and observed no heel boot, no Ace wrap, and no offloading of the resident's heels/feet. LPN #2 acknowledged that the heel boot and Ace wrap were not in the resident's room. On 11/21/22 at 11:07 AM, Resident #105 informed LPN #2 and Surveyor #2 that the heel boot had been gone for months and he/she never got them back. Resident #105 could not recall who took the heel boot or the exact date they were taken but that it was months ago. On 11/21/22 at 11:10 AM, in the presence of Surveyor #2, LPN #2 reviewed the physician orders and acknowledged she had not been applying the heel boots or Ace wraps to Resident #105. LPN #2 stated she should not have been signing off that she had been applying the heel boot and Ace wraps. LPN #2 stated that without the Ace wraps on, the resident's legs could swell more. The LPN further stated that Resident #105's wounds could get worse if the heel boot was not applied. LPN #2 stated she would need to reorder and replace immediately the supplies he/she (Resident #105) should have had. The LPN acknowledged again that she had been signing off the [redacted] heel boot, the Ace wraps, and offloading of the resident's heels without having applied them. LPN #2 stated that the Resident #105 had not refused any treatments. On 11/21/22 at 11:17 AM, during an interview with Surveyor #2, the DON stated if a resident had orders for heel boots, Ace wraps, and offloading and they were not applied, they should not be signed as done. The DON stated that if the [redacted] heel boots were removed, they should have been replaced immediately. The DON stated Resident #105's wounds or cellulitis could become worse without the ordered treatments. The DON stated the fourth floor did not have a unit manager but there was an ADON who should have been monitoring these things. On 11/21/22 at 11:20 AM, during an interview with Surveyor #2, ADON #2 stated he had only been in the facility since 10/27/22. ADON #2 stated his involvement with resident care would be to have a proper endorsement of shift but that has not started yet. He stated he was in charge of wound care as of now and he was trying to figure out how many times he should go on wound care rounds. On 11/22/22 at 10:02 AM, during an interview with Surveyor #2, the DON was asked about the Ace wraps, [redacted] heel boots, and offloading not being applied to Resident #105. The DON was also asked about the facility's pressure ulcer protocol. The DON stated she was not aware of the policy and not aware of how the placement (of the ordered treatments) was being monitored. The DON stated she would need to get back to us. On 11/22/22 at 10:23 AM, Surveyor #2 attempted to call the wound care nurse. There was no answer and no availability to leave a voice mail. The surveyor made a second call at 10:25 AM, to an alternate phone number and there was no answer and no availability to leave a voice mail. The facility provided the wound, Progress Note details dated 11/3/22, 11/10/22, and 11/17/22. A review of the reports revealed the following: 11/03/22: Wounds in bilateral feet. Duration date of initial wound evaluation 03/11/22. Context wound etiology is of diabetic origin. Diagnoses included cellulitis, sepsis, Type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer, and unspecified open wound left foot. Wound #2 right, lateral foot is partial thickness vasculitic ulcer, improved. Measurements 1.5 cm (centimeter) length x 1 cm width x 0.1 cm depth with an area of 1.5 sq (square) cm and volume of 0.15 cubic cm. Wound #7 left, plantar foot is partial thickness vasculitic ulcer, no change. Measurements 3.5 cm length x 2 cm width x 0.1 cm depth with an area of 7 sq cm and a volume of 0.7 cubic cm. There is no change noted in the wound progression. Wound #8 bilateral lower legs is partial thickness xerosis cutis (abnormally dry skin), initial exam. Measurements 0 cm length x 0 cm width Wound orders: Wound #2 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. Wound #7 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. Wound #8 included to cleanse and apply prescribed cream. 11/10/22: Wounds in bilateral feet. Duration date of initial wound evaluation 03/11/22. Context wound etiology is of diabetic origin. Diagnoses included cellulitis, sepsis, Type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer, and unspecified open wound left foot. Wound #2 right, lateral foot is partial thickness vasculitic ulcer and not healed. Measurements remained the same as 11/03/22. Wound #7 left, plantar foot is partial thickness vasculitic ulcer, not healed. Measurements 3.3 cm length x 2.2 cm width x 0.2 cm depth with an area of 7.26 sq cm and a volume of 1.452 cubic cm. Wound #9 left, dorsal foot is partial thickness vasculitic ulcer, initial exam. Measurements are 3.5 cm length x 4 cm width with no measurable depth, with an area of 14 sq cm. Wound orders: Wound #2 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. Wound #7 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. Wound #9 cleanse and apply cream. 11/17/22: Wounds in bilateral feet. Duration date of initial wound evaluation 03/11/22. Context wound etiology is of diabetic origin. Diagnoses included cellulitis, sepsis, Type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer, and unspecified open wound left foot. Wound #2 right, lateral foot is partial thickness vasculitic ulcer, improved. Measurements 1.5 cm length x 1 cm width x 0.1 cm depth, with an area of 1.5 sq cm and a volume of 0.15 cubic cm. [same measurements as 11/03/22]. Wound #7 left, plantar foot is partial thickness vasculitic ulcer, no change. Measurements 3.2 cm length x 2 cm width x 0.1 cm depth with an area of 6.4 sq cm and a volume of 0.64 cubic cm. Wound orders: Wound #2 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. Wound #7 included facility pressure ulcer prevention protocol, and offload heels per facility protocol. All three reports noted that the plan of care was discussed with the facility staff. A review of the facility provided, Boots Application in-service dated 04/19/22, revealed all staff must carry out doctor's orders on boots, offloading application. The sign in sheet did not include the LPN. A review of the facility provided, Licensed Practical Nurse Job Description undated, included but was not limited to purpose: to provide direct nursing care to the residents. Nursing Care Functions: review the resident's chart for specific treatments, etc, and administer professional services. A review of the facility provided competencies for LPN #2, dated 08/02/22, included but was not limited to reviewing treatment orders and documentation nurses notes; use the documentation guidelines for charting. The competencies revealed that LPN #2 had successfully completed the above skills and was able to work independently and was signed by the Registered Nurse. A review of the facility provided, Skin Assessment and Skin Breakdown Prevention dated 07/21/22, included but was now limited to ensures that interventions indicated to address the resident's skin risk factors are implemented as per plan of care. Will assess resident to evaluate for any preventative devices (i.e. pillows, booties). A review of the facility provided, Assistive, Adaptive, and Pressure Relieving Devices dated 07/12/22, included but was not limited to policy: to use assistive, adaptive, and pressure relieving devices to aide and improve our residents' quality of care, as well as to prevent further illness and decline. Assistive, adaptive, and pressure relieving devices may include j. heel booties. Procedure: MD (physician) will initiate an order, enter order in the EMR (electronic medical record) along with pertinent instruction. Instructions for the device management will be entered into CNAs task where appropriate. Education regarding device placement and management will be provided to nursing where appropriate. Device placement and management will be monitored by unit charge nurse. NJAC 8:39-27.1(a)

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

Complaints : NJ 0 Based on interviews and record review, as well as review of pertinent facility documents on [DATE], [DATE], and [DATE], it was determined that the facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 7:00 pm, Resident #1 complained of abdominal pain. The Resident had abdominal distention, and vomited coffee ground color. Registered Nurse (RN #1) received an order from the Primary Physician (PP) to send Resident # 1 to the Acute Care Hospital (ACH) for evaluation of abdominal pain. RN #1 called 911, however, the RN canceled 911 without notifying the PP. On [DATE] (the following day) at 9:45 am, Resident #1 was sent to the ACH for abdominal pain and abdominal distention. Resident #1 was resuscitated and was pronounced dead at 12:35 pm. This deficient practice is evidenced by the following: Reference: New Jersey Board of Nursing Laws 45:,d+[DATE] .b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist . 1. According to the ADMISSION RECORD (AR), Resident #1 was admitted on [DATE], and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool dated [DATE] showed that Resident #1's cognition was intact and required total assistance with Activities of Daily Living (ADLs). The Care Plan (CP), undated, showed that Resident was Ventilator dependent due to [CONDITION(S)]. Interventions included but were not limited to: Monitor/Document/report to MD [Medical Doctor] PRN [as needed] for GI (Gastrointestinal] problems. Preventative measures adequate communication system The Order Summary Report (OSR) dated [DATE], showed a telephone physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Note (PN) showed the following: On [DATE] at 11:20 pm, RN #1, the staff nurse assigned on duty during 3:00 pm to 11:00 pm shift, documented that Resident #1 complained of abdominal pain and vomited. Resident #1's bowel sounds to lower quadrant was hypoactive. The PP was made aware, RN #1 called 911. Then at 9:00 pm, RN #1 canceled 911 because Resident #1 was noted to have fecal impaction. On [DATE] at 6:17 am, RN #2, the staff nurse assigned on duty during 11:00 pm to 7:00 am shift documented, that she received a report from RN #1 that 911 was canceled because Resident #1 had large BM and [MEDICATION(S)] medication was administered. RN #2 further documented that Resident #1's abdomen was moderately distended, fluids were provided through the Resident's gastrostomy tube (GT), had small soft BM, and to follow up with the PP. On [DATE] at 10:23 am, Licensed Practical Nurse (LPN #1), the staff nurse on duty during 7:00 am to 3:00 pm shift, documented that Resident #1's abdomen was distended and the Unit manager (RN #3/UM) was made aware. LPN #1 called the PP. The PP asked the LPN to get the UM or Director of Nursing (DON) to assess Resident #1, and order recieved to send Resident #1 to ACH for further evaluation. At 9:55 am, 911 was called and at 10:15 am Resident #1 left the facility. On [DATE] at 10:53 am, RN #3, who was the UM during 7:00 am to 3:00 pm shift, documented that she assessed Resident #1, at 9:00 am, Resident #1's abdomen was distended with abdominal pain. The PP was made aware and ordered to send Resident #1 to the ACH for further evaluation. At 9:45 am the 911 was called and arrived at 10:00 am. Resident #1 left the facility in poor condition. Family was notified. On [DATE] at 7:47 pm, LPN #2, documented in the PN that Resident #1 died in the hospital. On [DATE] at 10:28 pm, PP, the Primary Physician and was also the Medical Director at the facility documented that on [DATE] at 8:30 pm, the PP received a call from nursing staff on 3:00 pm to 11:00 pm shift. The nurse reported that Resident #1's abdomen was distended with episode of vomiting. The PP advised the nursing staff to assess vital signs, do abdominal exam, and get help from the nursing supervisor (NS) to examine Resident #1 prior to sending to the ACH. The PP further documented that nursing staff reported that vomitus appeared coffee ground, at that point the PP advised nursing staff to send the Resident to the ACH; and did not hear back from the nursing staff. The PP was under the impression the Resident was in the hospital during that time. On [DATE] (the following day) at 8:45 am, the PP received a call from nursing staff on the 7:00 am to 3:00 pm shift that the Resident was still at the facility with abdominal distention. The PP asked why the Resident was not sent to the ACH the night before ([DATE]). She was told because the Resident had a large BM and the Resident's abdomen felt softer. She then advised the nursing staff to ask the UM to assess the Resident and to send the Resident to the ACH. At 8:55 am the UM reported to her that Resident #1's abdomen was very distended and being transferred to ACH. At 2:17 pm, the PP received a telephone call from the DON that the Resident expired in the emergency room (ER). Review of the facility SUMMARY OF INVESTIGATION IN [Resident #1] SUDDEN DEATH (SISD), date of occurrence, [DATE], showed that on [DATE], the Resident's abdomen was distended and the PP ordered to send the Resident to the ACH. RN #1 decided to stop the transfer to the ACH. The Resident's abdomen remains distended. On [DATE], the Resident's abdomen remains distended with pain on palpation. The PP was called and instructed to send the Resident to the ACH. Attached with the SISD, a statement from RN #1, showed that on [DATE] at 5:30 pm, during peg tube care, Resident #1 had small amount of dark brown color residual output from the peg tube. At 8:00 pm, Resident #1 complained of abdominal pain and bowel sound was hypoactive on the lower quadrant. RN #1 also stated that she administered Milk of Magnesia and few minutes later Resident #1 vomited dark brown color. RN #1 further wrote that the PP was notified with orders for Resident #1 to be assessed by the Nursing Supervisor (NS) and to call the PP back. However, RN #1 did not call the PP again. RN #4 (NS) was unable to assess Resident #1 because she was performing admissions to the facility. RN #1 called 911. Then prior to 911 arrival, Resident #1 had BM, abdomen felt slightly soft, and the Resident was monitored throughout the night. RN #1 wrote that the PP was not notified because Resident #1 felt much better after she/he had BM and that the abdominal content was not coffee ground. Attached with the SISD, Resident #1's Acute Care Medical Record (MR) from the hospital dated [DATE]. The MR showed at 11:09 am, Resident #1 was to be found bradycardio (Also known as bradyarrhythmia, slow heart rate) before going into asystole (also known as flatline, no cardiac output eventually occurs in all dying patients), with high possibility of imminent or life threatening deterioration in condition. Cardiopulmonary resuscitation (CPR) and Advanced Cardiovascular Life Support (ACLS) protocol initiated immediately. Surgery was consulted to evaluate for bowel obstruction; however, Resident #1 continue to be too unstable for any interventions. At 12:35 pm, Resident #1 was pronounced dead. Resident #1 had Cardiac Arrest secondary to Septic Shock and Bowel Obstruction. Attached with the MR, the ER Physician ([NAME]) on [DATE] documented at 1:54 pm, the MR showed that Resident #1 presented to the ER from the Nursing Home for Altered Mental Status and abdominal distention. The [NAME] and Respiratory Therapist at immediate bedside. The MR further indicated Per EMS, patient was said to have been found altered at 8:30 AM today [[DATE]] is said to have been displaying abdominal distention since yesterday [[DATE]], associated with multiple episodes of vomiting today [[DATE]] .arrived in the ED [emergency department] being ventilated by [CONDITION(S)] was subsequently transferred to the ventilator The Surveyor conducted an interview with the PP on [DATE] at 12:31 pm, the PP confirmed what was documented on PN dated [DATE] at 10:28 pm. The PP further stated that she gave an order to send Resident #1 to ACH on [DATE] and the PP stated she was surprised that the morning ([DATE]) another nurse was calling her about Resident #1. The PP further stated that if her order was not followed, she expects the nursing staff to update her for any changes in condition or change in physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Surveyor attempted to conduct a telephone interview with the with RN #1 from [DATE] to [DATE], however, RN #1 was not available. The Surveyor conducted an interview with the NS on [DATE] at 4:56 pm. The NS confirmed the aforementioned statement dated [DATE]. NS further stated that she did not see Resident #1 on [DATE] because she was not aware that there was an order to reassess Resident #1 prior to sending to ACH. The NS added that she would have called the PP back with the reassessment update because it would be the PP's decision whether to send Resident #1 to ACH or remain in the facility. The Surveyor reviewed the facility's policy titled CHANGE IN CONDITION, dated [DATE], showed It is the policy of THIS FACILITY to identify and communicate changes in condition to the physician and other team members to implement interventions to prevent further deterioration and possibly prevent hospitalization To provide prompt and appropriate interventions to promote resident's health and well-being and positive outcomes .The nurse will contact the physician or NP, discuss findings and formulate a plan The Surveyor reviewed the facility's policy titled physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .To ensure that the plan of care is followed in accordance with the orders established by the physician and/or nurse practitioner . NJAC 8:,d+[DATE].2(b) NJAC 8:,d+[DATE].1 (a)

A. Based on observation, interview, and review of the medical record and other facility documentation, it was determined that the facility failed to maintain appropriate infection control practices to address the risk for the spread of infections by failing to: a.) clean and disinfect a multi-use glucometer (blood sugar monitoring device) between residents, as identified for 5 of 5 residents observed on 09/12/19 (Residents #11, #25, #33, #99, #162); b.) follow the manufacturer's directions for the cleaning and disinfecting of glucometers for 8 of 8 residents observed during blood sugar monitoring (fingerstick) on 10/02/19, (Residents #25, #33, #32, #34, #56, #76, #111, #313); and identified for 4 of 4 nurses observed on 4 of 4 units; c.) wear appropriate Personal Protective Equipment (PPE) while performing a fingerstick on a resident on contact isolation precautions (Resident #162); and d.) ensure that blood sugar monitoring items are not transported from one resident's room to another without cleaning or disinfecting the items/and or cleaning the bedside tables on which the items were placed. This deficient practice was evidenced by the following: The facility's failure to cleanse and disinfect the glucometer between residents, including lack of disinfecting of glucometer after use with a resident on contact isolation precautions for [CONDITION(S)] ([CONDITION(S)], a contagious bacteria that is difficult to treat because of it's resistance to antibiotics) in the sputum, had the likelihood to negatively affect all residents that required a fingerstick. The facility's failure to don appropriate PPE while performing a fingerstick on a resident on contact isolation precautions; taking blood sugar monitoring items from one resident's room to another; and clean and disinfect the residents' bedside tables after use, had the likelihood to affect all residents on the unit through the staff's transmission of infectious agents from resident to resident. On 10/02/19 at 6:15 PM, the facility Administrator and the Director of Nursing were notified that an Immediate Jeopardy situation (IJ) had been identified. The IJ removal plan was received and accepted by email on 10/03/19 at 5:25 PM for 11 of 11 resident reviewed for blood glucose monitoring (Residents #11, #25, #32, #33, #34, #56, #76, #99, #111, #313, and #162). On 09/12/19 from 11:30 AM to 12:20 PM, the surveyor observed a Registered Nurse (RN) #1 as she went from room to room to perform blood sugar checks (fingersticks) of residents on the first floor unit. The surveyor observed as the following: 1. On 09/12/19 at 11:42 PM, the RN #1 went to the medication cart (Med Cart), which was parked near the nurses' station. RN #1 removed a stack of alcohol wipes, a cup containing lancets, a container of blood glucose monitoring strips (strip), and a glucometer (a blood sugar monitoring device) from the Med Cart. RN #1 carried the items into Resident #33's room and placed them directly on the resident's bedside table, without cleaning the table. RN #1 washed her hands and donned gloves. She took one strip out of the container, opened an alcohol pad, wiped the resident's finger, inserted the strip into the glucometer, and then lanced the resident's finger to obtain blood. She collected the blood onto the strip and then placed the glucometer, with the strip containing blood, onto the resident's bedside table. RN #1 wiped blood from the resident's finger, removed the strip from the glucometer and discarded the gloves and strip into the trash. She then washed her hands, picked up the container of strips, the glucometer, the remaining alcohol pads, and the cup of lancets, and walked out of the resident's room without wiping off the bedside table. RN #1 went to the Med Cart and placed the glucometer, the remaining alcohol wipes, the container of strips, and the cup of lancets on the top of the Med cart. She did not clean the glucometer after use or discard the unused supplies. RN #1 wheeled the Med Cart to Resident #162's room and parked it outside of the room. Review of the Initial Minimum Data Set (MDS), an assessment tool dated 03/06/19, indicated Resident #33 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also showed the resident had severely impaired cognition, totally dependent on two staff members for transfer and bed mobility. The Quarterly MDS, dated [DATE], reflected the resident was totally dependent on staff for care. 2. On 09/12/19 at 11:50 AM, the surveyor noted there was a sign on the Resident #162's door which indicated to see the nurse before entering the room. There was also an isolation set-up bag (contained PPE) hanging on the resident's room door. RN #1 entered Resident #162's room to perform handwashing in the bathroom. She then exited the room. RN #1 removed a face mask and gloves from the isolation set-up bag and applied the mask and gloves. She then handed a face mask to the surveyor and indicated for the surveyor to apply the mask. The surveyor donned the mask and inquired about the isolation. RN #1 stated the resident had an urine infection. RN #1 did not wear a gown and did not state that a gown was necessary when entering Resident #162's room. RN #1 took the glucometer and above unused items (container of strips, alcohol pads, cup of lancets) from the Med Cart and entered Resident #162's room. She placed the glucometer and items on the resident's bedside table, without cleaning the table. RN #1 removed a strip from the container, opened an alcohol pad, wiped the resident's finger, inserted the strip into the glucometer, and then lanced the resident's finger to obtain blood. She collected the blood onto the strip and then placed the glucometer, with the strip containing blood, onto the resident's bedside table. During that time, the surveyor noted RN #1 leaned against the resident's bed frame and linens as she collected the blood from the resident's finger. After obtaining the blood sugar reading, RN #1 removed the strip from the glucometer and discarded the gloves and strip into the trash. She then washed her hands, picked up the container of strips, the glucometer, the remaining alcohol pads, and the cup of lancets, and walked out of the resident's room without wiping off the bedside table. RN #1 went to the Med Cart and placed the glucometer and unused items (alcohol wipes, container of strips, cup of lancets) on the top of the Med cart. She did not clean the glucometer after use or discard the unused supplies. RN #1 wheeled the Med Cart to Resident #11's room and parked it outside of the room. During the observation, the surveyor interviewed RN #1 regarding PPE use, and leaning against the resident's bed to check the blood sugar. RN #1 stated she knew Resident #162 was on contact isolation for an urine infection but she was not sure the type of infectious agent the resident had. Review of the Admission MDS, dated [DATE], showed Resident #162 had severe cognitive impairment; did not walk; required two-person assist for transfer, bed mobility, and dressing; and had limited ROM on the lower limb. The MDS also indicated the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On 09/12/19 at 12:00 PM, RN #1 took the glucometer and above unused items (container of strips, alcohol pads, cup of lancets) from the Med Cart and entered Resident #11's room. She placed the glucometer and items on the resident's bedside table. RN #1 washed her hands, donned gloves. She removed a strip from the container, opened an alcohol pad, wiped the resident's finger, inserted the strip into the glucometer, and then lanced the resident's finger to obtain blood. She collected the blood onto the strip and then placed the glucometer, with the strip containing blood, onto the resident's bedside table. RN #1 removed the strip from the glucometer and discarded the gloves and strip into the trash. She then washed her hands, picked up the container of strips, the glucometer, the remaining alcohol pads, and the cup of lancets, and walked out of the resident's room without wiping off the bedside table. RN #1 went to the Med Cart and placed the glucometer and unused items (alcohol wipes, container of strips, cup of lancets) on the top of the Med cart. She did not clean the glucometer after use or discard the unused supplies. RN #1 wheeled the Med Cart to Resident #99's room and parked it outside of the room. Review of the Quarterly MDS, dated [DATE], indicated Resident #11 was severely cognitively impaired, required two-person assistance with transfer and bed mobility, and did not walk. The MDS also showed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. On 09/12/19 at 12:05 PM, RN #1 took the glucometer and above unused items (container of strips, alcohol pads, cup of lancets) from the Med Cart and entered Resident #99's room. She placed the glucometer and items on the resident's bedside table. RN #1 washed her hands, donned gloves. She removed a strip from the container, opened an alcohol pad, wiped the resident's finger, inserted the strip into the glucometer, and then lanced the resident's finger to obtain blood. She collected the blood onto the strip and then placed the glucometer, with the strip containing blood, onto the resident's bedside table. RN #1 removed the strip from the glucometer and discarded the gloves and strip into the trash. She then washed her hands, picked up the container of strips, the glucometer, the remaining alcohol pads, and the cup of lancets, and walked out of the resident's room without wiping off the bedside table. RN #1 went to the Med Cart and placed the glucometer and unused items (alcohol wipes, container of strips, cup of lancets) on the top of the Med cart. She did not clean the glucometer after use or discard the unused supplies. RN #1 wheeled the Med Cart to Resident #25's room and parked it outside of the room. Review of the Annual MDS, dated [DATE], indicated Resident #99 was severely cognitively impaired and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS, dated [DATE], indicated the resident was in a persistent vegetative state, and dependent on staff for care. 5. On 09/12/19 at 12:10 PM, RN #1 took the glucometer and above unused items (container of strips, alcohol pads, cup of lancets) from the Med Cart and entered Resident #25's room. She placed the glucometer and items on the resident's bedside table. RN #1 washed her hands, donned gloves. She removed a strip from the container, opened an alcohol pad, wiped the resident's finger, inserted the strip into the glucometer, and then lanced the resident's finger to obtain blood. She collected the blood onto the strip and then placed the glucometer, with the strip containing blood, onto the resident's bedside table. RN #1 removed the strip from the glucometer and discarded the gloves and strip into the trash. She then washed her hands, picked up the container of strips, the glucometer, the remaining alcohol pads, and the cup of lancets, and walked out of the resident's room without wiping off the bedside table. RN #1 went to the Med Cart and placed the glucometer and unused items (alcohol wipes, container of strips, cup of lancets) on the top of the Med cart. She did not clean the glucometer after use or discard the unused supplies. Review of the Quarterly MDS, dated [DATE], indicated Resident #25 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated the resident required two-person assist for transfers and one-person assist for ADLs. On 09/12/19 at 12:22 PM, the surveyor interviewed RN #1 regarding the cleaning of the glucometer. RN #1 stated her practice was to clean the glucometer after she checked the blood sugar on all the residents. When asked how she cleaned the glucometer, RN #1 stated she used the purple top Sani-cloth (germicidal wipe) to wipe the glucometer. When asked about the facility's infection control protocol and process for cleaning the glucometer, RN #1 stated she had training and in-services on infection control, but she was not sure if she was supposed to clean the glucometer between residents or clean the glucometer after all the residents' blood sugars were completed. RN #1 did not provide further information regarding her practice of taking items room to room, setting items on the residents' bedside tables without cleaning the table, and taking items back to the Med Cart. The RN also did not provide information regarding the appropriate PPE needed to care for Resident #162. On 09/20/19 at 9:35 AM, the surveyor interviewed the first floor unit Registered Nurse Unit Manager (RN/UM) regarding the infection control protocol for Resident #162. The RN/UM stated that Resident #162 was on contact isolation precautions for [CONDITION(S)] in the sputum. She added that staff were supposed to wear a gown and gloves when going into the resident's room to provide care, such as glucose monitoring, and that they should also wear mask, gloves and gown when they suctioned the resident because of the potential for splashing during suctioning. The surveyor did not observe any other staff go into Resident #162's room. On 09/20/19 at 10:30 AM, the surveyor informed administration of the findings. On 09/20/19 at 1:30 PM, the Administrator provided a copy of the facility Blood Glucose Monitoring policy, dated 04/05/19. The policy indicated that glucomenters will be discinfected with germicidal disposable wipes before the first use of the day, cleaned between residents and before being placed in storage. Under the procedure, the policy stipulates to gather supplies that included but not limited to: manufacturer's instructions and to wipe meter clean with recommended germicidal wipes before use with resident. Review of the facility's undated, Contact Isolation Precaution policy reflected that staff should wear a mask if in close contact with resident, wear gloves when touching infective material and to wear gowns if soilage was likely. The policy also indicated that resident's linens were considered potentially contaminated. Review of Resident #162's Care Plan, dated 09/05/19, indicated the resident was on contact precautions and to wear gowns and mask when changing contaminated linens and to instruct visitors to wear disposable gloves and gown when in the resident's room. Review of the new employee Orientation Checklist, dated 09/26/18, reflected RN #1's signature showed she was educated on appropriate infection protocol. Review of an Infection Control In-Service Program, dated 03/03/19, showed the summary as Inservice given to staff on infection control in order to stop the spread of infections. Handwashing being for universal precaution. Consider all blood and body fluids as potentially infections. Always use personal protective equipment (PPE) as appropriate to the task or procedure. There was no signature by RN #1 to reflect that she attended this in-service. Review of an Infection Control In-Service Program, dated 04/16/19, showed the summary as review proper infection control measures and handwashing. RN #1 signed the in-service sheet which indicated she was in attendance. Review of an Isolation/PPD In-Service Program, dated 08/08/19, showed the summary as proper use of protective equipment. RN #1 signed the in-service sheet which indicated she was in attendance. After surveyor inquiry, the facility conducted a Glucometer In-Service Program, dated 09/12/19. The in-service summary reflected staff where educated on cleaning the glucometer between residents. RN #1 signed the in-service sheet which indicated she was in attendance. Review of an Infection Control/Glucometer Use In-Service Program, dated 09/17/19, revealed one to one education for RN #1 on the use of germicidal disposable to cleanse glucometer between patients. Allow glucometer to dry for 2 minutes after wiping with germicidal wipes (Purple Top). Continue practice throughout blood sugar regimen. Wipe with germicidal @ end of shift. Store in cart. RN #1 signed the in-service sheet which indicated she was in attendance. Review of an Infection Control In-Service Program, dated 09/19/19, showed the summary as Reinforcement of infection control practices, handwashing, cleaning of equipment, Isolation prec (precautions). RN #1 signed the in-service sheet which indicated she was in attendance. Review of a two-page undated document titled, Glucometer cleaning Instructions, provided by the Administrator, indicated glucometers should be disinfected with germicidal disposable wipes before the first use of the day, and cleaned between residents and before being placed in storage. Review of the glucometer manufacturer's instructions titled, Caring for your system, Cleaning and Disinfecting Procedures revealed the following instructions: wear gloves, use one towelette of the germicidal wipe and wipe the entire surface of the glucometer three times horizontally and vertically to clean blood and other body fluids, and dispose the used towelette. Use a new towelette, and wipe the entire surface of the glucometer horizontally and vertically three times to remove blood-borne pathogens, and to allow one minute contact time for disinfectant before proceeding to the next resident. 6. On 10/02/19 at 11:55 AM, the surveyor observed RN #1 on the first floor unit perform a fingerstick on Resident #76. RN #1 washed her hands, donned gloves and then used a lancet to obtain blood for the glucometer. After obtaining the blood sample, RN #1 removed her gloves, washed her hands and then brought the glucometer to the Med Cart where she placed it on top of the Med Cart. RN #1 donned a gloves, removed a germicidal wipe from the purple top container and wiped down the surface of the glucometer once. Review of an Admission MDS, dated [DATE], indicated Resident #76 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was not able to be interviewed due to the presence of the [CONDITION(S)]. 7. On 10/02/19 at 12:05 PM, the surveyor observed RN #1 perform a fingerstick on Resident #25. RN #1 washed her hands, donned gloves and then used a lancet to obtain blood for the glucometer. After obtaining the blood sample, RN #1 removed her gloves, washed her hands, and then brought the glucometer to the Med Cart where she placed it on top of the Med Cart. RN #1 donned one glove to the right hand, removed a germicidal wipe from the purple top container and wiped down the surface of the glucometer once. 8. On 10/02/19 at 12:10 PM, the surveyor observed the RN #1 take the glucometer and lancet to the room of Resident #33 and set the items on the resident's bedside table without cleaning the table. After lancing the resident's finger, she obtained blood onto the strip which was inserted into the glucometer. RN #1 placed the glucometer onto the bedside table and read the result of the blood sugar. She removed her gloves, cleaned her hands, and then took the glucometer to the Med Cart, where she placed it on the top of the Med Cart. RN #1 donned gloves, removed a germicidal wipe from the purple top container and wiped down the surface of the glucometer once. RN #1 did not wipe the Resident #33's bedside table afterwards. 9. On 10/02/19 at 12:15 PM, the surveyor observed RN #1 perform a fingerstick on Resident #34. RN #1 washed her hands, donned gloves and then placed the glucometer on the resident's bedside table, without cleaning the table first. After lancing the resident's finger RN #1 picked up the glucometer from the bedside table, collected the blood on the strip and then placed the glucometer with the blood on the strip back on to the bedside table. After reading the blood sugar result, she removed the strip and her gloves and discarded into the trash. RN #1 washed her hands and then took the glucometer to the Med Cart, where she placed it on top of the Med Cart. RN #1 donned gloves, removed a germicidal wipe from the purple top container and wiped down the surface of the glucometer once. RN #1 did not wipe the resident's bedside table afterwards. Review of the Quarterly MDS, dated [DATE], indicated Resident #34 was severely cognitively impaired, and totally dependent on staff for all ADLs. The MDS also showed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . When interviewed on 10/02/19 at 12:11 PM, RN #1 stated she did not touch the residents bedside tables and did not need to clean them. She did not offer an explanation for not following manufacturer's instructions for cleaning the Glucometer. 10. On 10/02/19 at 11:35 AM, the surveyor observed the Licensed Practical Nurse (LPN) #1 on the fourth floor unit, ask Resident #111 to go inside a room, located across the hall from the dining room, and wait for a fingerstick. LPN #1 removed the glucometer from the top drawer of the Med Cart, cleaned the surface of the glucometer with a germicidal wipe from the purple top container once, and went into the storage room, where the resident was seated in his/her wheelchair and waiting. The LPN #1 performed the fingerstick but was unable to obtain a blood sugar reading for Resident #111 from that glucometer. She placed the used glucometer on top of a box containing 8 ounce cups. When interviewed at 11:45 AM, the nurse stated the glucometer was broken, and that she needed to get another one. She also stated that she used the room for privacy and the doctor had used that room before to examine residents. The surveyor observed that the room contained a weighing scale and various unopened boxes that contained items such as medicine and water cups. LPN #1 obtained another glucometer from another nurse and wiped the glucometer once with a purple top germicidal wipe. She then went back into the storage/exam room where she performed Resident #111's fingerstick. LPN #1 took the two glucometers and exited the room and placed both glucometers inside the top drawer of the Med Cart without cleaning and disinfecting the glucometers. During a follow-up interview on 10/02/19 at 11:55 AM, LPN #1 stated she was supposed to clean the glucometer before and after use. She stated she forgot to clean the glucometers before placing them in the Med Cart. When asked about the process for cleaning and disinfecting the glucometer, she stated they were supposed to wait about 1-2 minutes after cleaning and disinfecting the glucometer before using. LPN #1 could not state the steps for the cleaning and disinfecting as outlined in the glucometer manufacturer's instructions. During an interview on 10/02/19 at 12:10 PM, with the fourth floor RN Unit Manager, she stated that nurses were supposed to clean the glucometer before and after use, with the purple top germicidal wipes, and to wait 2-3 minutes after cleaning the glucometer before using on the next resident. Review of the Admission Record (AR) reflected Resident #111 was admitted to the facility with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 11. On 10/02/19 at 11:53 AM, the surveyor observed the second floor LPN #2 perform a fingerstick on Resident #313. The LPN used an alcohol based hand sanitizer (ABHS) to cleanse her hands and then donned gloves. She cleaned the glucometer once with the purple top germicidal wipe and then placed it on a tissue barrier on top of the Med Cart. She allowed the glucometer to dry for two minutes. LPN #2 then removed a lancet and a test strip from the top drawer of the Med Cart. She used ABHS to cleanse her hands, and donned gloves. The surveyor entered the resident's room with LPN #2 and observed her perform the fingerstick. When she finished, LPN #2 removed her gloves and washed her hands. She donned gloves and wiped the glucometer once with the purple top disinfectant wipe and then placed the glucometer on a tissue barrier on top of the Med Cart. Review of the Admission MDS, dated [DATE], indicated Resident #313 had severe cognitive impairment and required two-person assistance with all ADLs. Review of the AR reflected Resident #313 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/02/19 at 12:15 PM, the surveyor interviewed the second floor unit RN #2 about the process for cleaning the glucometer. RN #2 stated she would wash her hands, don gloves gather all needed supplies, wipe the entire surface of the glucometer with the purple top germicidal wipe, and allow to air dry, before performing the fingerstick. RN #2 did not describe the entire process for cleaning and disinfecting the glucometer as described in the manufacturer's instructions. On 10/2/19 at 12:30 PM, the surveyor interviewed RN #3 on the second floor, and asked him about the process for glucometer use and cleaning. RN #3 stated he would cleanse his hands, don gloves, wipe off the glucometer with the purple top germicidal wipe and allow to air dry before using. He added that he would clean the glucometer again with the purple top germicidal wipe and allow to air dry at least 3-5 minutes after use and before storing. RN #3 did not describe the glucometer cleaning and disinfection process as outlined in the manufacturer's instructions. 12. On 10/02/19 at 11:33 AM, the surveyor observed RN #4 on the third floor as she performed a fingerstick on Resident #56. RN #4 donned gloves, removed a germicidal wipe from the purple top container and wiped the glucometer once. She then placed the glucometer inside a plastic cup to dry. She held the cup in her hand and after a minute, RN #4 removed the glucometer from the cup, inserted a strip into the glucometer, donned new gloves, and performed a fingerstick on Resident #56. After checking the blood sugar, she washed her hands, donned gloves and wiped the glucometer once with a purple top germicidal wipe before immediately placing the glucometer into the Med Cart. Review of the Quarterly MDS, dated [DATE], showed Resident #56 was severely cognitively impaired, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 13. On 10/02/19 at 12:08 PM, the surveyor observed RN #4 as she performed a fingerstick on Resident #32. RN #4 donned gloves and wiped the residents overbed table. She then changed gloves and cleaned the glucometer with one purple top germicidal wipe. With gloved hands, RN #4 gathered the blood sugar supplies on a tissue. She took with tissue with the supplies on it and placed them on the resident's bedside table. She removed her gloves, washed her hands, donned new gloves, and performed the fingerstick. When she was finished, she changed her gloves, without performing hand hygiene, and wiped the glucometer once with a purple top germicidal wipe before she immediately placed the glucometer into the Med Cart. On 10/02/19 at 12:30 PM, the surveyor interviewed RN #4 who stated she was an as needed nurse and had been working at the facility for about nine months. When interviewed about the steps in cleaning the glucometer, RN #4 stated her practice was to wipe the glucometer with a purple top germicidal wipe before and after use. She did not describe or perform the glucometer cleaning and disinfection process as outlined in the manufacturer's instructions. RN #4 stated she received an in-service a few times on how to take blood sugars. She stated she knew the glucometer was multi-use and was used for all residents, except if a resident was on isolation; in which case they would have their own glucometer. The RN did not explain where she got the information about a resident having their own glucometer when on isolation. RN #4 did not describe or perform the glucometer cleaning or disinfection process as outlined in the manufacturer's instructions. Review of the Admission MDS, dated [DATE], indicated Resident #32 had severe cognitive impairment and required extensive assist for bed mobility and transfer. The MDS also showed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/02/19 at 4:25 PM, the surveyor interviewed the Director of Nursing (DON), who stated the facility's Infection Preventionist (IP) resigned on Friday 09/27/19 and that she was in charge of infection control until they appoint a new IP. When questioned about the process for glucometer cleaning, she stated, they follow their policy. When asked about PPE and taking items from room to room, she stated staff should wear appropriate PPE when entering isolation rooms and should wipe bedside tables before and after use. Items should not be taken room to room. This deficiency is continued at a scope and severity of a Level E: B. Based on observation, interview, record review, it was determined that the facility failed to a.) change oxygen tubing weekly to prevent respiratory infections for Resident #38, 1 of 5 residents reviewed for oxygen. This deficient practice was evidenced by the following: On 09/12/19 at 11:41 AM, the surveyor observed Resident #38 seated in a reclining chair in his/her room. The resident had a [CONDITION(S)] with a [CONDITION(S)] collar (an oxygen delivery system to provide oxygen to a [CONDITION(S)]). There was blue tubing from the oxygen concentrator that lead to the [CONDITION(S)] collar. In the center of the tubing was a small clear bag to collect the condensation that developed from the humidity. On the clear collection bag, the date 07/29/19 was written in black marker. Review of the Annual MDS, 06/23/19, it showed the resident had severe cognitive impairment. The MDS indicated the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was identified as needing two-person physical assistance for bed mobility and transferring from the bed, and into a chair. The resident was also identified as requiring one-person physical assistance for all other ADLs. On 09/12/19 at 12:35 PM, the surveyor observed the date on the oxygen tubing reflected the date 07/29/19. During an interview conducted by the surveyor, the Licensed Practical Nurse (LPN) stated the [CONDITION(S)] oxygen tubing was supposed to be changed weekly. When the surveyor showed the LPN the oxygen tubing dated 07/29/19, the LPN stated the tubing should have been changed. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/19/19 at 1:50 PM, the surveyor reviewed the facility's oxygen policy, dated 12/2018. The policy stated that all oxygen tubing was to be changed every seven days and as needed. NJAC 8:39-19.4