Every finding on record at Brighton Gardens of Edison

Based on observation, interviews, and review of facility documentation it was determined that the facility failed to a.) handle, clean and sanitize dishware in a manner to prevent microbial growth and cross contamination, and b.) wear hair restraints to maintain proper kitchen sanitation. This deficient practice was evidenced by the following: On 10/10/24 at 9:22 AM, the surveyor entered the kitchen with a second surveyor. The surveyors observed a staff member at the dish machine without a hair restraint. At 9:35 AM, the surveyors began the kitchen tour with the Dining Director. The surveyors observed the same staff member (now with a hair restraint worn) load the dish machine with soiled dishware and bare hands. He then removed clean bowls from the clean side of the dish machine without performing hand hygiene and glove application. The Dining Director acknowledged that the staff member should have washed his hands and applied gloves prior to removing clean dishware from the dish machine to prevent cross contamination. She stated that there was usually one dishwasher that worked the soiled side and one dishwasher on the clean side of the dish machine. A review of the facility's policy Food Safety and Seniors - Additional Food Safety Tips dated 2015, included Restrain hair in food preparation areas. A review of the facility's policy Dishwashing Procedure dated 11/19/2019, included Objective: Participants will understand the correct dishwashing procedures .; Either two people are in the dish room, one on the dirty side, one on the clean side. If one person does both, they must wash their hands between dirty and clean areas . A review of the facility's policy Proper Handwashing dated 8/16/23, included Hands must be washed: . After contact with unsanitary surfaces i.e. soiled dishes . A review of the facility's policy Food Safety and Seniors - Facts About Handwashing dated 2015, included When to Wash Your Hands . After washing dirty dishes. A review of the facility's policy Food Safety and Seniors - Four Steps to Food Safety dated 2015, included Wash and sanitize . to prevent cross contamination. A review of the facility's policy Food Safety and Seniors dated 2015, included Objective: to recognize the consequences of unsafe food practices and identify ways to prevent foodborne illness. Be sure to: . Avoid cross contamination. A review of the Dishwasher Job Description, dated November 2023, included The Dishwasher is responsible for cleaning and janitorial duties . while adhering to all food safety and sanitation requirements and maintaining a safe and orderly kitchen. Performs dishwashing tasks to properly wash and sanitize all dishes and china, silverware, glassware, utensils and cookware. N.J.A.C 18:39-17.2(g)

Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete reference checks on employees before their start date. The deficient practice was identified for 5 of 6 employees reference checks reviewed under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by the following: On 10/15//24, the surveyor reviewed six employee files of employees hired since the last standard survey which revealed that five of the six did not have reference checks done prior to the start of employment. RN #1, date of hire 12/4/23 LPN (Licensed Practical Nurse) #1, date of hire 9/5/23 LPN #2, date of hire 8/17/23 LPN #3, date of hire 1/30/24 Housekeeper#1, date of hire 11/20/23 On 10/15/24, the surveyor requested the reference checks on the above employees. On 10/16/24 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) who stated that he was unable to provide the reference checks at this time. He further stated that they used to be handwritten but now are on an electronic system. He acknowledged that the reference checks should be readily available. On 10/16/24 at 12:32 PM, the surveyor interviewed the Human Resources Director and the Administrator, who stated that they do reference checks on newly hired employees. They use a software program that requests electronically references from the previous places of employment. They were stored in one software program but were moved to another software program. They stated that was why they couldn't retrieve the reference checks. The Administrator further stated that she understood and stated we should be able to print them out. A review of the facility's policy Employment Verifications and Backround checks reviewed 5/16/24, revealed: 4.1 Background Check Components: .Prior Employment Verificaition confirms applicant's employment with the provided companies, includeing dates of employments, position held .performance ratings, reason for departure and eligibility for rehire. This generally will be run on past two employers or past five years, which ever is most recent. N.J.A.C. S 8:39-9.3(b)

Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to notify the resident and or resident representative in writing of the reason for transfer or discharge to the hospital for 2 of 2 residents (Resident #8 and Resident #173) reviewed for hospitalization . This deficient practice was evidenced by the following: 1.) On 10/11/24 at 9:52 AM, the surveyor observed Resident #8 out of bed in a high back wheelchair in the common area with activities. On 10/11/24, the surveyor reviewed the Electronic Medical Record (EMR) which indicated that Resident #8 was admitted to the facility for long term care. Further review showed there was a Discharge/Return Anticipated MDS completed on 5/16/24 following a transfer to the hospital for treatment of a sacral wound. The surveyor review of the Admission Record indicated Resident #8 had medical diagnosis which included but were not limited to; stage 4 pressure ulcer of the sacral region and osteomyelitis (an infection of the bone). A review of the annual Minimum Data Set (MDS), an assessment tool, dated 8/26/24, revealed a Brief Interview for Mental Status (BIMS) score of 9 out 15, indicating moderate cognitive impairment. The surveyor reviewed the progress notes which revealed that on 5/16/24 at 7:30PM, Resident #8 was transferred to the Hospital. On 10/15/24 at 10:13AM, the surveyor asked the Director of Nursing (DON) for the location of the family and ombudsman notification of hospitalization . He stated the family notification is in the progress notes. On 10/16/24 at 9:17AM, the surveyor was unable to locate written notifications to the resident or family for the reason of transfer in the medical records. On 10/16/24 at 9:51 AM, in the presence of the survey team, the Social Service Coordinator, and the Licensed Nursing Home Administrator (LNHA), the LNHA stated when a resident was hospitalized , a written notice goes to the hospital with the resident's transfer paperwork. The LNHA further stated in most cases the facility retains a copy; however, in this case they did not have a copy to provide to the surveyor. 2. On 10/10/24 at 11:19 AM, during the initial tour, the surveyor observed Resident #173 in bed with their eyes closed. The resident's family member was at the bedside and stated the resident had just been readmitted to the facility. The surveyor reviewed the electronic medical record (EMR) for Resident #173. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; end stage renal disease (the kidneys can no longer function properly) and dependence on renal dialysis (a renal replacement therapy that removes waste and excess fluids from the blood). A review of the progress notes revealed: 10/4/2024 08:01 COMMUNICATION - with Physician - Narrative Note Text: Nephrologist called at 7:30 AM 10/04/2024 .requested that [identifier redacted] be sent to hospital for evaluation .Dr. (doctor) and Son [name redacted] were both notified of the situation. Further review of the medical record, did not revealed written notification of reason for transfer to the resident or family. On 10/16/24 at 11:52 AM, the Director of Nursing (DON) provided a copy of Skilled Nursing Facility Notice of Transfer for Resident # 173. The letter dated was 10/4/24. The DON stated the letter was sent with the resident to the hospital. He was unable to verify if a copy was sent to the family/representative or if a copy was given to the resident. On 10/16/24 at 12:31 PM, in the presence of the survey team, the DON confirmed a written copy of the notification of hospitalization was not sent to the family or given to Resident #173. Review of facility provided policy Transfer, Discharge & Bed-Hold Notices reviewed 5/16/24,included: 4. The Social Service Coordinator/designee will complete the following steps before the community transfers or discharges a resident (voluntary or involuntary): a. Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move, in writing and in a language and manner they understand. NJAC 8:39-4.1(a) 31 41858

Based on observation, interview, and record review, it was determined that the facility failed to obtain an admission weight for 1 of 3 residents, Resident # 173, reviewed for nutrition. This deficient practice was evidenced by the following: On 10/10/24 at 11:19 AM, during the initial tour, the surveyor observed Resident #173 in bed with their eyes closed. The resident's family member was at the bedside and stated the resident had just been readmitted to the facility. The surveyor reviewed the electronic medical record (EMR) for Resident #173. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; end stage renal disease (the kidneys can no longer function properly) and dependence on renal dialysis (a renal replacement therapy that removes waste and excess fluids from the blood). A review of the admission Minimum Data Set, an assessment tool, dated 10/8/24, revealed it was in progress. A review of the individual comprehensive care plan (ICCP) revealed: FOCUS: .resident has nutritional problem or potential nutritional problem r/t (related to) wound and current dx. (diagnosis) Date Initiated: 10/10/2024. Goal: [name redacted] will consume at least 75-100% of meals and supplements offered resulting in stable weight and wound improvement over next 30 days. Date Initiated: 10/10/2024. The surveyor reviewed both the EMR and paper chart for the resident's admission weight. There was no documented readmission weight taken by the facility in the resident's medical record. The last weight entry was 9/26/2024 at 12:28 PM. A review of the progress notes revealed the Registered Dietician's (RD) progress note: 10/10/2024 12:01 PM Type: Nutrition/Dietary Note . Resident known from previous admission .Updated weight pending . RD from dialysis center to be in contact with community dietitian .RD will continue to follow up. On 10/15/24 at 10:32 AM, the surveyor interviewed the RD, who stated a resident's weight should be obtained within 24 hours of admission. He stated he completes the nutrition section on the Service Evaluation and Health Assessment (SEHA) for all new admissions. He stated the purpose of the admission weights was for a baseline weight. The RD reviewed the SEHA for Resident #173 in the presence of the surveyor and acknowledged a new admission weight was not used. He acknowledged the weight from 9/26/24 was used. He further reviewed the EMR and confirmed he was unable to find a new admission weight for the resident. He stated if there was not an admission weight, he would ask the nurse. He stated he had told the nurse but was unable to say when or who he told. On 10/15/24 at 10:50 AM, the surveyor interviewed Resident #173's assigned Certified Nursing Assistant (CNA), who stated the residents should have been weighed yesterday (Monday) but the resident did not want to get out of bed. On 10/15/24 at 10:53 AM, the surveyor interviewed Resident #173's assigned Licensed Practical Nurse (LPN), who stated new admission should be weighed upon admission and then in 3 days. She stated weights should be done usually within 24 hours so you know the parameters. The LPN reviewed the EMR in the presence of the surveyor and acknowledged the last entered weight was 9/26/24. On 10/15/24 at 11:10 AM, the surveyor interviewed the Director of Nursing (DON) and the Assistant DON (ADON). The DON stated new admissions should be weighed within 24 hours, and then weekly x 4 weeks. He then stated all weights would be in the EMR. The DON reviewed the EMR for Resident #173 in the presence of the surveyor. He acknowledged that a new admission weight was not entered. He reviewed the SEHA, effective date 10/8/24, completed by the RD and acknowledged the RD should not have used the weight from 9/26/24. He then stated, We missed the admission weight. He stated our policy is to weigh them (the residents) ourselves and if a weight was not obtained the reason should be documented. On 10/15/24 at 1:18 PM, in the presence of the survey team, the Licensed Nursing Home Administrator and the DON were made aware of the above concerns. A review of the facility's policy Nutrition & Weight Management Program reviewed 5/16/24, revealed: Goal: The Goal of this program is to evaluate residents .prevent unanticipated weight gain or loss .Section 2: .Weight Monitoring: Ongoing weight is integral to the plan to manage the resident's weight: Residents are upon admission, weekly for 4 weeks, then monthly to evaluate trends or in accordance with physician's orders .All weights are recorded int the resident's electronic health record. NJAC 8:39-11.2(e), 17.1(c), 27.1(a)

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation performed on 10/11/24, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 27 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.41 %. This deficient practice was identified for two (2) of four (4) residents, (Resident #12 and #13), that were administered medications by one (1) of two (2) nurses (Licensed Practial Nurse (LPN #1). The deficient practice was evidenced by the following: 1. On 10/11/24 at 9:27 AM, during the medication pass, the surveyor observed LPN #1 preparing to administer five (5) medications to Resident #12 which included one 81 milligram (MG) chewable tablet of Aspirin. LPN #1 stated that the resident had a physician's order (PO) for Aspirin 81 MG according to the electronic medication administration record (eMAR). LPN #1 also stated that the Aspirin 81 MG tablets were a house stock over the counter (HS/OTC) medication, meaning that the facility purchased a bottle to be used for any resident that had a PO. LPN #1 stated that the Aspirin was a chewable tablet and was the only formulation of Aspirin 81 MG in the medication cart. On 10/11/24 at 9:32 AM, the surveyor observed LPN #1 administer the Aspirin chewable tablet to Resident #12 and told the resident to chew the tablet. On 10/11/24 at 9:46 AM, after the surveyor observed LPN #1 administer an Aspirin EC (enteric coated) 81 MG tablet to Resident #13, LPN #1, with the surveyor, reviewed the eMAR for Resident #12 which revealed a PO for Aspirin EC 81 MG which was the same PO for Resident #13. LPN #1 explained that Resident #13 had their Aspirin EC 81 MG tablets packaged by the provider pharmacy and labeled for them and had not had to use the HS/OTC. LPN #1 acknowledged that the PO for Resident #12 was for Aspirin EC 81 MG tablets and that he had administered Aspirin 81 MG chewable tablets. (ERROR #1) On 10/11/24 at 10:33 AM, the surveyor interviewed LPN #1, in the presence of the Assistant Director of nursing (ADON). LPN #1 stated that there were no bottles of Aspirin EC 81 MG in the medication room where the backup supply of HS/OTC medications were stored. The ADON stated that if the PO was for Aspirin EC 81 MG and there was not any available, then the physician had to be called and the order changed to chewable. LPN #1 stated, It was already administered. The surveyor reviewed the medical record for Resident #12. A review of the Admission Record revealed diagnoses which included but not limited to; dementia and acute ischemic heart disease (heart problems caused by narrowed heart (coronary) arteries that supply blood to the heart muscle). A review of the October 2024 Order Summary Report revealed a PO with an order date of 10/1/24 for Aspirin EC tablet delayed release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for CAD (coronary artery disease)(a narrowing or blockage of the coronary arteries). A review of the October 2024 electronic medication administration record (eMAR) revealed a PO with a start date of 10/2/24 for Aspirin EC tablet delayed release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for CAD. On 10/11/24 at 11:53 AM, the surveyor interviewed the Health Information Coordinator (HIC), who stated she was responsible for ordering the HS/OTC medications. The HIC stated that she was aware of what had happened this morning, meaning that there were no Aspirin EC 81 MG tablets available. The HIC stated that she usually ordered by visualizing what was low in the medication room where the HS/OTC medications were stored or what she was told by the nurses. The HIC added that she was just given a list of what HS/OTC medications the facility were to keep on hand and would now check the list against what was on hand. A review of the facility Stock List provided by the Director of Nursing (DON) reflected that Aspirin EC 81 MG 100 ct (count) was on the list as a HS/OTC medication. On 10/11/24 at 2:00 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone, who stated that Aspirin EC and Aspirin chewable were the same drug but not the same formulation and that one could not be substituted for the other. The CP added that the chewable formulation is absorbed in the stomach and that the EC formulation was absorbed in the intestine. The CP also stated that he had completed medication observations but had not completed an inservice on medication pass. On 10/15/24 at 9:08 AM, the surveyor interviewed the DON, who stated that he had completed a Medication Skill Capability Evaluation Checklist on 12/27/23 for LPN #1 which was a comprehensive medication pass observation. The DON also stated that Aspirin EC 81 MG was a HS/OTC medication but was not available on 10/11/24 and was obtained after the surveyor performed the medication administration observation. The DON acknowledged that if the Aspirin EC was not available then the physician was to be called and asked to switch to what was on hand. The DON added that the nurses were inserviced on the specific issue of what to do if a medication was not available and to make sure the correct HS/OTC was available. On 10/15/24 at 1:29 PM, the survey team met with the Licensed Nursing Home Administrator and the DON. The DON stated that the Aspirin EC 81 MG tablets were obtained on 10/11/24 after the surveyor performed the medication administration observation. A review of the manufacturer specifications for Aspirin included, but was not limited to, Aspirin is available in different formulations such as film-coated, enteric coated and chewable. In addition, the specifications reflected that Film-coated, extended-release, or enteric-coated may be associated with less GI irritation and/or symptomatic GI disturbances than uncoated tablets. 2. On 10/11/24 at 9:34 AM, during the medication pass, the surveyor observed LPN #1 preparing to administer nine (9) medications to Resident #13 which included Polyethylene Glycol 3350 (PEG3350) (a medication used to relieve constipation). LPN #1 stated that according to the eMAR the dose of PEG3350 was 17 grams (GM). LPN #1 added that sometimes the provider pharmacy sent 17 GM packets, but that Resident #13 had a labeled bulk powder bottle that was sent by the provider pharmacy and that he had to measure the 17 GM. At that time, the surveyor observed LPN #1 pour the PEG3350 powder into a 30 milliliter (ML) medication cup. LPN #1 stated that he was filling the medication cup up to 17 ML, which was an estimate between the 15 ML mark and the 20 ML mark on the medication cup. On 10/11/24 at 10:16 AM, the surveyor interviewed LPN #1, who stated that he thought 17 GM was the same as 17 ML. LPN #1 added that it was easier to use the 17 GM premade packets. LPN #1, in the presence of the surveyor, removed the resident's bulk bottle of PEG3350 from the medication cart and reviewed the label which revealed the instructions for use were to Use the measuring line on the bottle cap to measure a single dose (about 1 heaping tablespoon). (ERROR #2) At that time, LPN #1 removed the cap of the PEG3350 bottle and stated that there was a designation for 17 GM to be measured in the cap. LPN #1 then stated that he was unsure if the 17 ML that he had measured in the medication cup would be the same as the 17 GM measurement indicated on the cap of the PEG3350 bottle. On 10/11/24 at 10:19 AM, the surveyor observed LPN #1 measure 17 GM of PEG3350 from the resident's bulk bottle in a 30 ML medication cup as he had previously done by estimating 17 ML, and poured the measured 17 ML powder into a clear plastic 8-ounce cup. Then, LPN #1 poured a 17 GM packet of PEG3350 powder into another clear 8-ounce cup and put the two cups side by side. LPN #1 stated that he was unsure if they were the same but thought the two cups were close to the same amount. On 10/11/24 at 10:26 AM, the surveyor, in the presence of another surveyor, with LPN #1, showed the two clear cups of PEG3350 that were measured by LPN #1 to the ADON. The ADON stated that the plastic cup with the 17 GM packet measured a little more than the plastic cup with the 17 ML measured PEG3350 powder. LPN #1 explained that he had measured 17 GM of the bulk PEG3350 powder in a medication cup and had to make an estimation of 17 ML between the 15 ML mark and the 20 ML mark. At that time, the surveyor with the ADON reviewed the label on the PEG3350 bulk powder bottle which revealed Use the measuring line on the bottle cap to measure a single dose (about 1 heaping tablespoon). The ADON stated that the manufacturer instructions for measuring were to be followed for an accurate dose. The surveyor reviewed the medical record for Resident #13. A review of the Admission Record revealed diagnoses which included but were not limited to; gastro-esophageal reflux disease without esophagitis (stomach acid rises into the esophagus chronically), muscle weakness and difficulty in walking. A review of the October 2024 Order Summary Report reflected a PO with an order date of 10/3/24 Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)) Give 17 GM by mouth in the morning for constipation. A review of the October 2024 eMAR revealed a PO with a start date of 10/4/24 Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)) Give 17 GM by mouth in the morning for constipation. On 10/11/24 at 2:00 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone, who stated that the manufacturer instructions should be followed for measuring PEG3350 powder from the bulk bottle for an accurate dose. On 10/15/24 at 9:08 AM, the surveyor interviewed the DON, who stated that he had completed a Medication Skill Capability Evaluation Checklist on 12/27/23 for LPN #1 which was a comprehensive medication pass observation. The DON also stated he was aware that the PEG3350 was inaccurately measured using a 30 ML medication cup. A review of the manufacturers' specifications for PEG3350 reflected to Follow all directions on your prescription label. In addition, the specifications reflected to use the powder form of this medicine, measure your dose with the medicine cap on the bottle. This cap should contain dose marks on the inside of it. A review of the facility policy titled Medication Administration dated January 2023 provided by the DON revealed that Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing and principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Also, the policy revealed for the medication administration procedure that Medications are administered in accordance with written orders of the prescriber. In addition, the policy revealed for the medication administration procedure that Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart b. When dose is pulled c. Before dose is administered. NJAC 8:39-11.2(b), 29.2(d), 29.4(c)

Based on interviews, record review, and review of pertinent documents, it was determined that the facility failed to protect a resident (Resident #31) from verbal abuse by a Certified Nurse Aide (CNA #1) by failing to ensure: a.) the facility policy was followed to identify an allegation of abuse, b.) that upon receiving an allegation of abuse on 6/20/23 during the 7:00 AM to 3:00 PM shift, the facility immediately protected Resident #31, and other residents from potential abuse, and c.) a thorough investigation was immediately initiated. This deficient practice occurred for 1 of 3 residents reviewed for abuse. The facility's failure to ensure the abuse policy was followed to protect a resident from abuse and ensure a process was in place to protect all residents from potential abuse resulted in an Immediate Jeopardy (IJ) situation that began on 6/22/23 when a fell ow resident (Resident #15) informed the surveyor that CNA #1 on 6/19/23 the CNA was rude to my roommate and it's cruel to scream at Alzheimer's patient (Resident #31), and the facility failed to immediately initiate an investigation and CNA #1 proceeded to work on the same resident unit that day, 6/20/23, and was assigned to ten residents as well as being scheduled to work on 6/22/23. The facility administration was notified of the IJ situation on 6/22/23 at 5:56 PM. The facility submitted an acceptable removal plan on 6/23/23 at 4:30 PM. On 6/23/23 at 4:30 PM, the removal plan was verified as implemented by the survey team during the survey. The evidence is as follows: On 6/22/23 at 11:30 AM, during Resident Council Interview, Resident #15 informed the surveyor on 6/19/23 that CNA #1 had dropped flowers in a vase belonging to Resident #15. Resident #15 explained to CNA #1 that the flowers had special meaning and that Resident #15 would like the flowers put back into the vase. As per Resident #15, CNA #1 responded, Who cares? They're dead anyway. Resident #15 further described that CNA #1 aggressively threw their roommate's (Resident #31) call bell onto the roommate's bed and was verbally abusive toward the roommate. Resident #15 explained to the surveyor that they felt frightened and alerted the Director of Nursing (DON) the following morning, 6/20/23. On 6/22/23 at 12:15 PM, the surveyor reviewed the Electronic medical records (EMAR) for Residents #31 and #15. Resident #31's EMAR revealed the resident had diagnoses including but not limited to: Alzheimer's Disease, Dementia, Depression, and Other Specified Fracture of the Left Pubis. An assessment for Resident #31's cognition called Brief Interview for Mental Status (BIMS) Skilled, completed on 6/17/23, revealed that Resident #31 had a BIMS score of 0, which shows the resident has a severe impairment with mental cognition. The Admission Minimum Data Set, an assessment tool dated 6/19/23, revealed that Resident #31 was totally dependent on one person for bed mobility, transferring, toileting, dressing, and personal hygiene and had no behavioral symptoms. Resident #15 EMAR revealed the resident had diagnoses which included but was not limited to: Periprosthetic Fracture around Internal Right Hip Joint, muscle Weakness, and Aftercare following Joint Replacement Surgery. An assessment for Resident #15's cognition called Brief Interview for Mental Status (BIMS) Skilled, completed on 6/10/23, revealed that Resident #15 had a BIMS score of 15, which shows the resident is cognitively intact with mental cognition. On 6/22/23 at 2:15 PM, the surveyors interviewed the DON, who stated the facility did not have any reportable events for the month of June but remembered Resident #15 informing him of the incident. The DON stated he does not handle these investigations and informed the Social Worker (SW), who investigated the abuse incident as a grievance. CNA #1 continued to be scheduled to work one full shift of 10+ resident assignments on 6/20/22 and was scheduled to work on 6/22/23. On 6/22/23 at 2:30 PM, the SW provided the survey team with a copy of the grievance report. The SW stated her investigation still needed to be completed. The report includes a copy of statements made by Resident #15 and CNA #1 and a copy of the CNA #1 resident assignment sheet for the 3-11 PM shift, including both Resident #15 and #31. On 6/22/23 at 3:00 PM, the survey team interviewed the DON and SW, who agreed that the Licensed Nursing Home Administrator (LNHA) was unaware of the incident. On 6/22/23 at 4:00 PM, the survey team interviewed LNHA, who stated, The incident should have been reported to the NEW Jersey Department of Health (NJDOH), investigated, and the CNA should have been suspended pending the investigation. A review of the facility policy titled, Abuse, Neglect & Exploitation - prevention, Reporting and Investigation, Effective Date: 5/31/16 revealed under the Action Steps section 2, subsection a) All team members are mandated reporters and are required to report allegations or a known episode of abuse, neglect and/or exploitation to applicable state authorities within the time frame established by law. h) Steps to take to ensure the safety and protection of residents in situations of known or suspected abuse, neglect and/or exploitation, including escalation to the Executive Director/designee. Section 8 The SNA/designee, subsection b) Removes the individual alleged to be involved in the abuse, neglect or exploitation from the area, part i. Ensures that any team member alleged to be involved in the abuse, neglect or exploitation is placed on administrative leave, pending the results of the investigation. c) Ensures that the resident's (i) physician, (ii) legal representative and (iii) family member or other individual regularly involved in the resident's day to day care are notified as soon as practicable within timeframes established within laws/regulations. On 6/27/23 at 10:00 AM, the surveyor met with LNHA, which stated that the facility should have reported the abuse to the New Jersey Department of Health (NJDOH), the allegation was made, and per the facility policy, an investigation should have begun as well as the CNA #1 being suspended until the outcome of the investigation was reached. The LNHA also stated the DON and SW were going through retraining on abuse and reporting as part of the plan of correction. N.J.A.C. 8:39-4.1 (a)5,12; 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to treat a resident in a dignified manner. This deficient practice was identified for 1 of 1 resident observed for pressure ulcer wound dressing change, Resident #14. On 6/19/23 at 12:27 PM, the surveyor observed Resident #14 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor further observed that the resident had a dressing to the right foot. On 6/21/23 at 9:35 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform wound care to the right heel of Resident #14. At the conclusion of the wound care, the LPN taped the dressing and then proceeded to write her initials including the date 6/21/23, on the tape after it had been applied to the resident. The LPN stated to the surveyor that it was her practice to initial the tape for the other staff to know when the wound care was performed. The surveyor reviewed Resident #14's medical record. The Admission Record reflected that Resident #14 was admitted to the facility on [DATE] with medical diagnoses which included but not limited to, Atrial Fibrillation, Type 2 Diabetes Mellitus, Anemia, and Hypertension. A review of the Admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 6/2/23 reflected that the resident had a Brief Interview for Mental Status of 15 out of 15, indicating that the resident was cognitively intact. A review of the June 2023 Physician Order Summary revealed a physician's order dated 6/20/23 for Santyl External Ointment 250 unit/gm (Collagenase) Apply to right heel topically two times a day for wound treatment cleansed with Daikin solution cover with dressing. A review of the facility's Policy and Procedure titled, Skin Care & Pressure Ulcer Management Program did not specifically indicate the procedures of wound dressing changes. On 6/21/23 at 2:05 PM, the surveyor met with the facility's Licensed Nursing Home Administrator, Director of Nursing, Senior Director of Nursing Services, and Associate Executive Director to discuss the above concerns. There was no additional information provided. On 6/21/23 at 2:05 PM, the surveyor met with the facility's Licensed Nursing Home Administrator, Director of Nursing, Senior Director of Nursing Services (SDNS), and Associate Executive Director. The SDNS stated to the surveyor that nurses should not sign and date the dressing on the resident once the surgical dressing has been applied on the resident. The SDNS added that the surgical dressing should be signed and dated prior to applying it on the resident. There was no additional information provided. N.J.A.C. 8:39-4.1, 12

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident verbal abuse. This deficient practice was identified for 1 of 3 reportable investigations reviewed, involving Resident #31 and Resident #15. This deficient practice was evidenced by the following. On 6/22/23 at 11:30 AM, during Resident Council Interview Resident #15 informed the Surveyor that on 6/19/23 CNA #1 had dropped flowers in a vase belonging to Resident #15. Resident #15 explained to CNA #1 that the flowers had special meaning and that Resident #15 would like the flowers placed back into the vase. Resident #15 continued to explain that CNA #1 responded, Who cares they're dead anyway. Resident #15 further described that CNA #1 aggressively threw the roommate's (Resident #31) call bell onto the roommate's bed and was verbally abusive toward the roommate. Resident #15 explained to the surveyor that they felt frightened. Resident #15 informed the surveyor that on the morning of 6/20/23 they alerted the Director of Nursing (DON). On 6/22/23 at 12:15 PM, the surveyor reviewed the Electronic medical records (EMAR) for Resident #31. Resident #31's EMAR revealed diagnoses which included, but were not limited to: Alzheimer's Disease, Dementia, Depression, and Other Specified Fracture of Left Pubis. The Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 6/17/23 for Resident #31 provided a Brief Interview for Mental Status (BIMS) with a score of 0, revealing a severe impairment of cognition. On 6/22/23 at 12:20 PM, the surveyor reviewed the EMAR for Resident #15. The EMAR revealed that Resident #15 had diagnoses which included but not limited to Periprosthetic Fracture around Internal Right Hip Joint, muscle Weakness, and Aftercare following Joint Replacement Surgery. Review of the Admission MDS dated [DATE], for Resident #15 documented a BIMS score of 15, revealing that the resident has a cognitively intact cognition. A review of the Progress Notes starting 6/20/23 for Resident #31 and Resident #15, did not provide any information that there was an incident reported about either resident. On 6/22/23 at 2:15 PM, the surveyor team interviewed the DON, who stated that the facility did not have any reportable events for the month of June but remembered Resident #15 informing him of an incident. The DON stated he informed the Social Worker (SW). On 6/22/23 at 3:00 PM, the survey team interviewed the DON and SW, who informed the team that this incident was investigated as a grievance. Both the DON and SW agreed that the Licensed Nursing Home Administrator (LNHA) was not informed of the incident. On 6/22/23 at 4:00 PM, the survey team interviewed the LNHA, who stated, The incident should have been reported to the New Jersey Department of Health (NJDOH), investigated, and the CNA involved should have been suspended pending the investigation. A review of the facility policy titled, Abuse, Neglect & Exploitation - prevention, Reporting and Investigation, Effective Date: 5/31/16 revealed under the Action Steps section 2, subsection a) All team members are mandated reporters and are required to report allegations or a known episode of abuse, neglect and/or exploitation to applicable state authorities within the time frame established by law. Continued review of the policy section h) Steps to take to ensure the safety and protection of residents in situations of known or suspected abuse, neglect and/or exploitation, including escalation to the Executive Director/designee. On 6/27/23 at 10:00 AM, surveyor met with the LNHA who stated that the facility should have reported the abuse to the NJDOH at the time that facility staff was informed of the allegation. NJAC 8:39-9.4(f)

Based on observation, interview, record review, and review of pertinent facility documentation, the facility failed to implement their abuse policy to investigate an allegation of verbal abuse between a Certified Nursing Assistant (CNA #1) and resident. This deficient practice was identified for 1 of 3 resident's (Resident #31) reviewed for abuse. The deficient practice is evident by the following: On 6/22/23 at 11:30 AM, during Resident Council Interview Resident #15 informed the Surveyor on 6/19/23 that CNA #1 had dropped flowers in a vase belonging to Resident #15. Resident #15 explained to CNA #1 that the flowers had special meaning and that Resident #15 would like the flowers put back into the vase. As per Resident #15, CNA #1 responded, Who cares they're dead anyway. Resident #15 further described that CNA #1 aggressively threw their roommate's (Resident #31) call bell onto the roommate's bed and was verbally abusive toward the roommate. Resident #15 explained to the surveyor that they felt frightened and alerted the Director of Nursing (DON), on the following morning 6/20/23. On 6/22/23 at 12:15 PM, the surveyor reviewed the Electronic medical records (EMAR) for Resident's #31 and #15. Resident #31 EMAR revealed the resident had diagnoses which included, but were not limited to: Alzheimer's Disease, Dementia, Depression, and Other Specified Fracture of Left Pubis. An assessment for the Resident #31 cognition called Brief Interview for Mental Status (BIMS) Skilled completed on 6/17/23 revealed that Resident #31 had a BIMS score of 0, which shows the resident has a severe impairment with mental cognition. The Admission Minimum Data Set, an assessment tool, dated 6/19/23, revealed the Resident #31 was totally dependent on one person for bed mobility, transferring, toileting, dressing and personal hygiene and had no behavioral symptoms. Resident #15 EMAR revealed the resident had diagnoses which included, but were not limited to: Periprosthetic Fracture around Internal Right Hip Joint, muscle Weakness, and Aftercare following Joint Replacement Surgery. An assessment for the Resident #15 cognition called Brief Interview for Mental Status (BIMS) Skilled completed on 6/10/23 revealed that Resident #15 had a BIMS score of 15, which shows the resident is cognitively intact with mental cognition. On 6/22/23 at 2:15 PM, the surveyors interviewed the DON, who stated the facility did not have any reportable events for the month of June but remembered Resident #15 informing him of the incident. The DON stated he does not handle these investigations and informed the Social Worker (SW), who investigated the incident of abuse as a grievance. On 6/22/23 at 2:30 PM, the SW provided the survey team with a copy of the grievance report. The SW stated her investigation was not completed. The report includes a copy of statements made by Resident #15 and CNA #1 as well as a copy of CNA #1 resident assignment sheet for the 3-11 PM shift which included both Resident #15 and #31. On 6/22/23 at 3:00 PM, the survey team interviewed the DON and SW who both agreed that the Licensed Nursing Home Administrator (LNHA) was not made aware of the incident. On 6/22/23 at 4:00 PM, the survey team interviewed LNHA, who stated, The incident should have been reported to the New Jersey Department Of Health (NJDOH), investigated, and the CNA should have been suspended pending the investigation. A review of the facility policy titled, Abuse, Neglect & Exploitation - prevention, Reporting and Investigation, Effective Date: 5/31/16 revealed under the Action Steps section 2, subsection a) All team members are mandated reporters and are required to report allegations or a known episode of abuse, neglect and/or exploitation to applicable state authorities within the time frame established by law. h) Steps to take to ensure the safety and protection of residents in situations of known or suspected abuse, neglect and/or exploitation, including escalation to the Executive Director/designee. Section 8 The SNA/designee, subsection b) Removes the individual alleged to be involved in the abuse, neglect or exploitation from the area, part i. Ensures that any team member alleged to be involved in the abuse, neglect or exploitation is placed on administrative leave, pending the results of the investigation. c) Ensures that the resident's (i) physician, (ii) legal representative and (iii) family member or other individual regularly involved in the resident's day to day care are notified as soon as practicable within timeframes established within laws/regulations. On 6/27/23 at 10:00 AM, surveyor met with LNHA with stated, that the facility should have reported the abuse to the New Jersey Department of Health (NJDOH) well the allegation was made and per the facility policy an investigation should have begun as well as the CNA #1 being suspended until the outcome of the investigation was reached. The LNHA also stated the DON and SW were going through retraining on abuse and reporting. NJAC: 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to accurately code resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for one 1 of 12 residents, (Resident #21) reviewed for accurate coding of MDS. This deficient practice was evidenced by the following: On 6/20/23 at 10:01 AM, Resident #21 was observed lying in bed awake, alert, and responded appropriately to the surveyor. The surveyor observed floor mats against the wall by the window in the resident's room. Resident #21 had their call bell within reach. On 6/21/23 at 9:43 AM, Resident #21 was observed lying in bed awake, alert, and verbally responsive. The resident informed the surveyor that they were ok. The resident had no complaints of pain or discomfort. The floor mats for Resident #21 were noted against the wall by the window. The surveyor reviewed the resident's hybrid medical chart which included review of paper as well as computerized medical chart. A review of Resident #21's Face Sheet (a one-page summary of important information about the resident) documented the resident's diagnosis which included but was not limited to Unspecified Dementia Without Behavior, Major Depressive Disorder, Anxiety, History of Falls, Essential Hypertension, Type 2 Diabetes Mellitus A review of the Health Status Progress Note dated 2/19/23 documented, Patient was found sitting by the bed and asking for help. Buttock on the floor she was trying to grasp the wheelchair nearby. Further review of the Health Status Progress Note dated 3/12/23 documented, Resident was heard calling for help around 4:35 AM. The care manager went to the room and found the resident sitting on the floor, backing the bed and facing the door. Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 4/10/23, indicated that Resident #21 had a Brief Interview for Mental Status (BIMS) score of 5. This score established that Resident #21 had a severely impaired cognition. A review of Resident #21's MDS dated [DATE], Section J1800 - Any Falls Since Prior Assessment coded as 0, indicating that the resident had no falls since their last Quarterly Assessment of 1/16/23. The documentation in the MDS contradicted the resident's history of falls based on the Health Status Progress Notes dated from 1/1/23 to 6/20/23. On 6/22/23 at 11:02 AM, the surveyor along with MDS Coordinator reviewed the Quarterly assessment dated [DATE] which documented 0 falls and the Health Status Progress Notes dated 3/12/23, which revealed that Resident #21 had a fall with no injury. The MDS Coordinator reviewed her personal fall log in the presence of the surveyor, which revealed that Resident #21 had a fall on 3/12/23. The MDS Coordinator confirmed that she missed coding the fall. Further review of Health Status Notes dated 2/19/23, with the MDS Coordinator documented that Resident #21 had a fall on 2/19/23 with no injury. The MDS Coordinator reviewed her personal fall log and confirmed that she had also missed coding the 2/19/23 fall as well. No further information was provided. NJAC 8:39-33.2(d)

Based on observation, interview, and record review it was determined that the facility failed to carry out a comprehensive care plan (CP) for 1 of 12 residents reviewed for the fulfillment of a care plan, Resident #21. This deficient practice was evidenced by the following: On 6/20/23 at 10:01 AM, Resident #21 was observed lying in bed awake, alert, and verbally responsive. The surveyor observed floor mats that were leaning against the wall by the window. On 6/21/23 at 9:43 AM, Resident #21 was observed lying in bed awake, alert, and verbally responsive. The surveyor observed floor mats that were leaning against the wall by the window. The surveyor reviewed the resident's hybrid (paper and electronic) medical chart which revealed the following: A review of Resident #21's Face Sheet (a one-page summary of important information about the patient) documented the resident's diagnoses included but were not limited to Unspecified Dementia Without Behavior, Major Depressive Disorder, Anxiety, History of Falls, Essential Hypertension, Type 2 Diabetes Mellitus. A review of the Minimum Data Set (MDS), an assessment tool dated 4/10/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating that Resident #21 had severely impaired cognition. A review of Resident #21's CP with an effective date of 7/19/22 and 4/12/23 presented a goal that [Resident #21] will not sustain any fall related injury through the next review date. An intervention in the CP, dated 8/1/22 read The resident uses floor mats as ordered by MD. Ensure the device is in place at bedtime. A review of the Physician's Orders (PO) indicated an order, dated 7/20/22, for floor mats while in bed every shift for fall risk. On 6/21/23 at 9:48 AM, the surveyor interviewed the Registered Nurse (RN) assigned to Resident #21. The RN stated floor mats were used at night time only, placed on both sides of the bed, and that in the morning floor mats were not needed because the resident was being supervised. The surveyor reviewed with the RN the resident's PO, which revealed the physician order for floor mats while the resident was in bed for every shift. The RN stated that floor mats should be at both sides of the bed while the resident was in bed as per the physician's order. On 6/21/23 at 2:05 PM, the surveyor informed the Director of Nursing, Senior Director of Nursing Supervisor (DNS), Licensed Nursing Home Administrator, and Associate Executive Director, of the above concerns. The DNS stated it was expected that when the resident was in bed that the floor mats should have been in place. There was no further information provided by the facility. N.J.A.C. 8:39-11.2; 27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to revise a comprehensive care plan for 2 of 18 residents reviewed, Resident #14 and Resident #21. This deficient practice was identified by the following: On 6/19/23 at 12:27 PM, the surveyor observed Resident #14 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor further observed that the resident had a surgical dressing to their right foot. The surveyor reviewed Resident #14's hybrid medical records. The Admission Record reflected that Resident #14 was admitted . to the facility with medical diagnoses which included but were not limited to Atrial Fibrillation, Type 2 Diabetes Mellitus, Anemia, and Hypertension. A review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/2/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating that the resident had an intact cognition. A review of the June 2023 Physician Order Summary revealed a physician's order dated 6/20/23 for Santyl External Ointment 250 unit/gm (Collagenase) Apply to right heel topically two times a day for wound Treatment cleansed with Daikin solution cover with dressing. A review of the form titled; Wound Healing Solutions dated 6/20/23 revealed that Resident #14 had an unstageable pressure ulcer injury to the right heel due to eschar (a dry, dark scab). The surveyor reviewed the resident's care plan (provides direction on the type of nursing care for an individual) which had no documentation indicating that Resident #14 had a skin breakdown pressure ulcer to the right heel. On 6/21/23 at 10:30 AM, the Licensed Practical Nurse (LPN) who was assigned to care for Resident #14, stated that the care plan was not updated to indicate the resident's pressure ulcer. The LPN verified that Resident #14's care plan should have included the resident's pressure ulcer. 48273 2. On 6/20/23 at 10:01 AM, the surveyor observed Resident #21 lying in bed awake, alert, and responded appropriately to the surveyor. The Surveyor observed floor mats standing against the wall by the window of the resident's room. Resident #21 had their call bell within reach. On 6/21/23 at 9:43 AM, the surveyor observed Resident #21 lying in bed awake, alert, and verbally responsive. The resident informed the surveyor that they were doing ok. Resident #21 had no complaints of pain or discomfort. Once again, the surveyor observed the floor mats standing against the wall by the window of the resident's room. A review of Resident #21's Face Sheet (a one-page summary of vital information about the patient) revealed the resident had diagnoses which included but were not limited to Unspecified Dementia Without Behavior, Major Depressive Disorder, Anxiety, History of Falls, Essential Hypertension, and Type 2 Diabetes Mellitus. Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 4/10/23, the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating that Resident #21 had a severely impaired cognition. A review of the Health Status Progress Notes revealed that Resident #21 had falls on: 7/19/22, 8/1/22, 8/12/22, 10/20/22, 12/23/22, 2/19/23, 3/12/23, and 5/7/23. Resident #21 had a total of 8 falls since admission to the facility. A review of the resident's care plan (CP) initiated on 7/19/22, identified Resident #21 was at risk for falls, which included a list of dates when Resident #21 had falls. The CP Focus section failed to include the falls that occurred on 3/12/23 and 5/7/23. Further review of the Resident #21's CP identified an initiation date of 7/19/22 for fall interventions. The CP was revised on 8/1/22, with a new documented intervention of resident uses floor mat as ordered by MD. Ensure device is in place at bedtime. The CP was again revised on 10/21/22, with a new intervention for educate resident about safety and use of any device or to request assistance as needed. The CP had the most recent revision on 5/9/23, adding a new intervention for frequent staff check. On 6/22/23 at 11:40 AM, the surveyor interviewed the Director of Nursing Supervisor (DONS) and the Director of Nursing (DON) in reference to updating fall interventions when there is a new fall. The DNS explained that all fall interventions are documented on progress notes, the task section, and/or care plans. The DNS added that interventions documented in the progress notes or task section should be included in care plan interventions. A review of the facility's policy titled, Incident and Event Reporting presented, The intent of this policy is that the community identifies each resident at risk for events/incidents and/or falls, and adequately plans care and implements procedure to prevent accidents. On 6/26/23 at 2:17 PM, the surveyor interviewed the Acting DON who confirmed that all nurses or other disciplines can update the CP. The Acting DON verified that CPs should be updated and reviewed every time a fall occurs. No further information was provided. NJAC 8:39-11.2(i)

1) Based on observation, interviews, and record review, it was determined the facility failed to consistently follow standards of clinical practice with regard to a.) accurately documenting medication administration, and b.) correctly following physician's orders for 2 of 12 residents, Resident #19 and Resident #15. The deficient practice is evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. The surveyor reviewed the hybrid medical records of Resident #19, which revealed the following: The resident's Admission Record listed diagnoses that included but were not limited to Alzheimer's Disease [a progressive disease that destroys memory and other important mental functions], Hypertension, and Hyperlipidemia. The Quarterly Minimum Data Set (MDS), an assessment tool dated 4/3/23, indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 00 out of 15, which indicated that the resident had severe cognitively impairment. A review of the Order Summary Report and the electronic Medication Administration Record (eMAR) indicated Resident #19 had physician orders dated 11/10/22, that read: amlodipine Besylate Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day for HTN [Hypertension] Hold SBP [Systolic Blood Pressure] below 120. A review of the June 2023, May 2023, and April 2023 eMAR for Resident #19 revealed that at the time of the administration of the amlodipine, there was no documentation of the resident's blood pressure. On 6/21/23 at 11:28 am, the surveyor interviewed LPN #1 about the amlodipine order and any special instructions for the medication. LPN #1 stated he was aware Resident #19 had parameters to hold the amlodipine medication for a SBP less than 120. LPN #1 stated he checked the resident's blood pressure (BP) prior to administering the medication. He acknowledged that he did not enter the BP result in the electronic medical record at the time of the medication's administration. On 6/21/23 at 11:57 am, the surveyor interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN) about the amlodipine medication order and documentation of the resident's BP with medication administration. The LPN/CN stated the eMAR would prompt at the time of medication administration for the nurse to document the resident's BP. LPN/CN reviewed the physician's order and the eMAR with the surveyor and stated she did not know why it was not picked up by the nurses and why the order was not clarified in the eMAR. LPN/CN acknowledged it would be expected for the nurse to enter the BP at the time of the medication administration on the eMAR. On 6/21/23 at 12:12 pm, the surveyor interviewed the Director of Nursing (DON) about the above concerns. The DON stated it was expected for the blood pressure to be checked and documented prior to the medication's administration. The DON stated that the nurses and pharmacy consultant should have caught that the BP was not being documented at the time that the medication was administered. On 6/21/23 at 2:05 pm, the surveyor informed the Administrator, Senior Director of Nursing Services, Associate Executive, and DON of the above concerns. The surveyor reviewed the facility provided policy titled Medication Administration, with a date of 01/23. Under Medication Administration, it read: 1. Medications are administered in accordance with written orders of the prescriber .2. Obtain and record any vital signs as necessary prior to medication administration. 39399 2.) On 6/19/23 at 12:22 PM, the surveyor observed Resident #15 in the room, lying in bed, awake, alert, and verbally responsive. The surveyor reviewed the resident's hybrid medical records, which revealed that Resident #15 was admitted to the facility with diagnosis which included but were not limited to Type 2 Diabetes Mellitus, Periprosthetic fracture around the internal prosthetic right hip joint, and Hypertension. A review of the Admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 6/10/23, reflected that the resident had a Brief Interview for Mental Status of 15 out of 15, indicating that the resident had intact cognition. A review of the resident's June 2023 Order Summary Report indicated a physician's order (PO) having a start date of 6/6/23 for Losartan Potassium Oral Tablet 50mg. Give 1 tablet by mouth one time a day for Hypertension. There was also another PO having a start date of 6/12/23 for Losartan Potassium Oral Tablet 50mg. Give 1 tablet by mouth two times a day for Hypertension, hold SBP (Systolic Blood Pressure) (top number of a blood pressure reading) below 110, and heart rate below 60. A review of the June 2023 eMAR revealed the PO for Losartan Potassium Oral Tablet 50mg with a start date of 6/6/23 was scheduled to be administered to Resident #15 at 9:00 AM. Further review of the eMAR revealed the PO with a start date of 6/12/23 for Losartan Potassium Oral Tablet 50 mg was scheduled to be administered to Resident #15 at 9:00 AM and 5:00 PM. On 6/22/23 at 1:43 PM, the surveyor interviewed the Licensed Practical Nurse #1 (LPN #1), assigned to care for Resident #15, regarding the two different PO for the same medication to treat Hypertension. LPN #1 explained that she administered two tablets of Losartan Potassium 50mg, totaling 100mg, for the 9:00 AM dose. LPN #1 informed the surveyor that the LPN/CN obtained the 6/12/23 PO from the physician. On 6/22/23 at 1:50 PM, the surveyor interviewed LPN/CN, who acknowledged that when she obtained the PO dated 6/12/23 for Losartan Potassium 50mg 1 tablet two times a day. LPN/CN explained that she should have discontinued the PO dated 6/6/23 for Losartan Potassium 50mg 1 tablet one time a day and not have both POs active. LPN/CN stated that both orders should not have been active and administered to Resident #15 together. On 6/26/23 at 2:00 PM, the surveyor discussed the above concern with the facility's Licensed Nursing Home Administrator and Director of Nursing, who did not provide any further information. NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were 1. stored in a secure locked environment, 2. expired medications were removed from a resident's active inventory after it had expired and/or been discontinued by the physician in accordance with professional standards of clinical practice, 3. removed expired narcotics kept in a locked backup box. This deficient practice was identified for 1 of 1 units reviewed during the facility unit inspection process. This deficient practice was evidence by the following: 1. On 6/19/23 at 10:03 AM, a surveyor along with another surveyor requested from the Unit Clerk (UC), if someone could open the medication room door for inspection. At that time the UC volunteered to open the locked medication room door, and had access to the passcode. The UC entered the keypad code unlocking the medication room door. 2. Once within the locked medication room, the surveyors noted that there were 3 cassette boxes filled with numerous non-narcotic prescription back up medications secured with zip ties on the counter of the medication room. These medications were accessible to the UC, and any other non medical person who would have the access code to the keypad locking and securing the medication room. 2. Once in the medication room, the surveyor asked if the locked refrigerator could be opened. The UC stated that she'd be right back and left the medication room. The UC returned to the medication room with the key to the refrigerator, opening the locked refrigerator for the surveyors. On 6/19/23 at 12:11 PM, the surveyor interviewed the UC in the presence of another surveyor, the UC informed the surveyor that she was given the refrigerator key by the Registered Nurse (RN), who was busy administering medications. On 6/19/23 at 12:34 PM, the surveyors interviewed the DON in the presence of the Licensed Practical Nurse in charge of the unit (LPN), who stated that only nurses should have access to the medication room. The Concierge (UC) should not have access to the medication room. The LPN added that the access keys to the medication room and refrigerator are kept in the drawer of the nursing office and only nurses should have access to the keys. The LPN stated that the UC should not have had access or knowledge of the keypad code to the medication room. An interview of the UC on 6/19/23 at 12:40 PM, stated that the RN gave her the keys to the refrigerator. On 6/19/23 at 12:40 PM, the surveyor interviewed the RN who stated that she gave her refrigerator keys to the UC. I shouldn't have done that. She shouldn't have access. 3. On 6/19/23 at 12:12 PM, the surveyors encountered the LPN who entered the medication room to help the surveyors. The surveyors inspected the refrigerator and found 2 intravenous medication bags that had expired. The surveyors found Vancomycin 1250 mg (antibiotic therapy) 262.5 milliliters (ml) that had been manufactured by the Provider Pharmacy on 6/8/23 and had a documented expiration date of 6/17/23. In the presence of the LPN, the surveyors also found Ceftriaxone 1 gm (antibiotic therapy) 50 ml that had been manufactured by the Provider Pharmacy on 5/18/23 and had a documented expiration date of 6/7/23. The LPN explained that both of these medications were discontinued and should have been immediately removed from the refrigerator by the nursing staff and discarded. The LPN added that the Consultant Pharmacist (CRPh) performs unit inspections monthly. The LPN stated that he should have picked this up. 4. On 6/20/23 at 10:10 AM, the DON in the presence of the surveyor completed a narcotic inventory of all narcotics double locked in the wall lock box located in the medication room. During the narcotic inventory review, the surveyor found #10 tablets of Lyrica (non-narcotic pain reliever) 50 mg which had expired on 4/2023 and #10 tablets of Morphine Sulfate (Opioid narcotic pain reliever) 15 mg tablets which had expired 2/2023. On 6/20/23 at 12:29 PM the surveyor interviewed the LPN who stated that all narcotics are counted every shift by nursing, and they should have noticed the expired narcotics in the wall lock box and removed them from active stock. The LPN added that the Consultant Pharmacist (CRPh) performs unit inspections monthly. The LPN stated that he should have picked this up. 5. The surveyor reviewed the Consultant Pharmacist Unit Inspection Reports received from 1/2023 to the last inspection dated June 8, 2023. There were no documentations that alerted the facility of Ceftriaxone 1 gm (antibiotic therapy) 50 ml that had a documented expiration date of 6/7/23, Lyrica (non-narcotic pain reliever) 50 mg which had expired on 4/2023 and #10 tablets of Morphine Sulfate (Opioid narcotic pain reliever) 15 mg tablets which had expired 2/2023. On 6/26/23 at 11:26 AM, the surveyor interviewed the Consultant Pharmacist (CRPh) who stated that he was not aware of backup narcotics stored in the wall lock box. The CRPH admitted that he should have removed Ceftriaxone 1 gm (expiration 6/7/23) from the refrigerator when he performed the last facility unit inspection of the refrigerator on 6/8/23. The Storage of Medication policy was reviewed, Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Continued review of the procedures of The Storage of Medication policy, 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. In addition to the above documentation of The Storage of Medication policy, 14. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy. Review of the Controlled Medication Storage policy, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations. Under, PROCEDURES 1. The director of nursing and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled medications. Continued review of the Controlled Medication Storage policy, PROCEDURES 8. The consultant pharmacist, or pharmacy designee, routinely reviews a sampling audit of controlled medication storage, records, and expiration dates during medication storage inspections. On 6/21/23 at 2:05 PM, the surveyor discussed concerns related to the unit inspection findings with the DON, Senior Director of Nuring Services, Licensed Nursing Home Administrator (LNHA), and Associate Executive Director. There was no additional information provided. On 6/26/23 at 3:43 PM, the surveyor discussed concerns related to the interview with the CRPh that had transpired, with the LNHA, the temporary replacement DON, Director of Operations and Assistant DON. There was no additional information provided. NJAC 8:39-29.4(g)

Based on observation, interview, and record review, it was determined that the Consultant Pharmacist (CP) failed to identify and notify the facility of medication irregularities. These irregularities were identified for 2 of 12 residents reviewed, Resident #19, and Resident #21. The deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid medical records of Resident #19 which revealed the following: The resident's Admission Record listed diagnoses that included but were not limited to Alzheimer's Disease [a progressive disease that destroys memory and other important mental functions], Hypertension, and Hyperlipidemia. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/3/23, indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 00 out of 15 which indicated that the resident had severe cognitive impairment. A review of the Order Summary Report and the electronic Medication Administration Record (eMAR) indicated Resident #19 had physician orders, dated 11/10/22, Amlodipine Besylate Oral Tablet 5 MG[milligram] .Give 1 tablet by mouth one time a day for HTN [Hypertension] Hold SBP [Systolic Blood Pressure] below 120. A review of the June 2023, May 2023, and April 2023 eMAR for Resident #19 revealed that at the time of the administration of the Amlodipine, there was no documentation of the resident's blood pressure being monitored prior to administration of the medication. A review of the Consultant Pharmacist Progress Notes revealed the CP visited and documented comments monthly. There were no comments or recommendations documented informing the facility of the lack of documentation for the Amlodipine order evaluating the BP parameters for December 2022 through to June 2023. On 6/21/23 at 11:28 AM, the surveyor interviewed LPN #1 about the Amlodipine order and any special instructions for the administration of the medication. LPN #1 acknowledged that he did not document the SBP result in the eMAR at the time of the medication's administration. On 6/21/23 at 11:57 AM, the surveyor interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN) about the Amlodipine medication order and the documentation of the resident's BP with medication administration. The LPN/CN explained that the electronic medical record has a prompt associated with the eMAR at the time of Amlodipine administration that should alert the nurse to monitor and document the resident's SBP. The LPN/CN reviewed the physician's order and the eMAR with the surveyor, revealing that the prompt to alert the nurses for monitoring SBP was not turned on when the order was entered into the eMAR. The LPN/CN could not explain why it was not picked up by the nurses and why the order was not clarified in the eMAR. The LPN/CN acknowledged it would be expected for the nurse to enter the BP at the time of the medication administration on the eMAR. On 6/21/23 at 12:12 pm, the surveyor interviewed the Director of Nursing (DON) about the above concerns. The DON stated it was expected for the blood pressure to be monitored and documented prior to the medication's administration. The DON stated that the nurses should have corrected the eMAR to alert for the documentation of the SBP. The DON also remarked that the CP should have alerted the facility staff that the SBP was not being monitored or documented on the eMAR at the time that the medication was administered. On 6/21/23 at 2:05 PM, the surveyor informed the Administrator, Senior Director of Nursing Services, Associate Executive and DON of the above concerns. On 6/26/23 at 11:26 am, the surveyor interviewed the CP about the process for reviewing medications with BP parameters. The CP explained that he did not review the eMAR for irregularities. The CP indicated that the nurses administering medication ordered by the physician with parameters, are expected to monitor and document the BP on the eMAR. The surveyor interviewed the CP asking if an accurate and comprehensive monthly medication review could be conducted without reviewing the eMAR to verify correct transcription of medication orders and that the physician orders were being administered accurately. The CP provided no verbal response. On 6/26/23 at 12:35 pm, the surveyor interviewed the Associate Executive Director (AED) who informed the surveyor that the CP had access to the electronic medical records and eMAR. The surveyor reviewed the facility document titled, Pharmaceutical Consultant Services Contract Developed for [NAME] Gardens of [NAME] Skilled, from June 2016. The contract indicated the CP would be responsible for the general supervision of the facility's pharmaceutical services and services included: .Help establish policies and procedures to ensure safe and appropriate administrations of medications .Review all medication records on a monthly basis for the skilled sub-acute facility . The surveyor reviewed the facility provided policy titled, Medication Administration, with a facility review date of 1/23. Under Medication Administration it read: 1. Medications are administered in accordance with written orders of the prescriber .2. Obtain and record any vital signs as necessary prior to medication administration. 48273 2. On 6/20/23 at 10:01 AM, Resident #21 was observed lying in bed awake, alert, and responded appropriately to the surveyor. The surveyor observed floor mats against the wall by the window in the resident's room. The call bell was observed within reach for Resident #21's use. The surveyor reviewed the resident's hybrid chart which included a paper as well as a computerized medical chart. A review of Resident #21's Face Sheet (a one-page summary of relevant information about the patient) that documented the resident's diagnosis which included but was not limited to Unspecified Dementia Without Behavior, Major Depressive Disorder, Anxiety, History of Falls, Essential Hypertension, Type 2 Diabetes Mellitus. Review of Resident #21's Physician's orders (PO) presented active orders with start dates of 7/19/22 for Tylenol 325 milligram (mg) 2 tablets by mouth every 4 hours as needed for temperature greater than 100.2 and Tylenol 325 mg 2 tablets by mouth 2 tabs by mouth every 4 hours as needed for temperature 100 above. Review of the eMAR for the month of June 2023 and May 2023, revealed 2 separate sections for Tylenol 325 mg give 2 tablets by mouth every 4 hours as needed for temperature greater than 100.2 and Tylenol 325 mg give 2 tablets by mouth every 4 hours as needed for temperature 100 above. Documentation on the eMAR revealed that Resident #21 had not received either one of the ordered Tylenol as needed medications. A review of the Consultant Pharmacist Progress Notes revealed that the CP visited and documented comments monthly, with the last documented visit and comment on 6/8/23. A review of the initial pharmacy recommendations for Resident #21 dated 7/19/22 documented, no irregularities noted. There were no other comments or recommendations documented related to the resident's duplicate Tylenol order for August 2022 to June 2023. On 6/26/23 at 11:45 AM, the surveyor interviewed the CP who stated that he reviews all resident's medications once a month. The CP added that his review of medications includes as needed medications based on the resident's PO. The CP revealed that he does not review the eMAR. The CP identified that he would document any duplicate in his report making recommendations to discontinue one of them. During the interview with the CP about the two as needed Tylenol orders, the CP stated, I must have missed those orders based on what the order is stated. The CP agreed that he had never notified the facility of the duplicate Tylenol as needed orders. The surveyor reviewed the facility document titled, Pharmaceutical Consultant Services Contract Developed for [NAME] Gardens of [NAME] Skilled, created June 2016. The contract indicated the CP would be responsible for the general supervision of the facility's pharmaceutical services and services including: A review of all medication records on a monthly basis for the skilled subacute facility. Provide written reports to the Administrator and the Director of Nursing on a monthly basis for the skilled sub-acute facility. On 6/26/23 at 3:35 pm, the surveyor informed the Licensed Nursing Home Administrator, Acting DON, and Director of Operations of the interview with the CP. The Administrator stated that she would follow up with the CP. No further information was provided. On 6/27/23 at 9:37 AM, the surveyor along with the Registered Nurse (RN) reviewed Resident #21's PO, and the duplicate order for the as needed Tylenol 325mg. The RN explained that one of the Tylenol as needed orders should have been discontinued. The RN acknowledged that there should not have been duplicate orders for as needed Tylenol. NJAC 8:39- 29.3

Based on observation, interviews, and review of facility policies, it was determined the facility failed to properly label and date potentially hazardous foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following. On 6/19/23 from 09:45 AM through 10:30 AM, the surveyor completed the initial kitchen tour located in the Assisted Living (AL) section of the building with the Food Service Director (FSD) and observed the following: 1. On top of the Sandwich/Deli counter prep area, the surveyor observed multiple opened bags of assorted loaves of bread with received dates but no open and/or use-by dates: a. One loaf of Rye bread, with a received date of 6/16/23 b. One loaf of Wheat bread, with a received date of 6/16/23 c. One loaf of [NAME] bread, with a received date of 6/16/23 d. One loaf of Raisin bread, with a received date of 6/16/23 e. One bag of Hamburger buns, with a received date of 6/16/23. The FSD stated all bread is discarded 7 days after opening and have not been labeling the bread with an open and/or a use-by date. 2. In the Dry storage area, the surveyor observed multiple containers opened without opened and/or use-by dates: a. Two 1-gallon apple Cider Vinegar both with the received dates of 12/31/22 b. One 1-gallon Soy Sauce with the received date of 4/29/23 c. One 1-gallon Worcestershire Sauce with the received date 4/29/23. The FSD could not indicate the open dates of the items mentioned above were opened or the use-by date. Surveyor requested a copy of the facility's food labeling and storage policy. The FSD acknowledged having the open and use-by dates on all products are needed to ensure the facility has the information on the estimated period of time for which the product will be of best. On 6/21/23 at 9:19 AM, the FSD provided the surveyor with a facility policy titled, Labeling and Dating for Safe Storage of Food, with a revised date of 3/6/2020 which revealed, All products should be dated upon receipt. All products should be dated when opened. The Dry, Refrigerated, and Freezer Storage Charts note for staples, refrigerated, and freezer storage recommended storage time for unopened and opened products. On 6/21/23 at 2:05 PM, the survey team met with the Director of Nursing (DON), Administrator, and Associate Executive Director, who all stated that all items in the kitchen need to have received, open, and use-by dates. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices, which was identified during 1 of 1 wound treatment observation for Resident # 14. This deficient practice was evidenced by the following: On 6/19/23 at 12:27 PM, the surveyor observed Resident #14 in their room seated in a wheelchair. The resident was alert and verbally responsive. The surveyor further observed that the resident had a dressing on the right foot. The surveyor reviewed Resident #14's medical record on 6/1/23 at 12:29 PM. The Admission Record reflected that Resident #14 was admitted to the facility with medical diagnoses, which included but not limited to Atrial Fibrillation, Type 2 Diabetes Mellitus, Anemia, and Hypertension. A review of the Admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 6/2/23, reflected that the resident had a Brief Interview for Mental Status of 15, indicating that the resident was cognitively intact. A review of the June 2023 Physician Order Summary revealed a physician's order dated 6/20/23 for Santyl External Ointment 250 unit/gm (Collagenase) Apply to Rt heel topically two times a day for wound Tx cleansed with Daikin solution cover with dressing. On 6/21/23 at 9:45 AM, the surveyor observed the Licensed Practical Nurse (LPN) gather all the needed supplies for the wound treatment of Resident #14 and placed it on top of the resident's bedside table without using a clean drape or any barrier in between. At the conclusion of the wound care, the LPN discarded the supplies she used for the wound treatment and placed the bedside table next to the resident without disinfecting the table. The surveyor interviewed the LPN, who acknowledged that she did not sanitize the bedside table where she placed all the supplies for the wound treatment. On 6/21/23 at 2:05 PM, the surveyor met with the facility's Licensed Nursing Home Administrator, Director of Nursing, Senior Director of Nursing Services, and Associate Executive Director to discuss the above concerns. There was no additional information provided. A review of the facility's Policy and Procedure titled Skin Care & Pressure Ulcer Management Program did not specifically indicate the procedures for wound dressing changes. NJAC 8-39-19.4 (a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to implement appropriate infection control practices for performing hand hygiene prior to donning (putting on) and doffing (taking off) Personal Protective Equipment (PPE); donning and doffing PPE; and cleaning multi-use equipment between resident use. This deficient practice was identified during a focused COVID-19 survey for 2 of 5 residents reviewed, (Resident #4 and Resident #5) and was evidenced by the following: On 11/19/2020 at 1:25 PM, the surveyor observed a Stop Sign outside of Resident #4's bedroom door. The sign indicated the resident was on standard, droplet, and contact precautions and only enter the resident's room if wearing PPE. Underneath the Stop Sign, there were instructions on how to appropriately don and doff PPE in accordance with Center for Disease Control (CDC) guidelines. Outside of the resident's room, the surveyor observed two plastic bins stocked with alcohol-based hand rub (ABHR), gloves, face shields, disposable gowns, and KN95 masks. At this time, the surveyor observed the radiographer put on a pair of gloves, open the plastic bin with his gloved hands, take out a KN95 mask and place the KN95 mask over top the KN95 mask he was wearing. The radiographer then donned a gown and a face shield and entered the resident's room. The surveyor observed that the radiographer donned his PPE without first performing hand hygiene. After the radiographer entered the resident's room with his x-ray machine, the surveyor observed the radiographer reposition Resident #4 in his/her wheelchair by touching the resident's back with his gloved hands and then take a chest x-ray of the resident. After the x-ray was obtained, the radiographer removed the outmost KN95 mask with his gloved hands and throw it away in the garbage can positioned by the entrance to the resident's room. The radiographer then removed his gown and gloves, lifted the lid of the garbage can with his bare hands to dispose of the gown and gloves, and then exited the resident's room without performing hand hygiene. The radiographer entered the hallway and was observed still wearing the same face shield that he wore inside of Resident #4's room. The surveyor did not observe the radiographer wipe down or clean the x-ray machine. The surveyor then followed the radiographer down the hallway to Resident #5's room. Outside of Resident #5's room, the surveyor observed a Stop Sign which indicated the resident was on standard, droplet, and contact precautions. The sign further indicated to only enter the resident's room if wearing PPE. Underneath the Stop Sign were instructions on how to appropriately don and doff PPE per CDC guidelines. Outside of the resident's room the surveyor observed two plastic bins stocked with ABHR, gloves, face shields, disposable gowns, and KN95 masks. The surveyor observed the radiographer push the x-ray machine into the threshold of the resident's room. The surveyor further observed the radiographer remove his face shield and place it face down so that the front of the face shield was directly touching the top of the plastic bin. The surveyor observed the radiographer don a KN95 mask over the KN95 mask he wore into the facility, don gloves and a gown, and then put on the face shield that he had placed on top of the PPE bin. The surveyor never observed the radiographer perform hand hygiene prior to donning the PPE. At 1:37 AM, the surveyor stopped the radiographer prior to entering Resident #5's room and conducted an interview. The surveyor asked the radiographer why he needed to wear PPE prior to the entry of the resident's rooms? The radiographer stated that the residents were both positive for COVID-19. The radiographer stated that hand hygiene was supposed to be performed prior to donning and doffing PPE and admitted to the surveyor that he had never performed hand hygiene. The surveyor asked the radiographer when he cleaned the x-ray machine? The radiographer stated that every facility had different rules and he usually would wipe down the x-ray machine with a sanitizer wipe before he entered another facility. The radiographer stated that he had not wiped down the x-ray machine with a sanitizer wipe because he did not see any. The surveyor had observed that the facility had sanitizer wipes throughout the facility while touring the facility earlier that day. These wipes were available and accessible. At 2:21 PM, the surveyor interviewed the Director of Nursing/Infection Preventionist (DON/IP) who stated that hand hygiene was to be performed prior to the application of and after the removal of PPE. The DON/IP stated that hand hygiene was to be performed by washing hands with soap and water for 20 seconds or by utilizing an ABHR. The DON/IP stated that all PPE should be removed and thrown away prior to exiting a resident's room and should not be used for multiple residents. The DON/IP stated that multi-use equipment needed to be sanitized and cleaned between residents per the manufacturer guidelines and specifications for that product. The DON/IP stated that specific instructions on how to apply PPE were posted outside of all the resident's room who required contact and droplet precautions and the expectation was that those directions would be followed by all people who entered the resident's rooms. The DON/IP stated that she had not performed direct observations of vendors coming into the facility on their infection control practices and further stated that she would have to call the company the vendor worked for to find out what infection control education the radiographer had received. At 2:26 PM, the surveyor interviewed the Administrator who stated that the expectation was that all vendors that entered the facility were required to perform appropriate infection control practices while in the facility. The surveyor reviewed the medical record for Resident #4. Review of the resident's Admission Record reflected that the resident was a recent admission to the facility and had [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the MDS assessment was still in progress as the resident had been admitted to the facility for less than 14 days. Review of the resident's final laboratory report dated 11/18/20 indicated that [DIAGNOSES REDACTED]-CoV-2* (COVID-19) was detected. Review of the resident's Care Plan (CP) updated 11/18/20 revealed a focus area that the resident had a confirmed COVID-19 positive diagnosis. The goals of the resident's CP were to minimize risk of transmission to others through the next review date and the resident's symptoms would be managed through the next review date. Interventions for the resident's CP reflected to isolate the resident and implement full standard, contact and droplet/airborne precautions in room with door closed and use PPE which included a face mask, face shield, gown, and gloves. Further CP interventions reflected to monitor the resident for compliance with isolation precautions, screen and limit visitors to only essential visitors for medical needs and end of life support, and wipe down high-touch surfaces within the resident suite. The surveyor reviewed the medical record for Resident #5. Review of the resident's Admission Record reflected that the resident was a recent admission to the facility and had [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the MDS assessment was still in progress as the resident had been admitted to the facility for less than 14 days. Review of the resident's final laboratory report dated 11/18/20 indicated that [DIAGNOSES REDACTED]-CoV-2* was detected. Review of Resident #5's CP updated 11/18/20 revealed a focus area that the resident had confirmed COVID-19 diagnosis. The goals of the resident's CP were to minimize risk of transmission to others through the next review date and the resident's symptoms would be managed through the next review date. Interventions for the resident's CP reflected to isolate the resident and implement full standard, contact and droplet/airborne precautions in room with door closed and use PPE which included a face mask, face shield, gown, and gloves. Further CP interventions reflected to monitor the resident for compliance with isolation precautions, screen and limit visitors to only essential visitors for medical needs and end of life support, and wipe down high-touch surfaces within the resident suite. Review of the facility's COVID-19 Mitigation and Response Plan revised on 6/12/20 indicated, Essential medical visitors coming from an outside healthcare agency will be asked to supply their own personal protective equipment for moving through the community (mask) or for the care of residents on isolation precautions (mask, gown, gloves, goggles/face shield). Visitors who do not have personal protective equipment will be provided it as indicated by the condition of the resident they are visiting. In regard to hand hygiene practices the facility's Mitigation and Response Plan indicated, Team members perform hand hygiene before and after all resident contact, contact with potentially infectious material, before putting on and after removing PPE, including gloves and after petting any community pets. Note: Hand hygiene after removing PPE is important to remove any germs or virus that might have been transferred to bare hands during the removal process. Team members perform hand hygiene by using alcohol based hand rub (ABHR) with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. The facility's COVID-19 Mitigation and Response Plan further indicated that PPE the facility utilized for COVID-19 resident's included N95 respirator or face mask, eye protection, gloves, and gowns. The COVID-19 Mitigation Response Plan indicated that all of the non-reusable PPE needed to be discarded after use and, reusable eye protection (e.g. goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Clean with an EPA registered disinfecting wipe. Further review of the facility's COVID-19 Mitigation and Response Plan indicated, Dedicated or disposable resident care equipment (blood pressure cuffs, thermometers, mechanical lifts etc.) with an EPA registered disinfectant wipe in between each resident use. NJAC 8:39 19.4(l),(n);27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) the appropriate use of a thermometer in accordance with manufacturer instructions used to screen staff for COVID-19, b.) the necessary use of a face mask and eye protection while communicating with a resident under investigation for COVID-19, c.) the appropriate timing of hand hygiene, and d.) hand hygiene was offered to residents before a lunch meal. This deficient practice was identified for 4 of 12 residents on the census (Resident #1, #2, #3 and #4) during a COVID-19 focus infection control survey conducted on 7/7/2020, and was evidenced by the following: 1. On 7/7/2020 at 8:30 AM, two surveyors approached the healthcare entrance to the facility, and a Receptionist/Certified Nursing Aide (R/CNA) opened the door and allowed the surveyors to enter. At that time, the R/CNA prepared a COVID-19 health screening tool for the surveyors to complete and proceeded to check temperatures using a digital infrared thermometer in the presence of the facility's Health Information Coordinator. The R/CNA pointed the digital thermometer at the right side of the first surveyor's neck and obtained a temperature reading. The R/CNA then proceeded to check the temperature of the second surveyor and pointed the infrared thermometer at the right side of the other surveyor's neck and obtained a temperature reading. The R/CNA cleaned the thermometer using a disinfectant wipe and placed it on the nurses station counter. The surveyor observed the make and model of the thermometer, and imprinted on the thermometer was a picture of a visual instruction to point the thermometer at the forehead to obtain the temperature reading. The surveyor asked the R/CNA about the method in which she obtained temperature readings at the neck area, and the R/CNA stated, That's how I was trained to do it. The surveyor requested the manufacturer instruction booklet that came with the thermometer. The Health Information Coordinator present during the screening did not correct the R/CNA's method of obtaining the temperature screenings. At 9:02 AM, the surveyor observed the Director of Nursing/Infection Preventionist (DON/IP) enter through the healthcare entrance and completed the health screening tool and took her own temperature, scanning the infrared thermometer along her forehead to obtain a reading. She then put the thermometer down on the counter. At 9:05 AM, the surveyor observed another staff member enter through the healthcare entrance for a health and temperature screening. The R/CNA picked up the thermometer, and while standing behind the nurses station counter, she pointed the thermometer at the front of the neck of the staff member entering the building. The staff member extended her neck for the R/CNA to obtain the temperature reading and reported the reading for the staff to write down. The surveyor approached the R/CNA a second time and asked her about the method she was taking temperatures of staff. The surveyor asked her to look at the instruction picture printed on the thermometer, and the surveyor asked what the instruction picture represented, and the R/CNA stated, it's a head. The surveyor asked why she thought there might be a head printed on the instructions for the thermometer and she replied, Maybe I am supposed to take the temperature on the head or neck. The R/CNA consistently stated that she was trained to take the temperature on the neck. The surveyor asked who trained her on temperature screenings, and the R/CNA was unable to provide a name stating, I don't know, I got trained months ago. The surveyor asked who was the staff educator, and the R/CNA was unable to provide a name. The surveyor then asked who was the facility's Infection Preventionist? The R/CNA, responded, What? and aded that she did not know what individual handled infection control matters at the facility. The R/CNA stated, All the managers are that. At approximately 9:10 AM, the DON/IP introduced herself as the DON, and she stated she was the facility's current designated Infection Preventionist. At 10:00 AM, the R/CNA provided the surveyor a copy of the manufacturer instructions for the infrared thermometer used for screening the surveyors and the facility staff for signs of fever related to the COVID-19 outbreak. A review of the undated manufacturer instructions for the infrared thermometer included, This device must only be used for the purposes described in this instruction manual. It further included, It may affect the accuracy of measurements when the forehead is covered by perspiration or other factors, please take the temperature behind the ear lobe. The instructions specified the method to take the temperature which included to Aim (the thermometer device) towards the forehead .from a distance of 5 cm (centimeters) (2 in (inches)), press the measuring key, the temperature is displayed immediately . The instructions further included, You can take the temperature behind the ear lobe . Further review of the manufacturer instructions did not specify any other method in which the infrared thermometer was to be used when taking a temperature, including aiming the device toward the front or side of an individual's neck. At 10:37 AM, the surveyor interviewed the DON/IP in the presence of the Executive Director/Licensed Nursing Home Administrator (ED/LNHA), Associate Executive Director (AED) and a second surveyor. The DON/IP acknowledged that the manufacturer instructions did not specify that it was appropriate to obtain a temperature reading by aiming the device toward the front or side of an individual's neck. The DON/IP acknowledged that the R/CNA was not following the manufacturer's instructions for the use of the screening thermometer. She stated that the R/CNA was in-serviced on the thermometer, but the administrative staff were unable to speak to why the R/CNA was unable to provide the name of the staff member who had in-serviced her on the proper method to use the thermometer. The surveyor requested copies of in-service records. A review of an in-service record dated 3/6/20 - 3/10/20 reflected that the R/CNA attended a training instruction on the use of an infrared thermometer for screening. The in-service record did not specify the content of that education or the specific method in which staff were to be using the thermometer. An in-service training record dated 4/6/20 reflected that the R/CNA attended a COVID-19 infection control training presented by the DON/IP that included, Visitors such as direct medical staff should be pre-screened/temp/and wash hands . There was no evidence of a competency (a set of knowledge, skills and abilities needed for an individual to successfully perform various job duties) for the appropriate use of the infrared thermometer for the R/CNA conducted prior to surveyor inquiry. At approximately 1:50 PM, the ED/LNHA informed the surveyor that the facility used to use a probed thermometer for screening of staff, but the Center had made a switch to the infrared thermometers when the probes became more difficulty to purchase. The start date of the use of the infrared thermometer was unclear at the time of the survey. The ED/LNHA and the DON/IP acknowledged that the R/CNA had been trained on the proper use of the infrared thermometer and confirmed she should not be aiming the device at the front or side of the neck in accordance with manufacturer instructions. A review of the facility's COVID-19 Mitigation and Response Plan dated 3/18/20 included, All .entering the community will undergo screening for fever, symptoms of COVID-19, recent travel and exposure to someone with known or suspected COVID-19. It further included, At the beginning of every shift, team members will have their temperature taken to screen for fever . 2. On 7/7/2020 at 10:15 AM, the surveyor interviewed the DON/IP, the ED/LNHA and the AED in the presence of a second surveyor. The DON/IP stated that the facility had a COVID-19 outbreak that began on 3/13/20 and the most recent onset date was a staff member who tested positive on 6/23/20. She added that the facility currently had no residents who were COVID-19 positive but the facility currently had two residents that were considered persons under investigation (PUI) for COVID-19 (Resident #1 and Resident #2). She continued that those residents resided in private rooms in a separate hallway from the rest of the residents. The DON/IP stated that the PUI residents had tested negative for COVID-19 upon admission to the facility and were being monitored for signs and symptoms of [MEDICAL CONDITION] for 14 days, at which time they would be re-tested for COVID-19 to confirm the tests remained negative before moving their rooms. The DON/IP stated that Resident #1 and Resident #2 were on droplet precautions (a method of isolation in which persons entering the room wear specific personal protective equipment to protect from potential pathogen transmission spread through droplets caused by sneezing, coughing, or talking.) The DON/IP stated that droplet precautions meant that staff must wear the appropriate personal protective equipment (PPE) when entering the room, including a long sleeve disposable gown, a respirator face mask, eye protection such as a face shield, and gloves. The DON/IP stated that the staff discard all PPE at the exit of the resident's doorway in a step-trash bin with a red biohazard bag. At 11:35 AM, the surveyor observed the Certified Nursing Aide (CNA #1) and the Licensed Practical Nurse (LPN) wearing face masks standing outside the room of Resident #1. On the resident's door indicated a sign to stop and see nurse before entering. Next to the doorway was a clear plastic storage bin with PPE. The surveyor observed the CNA #1 open the PPE bin and the CNA #1 and the LPN removed PPE and began to don a long sleeve disposable gown and gloves. The CNA #1 did not don eye protection. At 11:37 AM, the surveyor observed the CNA #1 enter the room of Resident #1. Resident #1 was not wearing a mask and the CNA #1 began to take a lunch order for the resident, communicating back and forth the various options on the menu. The CNA #1 or the LPN did not offer or encourage the resident to don his/her face mask. The resident verbally selected the options from the menu. The LPN was in the room adjusting the resident's television with his/her TV remote. At approximately 11:43 AM, the surveyor interviewed the CNA #1 who was exiting the resident's room. The CNA #1 stated that she was not sure why Resident #1 had a stop sign outside the door to see the nurse. She stated it may be because he/she had a contagious disease. The surveyor asked if it was related to suspected COVID-19, and the CNA #1 stated she was not sure. At that time, the LPN performed hand hygiene and doffed his PPE. The LPN stated to the CNA #1 in the presence of the survey that Resident #1 was on droplet precautions because he/she was a new admission from the hospital and added that all new admissions were placed on droplet precautions for 14 days incase they develop signs or symptoms of [MEDICAL CONDITION]. The LPN added that the resident had tested negative for COVID-19 as a baseline. The CNA #1 stated that upon entering a room for a resident on droplet precautions, she should wear a gown, gloves, a respirator mask and a face shield. The surveyor asked why she mentioned a face shield was necessary upon entering the room, and the CNA #1 replied, to protect my eyes from droplets. The CNA #1 acknowledged she was not wearing a face shield or eye protection, and she also acknowledged that the resident was not wearing a face mask during their communication. The CNA #1 stated that she personally wears a face shield only when performing care for the resident. The surveyor asked if there was any other time she should wear it, and she indicated that she was supposed to wear it upon entering the room at any time. She further added that the reason the surveyor did not see a face mask on the resident or in stored in the resident's room was because Resident #1 liked to keep his/her personal mask kept under their shirt, and that he/she would only sometimes wear the surgical mask. At 11:45 AM, the surveyor interviewed the LPN who was wearing personal eye glasses at that time. The LPN confirmed he was not wearing a face shield while in the resident's room. He stated that he would wear a face shield when performing treatments from the treatment cart. He acknowledged droplet precautions indicated the use of eye protection. At 11:49 AM, the surveyor observed the items in the PPE bin outside the door of Resident #1 with CNA #1, which included respirator masks, surgical masks, long-sleeve disposable gowns, and gloves. There was no evidence of a face shield or eye protection available in the cart. The CNA #1 confirmed there was no eye protection in the bin outside the resident's room, but she took the surveyor down the hallway to observe two other bins of PPE which had several face shields available and accessible. At 12:30 PM, the surveyor observed Resident #1 sitting a wheelchair in his/her private room. The resident had a surgical face mask looped around the ears and the mask was tucked under his/her chin. The resident was not picking at the mask or attempting to remove it. A review of the in-service records revealed that CNA #1 had successfully met a skills competency for donning and doffing PPE on 6/11/20 and 6/21/20 which included, How to Safely Put on the Goggles or Face Shield. A review of the in-service records revealed the LPN had successfully met a skills competency for donning and doffing of PPE on 4/4/2020 which included, How to Safely Put on the Goggles or Face Shield. On the same day on 7/7/2020 at 1:30 PM, the surveyor interviewed the DON/IP in the presence of the ED/LNHA, the AED, and a second surveyor. The DON/IP acknowledged that droplet precautions included the use of a face shield upon entering the room of a resident who was under investigation for COVID-19, in accordance with the facility's infection control policy and procedure. The DON/IP acknowledged the surveyors findings and confirmed if no face shield was available in the bin outside of Resident #1's room, staff could either ask for more or temporarily use the face shield from another bin and restock the PPE bins after. A review of the facility's COVID-19 Mitigation and Response Plan dated 3/18/20 included, Put on eye protection (i.e. goggles or disposable face shield that covers the front and sides of the face) before entry to the resident's room. Personal eye glasses and contact lenses are NOT considered adequate eye protection. 3. On 7/7/2020 at 12:40 PM, the surveyor observed the lunch meal pass on the non-COVID hallway. The surveyor observed the following: At 12:44 PM, the surveyor observed the Lead CNA deliver a disposable lunch tray to Resident #3. The Lead CNA did not offer or encourage the resident to perform hand hygiene prior to meal service and she exited the room. The surveyor observed Resident #3 sitting on the edge of the bed attempting to open the disposable container with the lunch meal. The surveyor interviewed the resident at that time, and the resident stated that the facility does not offer hand wipes or alcohol wipes to clean the hands before meal service. At that time, the resident independently stood up and stated that he/she liked to wash the hands at the sink in the bathroom. The resident proceeded to go to the bathroom to wash his/her hands. At 12:50 PM, the surveyor observed the Lead CNA bring a disposable lunch tray to Resident #4. The Lead CNA assisted the resident in setting up the lunch on the bedside table. The Lead CNA did not offer or encourage the resident to perform hand hygiene prior to meal service. At that time, the surveyor interviewed the Lead CNA who stated that both Resident #3 and Resident #4 were not under investigation for COVID-19. She confirmed she did not offer hand hygiene to Resident #3 because he/she performs hand hygiene at the sink in the bathroom. The surveyor inquired about the hand hygiene for Resident #4, and the Lead CNA stated that she used the resident's personal care cloth wipes to wash his/her hands. The surveyor asked when she washed the resident's hands and she stated it was a little while ago. The Lead CNA showed the surveyor the wipes she used and she opened the resident's drawer in his/her cabinet and showed the surveyor a green package of aloe-based Personal Cleansing Cloths. She stated that those were the same cloths used for the resident during morning care. The surveyor and Lead CNA reviewed the active ingredients written on the package of the cleansing cloths, which reflected the product was alcohol-free. The surveyor asked if the residents were provided a method to wash their hands with an alcohol-based hand rub (ABHR) or ABHR-wipes, or a method of soap and water? The Lead CNA replied that there was no single process for offering hand hygiene to the residents and that it was individual to that resident. At 1:15 PM, the surveyor interviewed the resident's Registered Nurse (RN) who stated that the CNA's were responsible for providing hand hygiene to each resident prior to the lunch meal. She stated that residents are either offered to go to the bathroom and wash their hands at the sink with soap and water or they would be offered a basin with soap and water and a wash cloth to wash their hands. The surveyor asked the RN about the use of alcohol-free personal cleansing cloths to wash the hands of Resident #4 before lunch, and the RN stated that it was not appropriate to wash the hands of a resident with an alcohol free product before the lunch meal, due to COVID-19. The RN confirmed that ABHR should contain 60% or greater of alcohol to be effective against COVID-19. A second surveyor observed the lunch meal pass on the hallway with the residents who were PUI (Resident #1 and Resident #2), and observed the following: On 7/22/20 at 12:50 PM, the surveyor observed CNA #1 bring a meal tray toward Resident #1's room and place the tray on a PPE storage outside the resident's room. The tray did not contain a hand wipe or method to perform hand hygiene for the resident. The CNA #1 placed the tray outside of the room and without performing hand hygiene she donned some PPE. The surveyor observed Resident #1 sitting upright in a wheelchair in the room. The CNA #1 placed the tray on the resident's bed side table positioned in front of him/her. The CNA #1 did not offer or encourage the resident to perform hand hygiene prior to the lunch meal, and the CNA #1 proceeded to unwrap a sandwich and place it in the resident's hand. At approximately 1:00 PM, the surveyor interviewed the CNA #1 who could not speak to when Resident #1 was afforded the opportunity to perform hand hygiene prior to the lunch meal. At 1:30 PM, the surveyors interviewed the DON/IP regarding if the facility had a policy regarding hand hygiene for residents prior to meals and the method in which that was to be performed. The DON/IP stated staff would either wash the residents hands using soap and water at a sink or using a basin at the bedside, or they could use provide ABHR to the residents prior to the meals. The DON/IP confirmed alcohol-free personal cleansing cloths were not an appropriate method of hand hygiene prior to lunch service during the COVID-19 outbreak. A review of the Infection Prevention and Control Program last updated 12/2019 included that the timing of hand hygiene was done before eating. At 1:40 PM, the surveyor asked the DON/IP if the policy spoke to the method in which residents were offered hand hygiene before meals, and the DON/IP acknowledged the policy that she pointed out to the surveyor did not address that topic, but that she would search for it. 4. On 7/7/2020 at 9:00 AM during a tour of the PUI hallway, the surveyor observed Resident #1 sitting in a wheelchair in front of a bedside table inside his/her room. The resident was not wearing a face mask and the door was wide open. The resident spoke to the surveyor from the hallway. At that time, CNA #1 was observed exiting the room of Resident #2, another PUI resident. The CNA #1 was holding a red plastic bag that appeared to be weighted with contents. While holding the filled red plastic bag, the CNA #1 then entered the room of Resident #1, without donning a face mask, gloves, gown or a face shield, and the surveyor heard CNA #1 conversing with the resident in the resident's room. At approximately 9:05 AM, CNA #1 then exited the room of Resident #1 un-masked and still holding the red bag from the room of Resident #2. At that time, the surveyor stopped and interviewed CNA #1, who stated the red bag contained a gown that she wore while assisting Resident #2 with the breakfast meal. She stated she had to wear a gown, gloves, a respirator mask and face shield when she entered the PUI rooms because those residents were on droplet precautions. She stated that Resident #1 and Resident #2 were new admissions to the facility. She further stated that she would need to put the same PPE on when she cared for those residents, but since she was just talking to the resident, she did not need to wear any PPE. She then proceeded down the hallway, not wearing a face mask and holding the red bag. The CNA #1 placed the red bag in the soiled utility room. At approximately 9:10 AM, the surveyor observed CNA #1 wearing a blue surgical mask in the hallway. At 10:30 AM, the surveyors interviewed the facility DON/IP who stated that the facility was not extending the use of any PPE and that after doffing any PPE, it was all considered soiled. She further added that all soiled PPE was to be discarded inside of a resident's room in a red plastic bag, and if the bag was being emptied, it should be immediately brought down into the soiled utility room. She added that the staff should not be entering another resident room while holding a red plastic bag, continuing that the red plastic bag was a method to identify the contents were considered potential biohazard. She further stated that the facility had implemented universal masking for all staff in accordance with requirements and that surgical masks were to be worn throughout the hallways, and are switched to a respirator mask when providing care for a PUI resident. She stated that staff cannot enter a resident's room on the PUI unit without wearing a respirator mask. At 12:40 PM on the PUI unit, the surveyor observed CNA #1 carry a meal tray toward the room of Resident #2 and placed the tray on the PPE storage bin outside of the resident's room. CNA #1 then donned a gown and performed hand hygiene using an alcohol-based hand rub. With her bare hand, she then removed her used surgical mask and donned a respirator mask followed by a pair of gloves. She did not perform hand hygiene after discarding her used surgical mask with her bare hand or before applying the new pair of gloves upon entering the room of Resident #2. In addition, CNA #1 did not don a face shield upon entering the resident's room. At that time, the surveyor observed Resident # 2 in bed with a bed side table positioned over the bed. The CNA #1 removed and discarded a cup from the resident's bedside table with her gloved hand and placed it inside the small trash bin located at the resident's bedside. CNA #1 then proceeded to un-wrap the resident's meal. The resident was then observed drinking from the beverage without being offered hand hygiene. While the resident was eating, the CNA #1 then doffed the PPE in a garbage can lined in a red plastic bag located at the resident's head of the bed. The surveyor observed a large step-trash can available at the exit of the room. The CNA #1 exited the resident's room holding the red bag. She then donned a surgical mask from the PPE storage cart and walked down the hallway toward the soiled utility room. At 12:50 PM, the surveyor observed CNA #1 bring a meal tray toward Resident #1's room and place the tray on a cart outside the resident's room. The CNA #1 placed the tray outside of the room and without performing hand hygiene she donned a gown and doffed her used surgical mask. She then proceeded to don a respirator mask and performed hand hygiene using an alcohol-based hand rub prior to donning a pair of gloves. She did not don a face shield prior to entering the resident's room and proceeded to place the resident's meal items on a bed side table located in front of the resident while the resident was seated in a wheelchair. CNA #1 unwrapped a sandwich and placed it in the resident's hand. At approximately 1:30 PM, the surveyors reviewed all findings with the DON/IP, Executive Director/LNHA and the AED. A review of the facility's, The Face Masks & Personal Protective Equipment Policy dated 4/2020, included that team members will wear regular medical facemasks throughout the day and in the community. Hands should be washed, or hand sanitizer used when putting on or taking off any PPE. When delivering or picking up meal trays, the required PPE is a regular medical face mask, gloves and goggles/face shield. Other than regular medical face masks, PPE must be removed just outside of resident room or designated isolation area . NJAC 8:39-19.4; 27.1 (a)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to maintain infection control practices to reduce the risk of infection for; a.) 2 of 2 wound treatment observations (Resident's # 3 and #6), b.) storage of indwelling urinary catheters for 2 of 2 residents reviewed for catheters (Resident #3 and #6), c.) conduct an annual review of the infections prevention and control practices policies and procedures, and d.) for the storage of clean housekeeping equipment. This deficient practice was evidenced by the following: 1. On 10/24/19 at 10:11 AM, the surveyor observed Registered Nurse (RN) #1 complete the wound treatment on the right heel of Resident #6. RN #1 reviewed the Treatment Administration Record (TAR) for Resident #6. RN #1 then gathered the needed supplies; an open package of woven 4x4 gauze sponges, tongue depressor, five individual plastic saline vials, [MEDICATION NAME] dressing ( a dressing with a silicone adhesive border and waterproof backing), tube of [MEDICATION NAME] (used to promote wound healing), bottle of hand gel, box of gloves, and a tub of sanitizing wipes) from the treatment cart and placed them on the top of the cart. On the same day at 10:15 AM, the surveyor observed RN #1 pick up all the supplies and carried them into the room of Resident #6 and placed them on to the left side of the resident's overbed table. At 10:16 AM, the surveyor observed RN #1 washed her hands for 20 seconds under the flow of water, then dried her hands with a paper towel. RN #1 put on a pair of gloves and cleaned off the right side of the overbed table with the sanitizing wipes. At 10:17 AM, the RN washed her hands for 16 seconds under the flow of water. RN #1 then put on a pair of gloves and placed a poly-lined barrier on the right side of the overbed tabletop. The RN then moved the garbage can to the end of Resident #6's bed, removed her gloves, gelled her hands, and then washed them with soap and water under the flow of water for 16 seconds. At 10:20 AM, RN #1 put on gloves and removed some 4x4's from the open package of dressings, and along with the five saline vials, [MEDICATION NAME] dressing, tongue depressor placed them on to the clean barrier on the right side of the table. At 10:22 AM, RN #1 put on a clean pair of gloves and removed the padded blue heel boot and non-skid sock from the right foot of Resident #6. After she removed her gloves, RN #1 gelled her hands and put on a clean pair of gloves. RN #1 then placed a barrier on the bed and under the right foot of Resident #6. RN #1 then removed her gloves and gelled her hands. At 10:23 AM, RN #1 removed the [MEDICATION NAME] dressing from Resident #6's right heel and discarded the dressing and gloves in the garbage can. At 10:25 AM, RN #1 washed her hands with soap and water for seven seconds outside the flow of water, followed by 10 seconds under the flow of water. RN #1, assisted by the resident, lifted their right leg while RN #1 placed a barrier under the residents' right foot. RN #1 then used a saline vial to clean the wound while holding a 4x4 gauze dressing under the right heel of Resident #6. Some of the saline went onto the barrier that had been placed under the residents' foot. The resident then lowered their foot, and it rested on the wet spot on the barrier. At 10:29 AM, RN #1 removed her gloves, gelled her hands, put on a clean pair of gloves, and returned the non-skid sock and heel bootie to the right foot of Resident #6. At 10:34 AM, RN #1 completed the wound treatment, tied the bag of garbage closed, and left it in the garbage can in the room. RN #1 then removed the opened package of 4x4 gauze dressings, tube of [MEDICATION NAME], and tub of sanitizing wipes from the overbed table and returned them to the treatment cart. RN #1 returned the hand gel and gloves to the top of the medication cart. At 10:50 AM, the wound treatment garbage remained in Resident #6's garbage can in the room. At 11:01 AM, Resident #6 was out of their room, and the wound treatment garbage remained in the garbage can in the room. At 11:37 AM, the wound treatment garbage had been removed from the garbage can in Resident #6's room. On 10/25/19 at 8:15 AM, the surveyor reviewed the facility form titled, Admission Record, which revealed that Resident #6 most recent admission to the facility was 9/23/19 and identified [DIAGNOSES REDACTED]. The surveyor then reviewed Resident #6's most recent Minimum Data Set (MDS), an assessment tool, dated 10/7/19, which showed that the resident's Brief Interview of Mental Status was coded as a 3 of a possible 15, which indicated that the resident had severe cognitive impairment. 2. On 10/25/10 at 9:58 AM, the surveyor observed RN #1 prepare the needed supplies for the wound treatment on Resident #3. RN #1 washed her hands with soap and water for 18 seconds under the flow of water. At 10:00 AM, the surveyor observed RN #1 washed her hands for 21 seconds and then rinsed them under the flow of water. RN #1 then picked up a garbage bag that had been sitting on the floor of the bathroom in the resident's room and carried it over and placed it on top of Resident #3's wheelchair. At 10:01 AM, RN #1 washed her hands for 11 seconds, then rinsed them under the flow of water. RN #1 stated that the paper towel dispenser was empty and picked up a loose paper towel from the countertop and dried her hands, and used the same paper towel to shut off the faucet. At 10:02, RN #1 gelled her hands and informed the housekeeper that paper towels were needed in the bathroom of Resident #3. At 10:20 AM, RN #1 informed the surveyor that housekeeping had filled the paper towel dispenser and that they had also cleaned off the wheelchair because of the garbage bag that had been placed on it. Immediately following, the surveyor interviewed the housekeeper, who confirmed that she had cleaned Resident #3's wheelchair and disposed of the garbage bag in the soiled utility room. At 10:25 AM, RN #1, with the assistance of RN #2, explained to Resident #3 that they would be completing the wound treatment. Resident #3 consented to the treatment. At 10:31 AM, the surveyor observed that RN #1 reviewed the TAR and gathered the supplies; one opened package of 4x4 woven gauze dressings, one package of a gauze bandage roll, seven packages of individually wrapped tongue blades, a clear bag that contained a bottle of Dakin solution and a tube of Santyl, a tub of sanitizing wipes, a bottle of hand gel, a box of gloves, two packages of [MEDICATION NAME] dressings (a non-adhering dressing) and three packaged sterile covers. RN #1 then removed a pair of bandage scissors and a marker from the pocket of her shirt and placed them on the top of the supplies that were on the top of the treatment cart. RN #1 then gathered the supplies from the top of the cart and carried them into the room, and placed them on the left side of the overbed table of Resident #3. At 10:34 AM, the surveyor observed RN #1 wash her hands with soap and water for 12 seconds and then rinsed them under the flow of water. RN #1 then put on a pair of gloves and wiped the right side of the overbed table with a sanitizing wipe. RN #1 then washed her hands with soap and water for seven seconds and then rinsed them under the flow of water for 10 seconds. RN #1 then placed a barrier to the right side of the overbed table and moved the wound treatment supplies from the left side of the table and placed them on the clean barrier that had been placed on the right side of the table. RN #1 then removed her gloves and gelled her hands. After putting on a pair of gloves, RN #1 removed the bedspread from the bed of Resident #3. At 10:44 AM, RN #1 removed her gloves and washed her hands for 25 seconds under the flow of water, added more soap, and rubbed her hands for an additional five seconds under the flow of water. At 10:45 AM, RN #1 put on a pair of gloves and removed multiple 4x4's gauze dressings from the opened package and placed them on the clean barrier. RN #1 then washed her hands for 10 seconds under the flow of water. RN #1, with the assistance of RN #2, placed a barrier on top of the sheet and under the right leg of Resident #3. RN #1 then washed her hands for 15 seconds under the flow of water. RN #1, then put on a pair of gloves, removed the Dakin solution (an antiseptic) from the clear bag and cleaned the wound on the second and third toes on Resident #3's right foot. RN #1 then placed the bottle of Dakin's solution onto the clean barrier and patted the two wounds dry with a separate 4x4 gauze dressing. RN #1 used a separate tongue blade and placed a small amount of Santyl gel (a medication used to treat wounds) onto the open areas on the second and third toes with a different tongue blade. At 10:51 AM, RN #1 washed her hands for 12 seconds outside of the flow of water before she rinsed them off under the stream. The clear bag that held the bottle of Dakin Solution and tube of Santyl was empty and lying on the clean barrier on the overbed table. RN #1 then put on a clean pair of gloves and prepared the resident for the treatment on their left foot. RN #1 then washed her hands with soap and water for five seconds outside of the flow of water and then rinsed them under the flow of water for 10 seconds. At 10:56 AM, RN #1 put on a pair of gloves, and with the assistance of RN #2, lifted the left leg of Resident #3. RN #1 then placed a clean barrier under the left foot of Resident #3. At 10:58 AM, RN #1 picked up the scissors that had been on the clean barrier and then returned them to the barrier. At 11:02 AM, RN #1 washed her hands for eight seconds and then rinsed them under the flow of water. RN #1 then put on a clean pair of gloves and after cleaning the wounds with the bottles of Dakin solution and patted them dry with a different 4x4 gauze dressing and with the same gloved hands, picked up the Santyl tube and placed a small amount of the gel onto a tongue blade and repeated the process five more times using a different tongue blade to apply the Santyl to the wounds. RN #1 then recapped the tube of Santyl and returned it to the barrier on the right side of the table. RN #1 then removed her gloves and gelled her hands. RN #1 then put on a pair of gloves and removed the [MEDICATION NAME] dressing from its packaging. RN #1 picked up the scissors and used them to cut the [MEDICATION NAME] dressing and placed a piece on each of the wounds of the left foot. RN #1 then removed her gloves, gelled her hands before putting on a new pair of gloves and wrapped the left foot of Resident #3. At 11:00 AM, RN #1 informed Resident #3 that the wound treatment had been completed and removed the barrier from the bed and then removed the supplies from the right side of the overbed table. RN #1 returned the bottle of Dakin Solutions and tube of Santyl to the clear plastic bag and placed it on the left side of the table, along with the scissors and marker. RN #1 then placed the used treatment supplies into the garbage can and tied the two garbage bags off and left them in the garbage can. RN #1 told RN #2 that she would inform housekeeping that the garbage needed to be removed from Resident #3's room. RN #1 then lowered the bed of Resident #3 and touched the urinary drainage bag that was secured to the right side of the bed before she placed the call bell into the right hand of Resident #3. At 11:14 AM, RN #1, washed her hands for 10 seconds before rinsing them under the flow of water. RN #1 then picked up the supplies from the left side of the overbed table and returned the bag with the Dakins and Santyl to the treatment cart, as well as the pair of scissors, a package of 4x4's and tub of sanitizing wipes. RN #1 then returned the box of gloves and hand gel to the medication cart. Immediately following the treatment, the surveyor interviewed RN #1 about the wound treatment observations they had completed on Resident #6 and Resident #3. RN #1 confirmed that they had been inserviced on proper handwashing technique and that the wound treatment was not a sterile technique. RN #1 stated that she had cleaned the scissors before the treatment and added that she would clean them after the interview. On the same day at 11:25 AM, the surveyor interviewed the Director of Nursing Services/Infection Preventionist (DNS/IP) and informed them of the wound treatment observations that had been made on 10/24/19 and 10/25/19. The DNS/IP stated that the proper technique for handwashing was to turn on the water, not hot or cold, and gather soap and wash between your fingers, scrubbing outside the flow of water for at least 20 seconds, and added that she told them 30 seconds with friction. She continued, that staff should then rinse their hands, holding them downward to rinse, grab and dry their hands with a paper towel, discard, grab another paper towel and use it to turn the faucet off. The DNS/IP stated that hand hygiene should take place between wounds and that the nursing staff were told to tie off the bag of garbage after the treatment and have the housekeeper, or the nurse themselves, remove it from the residents' room. The DNS/IP said that she started working at the facility in (MONTH) of 2019 and that she had not conducted a wound treatment competency with the nursing staff. The DNS/IP added that a hand hygiene inservice and competency was conducted upon hire, annually and at any time, a breach was observed. She said, We do it a lot. On 10/25/19 at 11:44 AM, The DNS/IP provided the surveyor with a completed competency for the proper handwashing technique that had been completed with RN #1 on 10/25/19 and the facility form titled, Transcript Report - Individual Team Member for RN #1 which included the successful completion of web-based training of Infection Control Essentials on (MONTH) 16, 2019. On the same day at 12:25 PM, the surveyor reviewed the facility Wellness Program titled, Skin Care & Pressure Ulcer Management Program which included: 1. Assessment of identifying resident that were at risk for developing wounds. 2. Plan - An Individualized Plan which included Infection Control and read: * Current Recommendations specific to wound care: * Wash/decontaminate hands prior to contact with a resident * Wash/decontaminate hands after contact with intact skin * wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur * Wash/decontaminate hands when moving from a contaminated-body site to a clean body site during patient care * Remove and discard gloves after caring for a resident and wash/decontaminate hands 3. Implement - Putting the Plan into Action 4. Evaluate - Evaluating Outcomes At that time, the Executive Director (ED) and RNS/IP confirmed that the Wellness Training Program identified above was the procedure used for the management and treatment of [REDACTED]. At 1:52 PM, the surveyor reviewed the facility provided form from the World Health Organization titled, How to Handwash, dated (MONTH) 2009, read as follows: Wash hands when visibly soiled! Otherwise, Use hand rub. Duration of the entire procedure: 40 - 60 seconds. Wash hands with water; Apply enough soap to cover all hand surfaces; Rub hands palm to palm; Right palm over left dorsum with interlaced fingers and vice versa; Palm to palm fingers interlaced; Backs of fingers to opposing palms with fingers interlocked; Rotational rubbing of the left thumb clasped in right palm and vice versa; Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa; Rinse hands with water; Dry hands thoroughly with a single use towel; Use towel to turn off faucet; Your hands are now safe. 3. On 10/23/19 at 7:00 AM, the surveyor observed Resident #6 in bed and covered with blankets. There was a visible catheter bag secured to the bed, and the tubing was half on the floor and half on the mat that was on the floor next to the resident's bed. On 10/25/19 at 10:11 AM, the surveyor observed Resident #6 in bed with the head of the bed elevated. The tubing emptied into a large urinary drainage bag secured to the right side of the bed. The drainage bag had a blue cover and was resting on the floor. On the same day after the wound treatment at 10:31 AM, as identified in example #1, RN #1 lowered the bed, and the urinary drainage bag again rested on the floor. 4. On 10/23/19 at 7:45 AM, the surveyor observed Resident #3 in a low bed in the resident's room. There was a urinary drainage bag attached to the bed frame. The collection bag was resting on the floor. There was a privacy drape covering the front of the bag. On 10/24/19 at 9:00 AM, the surveyor reviewed the Admission Record, which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was also a lab report which indicated that the resident was diagnosed with [REDACTED]. On 10/24/19 at 9:14 AM, the resident was in the dining room in a wheelchair. The urinary drainage bag was under the wheelchair. The back of the bag was covered by a blue plastic drape. The blue plastic drape was touching the floor. On 10/24/19 at 9:32 AM, the DNS wheeled the resident down the hall and stopped in front of the surveyor. The DNS went into another resident's room and left Resident # 3 in the wheelchair next to the surveyor. The surveyor observed the urinary drainage bag attached to the underside of the wheelchair, was touching the floor as well as the blue drape covering the front of the drainage bag. At 9:35 AM, the DNS came back to the resident and wheeled the resident to therapy with the urinary drainage bag dragging along on the floor under the wheelchair. On 10/24/19 at 12:04 PM, the surveyor observed the resident in the day room at a table during an activity. The urinary drainage bag was attached to the underside of the wheelchair and was touching the floor. At that time, the Assistant Director of Nursing (ADON) approached the surveyor. The surveyor asked the ADON if anything was wrong with the way the catheter was positioned under the wheelchair. The ADON first said it's too far back, then asked about the tubing. The surveyor then asked if the urinary drainage bag should have been touching the floor. The ADON stated, Oh, that, No. The surveyor asked her why it shouldn't be touching the floor. The ADON said, Infection. The ADON further stated, It's usually not like that. The ADON then took the resident to the resident's room and positioned the drainage bag, so it was hooked onto a higher bar under the wheelchair and not onto the floor. On 10/24/19 at 2:00 PM, the surveyor spoke with the DNS, the ED, and the Assistant Administrator about the observation of Resident #3's urinary drainage bag viewed on the floor multiple times. The surveyor asked them if the indwelling catheter bag or tubing should have been on the floor. The DNS stated, No. The DNS further said, When the bed goes low, it is a challenge to find a spot, so they are not on the floor. A lot of the wheelchairs are different, and so we really have to crawl on the floor and find a spot to put the bag, so it's not on the floor. On 10/24/19 at 2:00 PM, the survey team asked for the policy and procedure for the care of resident's with urinary catheters. The DNS said that they didn't have a policy and procedure; they had a Wellness Program. The surveyor reviewed the Wellness Program titled, Continence Management Program Forms and Tools, which did not address the positioning of urinary drainage bags. 5. On 10/23/19 07:13 AM, the surveyor observed two housekeepers standing at the doorway of the soiled linen room of the laundry room. Upon entrance to the room, on the right side, there was a bucket with mop heads. A housekeeper stated that was where they placed the dirty mop heads. In addition to the mop heads, two covered bins were used for the placement of soiled linen. On the opposite side of the small, soiled linen room, was a large gray garbage can with mop heads. The housekeepers confirmed that was where the clean mop heads were stored. 6. On 10/23/19, during the entrance conference, the surveyor requested the Infection Prevention and Control Program Policy (IPCP), Antibiotic Stewardship Program, and the Influenza and Pneumococcal Policy and Procedures (P&P's). The surveyor reviewed the IPCP that had an effective date of 1/24/16. The surveyor then reviewed the facility policy titled, Antibiotic Stewardship Program had a date of (MONTH) (YEAR). The Influenza and Pneumococcal Immunizations policy had an effective date of 11/28/16. On 10/25/19 at 10:52 AM, the surveyor interviewed the DNS/IP on IPCP. The DNS/IP stated that she would have to look into when the annual review of the IPCP policies and procedures took place. On the same date at 3:00 PM, the surveyor interviewed the ED and DNS/IP regarding the annual review of the IPCP P&P's. The DNS/IP stated that she had spoken to the Regional Representative and confirmed that the policies had been reviewed annually but did not provide any evidence as to the last time they had been reviewed. The ED stated that the policies and procedures were reviewed on the Corporate Level and that those provided were the active and current policies and procedures. The ED added that they were made aware of new policies and procedures, as well as revisions when they were sent out by Corporate, and then they would be reviewed, accepted, and the staff would be in-serviced on them. The ED confirmed that they do not review and sign off on the P&P's at the individual facility level. N.[NAME][NAME]C. 8:39- 19.4 (a)(e)(f)

Based on observation, interview, and record review it was determined that the facility PART A - failed to maintain proper temperatures of water in a hot and cold water dispenser which had the potential to burn residents, visitors and staff. The hot water section dispensed water at a temperature of 180 degree Fahrenheit. This resulted in an immediate jeopardy to residents and visitors who were potentially at risk for possible burns from the hot water. PART A The immediate jeopardy was identified on 10/12/16 at 12:50 p.m. and after consultation with the office the surveyors reported the situation to the Administrator at 1:00 p.m The Immediate Jeopardy was lifted at 1:55 p.m. when an acceptable Plan of Correction (POC) was received by the survey team and implemented by the facility. This deficient practice for Part A was evidenced by the following: On 10/12/16 at 11:30 a.m. during the standard survey, the surveyor observed a free standing hot and cold water dispenser located in a resident's hallway, outside resident room 108. The dispenser was connected directly to the plumbing. The dispenser was located on the first floor and was centered between wing one and wing two across from the main dining area. On 10/11/16 at 11:15 a.m. the surveyor observed the family member of Resident #4 utilizing the water dispenser. The cups available at the water dispenser were plastic cups used for cold water and were held in a cup dispenser attached to the water dispenser. Two surveyors tested the temperature of the hot water in a Styrofoam cup that was obtained from the dining area. The temperature reading of the hot water with a manual thermometer read 172 degrees Fahrenheit. The temperature of the hot water with a digital thermometer read 181.3 degrees Fahrenheit. (at 150 degrees F for 2 seconds, a 3rd degree burn will occur; at 160 degrees F for 0.5 seconds, a 2nd degree burn will occur.) The Director of Nurses (DON) observed the surveyors taking the temperatures of the cup of hot water and confirmed the temperature were accurate. The DON then notified the Maintenance Coordinator at 11:35 a.m. During interview with the Maintenance Coordinator at 11:35 a.m., he informed the surveyor that no one checks or inspects the water dispenser and the water dispenser had been in place for at least five years. The Maintenance Coordinator then shut off the hot water from the back of the dispenser. During an interview with the DON on 10/12/16 at 11:50 a.m. the DON informed the surveyor the census of the facility was 26 residents and 23 of the 26 residents had some degree of cognitive impairment. She also stated six of the residents were able to ambulate or self-propel their wheelchairs to get to the water dispenser without assistance. At 12:30 p.m. the surveyor further inspected the water dispenser and observed an inspection sticker on the side of the water dispenser dated 10/18/14. The surveyor also observed only cold water plastic cups were available at the water dispenser. These cups are not designed to hold hot water and therefore would easily spill or collapse when filled with hot water and burn the person holding the cup. At 1:00 p.m. the Executive Director was notified of the immediate jeopardy. The DON informed the surveyor that the facility had no burn injuries. The immediate jeopardy was corrected on 10/12/16 at 1:55 p.m. based on acceptable plan of correction which included: 1. No residents were identified as being affected by the high temperature in the water dispenser. 2. Any resident who was able to use the water cooler (either by ambulating to it or wheeling themselves) had the potential to be affected by the high hot water temperature in the water dispenser. 3. The water dispenser was immediately removed from the facility. The Maintenance Coordinator was immediately in serviced by the Executive Director on checking hot water temperatures. 4. Only cold water dispensers will be used in the future to assure that this deficient practice does not recur. On 10/12/16 at 2:20 p.m. the surveyor confirmed the hot and cold water dispenser had been removed. On 10/13/16 at 8:00 a.m. the surveyors confirmed again that the hot and cold dispenser was removed. On 10/13/16 at 9:00 a.m. the Maintenance Coordinator informed the surveyors and provided contract invoices from the company that inspects and maintains the water dispenser. The surveyor reviewed the contract invoices and work order reports that were supplied. The work order supplied form indicated the facility received the water dispenser on 11/3/14. PART B - Based on observation, interview, and record review it was determined that the facility failed to consistently implement safety interventions following a resident fall in order to safeguard the resident from further injury. This deficient practice was noted for 1 of 3 residents reviewed for falls, Resident #6. This deficiency continues at a scope and severity of D based on the evidence in Part B. The surveyor observed Resident #6 awake in a low bed on 10/11/16 at 10:00 a.m The Director of Nursing (DON) stated the resident had fallen approximately 2 months ago. She stated the resident slid out of bed. The surveyor reviewed Resident #6's medical record on 10/12/16. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/15/16 Admission Minimum Data Set Assessment (MDS) indicated the resident had no cognitive deficits and required extensive assistance of one caregiver for transferring from one surface to another and for toilet use. On 10/12/16 the DON provided the surveyor with 2 Resident/General Liability Incident Reports (IR) pertaining to falls which occurred on 8/28/16 and 10/8/16. The 8/28/16 IR indicated that on 8/28/16 at 2:30 p.m. the Unit Licensed Practical Nurse (LPN) was notified by the Care Manager (Certified Nursing Assistant - CNA) that the resident was observed on the floor in the bedroom area. The LPN documented in the IR when I assessed the resident, (he/she) was in bed. It was not documented who transferred the resident back to bed. The DON provided the surveyor with the facility Policy for Accidents/Incidents (effective date 2/29/16). Action Step #4 read: In the event an accident or incident occurs, the Licensed Nurse does not move the resident until examined for possible injury. On 8/12/16 at 2:00 p.m. the surveyor spoke with the Administrator and DON regarding the circumstances of the 8/28/16 fall when the resident was transferred back to bed without a nursing assessment for the presence of injuries. The LPN documented that when she entered the resident's room to assess the resident, the resident was lying in the bed. There was no documentation provided to indicate how the resident was transferred from the floor to the bed. On 10/13/16 at 11:00 a.m. the Administrator provided documentation of an inservice conducted on 10/12/16 which instructed nursing staff to alert a nurse to assess a fallen resident before transferring the resident back to bed or a chair. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to consistently implement resident care plans in the areas of falls and pressure ulcers. This deficient practice was noted for 1 of 9 residents sampled for care plans, Resident #5, as evidenced by the following: 1. The surveyor observed Resident #5 on 9/22/15 at 9:00 a.m. in bed with eyes closed in bed. The surveyor reviewed the resident's electronic and paper medical records on 9/22/15. The resident was admitted to the facility with a casted right arm in May, 2015. A fall risk care plan was initiated on 5/15/15 due to actual falls and a fracture. The care plan included an intervention to monitor the right casted arm for proper circulation, color, [MEDICAL CONDITION], and pain. A review of Progress Notes revealed a 5/15/15 nursing new admission assessment note which failed to document the resident had a cast to the right arm. Intermittent nursing progress notes from 5/16/15 through 6/12/15 noted the presence of a cast, however, no assessment of circulation was documented. On 6/14/15 at 2:59 p.m. the nurse documented the first note reflecting an assessment of the casted right arm's circulation. This was nearly 1 month after admission. Refer to F309 2. The fall care plan was revised on 6/9/15 when the resident fell from a raised bed onto the floor and sustained a fractured spine. The intervention instructed staff to be sure the bed was kept in the lowest position. On 9/23/15 at 11:00 a.m. the surveyor observed a pressure ulcer treatment performed by a Licensed Practical Nurse (LPN) and assisted by a Certified Nursing Assistant (CNA). The LPN and CNA entered the resident's room to begin the treatment. The CNA raised the bed to the highest position. The LPN and CNA stood at the bedside on the resident's right side and rolled the resident onto the resident's left side. There was no one standing on the left side of the resident's bed and the side rail was in the down position. The LPN did not instruct the CNA to move to the other side of the bed to protect the resident from falling from the left side of the raised bed. The surveyor quickly moved to the left side of the bed and requested that one of the staff move to that side. The LPN left the resident's bedside and entered the bathroom to wash her hands. The resident remained in a left side lying position on the raised bed without side rails in use. The CNA left the resident's side and walked away from the bed. The surveyor again instructed the CNA to return to the bedside to protect the resident from falling. The LPN returned to the resident's bedside, removed the wound dressing, cleansed the wound, and went into the bathroom to wash her hands. The CNA again walked away from the resident's side while the resident was in a side lying position on the raised bed without siderails. The surveyor instructed the CNA to stay at the resident's bedside to ensure the resident did not fall from the raised bed. Refer to F323 3. Resident #5 was admitted to the facility on [DATE] with an unstageable pressure ulcer and assessed by the facility to be at risk for further skin breakdown. A pressure ulcer care plan was initiated on 5/15/15. The care plan included an intervention to float heels while in bed. The surveyor observed the resident in bed with bare feet resting directly on the bed mattress on 9/22/15 from 9:00 a.m. through 1:30 p.m. and on 9/23/15 from 8:30 a.m. through 2:00 p.m. NJAC 8:39-8:39-11.2(f)

Based on observation, interview, and record review it was determined that the facility failed maintain a safe environment and to implement safety interventions to prevent repeat falls for a resident with a history of a falls at home and from a raised bed while in the facility. Both of these falls resulted in fractures. The resident was observed multiple times during the survey left unattended in a raised bed with the side rails down. This deficient practice was noted for 1 of 2 residents reviewed for accidents and incidents, Resident #5, as evidenced by the following: 1. The surveyor observed Resident #5 on 9/22/15 at 9:00 a.m. in bed with eyes closed, bed in low position, and a floor mattress on each side of the bed. The surveyor reviewed the resident's electronic and paper medical records on 9/22/15. The resident was admitted to the facility with a casted right arm in May 2015, after having fallen and fractured the arm at home in an assisted living facility. The 5/22/15 initial Minimum Data Set, (MDS), an assessment tool, indicated the resident had severe cognitive impairment and required extensive assistance with bed mobility and transfer. A fall risk care plan was initiated on 5/15/15 due to a history of previous falls at home, one of which had resulted in a fracture. On 9/23/15 the surveyor reviewed a 6/9/15 Resident/General Liability Incident Report provided by the Director of Nursing (DON). The report indicated that at 2:20 p.m. the resident was observed on the floor next to the bed. The resident was transferred to the hospital and was diagnosed with [REDACTED]. A Certified Nursing Assistant (CNA) provided a written statement and admitted she left the resident's bed in the high position when she left the room. The CNA reported she was doing oral care on the resident when the Speech Therapist came into the room. The CNA left the room with the bed in the high position. There was no statement from the Speech Therapist included in the investigation. The fall risk care plan was revised on 6/9/15 with new interventions to include frequent monitoring of the resident and to be sure to keep the bed in the lowest position. On 9/23/15 at 11:00 a.m. the surveyor observed a pressure ulcer treatment performed by a Licensed Practical Nurse (LPN) and assisted by a CNA. The LPN and CNA entered the resident's room to begin the treatment. The CNA raised the bed to the highest position. The LPN and CNA stood at the bedside on the resident's right side and rolled the resident onto the resident's left side. There was no one standing on the left side of the resident's bed. The side rail was in the down position and the LPN did not instruct the CNA to move to the other side of the bed to protect the resident from falling from the left side of the raised bed. The surveyor quickly moved to the left side of the bed and requested that one of the staff move to that side. The LPN left the resident's bedside and entered the bathroom to wash her hands. The resident remained in a left side lying position on the raised bed without side rails in use. The CNA left the resident's side and walked away from the bed. The surveyor again instructed the CNA to return to the bedside to protect the resident from falling. The LPN returned to the resident's bedside, removed the wound dressing, cleansed the wound, and went into the bathroom to wash her hands. The CNA again walked away from the resident's side while the resident was in a side lying position on the raised bed without siderails. The surveyor instructed the CNA to stay at the resident's bedside to ensure the resident did not fall from the raised bed. On 9/23/15 at 3:30 p.m. the surveyor discussed with the Administrator and Director of Nursing observations made during the 9/23/15 wound treatment and the resident's past history of a fall from a raised bed on 6/9/15 which resulted in a fractured spine. No further information was offered by the facility staff. NJAC 8:39-27.1(a) Refer to F282