Every finding on record at Careone at Evesham

COMPLAINT #2083729, 2805511 Based on interviews, review of medical records and pertinent facility documentation on 5/1/26, it was determined that the facility failed to thoroughly investigate a fall after the resident reported to staff that their injury, which the facility labeled as injury of unknown origin was sustained from a fall. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for falls and was evidenced by the following:Resident #2 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: discitis (an infection of the intervertebral disc space) of the lumbar region, cirrhosis of liver, and difficulty walking. Review of the comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 3/14/26 indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating that the resident's cognition was moderately impaired. Review of Resident #2's Care Plan (CP) revealed a focus related to the resident being at risk for falls due to having an unsteady gait which was initiated on 3/9/26. A review of an Incident Report (IR) provided by the facility, dated 3/12/26 at 9 AM, revealed that the resident had an injury of unknown origin. The resident was observed to have bruising around the left eye. The resident reported being unsure of how it happened. A review of Resident #2's progress notes (PN) revealed a physician note dated 3/13/26 at 2:19 PM, which revealed that the resident was assessed by a physician due to a recent fall causing bruising to the left eye. Further review of the PN revealed a nursing note dated 3/13/26 at 4:56 PM, which stated that the resident reported that the bruising on their eye occurred because the resident fell. According to the Facility Reportable Event (FRE) which the facility submitted to to the Department of Health on 3/12/26, a nurse observed a bruise on the resident's left eye while providing care. The resident was unsure how the bruise occurred at the time. The facility concluded that the injury was determined to be of unknown origin. No information was provided to the surveyor that the facility reassessed the incident as a result of a fall as indicated in the PN above. An interview was conducted on 5/1/26 at 1:40 PM, with Registered Nurse (RN #1) who stated that if a resident reported that they fell, she would report to a supervisor immediately, and an incident report would be completed along with a Risk Assessment. RN #1 stated that she remembered seeing Resident #2 with a black eye one morning and she reported it immediately. She further stated that the resident's family had mentioned that Resident #2's black eye was sustained when the resident fell in the bathroom. When the surveyor asked RN #1 what she did after the resident family's report, she stated that she told the nursing supervisor who informed her the injury was already being investigated. RN #1 further stated that she was not sure if a fall incident report was completed. The Surveyor requested for a list of all residents that had fallen at the facility in the month of March 2026 which did not include Resident #2. No documentation was provided that Resident #2's fall was investigated. An interview was conducted on 5/1/26 at 2:28 PM with the Assistant Director of Nursing (ADON), she stated that if a resident reported that they fell, she expected staff to start gathering information about the fall. She further stated that she expected that staff would complete an IR, and that an investigation would be initiated into the incident for the the team to determine if any interventions needed to be updated and/or added to ensure that residents remained safe. In the presence of surveyor, ADON reviewed the PN for the resident which revealed that the resident had a fall. A joint interview was conducted on 5/1/26 at 4:35 PM with the ADON and the Licensed Nursing Home Administrator (LNHA). The surveyor asked if the facility was aware that the resident's report of a fall and they both stated yes. The surveyor asked if the facility's fall policy had been fully implemented and they stated that it had not. Review of the facility's Assessing Falls and Their Causes policy, revised March 2018, revealed that after a fall an IR would be completed within 24 hours of the fall by the nursing supervisor. The policy further revealed that an attempt to identify a cause would begin within 24 hours. Review of the facility's Accidents and Incidents - Investigating and Reporting policy, revised July 2017, revealed that, .The circumstances surrounding the accident or incident . along with any follow-up information and pertinent data would be included in the Report of Incident/Accident form. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 31 residents reviewed. (Resident #63). This deficient practice was evidenced by the following:A review of Resident # 63's admission Recorded revealed the resident was admitted to the facility with the following but not limited to diagnosis, unspecified sequelae of cerebral infarction. (stroke)A review of Resident # 63's Electronical Medical Record (EMR) revealed physician's orders for escitalopram oxalate oral tablet 20 milligrams (MG) (a medication used to treat depression and anxiety). The EMR also revealed a physician's order for valproic acid 250mg/5 milliliters (a medication that can be prescribed to manage mood disorders) was to be given three times a day for mood.A review of Resident #63's Care Plan (CP) revealed a focus stating At risk for changes in mood related to diagnosis of depression with an initiated date of 07/07/2025.A review of Resident # 63's admission Minimal Data Set (MDS; an assessment tool) from 07/09/2025 revealed under section I that there was no active diagnosis for depression or mood disorders. Also, on the MDS in section N revealed that Resident # 63 was taking an antidepressant.During an interview on 09/11/2025 at 09:34 AM with the surveyor, the MDS coordinator said they review hospital records, care plans, lab work, x-rays and medications when completing the MDS. When asked if Resident # 63 should have a diagnosis depression on their MDS, the MDS coordinator stated, Absolutely it should be there, we missed thatDuring an interview on 09/11/2025 at 12:01 PM with the surveyor, the Director of Nursing, (DON) said it was important for the MDS to be accurate because if captures the level care the resident needs. The facility policy titled Resident Assessment revealed under POLICY INTERPRETATION AND IMPLEMENTATION that, 6. The resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessment.NJAC 8:39-11.2(e)1

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure nutritional formula connected to a feeding tube (surgically placed tube into the stomach to provide nutritional formula) was accurately labeled for 1 of 1 resident (Resident #7) reviewed for tube feeding. The deficient practice was evidenced by the following: On [DATE] at 08:25 AM, the surveyor observed a bottle of nutritional formula hanging from a pole that was connected to a feeding pump attached to Resident #7's feeding tube while he/she was in bed. The feeding pump was operating. At that time, the surveyor observed that the bottle was not labeled with the residents, name, start time or the amount that was to be infused. A review of Resident #7's admission Minimum Data Set (an assessment tool) dated [DATE], revealed that he/she had a feeding tube while a resident in the facility. A review of Resident #7's physician orders located in the electronic medical record (EMR) revealed an order for Glucerna 1.5 (nutritional formula) to be given at 65mL (milliliters) an hour via pump infusion through the feeding tube at 6:00 PM to infuse a total of 1300mL has infused. During an interview on [DATE] at 09:26 AM with the surveyor the, Registered Nurse Unit Manger (RNUM) said that when nutritional formula is hung it should be labeled with the name, date, time and volume to be infused. When the surveyor reviewed the findings of the unlabeled hanging formula bottle with the RNUM, she said It should be labeled. That is unacceptable.During an interview on [DATE] at 12:01 PM with the surveyor, the Director of Nursing (DON) said the hanging nutritional formula should be labeled with the date, time, and residents name. The DON said labeling is important to know exactly when the feeding started to make sure it has not expired or has been infusing for too long. A review of the facility policy titled, Enteral Tube Feeding via Continuous Pump updated on 11/2018, revealed under initiate feeding number 5., On the formula label document initials, date and time the formula was hung/administer, and initial that the label was checked against the order. NJAC 8:39-27.1(a)

NJ Complaint: #360874 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and acceptable professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #121's admission record reflected that this resident had diagnosis which included but not limited to: surgical aftercare following surgery on the skin and heart failure (a weakened heart muscle). A review of Resident #121's physician's orders revealed the following orders but not limited to: 2/14/25 Aspirin tablet chewable 81 MG (milligram) give 1 tablet by mouth one time a day for coronary artery disease, Plavix tablet 75 MG give 1 tablet by mouth one time a day for coronary artery disease, gabapentin 300mg give 1 capsule by mouth three times a day for neuropathy. A review of Resident #121's Medication Administration Audit Report for February 2025 revealed the following medications were administered past the required time frame as follows: On 02/15/2025:Aspirin scheduled for 09:00 AM was given at 12:29 PM Plavix scheduled for 09:00 AM was given at 12:33 PMGabapentin scheduled for 09:00 AM was given at 12:32 PMOn 09/10/2025 at 10:41 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) stated that medications should be administered one hour before or one hour after the scheduled medication administration time. She said that the medications should be documented as administered right after they are given to the resident. Lastly, she said that medications should not be signed out late but should be documented if that occurred. On 09/11/2025 at 12:03 PM, during an interview with the surveyor, the Director of Nursing said that medications should be administered according to the physician orders and should be documented at the time of administration. A review of the facility policy titled, Administering Medications with a revision date of November 2017, reflected under number 11., Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. A review of the facility provided policy titled, Documentation of Medication Administration, with a revision date November 2022 reflected 3. documentation of medication administration includes at a minimum: e. date and time of administration. N.J.A.C.: 8.39-29.2 (d)

Based upon observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain an orderly physical environment for 2 of 2 facility units (100 & 200) reviewed under the Environmental Task. The deficient practice is evidenced by the following: On 04/11/2024 at 10:20 AM during a tour of the 100 Unit communal shower room, the surveyor observed a shelf on the wall adjacent to the shower stall. On the shelf was an unpackaged incontinence brief, a hairbrush with hair entangled in the bristles, and various hygienic bottled toiletries. The room also emanated a foul odor. On the same date at 10:27 AM during a tour of the 100 Unit common area across from the nurses station, the surveyor observed a table that had food debris and two partially consumed beverages left on top. On the floor under the table was a single, blue slipper. The surveyor observed Residents participating in an activities exercise in the same common area at the time of the observation. On the same date at 10:37 AM during a tour of the 100 Unit communal shower room, the surveyor observed five PVC (polyvinyl chloride) constructed mobile trash bins stored in the shower room. At least one of the trash bins still contained clear plastic bags filled with trash. The room contained a scale chair (chair fitted with a scale to measure a persons weight) that had but was not limited to unpacked incontinence briefs, disposable glove boxes, and plastic bags on top of it. On the same date at 10:52 AM, the surveyor observed Resident # 72's room. At that time, the surveyor observed a chair near the foot of the bed. The chair had an unpackaged incontinence brief, towels, a linen sheet, and a hospital gown left on the seat. At that time, during an interview with the surveyor, Resident # 72 stated, I don't want it [items observed on chair] there because my son and grandbaby visit and I don't want them seeing a diaper. I keep telling them [the facility] to not do that. On 04/16/2024 at 10:58 AM in the hallways outside of room [ROOM NUMBER], the surveyor observed a geriatric recliner chair. On the chair was a grey plastic container that included unpackaged, blue incontinence briefs. On the same date at 11:02 AM while in Resident # 11's room, the surveyor observed a chair near the foot of the bed. The chair had a hospital gown and white linens left on the seat. At that time during an interview with the surveyor, Resident # 11 replied , I don't want that there. when the surveyor asked if he/she wanted the hospital gown and linens on the chair. Resident # 11 further said he/she does not use hospital gowns because they are not warm enough. On 04/16/2024 at 10:58 AM during an interview with the surveyor, Housekeeper # 1 said he was not responsible for removing linens from room. He said he was responsible for mopping, sweeping, garbage, and cleaning. On 04/17/2024 at 12:29 PM during an interview with the surveyor, the Director of Nursing (DON) replied, They should be stored in the closets and if on the floor, in carts. when the surveyor asked what was her expectation for storing linens including but not limited to unpackaged incontinence briefs and linens. Lastly, she replied, Closets in the rooms. when the surveyor asked where should they (incontinence briefs, linens) be stored. 49707 On 04/11/2024 at 12:04 PM during the initial tour, Surveyor # 2 entered room [ROOM NUMBER]-D and observed linen mixed with unpackaged incontinence briefs in the chair. Further, there were pillows and more linen observed on another chair in the corner. On 04/16/2024 at 10:22 AM, Surveyor # 2 entered room [ROOM NUMBER]-B, and observed untied bags of linen on the floor. On 04/17/2024 at 12:38 PM, during an interview with surveyor # 2, the Director of Nursing (DON) confirmed that resident's linen should be kept in the supply closet. Secondary, the DON confirmed that the nursing staff was responsible for removing linen and incontinence briefs from resident rooms. Lastly, the DON and the Licensed Nursing Home Administrator confirmed that linen and incontinence briefs should be kept in the resident's room closet and not on their chairs. A review of the facility policy titled, Departmental (Environmental Services) - Laundry and Linen with a revised date of January 2014, revealed under Washing Linen and Other Soiled Items but not limited to, 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. N.J.A.C. S 8:39-31.4 (a)

NJ Complaint # NJ00169132, NJ00171624 Based on observations, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) obtain a physician's order for residents to be discharged from the facility prior to discharge, b). change a central line catheter dressing as ordered by the physician (Resident #84), c.) follow physician orders to offload a residents heels while in bed (Resident #467), d.) follow physician order to check for helmet placement every two hours (Resident #468), and e.) maintain medication records that were complete with staff signatures according to professional standards of clinical practice for Resident #35, 1 of 29 residents reviewed for professional standards. This deficient practice was identified for 3 of 3 residents (Residents #88, #34 and #46) on 2 of 2 nursing units (100 and 200 units) and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and 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. a. The surveyor reviewed Resident #88, Resident #34, and Resident #46's closed medical records. Review of the physician orders revealed that none of the resident's had a physician's order placed in the medical record prior to resident discharge from the facility. On 04/17/24 at 12:45 PM, during an interview with both the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) in the presence of the survey team, the LNHA stated that she confirmed that Resident #88, Resident #34 and Resident #46 did not have a physician's order to be discharged from the facility but were required to. On 04/18/24 at 8:49 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) and asked why Resident #88 and Resident #34 did not have discharge orders placed in their medical records prior to being discharged from the facility. LPN/UM stated a discharge order was required to be obtained from the physician prior to resident discharge. LPN/UM stated the nurse must have forgotten to put the order in the computer. LPN/UM further stated that the assigned desk duty nurse was responsible to put the discharge order in the computer prior to a resident being discharged from the facility. On 04/18/24 at 8:55 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that a discharge order was required prior to resident discharge from the facility. RN/UM stated the doctor was notified and a discharge order was obtained prior to resident discharge. RN/UM stated that she was responsible to put the order in the computer. RN/UM further stated that it must have been a nursing oversight that a discharge order not placed in the computer before Resident #46 was discharged from the facility. Review of the facility policy, Discharging a Resident without a Physician's Approval (Revised 10/22) revealed the following: An order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record no later than seventy-two (72) hours after the discharge. 40744 b. On 04/10/24 at 10:21 AM, during the initial tour of the facility Resident #84 was in the bed awake. The resident told the surveyor that he/she was on intravenous (IV) antibiotics (medications given through an access in a vein) for a long time. The surveyor asked the resident about his/her IV access and the resident showed the surveyor a clear plastic dressing on the resident's right chest wall and said it was a [NAME] (central line catheter placed on the right side of the chest wall). The surveyor asked if the staff were changing the dressings or if the dressing had a date and the resident showed the surveyor the dressing that was dated 03/27/24. The resident then told the surveyor that it's been a long time since they changed it, maybe they didn't change it because it may come out soon. Review of Resident #84's Admission Record (an admission summary) revealed that the resident had medical diagnoses which included but were not limited to bacteremia (bacteria in the blood stream), appendicitis (appendix becomes inflamed and painful), and septic shock (a widespread infection causing organ failure and dangerously low blood pressure). The surveyor reviewed the most recent Minimum Data Set (MDS), an assessment tool dated 03/05/24, which indicated the resident had a Brief Interview of Mental Status of 15/15, which indicated the resident was cognitively intact. On 04/12/24 at 09:52 AM, the surveyor reviewed the physician orders which showed the following order dated 2/28/24: Dressing: PICC (peripherally inserted central catheter, a type of central catheter inserted in the arm)/Midline/ Tunneled & Non-Tunneled: 24 hours after insertion, then weekly and as needed. Change needleless connector with weekly dressing change and after blood draw. If securement device is used, change at time of dressing change. No signs and symptoms of any infusion related complications present. Dressing is adherent and intact; catheter & tubing properly secured; needleless connectors are present. After reviewing the physician orders, it revealed the resident was no longer on IV antibiotics. On 04/12/24 at 10:01 AM, the surveyor reviewed the care plan which showed a focus of IV insertion and potential for complications. The care plan was initiated 01/02/24. One of the interventions included: Change IV site dressing per physician order and as needed if soiled or wet. On 04/12/24 at 11:42 AM, the surveyor reviewed the Treatment Administration Record (TAR) for Resident #84 which showed the resident was scheduled for a tunneled catheter dressing change on 04/03/24 and it was left blank, meaning not signed as completed by the nursing staff. Further review of the TAR showed that the dressing was changed on 4/10/24. On 04/17/24 at 11:48 AM, the surveyor interviewed facility Licensed Practical Nurse (Agency LPN #1) regarding care of central catheters. The surveyor asked what was the date that on a central line dressing indicated and Agency LPN#1 said, That is the date that it was changed. The surveyor asked how often the dressings for central catheters were changed and Agency LPN#1 said, weekly and as needed. The surveyor then asked where the dressing changes would be documented when completed by the nursing staff and Agency LPN#1 said it would be documented in the Medication Administration Record (MAR) or TAR. Agency LPN#1 said, It will pop up for the weekly changes on the MAR or TAR and there will also be an area for the as needed changes. On 04/18/24 at 10:50 AM, the surveyor reviewed the policy titled, Central Venous Catheter Care and Dressing Changes, a policy with a revision date of 03/2022. Under the general guidelines section of the policy, number 3 indicated to change the catheter dressing if it becomes damp, loosened or visibly soiled and at least every seven days for transparent dressing. Review of the documentation section indicated that the medical record should include the date and time the dressing was changed. c. On 04/17/24 at 11:08 AM, the surveyor reviewed the physician orders for Resident #467 which showed an order to offload heels while in bed as tolerated. It was ordered on 02/13/24. The surveyor reviewed Resident #467 Admission Record which revealed the resident was admitted to the facility for short term rehabilitation. Medical diagnoses included but were not limited to hypertension (high blood pressure), repeated falls, heart failure, and muscle weakness. Review of the Admission Minimum Data Set (MDS) indicated the resident had a Brief Interview of Mental Status score of 12/15, which indicated the resident had moderate cognitive impairment. Review of section M, skin conditions indicated the resident was at risk for developing pressure ulcers. On 04/17/24 at 11:30 AM, the surveyor reviewed Resident #467's Medication Administration Record (MAR) and the Treatment Administration Record (TAR). The order for offloading of the heels was not documented on either record. On 04/17/24 at 11:46 AM, the surveyor reviewed the Certified Nursing Assistant (CNA) task list which included float/offload heels marked as for your information. There was no documentation by the CNA that the task was completed, tolerated, or refused by the resident. On 04/17/24 at 11:52 AM, the surveyor interviewed Agency LPN #1 regarding residents with orders to offload heels while in bed and was that a task that would be documented if done. Agency LPN #1 said, If it was a physician order it would pop up on the MAR or TAR for nursing to sign it as done. On 04/17/24 at 1:20 PM, the Director of Nursing (DON) met with the surveyor and provided a care plan that showed offload heels while in bed. The intervention was initiated on 2/19/24. The surveyor asked where it was documented from the order date of 2/13/24 until the care plan intervention was initiated on 2/19/24 and the DON responded, I understand. 44833 d.) On 4/16/24 at 9:56 AM, the surveyor reviewed Resident #468's closed medical records. Review of the resident's Admission Record indicated Resident #468 was admitted to the facility with diagnosis which included but were not limited to hemiplegia and hemiparesis (weakness and paralysis of one side) following cerebral infarction (stroke), seizures, and nontraumatic subarachnoid hemorrhage from unspecified middle cerebral artery (the accumulation of blood in or around the brain not caused by trauma). Review of the resident's admission MDS indicated the resident had a BIMS score of 9 out of 15, which indicated moderate impaired cognition. Review of the physician orders included an order with a start date of 8/31/2023 to check helmet placement every two (2) hours. Must be worn at all times. Review of Resident #468's TAR for September and October 2023 revealed the following missing or blank documentation areas for the physician's order to check placement every two hours: 9/10 4 PM, 6 PM, 8 PM, 10PM 9/30 4 AM, 6 AM 10/3 4 AM, 6 AM 10/8 10 AM 10/27 2 PM On 4/17/24 at 11:09 AM, the surveyor interviewed LPN2 who stated that when administering medication or performing ordered treatments, nurses should document in the electronic medical record. She further stated there should be no blanks in the TAR and that if it is blank, it would indicate it was not done. LPN2 also informed the surveyor that there are appropriate codes to use in the TAR to indicate why a treatment was not completed, for example, if the resident was unavailable at that time, but it should still be documented and not left blank. On 4/17/24 at 11:15 AM, the surveyor interviewed the DON who confirmed that there should not be any blanks in documentation on the TAR and nursing staff should use one of the available numeric codes to document why a treatment was not done. The DON stated she did not agree with the adage if it's not documented, it's not done stating, I would say it was done, just forgot to sign it. While presenting the DON with the blank documentation in the resident's TAR to check for helmet placement, the DON stated, the resident has his helmet on in the picture referring to the picture used on the medical record for resident identification. Review of the facility's Charting and Documentation policy with edited date 5/27/2022 included but was not limited to: 4. The following information is to be documented in the resident's medical record: a. objective observations; b. medications administered; c. treatments or services performed; d. changes in the resident's condition; e. events, incidents or accidents involving the resident; and f. progress toward or changes in the care plan goals and objectives. 38680 e. According to the admission record Resident #35 was admitted with diagnoses that included, but were not limited to, paranoid schizophrenia and major depressive disorder. The surveyor reviewed the 1/20/24 Minimum Data Set, an assessment tool, and observed that the facility had identified Resident #35 as not being cognitively intact. On 4/16/24 at 9:51 AM, the surveyor reviewed the March and April Medication Administration Record (MAR) for Resident #35. When medications are ordered by the physician, the order is placed on the MAR. When administered by the nurses, the nurse will sign their initials on the MAR indicating that they have given the medication. The surveyor noted a 11/9/2023 physician's order (PO) for the cognition enhancing medication donepezil give 1 tablet by mouth at bedtime. The surveyor observed a blank on the MAR, there were no nurse's initials indicating administration on 3/29/24 and 4/7/24 at 2100. The surveyor observed a PO for levothyroxine sodium (a medication used to treat a low thyroid) 50mcg ordered on 3/16/24 give 1 capsule by mouth in the morning. The MAR had a blank on 3/22/24 at 2200. The surveyor observed a PO for Lipitor (used to treat high cholesterol) 40mg ordered on 7/13/23 give 1 tablet by mouth at bedtime. The MAR had blanks on the MAR on 3/29/24 and 4/7/24 at 2100. The surveyor observed a PO for metoprolol succinate (used for high blood pressure) ER 25mg ordered on 7/14/23 give 1 tablet by mouth in the evening. The MAR had blanks on 3/3/24, 3/29/24, 4/7/24, and 4/8/24 at 1700. The surveyor observed a PO for Paxil (an antidepressant) ordered on 7/14/23 give 1 tablet by mouth in the evening. The MAR had blanks on 3/3/24, 3/29/24, 4/7/24, and 4/8/24 at 1700. The surveyor observed a PO for Seroquel (a medication used for schizophrenia) ordered on 2/28/24 give 1 tablet by mouth at bedtime. The MAR had blanks on 3/29/24 and 4/7/24 at 2100. The surveyor observed a PO for Depakote delayed release (used for mood disorders) ordered on 10/13/23 give 1 tablet two times a day. The MAR had blanks on 3/3/24, 3/29/24, 4/7/24, and 4/8/24 at 1700 and on 4/14/24 at 0900. The surveyor observed a PO for metformin (used for diabetes) ordered on 7/14/23 give 1 tablet two times a day. The MAR blanks on 3/3/24, 3/29/24, 4/7/24, 4/8/24 at 1700 and on 4/14/24 at 0900. The surveyor observed a PO for Namenda ( a medication used to improve cognition) ordered on 7/14/23 give 1 tablet by mouth every morning and at bedtime. The MAR had blanks on 3/29/24 and 4/7/24 at 2100 and 4/14/24 at 0900. The surveyor observed a PO for Xanax (a medication used for anxiety) ordered on 3/21/24 give 1 tablet every 12 hours. The MAR had blanks on 3/27/24, 3/29/24, and 4/7/24 at 2100 and 4/14/24 at 0900. The surveyor observed a PO for amlodipine besylate (used to treat high blood pressure) ordered on 7/14/23 give 1 tablet once a day. The MAR had a blank on 4/14/24 at 0900. The surveyor observed a PO for Aspirin delayed release 81mg (used for the heart) ordered on 7/14/23 give 1 tablet by mouth once a day. The MAR had a blank on 4/14/24 at 0900. There was no documented evidence in the medical record that Resident #35 experienced a negative reaction/harm for not receiving the medications. During an interview on 4/16/24 at 9:58 AM, Licensed Practical Nurse (LPN)1 stated that If there is a blank in the MAR the medication was not signed out. She would assume that if the MAR was not signed out, the medication was not given. During an interview on 04/16/24 at 10:15 AM the Registered Nurse/Nurse Manager stated that if the MAR is blank, it means the medication was not signed out. If not signed out there is no way of knowing if a medication was given or not. A review of facility provided policy titled Documentation of Medication Administration edited on 04/06/2023, reflected that administration of medication is documented immediately after it is given. Documentation of medication administration includes at minimum: g. initial, signature, and title of the person administering the medication. NJAC 8:39-27.1(a)

Based on interview and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level 1 assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 1 resident reviewed for PASRRs (Resident #54) and was evidenced by the following: On 04/15/2024 the surveyor reviewed Resident #54's electronic medical record (EMR) which included review of the PASRR level 1 completed on 06/21/2019, which was negative and marked no for any diagnosis of mental illness. A review of the Admission Minimum Data Set (MDS), an assessment tool dated 07/15/2019, revealed a Brief Interview of Mental Status (BIMS) score of 7/15, indicating severe cognitive impairment and review of section I did not include any psychiatric diagnoses. A review of the annual MDS dated [DATE], indicated diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia noted in Section I. A review of the quarterly MDS dated [DATE], indicated diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia noted in Section I. A review of Resident #54's care plans included but were not limited to a focus of At risk for changes in mood related to anxiety, depression, hx (history) of alcohol dependence and At risk for adverse effects related to use of antidepressant medication, use of antipsychotic medication. No additional PASRR including the diagnosis of anxiety disorder, depression, psychotic disorder, or schizophrenia was located. On 04/15/24 at 10:50 AM, the surveyor interviewed the Social Worker (SW) who stated that if a resident presents with a new diagnosis, then a new PASRR was done and sent to the state. When asked for new PASRR on Resident #54, after searching the EMR, SW stated, I don't see where that is captured. I don't see one. A new PASRR should've been completed. On 04/17/24 at 12:38 PM, the surveyor interviewed the Administrator who stated there was no policy on reevaluating PASRR. She stated that audits were done, but there is no regulation that they have to be updated annually. Review of facility policy Admission Criteria, edited 06/23/22, which addressed PASRR under number 9, does not address a resident with a new psychological diagnosis after admission. N.J.A.C. 8:39.5.1(a)

Based on observation, interview, and review of facility documentation, it was determined the facility failed to develop a comprehensive person-centered care plan for a resident with pain. This deficient practice was identified for Resident #27, 1 of 24 residents reviewed for care plans and was evidenced by the following: On 04/10/24 at 10:06 AM, during the initial tour of the facility Resident #27 told the surveyor he/she had right hip pain and left foot pain. The surveyor asked if he/she received pain medication and the resident replied, Oh they are so busy. The surveyor asked the resident to rate the pain on a zero to 10 scale and the resident said it was a seven, meaning moderate pain level. Review of the Admission Record revealed Resident #27 had medical diagnoses which included but were not limited to sciatica (pain affecting back, hip, and outer side of leg), fibromyalgia (long term condition that involves body pain and tiredness), depression, anxiety, and low back pain. Review of the Admission Minimum Data Set (MDS), an assessment tool dated 03/31/24, indicated the resident had a Brief Interview of Mental Status of 14/15, which indicated the resident was cognitively intact. Section J of the MDS, health conditions, showed the resident had moderate pain and was receiving pain medications when necessary. On 04/12/24 at 12:10 PM, the surveyor reviewed the following orders: Acetaminophen Tablet 325 milligrams, give two tablets by mouth every six hours as needed for mild pain (Pain Score 1, 2, 3, 4). Do not exceed three grams in 24 hours. Total 650 mg. Pain Score every shift 0=No pain 1,2,3,4 =Mild Pain 5,6,7 = Moderate pain 8,9,10 =Severe pain every shift for Pain. Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give one tablet by mouth every eight hours as needed for moderate to severe pain (5-10). On 04/12/24 at 12:24 PM, the surveyor reviewed the Medication Administration Record (MAR) which showed that for the month of April 2024 the resident's pain was assessed every shift. Twice the resident had a pain level of 1, meaning mild pain, and once the resident had a pain level of 7, meaning severe pain. On 04/15/24 at 01:17 PM, the surveyor reviewed the care plan which did not include a focus of pain. At the same time, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) regarding the pain care plan. The care plan was then updated with a focus of pain after surveyor inquiry. On 04/17/24 at 01:10 PM, the surveyor reviewed the most recent physician progress note which indicated the following documentation under the physician assessment: Right sided sciatica-Continue Lyrica, lidocaine patches, and tramadol. On 04/22/24 at 11:55 PM, the surveyor reviewed the policy titled, Care plans, Comprehensive Person-Centered, the policy was dated 04/25/22. Under number eight it indicated that services are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. On 04/22/24 at 12:38 PM, the surveyor reviewed the policy titled, Pain Assessment and Management, a policy dated 11/10/22. Under the section titled, Defining Goals and Appropriate Interventions, number one indicated that the pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. NJAC 8:39-11.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a safety device used to prevent residents from elopement was in place for 1 of 3 residents reviewed for accidents (Resident #35). This deficient practice was evidenced by: According to the admission record Resident #35 was admitted with diagnoses that included, but were not limited to, paranoid schizophrenia and major depressive disorder. The surveyor reviewed the 1/20/24 Minimum Data Set (MDS), an assessment tool, and observed that the facility had identified Resident #35 as not being cognitively intact. The MDS reflected that Resident #35 had no wandering behavior during the lookback period and he/she used an elopement alarm daily. During initial tour on 04/10/24 at 10:45 AM, the surveyor observed Resident # 35 in the activity area painting. According to the Registered Nurse/Unit Manager (RN/UM) Resident #35 utilized an elopement alarm. On 04/11/24 at 10:27 AM, the surveyor observed Resident #35 in the room ambulating. The resident did not have an elopement alarm to the right wrist. On 04/12/24 at 9:30 AM, the surveyor observed Resident #35 in the room on the telephone. The resident did not have an elopement alarm to the right wrist. The surveyor spoke to a staff member who is familiar with this resident. The staff member stated that Resident #35 had never tried to leave the facility. On 04/15/24 at 10:54 AM and 12:57 PM, the surveyor observed Resident #35 in bed. The resident did not have an elopement alarm to the right wrist. The surveyor reviewed Resident #35's Physician's Orders. There was an order dated 7/13/23 for: Wanderguard every shift Wanderguard to right wrist. Check placement and function every shift. The April 2024 Medication Administration Record reflected that the wanderguard was in place each shift from 4/2/2024 through 4/15/24. A review of Resident # 35's care plans reflected a focus of wandering/pacing related to Dementia and elopement risk related to Cognitive impairment. The interventions included but were not limited to check for replacement and function of security bracelet (elopement alarm) as indicated. During an interview on 04/16/24 09:51 AM, the Lisensed Practical Nurse1 (LPN1) stated that elopement alarms require a physician's order. LPN1 furthered that the nurses check for placement and function each shift and document in the MAR. She stated that if the elopement alarm is missing then the nurse should replace the elopement alarm immediately. On 04/16/24 at 09:58 AM LPN1and the surveyor visualized Resident #35. LPN1 confirmed that Resident #35 should have an elopement alarm on her wrist but did not. LPN1 stated that she did not thouroughly check Resident #35 to ensure that the elopement alarm was in place. During an interview on 04/16/24 at 10:10 AM, the RN/NM stated the nurses should ensure that an elopement alarm is in place and if not on the resident it should be replaced. When the surveyor informed the RN/NM that Resident #35 did not have an elopement alarm in place she stated that the nurses should have replaced the elopement alarm. During an interview on 04/16/24 at 12:01 PM, the Lisenced Nursing Home Administrator(LNHA) stated that the PO for the elopement alarm for Resident #35 was dated July 2023. She stated that Resident #35 was reassessed for the need for the elopement alarm in October 2023 and it was determined that he/she did not need the elopement alarm but the PO was not updated. The LNHA stated that the nurses were not following the PO for the elopement alarm. A review of the facility policy Wandering and Elopements revised March 2019 reflected that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. NJAC 8:39 - 27.1 (a)

Based on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to provide appropriate and sufficient services based upon current standards of practice and the resident's comprehensive care plan to document urinary output in the Treatment Administration Record (TAR). The deficient practice was identified for 1 of 2 residents (Resident # 72) investigated for Urinary Catheter or UTI. The deficient practice was evidenced by the following: A review of Resident # 72's Minimum Data Set (MDS; an assessment tool) dated 03/16/2024 under section, H revealed that he/she had an indwelling urinary catheter (tube inserted into the bladder through the urethra to allow urine to drain from the bladder for collection). A review of Resident # 72's Electronic Medical Record (EMR) revealed under the section, Diagnoses that he/she was diagnosed with Paraplegia (paralysis typically of the lower body) and Neuromuscular Dysfunction of Bladder (lack of lack bladder control due to a brain, spinal cord or nerve problem). A review of Resident # 72's EMR under the section, Orders revealed a physician's order to, Measure and record foley catheter output Q [every] shift every shift for Neurogenic Bladder. The order became active on 03/28/2023. A review of Resident # 72's EMR under the section, Care Plan revealed an intervention to, Report changes in amount, color or odor of urine. The intervention was initiated on 11/28/2022. A review of Resident # 72's Treatment Administration Record for March, 2024 revealed blank sections of documentation to measure and record catheter output Q [every] shift on the following dates and shifts: 03/04/2024 night shift blank 03/08/2024 day shift blank 03/12/2024 night shift blank 03/13/2024 day shift blank 03/21/2024 night shift blank 03/27/2024 evening & night shift blank 03/30/2024 day shift blank A review of Resident # 72's Treatment Administration Record for February, 2024 revealed blank sections of documentation to measure and record catheter output every shift on the following dates and shifts: 02/02/2024 day shift blank 02/06/2024 day shift blank 02/09/2024 day shift blank 02/12/2024 night shift blank 02/24/2024 day shift blank 02/27/2024 day shift blank On 04/17/2024 at 12:29 PM during an interview with the surveyor, the Director of Nursing replied, Document in the MAR [Medication Administration Record] or TAR if there is an order for it. Secondly, the DON replied, No when the surveyor asked should the Treatment Administration Record be left blank. Lastly, the DON replied, I wouldn't say it was or was not. It could be they forgot to document it. A review of the facility policy with a revised date of August 2022, titled, Catheter Care, Urinary revealed under section, Input/Output to, 2. Follow the facility procedure for measuring and documenting input and output. A review of the facility policy titled, Medication and Treatment Orders did not reveal pertinent information. N.J.A.C. S 8:39-27.1 (a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain the necessary care and maintenance of respiratory equipment for 3 of 4 residents, reviewed for respiratory care. This deficient practice was evidenced by the following: On 04/10/2024 at 10:02 AM during initial tour, the surveyor observed Resident # 53 oxygen tubing not labeled, and the bag that held the tubing when not in use was dated 04/2/2024. According to the Admission Record, Resident #53 was admitted to the facility with diagnoses including but not limited to; Chronic obstructive pulmonary disease (COPD). COPD is an airflow limitation caused by airway narrowing and/or obstruction, loss, or elastic recoil, or both. A review of the Order Summary Report for resident # 53, revealed a physician order for oxygen at 2 liters/minute via nasal canula (a device that delivers extra oxygen through a tube into the nose) every shift for shortness of breath. There was no order to change oxygen tubing weekly. On 04/15/2024 at 11:21 AM during an observation of other residents on oxygen, the surveyor observed Resident # 15's nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing and mask laying on the bed side table not stored in a bag. The surveyor also observed Resident # 17's nebulizer mask and tubing laying not in a bag, and the oxygen tubing laying across the bed. A review of the Admission Record revealed, Resident # 15 was admitted to the facility with diagnoses including but not limited to, Interstitial Pulmonary Disease. A term used for a large group of diseases that case scarring of the lungs. A review of the Order Summary Report for resident # 15, revealed a physician order for oxygen at 2 liters/minute via nasal canula every shift for shortness of [NAME], and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams/3milliters, 1vial inhale orally every 6 hours for shortness of breath. There was no order to change respiratory tubing weekly. A review of the Admission Record revealed, Resident # 17 was admitted to the facility with diagnoses including but not limited to, Acute Respiratory Failure with hypoxia. A condition where you don't have enough oxygen in the tissues in your body, A review of the Order Summary Report for resident # 17, revealed a physician order for oxygen at 2 liters/minute via nasal canula every shift for desaturation, Albuterol Sulfate Nebulization Solution (2.5 milligrams/3 milliliters) 0.083% 1 vial inhale orally via nebulizer every 4 hours as needed for wheezing or shortness of breath. There was also an order to change respiratory disposable supplies weekly and as needed. During an interview on 04/15/2024 at 11:06 AM with the surveyor, The Licensed Practical Nurse Unit Manager (LPN/UM) said we change respiratory tubing weekly, we label the tubing and bag with the date. LPN/UM also said the tubing is placed in the bag when not in use. When asked how do you know when to change the tubing, LPN/UM stated, there are orders, we change them on Tuesday's The LPN/UM agrees there should be orders for changing the tubing weekly. During an interview on 04/15/2024 at 11:16 AM with surveyor, The Director of Nursing (DON) said the Respiratory Therapist changs the respiratory tubing once a week, they date the tubing and the bags. The DON said there aren't orders in for the weekly change due to the nurses don't change them. The DON agreed that respiratory tubing should be placed in the bag when not in use. A review of the facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection with an edited date of 03/18/2024 revealed under Infection Control Considerations Related to Oxygen administration 6. Change the oxygen cannulae and tubing every seven (7) days. Or as needed.; 8. Keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use. Revealed under Infection Control Consideration Related to Medication Nebulizers/Continuous Aerosol: 7. Store circuit in plastic bag, marked with date and residents name, between uses.; 9. Discard the administration set up every seven (7) days. N.J.A.C. S 8:39-27.1(a)

Complaint # NJ163924 Based on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 1 of 7 days reviewed for the week of 04/30/2023 through 05/06/2023 under the Sufficient and Competent Nurse Staffing Task. The deficient practice was evidenced by the following: A review of the Nurse Staffing Report completed by the facility for the week of 04/30/2023 through 05/06/2023 revealed the facility documented one Registered Nurse (RN) as having worked on 05/06/2023 during the day shift. A review of the facility provided schedule for 05/06/2023 revealed the previous Director of Nursing was scheduled. However, the Nurse Staffing Report, completed by the Facility revealed a resident census of 87. On 04/15/2024 at 12:49 PM during an interview with the surveyor, the Licensed Nursing Home Administrator confirmed that the previous Director of Nursing was counted as the RN on duty. A review of the facility policy with a revised date of August 2022 titled, Staffing, Sufficient and Competent Nursing revealed under the section titled, Sufficient Staff that, 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RN may be scheduled more than eight (8) hours depending on the acuity needs of the resident. N.J.A.C. S 8:39-25.2 7(h)

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that medications were stored appropriately. This deficient practice was identified in two (2) of four (4) medication carts inspected on one (1) of two (2) units. This deficient practice was evidenced by the following: On 04/12/2024, Surveyor #1 was observing medication pass on the 100 unit. At 08:40 AM, Agency Licensed Practical Nurse #2 (Agency LPN #2) left medication cart 2 in the hallway, locked, with a grey box of individual medication envelopes on top of the cart, in the hallway on the opposite side of the hallway from room [ROOM NUMBER], while he went into room [ROOM NUMBER] to take the resident's vital signs. Surveyor #1 stayed with the medication cart. While Agency LPN #2 was in room [ROOM NUMBER], another resident wheeled past the medication cart. When Agency LPN #2 came back to the medication cart at 08:43 AM, Surveyor #1 asked if the cart should've been left in the hallway the way it was. Agency LPN #2 stated, Sorry, the medications should not have been left on top of the cart. On 04/12/2024 at 09:07 AM, Surveyor #1 approached medication cart 3 on the 100 unit and noted a grey box with individual medication envelopes on top of the locked unattended medication cart. When Agency LPN #3 approached the medication cart, Surveyor #1 asked if the medication cart should've been left in the hallway as it was. Agency LPN #3 stated that the cart was okay, then added that she's only been to this facility a few times. On 04/12/24 at 09:23 AM, Surveyor #1 interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the grey boxes with medication envelopes should not be left on top of the medication carts if the medication nurses walk away from the cart. On 04/17/24 at 12:35 PM, Surveyor #1 interviewed the Administrator and Director of Nursing who stated that the individual medication envelopes should not have been left on top of the medication cart unattended. A review of the facility policy Administering Medications edited on 5/21/19, revealed: #19. During administration of medications . No medications are kept on top of the cart. 43936 On 04/11/2024 at 10:37 AM during a tour of the 200 Unit communal shower room, Surveyor # 2 observed two, sealed plastic bottles filled with clear liquid located in an opened cabinet on the wall. Upon closer observation, the bottles both had pharmacy labels. The labels revealed that the bottles contained, acetic ac 1000ml 0.25% irrig s (Acetic Acid Irrigation Solution; a sterile, nonpyrogenic hypotonic solution for irrigation of the urinary bladder). The labels revealed the name of an unsampled resident. On the same date at 10:41 AM during an interview with Surveyor # 2, Licensed Practical Nurse/Unit Manager (LPN/UM) replied I didn't know these were in here and they should not be in here. when Surveyor # 2 asked is there a any reason the bottled were in there. LPN/UM confirmed that the bottles belong in a medication cart or in the medication room. On 04/17/2024 at 12:29 PM during an interview with Surveyor # 2, the Director of Nursing (DON) replied, No when asked if prescribed medications be stored in the shower room cabinets. The DON confirmed that prescribed medications should be stored in a treatment cart of medication cart. A review of the facility policy titled, Medication Labeling and Storage revised February 2023 revealed under, Policy Heading that, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls . N.J.A.C. 8:39-29.4(h)

Based on observation, interview, and pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness in 1 of 2 Pantries, Pantry on Unit 1. This deficient practice was evidenced by the following: On 04/12/2024 at 09:42 AM during observations of the pantry on Unit 1, the surveyor observed 3 frozen meals, and a container of rice pudding not labeled in the freezer. On 04/16/2024 at 10:11 AM during a second observation of the pantry on Unit 1, the surveyor observed, a burger not labeled or dated in the refrigerator. Also observed in the refrigerator was a muffin tin covered with in foil with the edge folded back and a muffin exposed, and a cup with pink liquid without a lid not dated or labeled. During an interview with the surveyor on 04/10/2024 at 09:22 AM, the Food Service Director, they said that the pantries on the nursing floor are managed by housekeeping and nursing. During an interview with the surveyor on 04/16/2024 at 10:13 AM with Licensed Practical Nurse (LPN) # 3. The LPN # 3 stated all food should be labeled and dated, if they aren't they get thrown away. During an interview with the surveyor on 04/17/2024 at 10:01AM, the Director of Nursing (DON) said all food should be labeled and dated. When asked if all food should be covered the DON replied with yes. During an interview with the surveyor on 04/17/2024 at 10:33 AM, the Director of Environmental Services stated, the golden rule is that if it is not labeled it is thrown out. A review of a facility provided policy revised on March 2022 titled Foods Brought by Family/Visitors revealed under, Policy Interpretation and implementation that 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility food. The policy also revealed under section 5., b. Perishable foods are stored in re-sealable containers with tight-fitting lids. Containers are labeled with the resident's name, the item and the use by date. N.J.A.C. 18:39-17.2(g)

Based on observation, interviews, review of medical records, and other facility documentation, it was determined that the facility failed to prevent the potential spread of infection and cross-contamination in accordance with current infection prevention standards and failed to: a) ensure that staff utilized proper serving utensils to scoop ice in a safe and hygienic manner during the meal pass b) follow appropriate infection control protocol for hand hygiene, ensure that medications were handled in a sanitary manner and that medical equipment was properly cleaned and disinfected between residents during the medication pass c) maintain the infection prevention protocol for a resident on transmission-based precautions and d) failed to ensure that dedicated medical supplies were stored in a safe and sanitary manner. This deficient practice was identified for 2 of 2 nursing units (Elmwood Unit and Subacute Rehabilitation Unit) observed during meal pass, 2 of 2 nurses observed on 2 of 2 units during the medication pass which included 6 of 8 residents observed for medication administration (Residents #267, #75, #11, #23, #34 and an unsampled resident), 1 of 4 residents reviewed for Transmission-Based Precautions (Resident #46) and 1 of 3 residents reviewed for [CONDITION(S)] (Resident #41). This deficient practice was evidenced by the following: 1. During a meal service observation on 02/09/22 at 12:05 PM, Surveyor #1 observed the beverage cart enter the Elmwood Unit. The beverage cart included an ice bucket filled with ice. Surveyor #1 observed staff use a ceramic coffee cup to dispense ice to the residents from an ice bucket. The following was observed: At 12:05 PM, Surveyor #1 observed a staff member use a ceramic coffee cup to scoop ice from an ice bucket and placed the cup on the counter of the beverage cart. At 12:10 PM, Surveyor #1 observed another staff member use a ceramic coffee cup to scoop ice from an ice bucket and placed the cup on the counter of the beverage cart. At 12:30 PM, Surveyor #1 observed another staff member use the ceramic coffee cup to scoop ice from the ice bucket and left the cup in the ice bucket. On 02/10/22 from 11:56 AM - 12:18 pm, Surveyor #1 observed meal delivery on the Elmwood Unit. Surveyor #1 observed each staff member use a plastic handleless drinking cup with their bare hands to dispense ice to the residents from an ice bucket. The following was observed: At 11:58 AM, Surveyor #1 observed a staff member use the cup to scoop ice and placed the cup back into the ice bucket. At 12:01 PM, Surveyor #1 observed a staff member use the same cup to scoop ice and then placed the cup on the counter of the refreshment cart. At 12:02 PM, Surveyor #1 observed another staff member use the cup to scoop ice then placed to cup into the ice bucket. At 12:05 PM, Surveyor #1 observed another staff member use the cup to scoop ice and placed the cup in the bucket. At 12:07 PM, Surveyor #1 observed another staff member place the cup on a shelf under the cart and retrieved another plastic cup and scoop ice and placed the cup on top of the counter of the refreshment cart. At 12:18 PM, Surveyor #1 observed another staff member use the same cup to scoop ice and left the cup in the ice bucket. During an interview with Surveyor #1 on 02/10/22 at 12:45 PM, the Certified Nursing Assistant (CNA) stated the refreshment cart came to the unit daily with the ice bucket covered with plastic and the staff used a cup to retrieve the ice from the bucket. She stated that sometimes there was a scoop to use and stated she could not remember the last time she saw the scoop. During an interview with Surveyor #1 on 02/10/22 at 01:15 PM, the Licensed Practical Nurse (LPN) stated that she would use a new cup to retrieve the ice because reusing the cup, touching it, and placing it on the cart or in the ice bucket was not sanitary or a clean process. She stated they needed a scooper or tongs to retrieve ice. During a meal observation on 02/10/22 at 12:03 PM, Surveyor #2 observed a four-tiered rolling beverage cart positioned in the hallway on the Subacute Rehabilitation (SAR) Unit. On the top shelf of the cart, a ceramic coffee mug was noted inside of an ice filled silver-colored metallic ice bucket. The surveyor observed a Hospitality Aide (HA) as she utilized the ceramic coffee cup to scoop the ice out of the ice bucket and into a cup with her bare hands as she prepared a beverage for a resident. When interviewed, the HA stated that she just started working at the facility on Monday. At 12:05 PM, Surveyor #2 observed CNA #2 as she utilized the coffee mug to scoop out of the ice bucket and into a cup with her bare hands. When interviewed, CNA #2 stated that she utilized a coffee mug to scoop the ice instead of an ice scoop because it was just easier, as the handle of the ice scoop was too long. During an interview with Surveyor #2 at 12:10 PM, the Dietary Aide (DA) stated that staff was supposed to use an ice scooper when they scooped ice, not a coffee cup. She stated that the nurses should have had an ice scoop on the unit. At 12:11 PM, Surveyor #2 observed CNA #2 as she utilized the coffee mug to scoop ice into a cup a second time with her bare hands. At 12:12 PM, Surveyor #2 observed CNA #2 as she removed the coffee cup from the ice bucket with her bare hands and placed an ice scooper into the ice bucket. When interviewed, CNA #2 stated that there was no problem with using a coffee cup to scoop ice for the residents instead of an ice scooper because the coffee cup was clean. During an interview with Surveyor #2 at 12:15 PM, LPN #2 stated that she had never seen a staff utilize a coffee cup to scoop ice from the ice bucket before. She stated that nursing did not have an ice scoop on the unit. She stated that the ice scoop should have been sent to the unit on the beverage cart from the dietary department. She further stated that the problem with using a coffee cup instead of an ice scoop was that there was a potential that the cup could chip and break off into the ice. During a later interview with Surveyor #2, at 12:18 PM, CNA #2, examined the inside of the ceramic coffee cup utilized to scoop ice and stated that the coffee cup was not chipped but was stained with a brown substance on the inside of the cup. During an interview with Surveyor #2 on 02/11/22 at 1:47 PM, the Registered Nurse/Infection Preventionist (RN/IP) stated that it was not appropriate for the DA or CNA #2 to use a coffee cup to scoop ice for the residents instead of an ice scoop. She stated that by not using a plastic ice scoop that went through the dishwasher and was sanitized prior to use, there was a break in protocol and was an infection control issue due to the risk of contamination. During an interview with the surveyor on 02/14/22 at 12:36 PM, the Food Service Director (FSD) stated that staff was required to utilize an ice scooper when they served beverages because if they used a ceramic coffee mug it may be subject to chipping. He stated that he did not know if there was a possibility of contamination if the cup was stained with a brown substance on the inside as it was used to serve beverages. He further stated that if staff forgot to stock the beverage cart with an ice scoop, then they should have known to come back to the kitchen to get an ice scoop and should not have used a coffee cup. During an interview with the surveyor on 02/16/22 at 12:06 PM, the Licensed Nursing Home Administrator (LNHA) stated that she thought that since the coffee cup was previously run through the dishwasher that it was sanitized. The Director of Nursing (DON) who was present during the interview, stated that the staff would tend to touch the ice when a coffee cup was utilized to scoop ice and there was a risk of contamination if the handle touched the ice. The LNHA stated that it was also possible for the cup to chip into the ice. The DON stated that the coffee cup should not have been left in the bucket. 2. On 2/11/22 at 8:25 AM, Surveyor #2 observed LPN #3 on the SAR Unit, as she performed the medication administration pass. LPN #3 reviewed the Electronic Health Record (EHR) of an unsampled resident and utilized both a mouse and keyboard to review the resident's medications on the computer screen. She then opened a drawer of the medication cart and stated that the resident's medications were not available and were required to be obtained from the back up medication storage room. LPN #3 entered the medication storage room and obtained the first medication from the automated medication dispensing system and then proceeded to remove a multi-dose bottle of Acetaminophen (used to treat pain and fever) 325 milligrams (mg) that was located on an opened shelf within the medication storage room. LPN #3 returned to the medication cart and opened the drawer of the medication cart without first performing hand hygiene. She stated that she previously overlooked a bottle of Acetaminophen 325 mg that was in the top drawer of the cart and stated that she would use it instead of the bottle that she removed from the medication storage room. LPN #3 then placed the bottle of Acetaminophen in the right pocket of her uniform and stated that she would return it to the storage room after the medication pass. She placed both medications into a plastic medication cup. At 8:35 AM, LPN #3 entered the unsampled resident's room and stated that the resident's oxygen tubing was not properly positioned within the resident's nostrils. She donned (put on) a pair of gloves and adjusted the oxygen nasal cannula accordingly and accidentally knocked the resident's television remote off of the table and onto the floor. LPN #3 picked up the remote control with her gloved hands and handed it to the resident without cleaning it first. The resident placed the television remote on the over-bed table. LPN #3 then doffed (removed) her gloves without performing hand hygiene. She then handed the resident a cup of water and medications that were contained within the plastic medication cup. LPN #3 proceeded to obtain the resident's blood pressure, pulse oximetry level (a probe is used to measure the amount of oxygenated hemoglobin in the blood obtained from capillaries of a finger or ear), and temperature with a portable automated blood pressure cuff, touchless thermometer and pulse oximeter that she stated belonged to her and were not supplied by the facility. She placed the pulse oximeter probe on the resident's left index finger and removed it after and placed it in the left pocket of her uniform without cleaning it first. At 8:44 AM, LPN #3 returned to the medication cart and rolled it down the hall, and positioned it in front of a resident room. She donned one glove on her left hand and cleaned her portable blood pressure cuff with a disinfectant wipe that she obtained from a canister that was stored within a basket that was attached to a rolling automated blood pressure, pulse oximetry, and thermometer device that was positioned in the hallway. She did not perform hand hygiene after she doffed the single glove. She then returned her portable blood pressure cuff to a storage case that she kept in the bottom drawer of the medication cart. At 8:46 AM, LPN #3 picked up a plastic medication cup and placed it on top of the medication cart and the tip of her bare index finger touched the bottom of the inside of the medication cup as she laid it down on top of the med cart. She stated that she had to get Resident #267's blood pressure first and obtained the rolling automated blood pressure device from the hallway and applied the cuff to the resident's left wrist. She removed the blood pressure cuff from the resident and then cleaned the blood pressure cuff with a disinfectant wipe. She did not don gloves before she cleaned the blood pressure cuff and failed to perform hand hygiene after she cleaned it. LPN #3 then utilized the mouse and computer keyboard as she reviewed the medications that she prepared to administer in the resident's EHR. She then prepared the resident's scheduled medications and placed them in the plastic medication cup that she had previously placed on the cart. At 8:48 AM, LPN #3 entered Resident #267's room and administered his/her medications. She removed a portable pulse oximeter from her left pocket and placed it on the resident's left index finger. After she removed the pulse oximetry probe, she cleaned it with a disinfectant wipe with her bare hands and did not perform hand hygiene after. At 8:57 AM, Surveyor #2 interviewed LPN #3 who stated that she should have returned the multi-dose bottle of Acetaminophen to the medication storage room when she realized that she was not going to administer it. She stated that she also should have washed her hands after she left the medications storage room before she prepared the unsampled resident's medications. She stated that she also should have washed off the television remote and washed her hands before she returned the remote and cup of water to the resident. She further stated that she should have washed her hands each time that she doffed her gloves during the medication pass to prevent the spread of infection. Surveyor #2 observed that LPN #3 did not perform hand hygiene before she reached into her pocket and obtained the bottle of Acetaminophen and returned the medication to the storage room. During an interview with Surveyor #2 on 02/11/22 at 12:30 PM, the LPN/UM (Unit Manager) of the SAR Unit stated that nursing was required to clean their hands before they entered a resident room to administer medications and clean their hands before they exited the room after medications were administered. She stated that she would have placed the multi-dose bottle of Acetaminophen in the drawer of the medication cart instead of in her pocket so that the bottle did not become contaminated. She stated that when the television remote control fell on the ground, LPN #3 should have donned gloves and wiped the remote with a disinfectant wipe and doffed the gloves, and performed hand hygiene after. She stated that by failing to clean the remote before she handed it to the resident, she now contaminated the table where the remote was placed. She stated that she also potentially contaminated the resident's cup that she handed to her after she touched the remote that had been on the floor. The LPN/UM stated that nursing staff were required to don gloves and clean all reusable equipment in between resident use and should have used equipment that was provided by the facility rather than their own for accuracy. She stated when LPN #3 finished cleaning medical equipment, she should have doffed her gloves and performed hand hygiene. She stated that LPN #3 was also required to wash her hands after resident contact when she obtained a blood pressure to prevent contamination. She further stated that if LPN #3 returned a multi-dose vial of Acetaminophen to the medications storage room from her pocket without first performing hand hygiene or wiping the outside of the bottle with a disinfectant wipe it could potentially contaminate other medications that were stored on the shelf as both LPN #3's hands and pocket were contaminated. During an interview with Surveyor #2 on 02/11/22 at 12:50 PM, the RN/IP stated that LPN #3 could have immediately returned the multi-dose bottle of Acetaminophen to the medication storage room when she decided not to use it and failure to do so was an infection control issue. She stated that hand hygiene should have been performed before LPN #3 prepared the medications after she left the medication storage room. She stated that when LPN #3 dropped the television remote on the floor and picked it up and handed it to the resident there was a potential for the spread of infection. She stated that nursing was required to wear a pair of gloves when they sanitized equipment, not a single glove, and perform hand hygiene after gloves were doffed for infection control purposes. She stated that the nurse should have performed hand hygiene before and after she obtained vital signs and before and after medication administration. She stated that it was not appropriate for LPN #3 to touch the inside of a medication cup without first performing hand hygiene as it could have become contaminated. She further stated that the nurse should have performed hand hygiene after medication administration and before she returned the multi-dose bottle of Acetaminophen to the medication storage room for infection control purposes. On 2/14/22 at 7:39 AM, Surveyor #2 observed LPN #4 on the Elmwood Unit, during the medication pass. After LPN #4 used a blood glucose meter (a small, portable machine used to measure how much glucose (type of sugar) is in the blood for people with diabetes and was obtained via a finger stick with a lancet) to obtain Resident #23's blood glucose level she washed her hands, donned gloves and used a 75% alcohol wipe to disinfect the glucose meter. LPN #4 then doffed her gloves and did not perform hand hygiene after. LPN #4 then used the mouse and keyboard as she reviewed the resident's Electronic Health Record (EHR) in the computer and obtained the supplies from the medication cart that were required to obtain Resident #75's blood sugar (lancet (instrument used to pierce the skin), test strip, alcohol pad, glucose meter, and adhesive bandage) without first performing hand hygiene. At 7:41 AM, after LPN #4 obtained Resident #75's blood sugar, she doffed her gloves and washed her hands before she donned a pair of gloves and cleaned a second glucose meter that she used alternatively with a 75% alcohol wipe. She doffed her gloves and did not perform hand hygiene after. At 8:07 AM, LPN #4 washed her hands, donned gloves, and administered insulin to resident #11 via an insulin pen (a device that delivered insulin into the subcutaneous tissue) into the resident's left upper arm, doffed her gloves, and failed to perform hand hygiene before she removed the insulin pen tip and discarded it in the sharps container and returned the resident's insulin pen to the medication cart. She then accessed Resident #23's EHR in the computer and prepared the resident's medications without first performing hand hygiene. At 8:22 AM, LPN #4 prepared Resident #34's medications and carried the medications into the resident's bathroom and placed the plastic medication cup that contained the resident's medications on a paper towel on the edge of the sink, and washed her hands. She then handed the plastic medications cup to the resident and directed the resident to take the medications. During an interview with Surveyor #2 at 8:52 AM, LPN #4 stated that she should have washed her hands after she cleaned the glucose meter and doffed her gloves and before she accessed the computer and medication cart as it posed an infection control issue. She stated that she should have washed her hands after she disposed of the insulin pen tip and related supplies in the sharps container before she resumed medication preparation as it posed an infection control issue. LPN #4 stated that she should not have placed Resident #34's medications on the edge of the sink while she washed her hands as there was a chance that she could have splashed water on them which was a potential infection control problem. She further stated that she thought that she was required to keep the medications within her sight and was not sure where to put the medications while she washed her hands. During an interview with Surveyor #2 at 12:49 PM, the LPN/UM of the Long-Term Care Unit (LTC), stated that if LPN #4 failed to wash her hands when she doffed her gloves after she cleaned the blood glucose meter it posed a potential infection control issue. She stated that if medications were kept on the side of the sink while LPN #2 washed her hands, there was a potential for cross-contamination. During an interview with Surveyor #2 on 02/15/22 at 12:21 PM, the RN/IP stated LPN #4 should have performed hand hygiene with hand sanitizer after she doffed her gloves when she finished cleaning the blood glucose meter because there could have been blood on the meter when it was handled for the resident it was used for. She stated that there was a risk for contamination if medications were poured without hand hygiene after blood glucose meter contact. She further stated that the edge of the sink was not an appropriate place to store medications during hand hygiene and there was a risk of contamination. She further stated that LPN #4 posed a risk of contamination after she doffed her gloves and put the insulin pen in the medication cart and began to pour medications without first performing hand hygiene. 3. During the initial tour of the facility on 02/09/22 at 9:55 AM, Surveyor #2 observed a Personal Protective Equipment (PPE) (protective clothing, or equipment used to protect the wearer's body from injury or infection) caddy that was hung on the outside of Resident #46's door. A Registered Nurse (RN) hung a sign on the wall above the resident's room number that cautioned: Stop, See Nurse. The RN stated that the resident had just came to the facility the prior night. Surveyor #2 donned a gown and gloves and entered the resident's room and observed the resident lying awake in bed. The resident stated that he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Admission Record (an admission summary), Resident #46 was readmitted to the facility in February of 2022 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's Admission Minimum Data Set (MDS), an assessment tool dated 12/23/21, reflected that the resident had a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was fully, cognitively intact. Further review of the MDS revealed that the resident required extensive assistance of two persons for bed mobility and transfers. A review of Resident #46's Care Plan revealed an entry dated 02/13/22, indicated that the resident had an infection of ESBL in the urine and was maintained on isolation precautions as indicated. Review of the Order Summary Report dated 02/17/22, revealed that an order was placed on 02/08/22 for Isolation and contact precautions ([CONDITION(S)] onj [sic.] right hip) and on 02/09/22 an order was placed for Contact Isolation-ESBL in urine. On 02/11/22 at 11:34 AM, as Surveyor #2 interviewed Resident #46 at his/her bedside, Licensed Practical Nurse (LPN) #3 entered the resident's room and did not don a gown or gloves prior to entry. LPN #3 held a glove in her left hand and a plastic medication cup in her right hand. She asked the resident about his/her air mattress function and pressed down on the mattress over top of the blankets that covered the foot of the bed with her bare hands. She stated that she would call Maintenance and inform them that there was a problem with the air mattress. LPN #3 left the resident's room with both the glove and plastic medication cup still in her hands without first performing hand hygiene. During an interview with Surveyor #2 at 11:47 AM, LPN #3 stated that she had not planned to administer medications to Resident #46 when she entered his/her room. She stated that both the plastic medication cup and the gloves that she held in her hands when she entered the resident's room were trash and she should have thrown them away before she entered the resident's room. She stated that she only wanted to look at the resident's bed and forgot to put a gown and gloves on before she entered the room. During an interview with Surveyor #2 at 12:30 PM, the LPN/UM of the SAR Unit stated that before LPN #3 entered Resident #46's room who was on transmission-based precautions ( initiated when a resident develops signs and symptoms of a transmissible infection), she should have donned both a gown and gloves. She stated that by failing to do so she risked contamination when she touched the resident's bed linens. She further stated that the nurse should not have carried gloves or a medication cup into the resident's room and should have discarded them prior to entry and washed her hands before and after entry due to the risk of contamination. Review of LPN #3's Personal Protective Equipment (PPE) Competency Validation Donning and Doffing Standard Precautions and Transmission Based Precautions dated 01/27/22 revealed the following: Perform hand hygiene, don gown ., don gloves ., doff PPE, remove gloves ., remove gown ., discard in waste container, perform hand hygiene. 4. During the initial tour of the facility on 02/09/22 at 12:06 PM, Surveyor #2 attempted to meet with Resident #41 and was instead greeted by his/her family member (FM) who stated that transport was at the facility to take the resident to the [CONDITION(S)] center (clinical purification of blood as a substitute for normal kidney function) and further stated that he/she did the resident's peritoneal (type of [CONDITION(S)] which used the peritoneum in a person's abdomen to remove excess fluid, correct electrolyte problems, and remove toxins in those with kidney failure) [CONDITION(S)] treatments and the resident went to the center primarily for lab draws three times per week. A review of the Admission Record revealed that Resident #41 was readmitted to the facility in December of 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed that Resident #41 had a BIMS Score of 15 which indicated that the resident was cognitively intact. Further review of the MDS specified that the resident required extensive assistance of two persons for bed mobility and transfers. On 02/11/22 at 12:14 PM, Surveyor #2 entered Resident #41's room and saw that there were multiple boxes of peritoneal [CONDITION(S)] supplies stored both directly on the resident's floor and three boxes were opened with their contents exposed and were placed on top of a thin, dark-colored piece of wood. There were seven boxes, stacked on top of one another stored directly on the floor and the top box was opened and contained supplies. There was another pile stacked on the floor that was two boxes high and had a plastic wash basin stored on top which contained additional sealed [CONDITION(S)] supplies. The resident was asleep and unable to be interviewed at that time. The resident's FM, who was present, stated that he/she waited for a shipment of [CONDITION(S)] supplies to be delivered to the facility and brought the supplies that were stored on the floor from home. The resident's FM further stated that he/she did not know who placed the piece of wood on the floor that held some of the opened boxes. During an interview with Surveyor #2 on 02/11/22 at 1:10 PM, the RN/IP stated that Resident #41 was hospitalized prior with peritonitis (inflammation of the peritoneum, typically caused by bacterial infection. She stated that the resident's peritoneal [CONDITION(S)] supplies were stored in the resident's private room and must be stored four inches from the floor on stacked pallets. She stated that it was an infection control issue if the boxes were stored directly on the floor. At 1:16 PM, Surveyor #2 and the RN/IP went to Resident #41's room and saw that there were boxes of peritoneal [CONDITION(S)] supplies stored directly on the floor, and some of the boxes were opened and laid on top of a thin piece of wood that was less than four inches thick. The RN/IP stated that the boxes should not have been stored directly on the floor and that was not protocol due to a risk of contamination. She stated that she did not know what the thin, slab of wood was that was placed beneath some of the opened boxes. She stated that staff should have used pallets and the boxes were required to remain at least four inches off the floor for infection control purposes. She stated that there was no way that staff would not have seen that many boxes being delivered when they were going in and out of the room and should have noticed that the boxes were laid directly on the floor. During an interview with Surveyor #2 on 02/14/22 at 11:22 AM, Resident #41's FM stated that last friday, their FM brought in boxes of peritoneal [CONDITION(S)] solution from home and used both a wheelchair and cart that were supplied by the front desk to bring them into the resident's room. She further stated that the wooden board was placed there previously and was supplied by the facility. The surveyor noted that the boxes were all now elevated off the floor on plastic pallets. During an interview with Surveyor #2 on 02/14/22 at 11:33 AM, Licensed Practical Nurse/Charge Nurse (LPN/CN) ,who was assigned to Resident #41, stated that the resident's boxes of peritoneal [CONDITION(S)] supplies were required to be stored off the floor for infection control purposes and to keep them from getting wet. She stated that she did not recall what the boxes were stored on to ensure that they remained elevated off the floor. During an interview with Surveyor #2 on 02/15/22 at 11:03 AM, the RN/IP stated that on friday, she notified Maintenance who then placed Resident #41's peritoneal [CONDITION(S)] supplies on pallets as required. She stated that she was unsure of how the boxes were placed on the floor or where the thin piece of wood came from that was utilized to hold some of the boxes previously and stated that it was too thin. During an interview with Surveyor #2 on 02/15/22 at 11:13 AM, the Director of Maintenance (DOM) stated that when peritoneal [CONDITION(S)] supplies were delivered to the facility, maintenance was responsible to transport them to the room on a [NAME]. He stated that the problem was that lately they delivered pallets of supplies and there was limited storage. He stated that when they stacked them, they had to be off the floor. He stated that they typically used a shelving base and in dire conditions, a milk crate was used. He stated that the piece of wood appeared to have come off the side of a cabinet and was too thin to be utilized to hold the boxes and thought that maybe a porter placed it there after hours. He stated that it was an infection control issue if the boxes of peritoneal [CONDITION(S)] supplies were stored on the floor because of the risk of germs, disease and opened boxes may have served as a nest for varmints. He stated that all boxes in the facility were required to be elevated off the floor by four inches and stated that he was unable to provide the surveyor with a policy that detailed this specification. During a later interview with Surveyor #2 on 02/15/22 at 12:08 PM, the RN/IP stated that she was unable to provide the surveyor with a policy though she knew that all boxes had to be either four or six inches off the floor for infection control purposes even though the inside of the box was sterile, and supplies were enclosed in plastic. During an interview with Surveyor #2 on 02/16/22 at 11:43 AM, the LNHA stated that when a peritoneal [CONDITION(S)] delivery arrived at the loading docks, the shipment would be delivered to the resident's room and Maintenance would be notified to ensure that the supplies were elevated off the resident's floor. She stated that if the delivery occurred at night, and the supplies were left on the floor then we need to raise it with what materials we have. She stated that if staff found the boxes on the floor, then they needed to get the boxes off the floor in the interim. During an interview with Surveyor #2 on 02/17/22 at 11:15 AM, the RN/IP stated that she never reviewed a policy that specified how many inches of peritoneal [CONDITION(S)] supplies needed to be stored off the floor. The Director of Nursing ([TRUNCATED]

Based on observations, interviews and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices and store, label, and date potentially hazardous foods to prevent the development of food borne illness. This deficient practice was evidenced by the following: On [DATE] at 09:21 am, during the initial tour of the kitchen in the presence of the Assistant Dietary Director (ADD), the surveyor observed the following: 1. The ADD was in the kitchen wearing a hair net. The hair net did not cover her hair to the hairline on the forehead and there were multiple long strands of hair that were not contained in the hair net. The ADD stated that she did not realize that all her hair was not contained in the hair net. The ADD stated that her hair should have been completely contained in the hair net to avoid hair from falling in the food. 2. There was a large stand-up mixer that had a clear plastic bag covering it. The ADD stated that the clear bag indicated that the mixer was clean and ready for use. The ADD removed the clear plastic bag in the presence of the surveyor. There was a dry white substance on the underside of the mixer above where the mixer blade would be attached. The ADD stated that the white substance should not have been there due to cross contamination. 3. In the reach-in refrigerator the following was observed: -A silver tray labeled red gelatin covered with clear plastic wrap with a use by date of [DATE] -A silver tray labeled sliced deli turkey covered with clear plastic wrap with a use by [DATE] -A sandwich wrapped in clear plastic labeled jelly sandwich with a use by date of [DATE] At that time, the ADD stated that the reason the items were dated was to make sure it was used by allotted time, so it doesn't go bad, 4. In the walk-in refrigerator: -An opened 1-gallon container of ranch dressing with a use by date of [DATE] -An opened 8-pound (lb) 10 ounce (oz) container of enchilada sauce with a use by date of [DATE] -An opened 1-gallon container of thousand island dressing with a use by date of [DATE] -An opened 5 lbs. container of teriyaki glaze with no open date -An opened 4 lb. 15 oz container of [NAME] style sauce with no open date The ADD stated that it was everyone's responsibility check the dates to make sure the items were labeled and still good. At 09:45 AM, the Dietary Director (DD) joined the tour. 5. In the walk-in freezer, the DD identified the following: -An opened box of chicken cutlets that contained a bag of the chicken cutlets that was opened to air. The DD stated that they shouldn't be open to air due to cross contamination. -A clear bag of long white logs, there was no identifier label, received on label, or use by label. The DD identified them as French fries. -A clear bag of long oval brown logs, there was no identifier label, received on label, or use by label. The DD identified them as hot dogs. -A clear bag of brown circular patties, there was no identifier label, received on label, or use by label. The DD identified them as beef steak fritters. -A clear bag of tan circular nuggets, there was no identifier label, received on label, or use by label. The DD identified them as chicken nuggets. -3 clear bags of white circular items, there was no identifier label, received on label, or use by label. The DD identified them as cookie dough. At that time, the DD stated the purpose of labeling items was so that everyone knows what the item was and when to use it. He also stated that it was everyone's responsibility to label the items. At 09:55 AM, the surveyor reviewed with the DD all the findings that were observed while touring with the ADD. On [DATE] at 01:12 PM, the above findings were reviewed with the Administrator and the Director of Nursing. Review of the facility's policy, Preventing Foodborne Illness-Employee hygiene and Sanitary Practices dated [DATE], Policy Interpretation and Implementation: 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Review of the facility's policy, Preventing Foodborne Illness-Food Handling revised [DATE], Policy Interpretation and Implementation: 9. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendation. Review of the facility's policy, Refrigerators and Freezer revised [DATE], Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines. Policy Interpretation and implementation: 7. All food shall be appropriately dated to ensure proper rotation by expiration dates .Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. NJAC 8:,d+[DATE].2(g)

Based on interview and review of the medical records and other facility documentation, it was determined that the facility failed to send the family representative a notification of transfer letter 1 of 2 residents reviewed for hospitalization transfers (Resident #112). This deficient practice was evidenced by the following: A review of the facility Admission Record revealed Resident #112 was originally admitted to the facility on ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 01/19/2022, revealed Resident #112 scored a 4/15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident had severe cognitive impairment. A review of Resident #112's progress note dated 01/04/2022 at 05:33 PM, revealed the resident was transferred to the hospital for evaluation for systemic infection or reaction. A review of Resident #112's progress note dated 01/05/222 at 02:56 AM, revealed the resident was admitted to the hospital for altered mental status. Further review of the progress note dated 01/13/2022 at 08:42 PM, revealed the resident was readmitted to the facility. A review of Resident #112's medical record did not include notification in writing to the family of the transfer to the hospital. During an interview with the surveyor on 02/14/2022 at 10:30 AM, the Director of Nursing (DON) stated that the facility did not send letters to the family or representative in writing of a discharge to the hospital, they notify the family by phone. During a meeting with the surveyor on 02/16/2022 at 01:10 PM, the Administrator was informed of the findings. A review of the policy labeled Transfer or Discharge Notice with a revised date of March 2021, revealed the resident and representative are to be notified in writing of the specific reason for transfer, the date, and the location of where the resident was transferred to. NJAC 8:39-4.1(a)(32)

Based on observation, interview and record review, it was determined that the facility failed to use proper infection control practices in a manner to prevent the potential spread of infection and/or cross-contamination for residents on transmission-based precautions on by failing to a.) handle and discard washable isolation gowns appropriately b.) wear isolation gowns in the hallways of Covid-19 positive units c.) disinfect protective face shields/eye wear after exiting a Covid-19 positive unit. This deficient practice was identified on 3 of 4 units and was evidenced by the following: The facility policy dated 10/26/2020 and titled, Care One Cohort Plan was comprised of general co-horting guidelines which indicated the following: The Red Zone is comprised of all Covid-19 positive residents. The residents in this zone were on isolation, and signage was posted on each resident's door to indicate as such. This zone was separate from all other cohorts. There were designated staff and designated equipment on this unit. Full (Personal Protective Equipment) PPE was required for this unit, such as eye protection, gown gloves, and mask. The Yellow Zone PUI (Persons under Investigation) was comprised of exposed, asymptomatic, or potentially incubating Covid-19 residents. Signage was posted prior to entrance to the unit and on each resident's door that indicated that separate gowns and gloves for each resident at point of use: extended use/reuse of mask and eye protection was permitted. The staff is required to wear a Respirator (facemask if not available), eye protection, separate gown, and gloves when rendering resident care. Extended use/re-use of a mask and eye protection is utilized as per facility policy. The Green Zone (clean) was comprised of residents that were Covid-19 negative, not exposed or asymptomatic Covid-19, and recovered over 14 days. Only fully recovered residents over 14 days may be moved into the Green Zone. 1.) On 11/10/20 at 10:04 AM, the surveyor observed closed double doors with a window and a red sign attached that read Covid Unit (Covid-19 Unit #1). The surveyor stood outside the Covid-19 Unit #1 and viewed the hallway of the Covid-19 unit through the window. The surveyor observed a staff member walking down the hallway carrying a yellow washable gown over her arm and then donned the gown outside the resident's room. At that time, the surveyor observed a staff member who was wearing a gown, gloves, N-95 mask, and eye goggles ambulating a resident in the Covid-19 Unit #1 hallway. The surveyor also observed staff on the Covid-19 Unit #1 hallway not wearing yellow isolation gowns. On 11/10/20 at 10:14 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN UM) for the Covid-19 Unit #1 who stated that the staff obtained clean yellow washable isolation gowns from a clothing rack that was located across at the nurse's station outside of the Covid positive Unit #1. Prior to entering the Covid-19 Units, the nurses and aides obtain a clean gowns for each resident's room and hang the gowns on the hooks outside each Covid positive room. The surveyor was told that the gowns are labeled CNA and LPN/NURSE. The yellow gowns are then donned prior to staff entering each residents' room. When the nurses or aides exit the resident's room, they hang the labeled, contaminated yellow gown on the outside door hook facing the hallway to be reused the next time staff enter the resident's room. The LPN UM stated I don't consider the hallway contaminated. On 11/10/20 at 10:45 AM, two surveyors toured the Yellow PUI Unit. Prior to entering the PUI unit, the surveyors observed a plastic zippered door with a yellow sign attached to plastic that read STOP: Quarantine: Droplet/Contact precautions. Inside the PUI unit, the surveyors observed a yellow arrow sign attached to the wall that indicated N95/KN95 masks and eye protection should always be worn and gowns worn when providing direct care. Upon entering the PUI Unit, the surveyors observed yellow washable gowns hanging on hooks on the outside of the open resident room doors facing the hallway. At that time, the surveyor interviewed the Registered Nurse Unit Manager (RN UM) who stated that the staff are not required to wear gowns in the hallways and only to wear gowns when providing direct patient care. On 11/10/20 at 11:00 AM, the surveyor observed a staff member in a resident's room on the PUI unit wearing a N-95 mask, goggles, gloves and a yellow disposable gown ambulating a resident with their hands touching the resident. Upon exiting the room, the surveyor observed the staff member remove and dispose of their gloves in the trash can in the resident's room. The staff member then took off the yellow contaminated gown and rolled the gown inside out and carried it through the hallway to the laundry bin located in the middle of the hallway. The staff member then used alcohol-based gel to perform hand hygiene. On 11/10/20 at 11:06 AM, the surveyor interviewed LPN #1 on the PUI unit who stated that after wearing a yellow isolation gown in a resident's room, the gown was to be wrapped up into itself and walked down the hallway and disposed of into the dedicated laundry bin. On 11/10/20 at 11:08 AM, the surveyor interviewed LPN #2 on the PUI unit who stated that she was an agency nurse and was informed by the facility that she was to put on a gown and gloves prior to entering a resident's room for patient care. Prior to exiting a resident's room, she was to take off the gown first, roll it outside towards the inside, then take off the gloves and dispose of the gloves in trash. The rolled-up gown was to go into the linen bin in the hallway that was closest to the resident's room. The surveyor observed that all laundry bins were located down the end of the hallway which required the staff to walk through the halls with contaminated isolation gowns in order to dispose of them. On 11/10/20 at 11:15 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN UM) who confirmed that the staff were removing contaminated washable gowns and turning them inside out and walking the contaminated gowns down the hallway for disposal in the laundry bin. The RN UM stated that this is how the staff were trained to dispose of the contaminated gowns. On 11/10/2020 at 01:10 PM, the Occupational Therapist (OT #1) stated that when treating a resident in their room on the Covid-19 positive unit, staff were to wear full PPE such as washable isolation gown, N95 mask, gloves and face shields. OT #1 indicated that when exiting the residents room after treatment that the yellow isolation gown was to be removed and disposed of in the laundry bin at the end of the hall. I do walk through the hall with the gown to the disposal bin. OT #1 also revealed that when he was assigned to the Covid-19 positive unit Red Unit that the whole unit is considered contaminated and contaminated PPE should not be worn off that unit. 2.) On 11/10/20 at 11:35 AM, two surveyors toured the Covid-19 positive Unit #1. The surveyors observed a red arrow sign attached to the wall of the unit that indicated that N95/KN95 mask and eye protections to be worn. The signage also indicated that a gown was to be worn for each room for each staff individualized person and was to be discarded at end of the shift. The surveyors observed yellow washable gowns hanging on hooks of each resident room doors with the gowns facing the hallway. Some the doors were closed and some were opened. The surveyors did not observe staff on the Covid-19 #1 Unit hallway wearing yellow washable isolation gowns. They were wearing their uniforms. On 11/10/20 at 11:40 AM, both surveyors observed a Physical Therapist (PT#1) not wearing a yellow washable isolation gown while ambulating a Covid-19 positive resident in the Covid unit #1. PT #1 was in direct contact with the resident during ambulation and was touching the resident and the resident's wheelchair during treatment. The surveyor interviewed PT#1 at this time who stated that she was told that day that she should not wear the washable isolation gown in the hallway on the Covid-19 Positive Unit #1. PT#1 further stated that she was treating a Covid-19 positive resident in the hall and did not understand why she was instructed by the nursing staff not to wear an isolation gown while in direct contact with a Covid-19 positive resident. PT#1 stated, I'm still in contact with the resident so I should be wearing a gown to protect myself and others from contacting Covid-19. I feel like I should be wearing the isolation gown. On 11/10/20 at 11:45 AM, both surveyors observed a resident sitting in a chair in the hallway of Covid-19 positive Unit #1 unmasked, and ungowned picking his/her nose and rubbing the secretions on the chair in the hallway. This resident was in close proximity to PT #1 who was treating a Covid-19 positive resident in the hallway as well as other staff members and LPN #3, all of whom were not wearing isolation gowns in the hallway. At that time, the surveyor interviewed LPN #3 who confirmed that residents who were in the hallway were positive for the Covid-19 virus and that the resident who was sitting in the chair unmasked and picking his/her their nose should be in their room and should be wearing a mask. The LPN added that the residents should not be in the hallway and should be in their rooms, but did not think that the hallway was contaminated even though there were two residents in the hallway who were both Covid-19 positive. The surveyors then inquired about proper use of the yellow isolation gowns and LPN #3 responded that when a nurse exits a resident's room on the Covid unit the nurse should remove the gown and hang it on the hook of the door with the dirty side facing towards the door and the clean side facing the hallway. The LPN added that when staff use an isolation gown one time that they should fold the gown inside out so that the dirty side is facing in. Then carry the gown to the disposal linen bin at the end of the hallway. On 11/10/20 at 12:50 PM, the surveyor interviewed the Director of Physical Therapy (DPT) who stated that when a therapist was on the PUI Unit the therapist apply a clean yellow gown and gloves prior to entering a resident's room. When exiting the room, the therapist was to remove the gloves and throw in trash can in the room, then remove the yellow washable gown from the inside out and roll it up and place in the linen bin in the hallway. The DPT further stated that the Covid-19 unit utilize the same procedure as the PUI Unit for disposal of the washable isolation gowns after treating a resident. The DPT stated that on the Covid-19 Unit, all therapy should be done in the resident's room but if the therapist needs to do therapy in the hall, the therapist should be wearing a yellow disposable gown and gloves in addition to the N-95 mask and goggles/face shield because the hallway of the Covid-19 Unit was contaminated. The DPT further stated that if the therapist was not in direct resident contact then they did not need to wear a yellow gown on the Covid-19 Unit hallway. On 11/10/2020 at 12:50 PM, the surveyor interviewed PT #2 who stated that while working on the Covid-19 positive Unit staff were to wear full PPE which included N95 mask, goggles or face shield, isolation gown and gloves. She stated that residents on that unit were positive for Covid-19. She added that the residents were ambulated in the hallways of the Covid-19 positive Unit. She added that she considered the entire Covid-19 Unit contaminated and that by not wearing an isolation gown to protect your clothing even in the hallway that [MEDICAL CONDITION] could contaminate your clothing which could transmit [MEDICAL CONDITION]. On 11/10/2020 at 01:00 PM, the surveyor interviewed a Lead Occupational Therapist who stated that therapy staff are designated to specific units and that she was designated to the PUI unit, but had one resident on the Covid-19 positive unit. She added that she would treat the residents on the PUI unit first and then would treat the resident on the Covid-19 positive unit last. She stated that she was told by the nurses on the Covid-positive unit that she was not to wear a isolation gown or gloves while in the hallway on the Covid-19 positive unit, but was to wear full PPE while in rooms housing Covid-19 positive residents. On 11/10/20 at 1:40 PM, the surveyor interviewed LPN #4 who stated that she was assigned to both Covid-19 units (Covid-19 Unit #1 and Covid-19 Unit #2). LPN #4 stated that prior to the start of the shift, the nurses would bring a clean gown and hang onto the hook of each resident's room. These gowns were labeled nurse or CNA. LPN #4 stated that the staff did not wear an isolation gowns in the hallway of the Covid-19 units and only gown up when entering a resident's room. The nurses put the yellow isolation gown on before entering the Covid-19 positive resident's room and upon exiting the room will then hang the gown on the designated hook on the door for later use. On 11/12/2020 at 10:30 AM, the surveyor toured the Covid-19 positive Unit #1 and observed washable yellow isolation gowns hanging on the resident's door. The gowns were hanging on hooks that were labeled Nurse on one side and CNA on the other side. The surveyor observed an employee who emerged out of a Covid-19 positive resident's room. The employee took off a contaminated washable yellow isolation gown, did not turn the contaminated gown inside out and hung the gown on the outside of the door where it was labeled CNA. The employee quickly left the unit. The surveyor interviewed the LPN #3 at this time and she revealed that the employee worked in the therapy department and was not a CNA. LPN #3 stated that the therapy employee should have removed the contaminated isolation gown inside out and then should have disposed in the isolation gown disposal bin and should not have hung a contaminated isolation gown on the hook that was labeled CNA. She also stated that employees do not share gowns and that the hook labeled CNA was strictly isolation gowns that were worn by the CNAs. On 11/12/20 at 11:24 AM, the surveyor observed LPN #4 take a yellow gown off the hook labeled nurse and enter a resident's room. Upon exiting the room, LPN #4 hung the gown up on a plastic hanger with the dirty side opening towards the hallway, then performed hand hygiene. At that time, the surveyor interviewed LPN#4 who stated that she considered the hallway to be clean even though she hung a contaminated isolation gown on a door facing the hallway. On 11/12/2020 at 11:30 AM, the surveyor interviewed the Social Worker (SW) who stated that when she enters the Covid-19 positive Unit that she wears a N95 mask and goggles. She said that she carried her washable isolation gown on the Covid-19 positive Unit and put it on prior to entering a resident's room who was Covid-19 positive. She then stated that after exiting a resident's room she would roll up the contaminated gown and walk the contaminated gown down the hall to the gowns only bin. She stated that the gowns only bin was usually at the end of the hallway. On 11/12/2020 at 01:30 PM, the surveyor interviewed the Director of Rehabilitation (DR) who stated that the therapist take isolation gowns in for each individual resident and upon exiting a resident room they remove the gown, turn it inside out, walk down the hall with the washable isolation gown and place it in the laundry bin. The DR stated that the staff do not wear isolation gowns in the hallway on the Covid positive units. The staff are suppose to treat residents in their rooms, but some residents are insistent on walking in the hall and if so then the therapist must wear a gown when treating the resident. The DR added the the staff was to wear the isolation gowns when in direct contact with the residents that were Covid positive to prevent contamination of clothes. 3.) On 11/12/2020 at 10:35 AM, the surveyor was standing near the double doors to the Covid-19 positive Unit 1 and observed multiple staff members exiting the Covid-19 positive Unit #1 without cleaning the face shields. The surveyor interviewed LPN #3 who was also observed exiting the Covid-19 positive Unit #1 without cleaning the face shield. LPN #3 confirmed that face shields should be cleaned with disinfectant prior to exiting the Covid-19 positive Unit and admitted that she should have cleaned her face shield. She also revealed that all staff exiting the Covid-19 positive Unit should clean their face shields. On 11/12/2020 at 10:45 AM, the surveyor observed an Occupational Therapist (OT) exit the Covid-19 positive Unit without cleaning his face shield. The OT was interviewed at this time and confirmed to the surveyor that he should have cleaned his face shield because germs, bacteria or viruses could be on the face shield and could be transmitted. On 11/12/2020 at 11:31 AM, the surveyor interviewed LPN #4 on the Covid-19 positive Unit #2 and confirmed that when she exited the Covid-19 positive units she wore her face shield outside the unit without disinfecting it until the end of her shift. On 11/12/2020 at 12:30 PM, the surveyors interviewed the DON and asked why Covid-19 positive residents were observed in the hallways of the Covid-19 unit without masks and were not in their rooms and why staff were not wearing isolation gowns while in the Covid-19 positive hallway. The DON explained to the surveyor that the Covid-19 positive Units were considered clean and this was why staff did not have to wear isolation gowns while in the halls. Staff were only to wear isolation gowns when in resident's rooms that were Covid-19 positive or when in direct contact with Covid-19 positive residents. The DON stated that she did not think that [MEDICAL CONDITION] could be on the employees clothing and could be transmitted that way. The DON added that when employees were removing their contaminated isolation gowns and rolling the contaminated isolation gowns inside out, that the inside of the gown was considered clean and that it was safe to walk the gown down the hall to put it in the disposal bin. Nothing should be contaminated. The hallway should be considered clean. The DON then stated that walking contaminated isolation gowns down a hall was safe as long as the gown was turned inside out, and that staff washed their hands afterward. The DON also revealed that she did not educate the staff to clean the goggles or face shields before leaving the Covid-19 positive Unit because she did not think that [MEDICAL CONDITION] could spread that way. Only if they touched the shields or goggles and then touched their eyes or mouths. On 11/12/2020 at 01:30 PM, the surveyor interviewed the DR who stated that staff should disinfect goggles and face shields when leaving the Covid-19 positive unit in case the shields or goggles are contaminated. The facility policy dated 10/11/2020 and titled, CareOne Strategies for Contingent Capacity Use of PPE Center for Disease Control (CDC) and Use by Cohort Group indicated the following: General Guidelines for PPE Use: -Full PPE is required for care of all residents regardless of Covid status if there is a current outbreak with staff or residents. -Avoid wearing gowns in the hallway and common areas (no base layer of PPE unless it is a Covid positive Unit). Eye Protection: -Disposable and reusable eye protection may be reused with appropriate cleaning and disinfection; Do not share. -Discard is damaged; do not touch or adjust and do not remove in patient care area. -Prioritize for aerosol, splash or spray generating procedures or where prolonged face to face/close contact is unavoidable. The facility provided the surveyor with a form titled, How to safely remove PPE and the form indicated: Remove all PPE before exiting the patient room and provided an example on how to remove PPE without contaminating clothing, skin, mucous membranes with potentially infectious materials. Goggles and Face Shields: -Outside of goggles and face shields are contaminated! -If your hands get contaminated during goggle or face shield removal, immediately wash your hands and use an alcohol-based hand sanitizer. -Remove goggles or face shield from the back by lifting head band and without touching the front of the goggles or face shield. -If the item is reusable, place in designated receptacle for reprocessing. Otherwise discard in the waste container. Gowns: -Gown front and sleeves are contaminated! -If your hands get contaminated during gown removal, immediately wash your hands and use an alcohol-based hand sanitizer. -Unfasten gown ties, taking care that sleeves don't contact your body when reaching for ties. -Pull gown away from neck and shoulders, touching inside of gown only. -Turn gown inside out. -Fold or roll into a bundle and discard in a waste container. The facility form dated 10/22/2020 and titled, Yellow Zone PPE Use indicated that No gowns are to be worn in the hallways. According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Responding to Coronavirus (COVID-19) in Nursing Homes updated 4/30/20 included, Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown .All recommended COVID-19 PPE (personal protective equipment) should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e. goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement . However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. NJAC 8:39-19.4(a)(1-2)(c)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that staff wear the appropriate personal protective equipment (PPE) for residents on contact isolation, to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This deficient practice was identified for Residents #85 and #56, 2 of 5 residents reviewed for infection control practices and was evidenced by the following: 1. According to the facility's Admission Record, Resident #85 was admitted to the facility in September 2020 with [DIAGNOSES REDACTED]. Review of Resident #85's Physician order [REDACTED]. During the initial tour on 09/24/2020 at 11:12 AM, the surveyor observed a stop/isolation sign on Resident #85's room door. There was no isolation/PPE kit observed near the room. During that time, the surveyor interviewed a Certified Nursing Assistant (CNA) #1 regarding the purpose of the stop/isolation sign. CNA #1 stated the sign meant that you should put on a gown and gloves before performing resident care. CNA #1 stated that there should have been a PPE kit (a kit that hung on the door containing isolation PPE) on the door. CNA #1 then entered the resident's room, donned gloves, walked across the room, and retrieved a linen cart that was near the resident's bed. CNA #1 placed the linen cart against the inside wall near the door entrance. On 09/24/2020 at 11:15 AM, the surveyor observed a housekeeper place a PPE kit on Resident #85's room door. During an interview with the surveyor at that time, the housekeeper stated that CNA #1 just reported that Resident #85 was on isolation and needed a PPE kit. The housekeeper stated that staff informs housekeeping when a resident was on isolation and the housekeeping staff would place the PPE kit on the door. During an interview with the surveyor on 09/24/2020 at 11:20 AM, a Licensed Practical Nurse (LPN) #1 stated that Resident #85 was on isolation for ESBL in the wound. LPN #1 stated that full contact isolation consisted of wearing a gown and gloves when coming into contact with Resident #85 or the linen cart. LPN #1 stated that the purpose of PPE was to protect the resident and staff from infection and if PPE wasn't worn, the illness could be spread. LPN #1 stated that the linen cart in the room of Resident #85 could have been contaminated and that CNA #1 should have been wearing a gown and gloves. During an interview with the surveyor on 09/30/2020 at 12:10 PM, the Activities Director (AD) stated that the stop/isolation sign meant that she had to see the nurse before she could enter the room. 2. According to the Admission Record, Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #56's Physician order [REDACTED]. On 09/24/2020 at 11:27 AM, the surveyor observed a Certified Occupational Therapy Assistant (COTA) enter Resident #56's room, wearing only a mask and goggles. The COTA donned gloves once inside the resident's room but did not don a gown. The surveyor noted there was a full PPE kit on the door but there was no stop see nurse sign on the resident's door. The surveyor observed that the COTA stood right next to Resident #56 while she counted and demonstrated dumb bell therapy to the resident while the resident performed the dumb bell therapy. The COTA was not wearing a gown during this observation. On 09/24/2020 at 11:40 AM, the surveyor observed the Unit Manager (UM) stand in Resident #56's room doorway and tell the COTA to put on a yellow isolation gown. The surveyor interviewed the UM at that time. The UM stated that gown and gloves should be worn because Resident #56 had ESBL in the wound and was on contact isolation. The UM stated that the purpose of the gowns and gloves was to avoid spreading the infection. At that time, the surveyor also interviewed the COTA who stated she was aware that the resident had ESBL in the incision and that she should have been wearing a gown along with the gloves in the room to keep any type of contaminant from me and the resident. On 09/30/2020 at 11:15 AM, the surveyor interviewed CNA #2 who stated that when an isolation (PPE) kit or a stop sign was on the door that meant full PPE consisting of gowns, gloves, mask and goggles, must be worn any time staff enter the room, even if it is just to pass a food tray. CNA #2 stated that the reason for PPE was to protect yourself and the residents so infections aren't passed. During an interview on 10/01/2020 at 10:07 AM, the DON/Infection Control Nurse (IC) stated if there was an isolation stop sign and/or a PPE kit on the door, staff should always stop and see the nurse before entering the resident's room. The DON stated staff should don a gown and gloves before entering a room for anything, even if only answering the call bell, if the resident was on contact isolation. The DON stated that CNA #1 should have donned a gown and gloves before entering Resident #85's room to move the laundry bin and that the COTA should have donned a gown and gloves before entering Resident #56's room and while doing therapy with the resident. The DON stated that the purpose of always wearing a gown and gloves before entering the room was to prevent the spread of an infection, even if the infection was contained, because you never know what the resident may need when entering the room. During an interview with the survey team on 10/02/2020 at 9:55 AM, the DON stated that if there was an active physician order [REDACTED]. Review of CNA #1 and COTAs' Personal Protective Equipment (PPE) Competency Validation, dated 08/21/2020, revealed they were both deemed competent with standard precautions and transmission based precautions and that they correctly identified the appropriate PPE for Contact/Contact [MEDICATION NAME] Precautions (gown & gloves). Review of the facility's Isolation-Initiating Transmission-Based Precautions policy, revised August 2019, revealed that when Transmission-Based Precautions were implemented, the Infection Preventionist (or designee) would determine the appropriate notification on the room entrance door. The policy reflected that the signage informed the staff of the type of CDC precautions(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. The policy included to ensure that protective equipment (i.e., gloves, gowns, masks, etc.) were maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment and that Transmission-Based Precautions would remain in effect until the Attending physician or Infection Preventionist discontinued them. Review of the facility's Multidrug-Resitant Organisms (MDRO) policy, revised August 2019, revealed under Enhanced Infection Control Precautions, to implement Contact Precautions routinely for all residents colonized or infected with a target MDRO. The policy included that Because environmental surfaces and medical equipment, especially those in close proximity to the resident may be contaminated, don gowns,and gloves before or upon entry to the resident's room or cubicle. Review of the facility's Personal Protective Equipment policy, reviewed 03/04/2019, revealed that training on the proper donning, use and disposal of PPE was provided upon orientation and at regular intervals. NJAC 8:39-19.4(a)(1-2)(c)

Based on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that all staff, and contracting services were familiar with, and adhered to infection control practices in accordance with CDC (Centers for Disease Control) and facility's guidelines in regards to donning (application) and doffing (removal) of personal protective equipment (PPE) to prevent the spread of infection on 2 of 2 isolation units. This deficient practice was identified during tour observation and was evidenced by the following: According to the facility's undated Cohorting Guidelines, the facility is divided into zones. The zones are as follows: The Red Zone is comprised of all Covid-19 positive residents. The residents in this zone were on isolation, and signage was posted on each resident's door to indicate as such. This zone was separate from all other cohorts. There were designated staff and designated equipment on this unit. Full PPE is required for this unit, such as eye protection, gown gloves, and mask. The Yellow Zone was comprised of exposed, asymptomatic, or potentially incubating Covid-19 residents. Signage was posted on the front of each resident's door, and separate gowns and gloves for each patient were made available at the point of use; an additional white re-usable lab jacket is labeled for each staff member and made available for use inside the yellow unit when not rendering care. The staff is required to wear a facemask, eye protection, separate gown, and gloves when rendering resident care. Extended use/re-use of a mask and eye protection is utilized as per facility policy. The Green Zone (clean) was comprised of residents that were Covid-19 negative, not exposed or asymptomatic Covid-19, and recovered over 14 days. Only fully recovered residents over 14 days may be moved into the Green Zone. On 6/16/2020 at 12:15 PM, the surveyor toured the unit designated as the Yellow Zone. The surveyor interviewed the Registered Nurse Unit Manager (RN/UM), who explained that she oversaw the Yellow Zone. The RN/UM stated that there was designated staff on Yellow Zone and that all staff were assigned a white re-usable lab jacket that was hung just inside the zippered plastic tent set up and was labeled for each staff member. She explained that all staff were assigned their own re-usable white lab jacket and were to wear when on the Yellow Zone. She also explained that before exiting the Yellow Zone, the staff was to remove the white lab jacket to prevent cross-contamination. On 6/16/2020 at 12:17, the surveyor observed signs posted on the outside and the inside of the plastic wall barrier tent set up that explained what PPE was required to enter the yellow zone and what PPE was to be removed when exiting the yellow zone. The sign posted on the plastic barrier before entering the Yellow Zone indicated the PPE required to enter the Yellow Zone was an N95 facemask, gown, gloves, and face. The sign posted on the plastic barrier before exiting the Yellow Zone indicated that gown, gloves, and face shield should be removed before exiting the Yellow Zone. At this time, the surveyor observed a staff member exiting the Yellow Zone wearing the re-usable white lab jacket and heading toward the Green Zone (clean) unit. The surveyor interviewed the staff member at this time, who identified herself as a Registered Nurse Supervisor (RNS). The RNS stated that she worked on the Yellow Zone, which was the Presumptive Covid-19 positive unit, and that all residents on that zone were considered positive for Covid-19. She admitted that she did not take off the white lab jacket before leaving the unit because she was only going to get supplies. The RNS acknowledged that she should have removed the white lab jacket because it did have the potential to be contaminated. She also stated that she was educated by the facility about proper donning and doffing of PPE to prevent the spread of infection. On 6/16/2020, at 12:25 PM, two surveyors observed a staff member exiting the Yellow Zone with a white re-usable lab jacket. The staff member identified herself as a Speech Therapist (ST). She admitted to leaving the Yellow Zone without removing the contaminated white lab jacket. She indicated that she was not educated that the white re-usable lab jacket was to be removed before exiting the Yellow Zone. The surveyor pointed to the sign that was posted in full view that indicated what PPE was to be removed before exiting the Yellow Zone, and the ST stated, Okay. The ST did not provide the surveyor with any additional information. On 6/16/2020 at 12:45 PM, the surveyor interviewed the RN UM, who stated that employees should not be exiting the Yellow Zone with contaminated PPE and that the RNS and the ST should have removed the white lab jacket before exiting the Yellow Zone. On 6/16/2020 at 1:10 PM, the surveyor toured the Red Zone, which was identified as the Covid-19 positive unit. Before entering the Red Zone, the surveyor observed signage posted indicating that an N95 mask, gloves, gown, and eye protectors must be worn when entering the unit. In the presence of 2 surveyors, a gentleman was observed at the nursing station wearing a mask, gloves, and a short-sleeve shirt with both arms fully exposed; no other PPE was noted. The surveyor interviewed him at this time, and he identified himself and the pharmacy medication deliverer. He stated that he delivered medications to the facility daily with only gloves and mask on. The surveyor observed that he had the medication bag lying directly on the unit's floor. The pharmacy medication deliverer picked the bag off the floor and left the unit without removing the gloves and headed directly to the facility exit; he did not go through any other units. On 6/16/2020 at 1:40 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN UM), who stated that the pharmacy deliverer should have worn full PPE, including gown and face shield before entering the Red Zone. She said that she never saw him come to the unit before, but that every vendor is educated at the front desk, and signage was posted about the proper application of PPE before entering the Red Zone. On 6/16/2020 at 1:45 PM, the surveyor interviewed the Director of Nursing (DON), who was also the Infection Preventionist (IP). She stated that the Pharmacy Delivery man should not have been allowed to go past the front desk and should not have gone to the Covid-19 positive unit without wearing the appropriate PPE. The DON/ IP further stated, I was not aware that he was going on that unit without the appropriate PPE. On 6/16/2020 at 2:00 PM, the surveyor interviewed the front door receptionist, who stated that she does the surveillance on all persons entering the facility's front door. All venders are required to fill out the questionnaire and have temperatures taken. We also provide them with PPE. I don't know how the pharmacy delivery man went on the COVID positive unit. On 6/16/2020 at 3:00 PM, the surveyor interviewed the DON who stated that when the staff exited the Yellow Zone, the staff must remove the re-usable white lab coat and hang it up inside the Yellow Zone to be used later. The DON acknowledged that the Yellow Zone was an isolation unit for residents that were exposed or potentially infected with the Covid-19 virus, but did not think the re-usable white lab coat was contaminated. The DON further stated, I don't think it is contaminated because the white lab coat is covered with a yellow gown before coming in direct contact with residents, but just to be safe, the staff should remove it (white lab jacket) before leaving the Yellow Zone. The surveyor reviewed the facility form dated 6/12/2020, tilted Yellow Zone PPE USE which indicated that Gown use-disposable or washable: Must be worn for each resident. May not be worn into more than one resident room. Each caregiver/staff member is assigned a gown (white lab jacket) for each resident for the shift. Gowns are to be hung on labeled hooks (contaminated side facing forward) and re-used for any encounter with the same patient by the same staff member during the shift. Staff members without direct contact with the resident or environment may cover a base gown with an apron to preserve gowns. The surveyor reviewed the facility Cohort Plan revised date of 5/29/2020, that indicated that The PPE use in the Red Zone was as follows: Full PPE Respirator of facemask if not available Eye protection-shield or goggles Gown and gloves The surveyor reviewed Employee Educational Attendance Records with staff signatures that reflected that the RNS was educated on: 3/21/2020- Covid-19, Infection Control and Prevention, Standard and Transmission based precautions to prevent the transmission of various illnesses, including Covid-19. 3/30/2020- Donning and Doffing PPE. 4/8/2020 and 4/11/2020- PPE use, Covid patients, and Crisis PPE use. Conservation of PPE use is crisis pandemic with safety and handwashing and hygiene. 4/21/2020- Use of PPE with return demonstration. 4/28/2020-PPE review, Zones for patients in each stage=Red, Yellow, Green. 6/12/2020-Removing PPE when leaving the Red and Yellow Zone, Donning and Doffing PPE, Infection Control Practices, and Review of transmission and infection control procedures. The surveyor reviewed Employee Educational Attendance Records with staff signatures that reflected that the ST was educated on: 4/21/2020-Covid-19, N95 mask, use of fabric gowns re-use, and laundering protocol. 5/20/2020- Covid-19 updates and overviews. 6/12/2020-Removing PPE when leaving the Red and Yellow Zone, Donning and Doffing PPE, Infection Control Practices, and Review of transmission and infection control procedures. The surveyor reviewed the facility policy dated 3/4/2019 and titled, Infection Control that indicated that the facilities infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, general public alike regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status or payor source. The objectives of our infection control policy and practices are to: a. Prevent, detect, investigate, and control infections in the facility. b. Maintain a safe sanitary and comfortable environment for personnel, residents, visitors, and the general public. c. Establish guidelines for implementing Isolation Precautions, Including Standard and transmission-based precautions. NJAC 8:39-19.4 (a), 19.8 (g)

Part A C#NJ Cross Reference F 323 Based on interviews and review of the medical records and other facility documentation it was determined the facility failed to implement their own policy, Accidents and Incidents - Investigating and Reporting, and investigate and/or thoroughly investigate 4 incidents for 1 of 15 sampled residents (Resident #9). On 1/1/16, Resident #9, a newly admitted resident was found unresponsive and was administered [MEDICATION NAME] with positive results. On 2/8/16, Resident #9 was found a second time, unresponsive and was administered [MEDICATION NAME] with positive results. On 3/14/16, Resident #9's room was searched and medications, [MEDICAL CONDITION] and foley supplies were found in the resident's room. Two non facility pharmacy bottles containing medication that was not prescribed or authorized by the resident's physician were found by staff in the resident's closet. On 3/15/16 Resident #9 was found with an illegal drug and paraphernalia. There was no investigation provided to the surveyor for these incidents. The failure to conduct investigations for the incidents and the lack of preventative and corrective interventions placed Resident #9 in Immediate Jeopardy (IJ) and had the potential to place future residents with the risk of possible unordered opioid ingestion in an IJ situation. The IJ to Resident #9's health and wellbeing began on 2/8/16, the facility Administrator was notified on 4/29/16 at 5:10 P.M. and was lifted the same day at 8:05 P.M. when the facility implemented an acceptable plan of correction (POC). This deficient practice is evidenced by the following: Reference: http://stopoverdoseil.org/[MEDICATION NAME].html [MEDICATION NAME] ([MEDICATION NAME]) is an opiate antidote. Opioids include heroin and prescription pain pills like [MEDICATION NAME] and [MEDICATION NAME]. When a person is overdosing on an opioid, breathing can slow down or stop and it can (be) very hard to wake them from this state. [MEDICATION NAME] is a prescription medicine that blocks the effects of opioids and reverses an overdose. It cannot be used to get a person high. If given to a person who has not taken opioids, it will not have any effect on him or her, since there is no opioid overdose to reverse. Reference: http://www.drugabuse.gov/publications/drug/drugfacts/heroin Heroin can be injected, inhaled by snorting or sniffing, or smoked. All three routes of administration deliver the drug to the brain very rapidly, which contributes to its health risks and to its high risk for addiction, which is a chronic relapsing disease caused by changes in the brain and characterized by uncontrollable drug-seeking no matter the consequences. 1. See Example #1 The IJ to Resident #9's health and wellbeing which began on 2/8/16 was identified by the surveyor on 4/29/16. The facility Administrator was notified on 4/29/16 at 5:10 P.M. and the IJ was lifted the same day at 8:05 P.M. when the facility implemented an acceptable plan of correction (POC). 1. The facility does and will continue to have policies in place to address the prevention of abuse and neglect. The resident no longer resides in the facility. The resident was safely discharged home. 2. Current residents have the potential to be affected. 3. All licensed staff will be inserviced on the need to do an investigation when a resident has a change in condition or mental status incident to develop a plan of care that addresses the change. Following a change in resident condition or mental status the facility will investigate and initiate a plan of care to address the change. Policy has been updated to reflect the same. 4. Audits will be conducted by the DON or designee on investigations weekly for one month and biweekly for two months to validate that investigation is thorough and that interventions are developed to address identified issues. Audits will continue for 3 months or until the QAPI committee determines the audits are no longer needed. Results of the audit will be reviewed by the QAPI committee and if any patterns or trends are identified new interventions will be put in place. This deficiency continues at a scope and severity of D based on Part B Part B C#NJ Based on interviews and review of medical records and other facility documentation it was determined the facility failed to implement their own policy to conduct a thorough investigation for 1 of 15 sampled residents, Resident #9, to determine if the resident was following facility smoking policies after there was the smell of smoke in Resident #9's room on 3/5/16 and on 3/14/16 staff discovered cigarettes and a lighter in Resident #9's room. This deficient practice is evidenced by the following: 1. A record review revealed Resident #9 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. A review of the 2/8/16 Minimum Data Set (MDS), an assessment tool, documented Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. A further review revealed Resident #9 required extensive staff assistance by two staff with all Activities of Daily Living (ADLs), except eating. A review of the Care Plan (CP) initiated on 12/31/15 revealed Resident #9 had a focus of Safe Smoking which included interventions to educate family and visitors not to leave smoking materials in patient's room, educate resident to interventions and center smoking policy and procedures, resident independent smoking with apron, secure smoking materials (cigarettes, matches, lighters, etc.) at nursing station, and wear smoking apron when smoking. The goal was to have no adverse events related to smoking during stay and the resident would adhere to facility smoking policy during stay. A review of a 12/31/15 Safe Smoking Evaluation documented Resident #9 was determined to be an At risk smoker requiring supervision to smoke. Despite this evaluation Resident #9 was care planned as an independent smoker. Subsequent Safe Smoking Evaluations dated 2/24/16 and 3/7/16 determined the resident to be an Independent Smoker, requiring no supervision. Resident #9 was discharged from the facility prior to survey and was unavailable for interview. A review of Progress Notes (PN) revealed a 3/5/16 PN, timed at 10:08 A.M., documented This nurse was asked to come to resident's (Resident #9) room because of the smell of smoke. Upon my entrance into the room the smell is over powering I found black ash on his bed and cigarette tobacco. Resident denies smoking and denies having cigarettes. Resident refuse to allow me to check his space. In a post survey telephone interview Licensed Practical Nurse (LPN) #5 stated Resident #9 did wear a smoking apron when he/she smoked but that the resident was not observed smoking on her shift. When asked how the ash and tobacco got onto the resident's bed LPN #5 stated it may have fallen off (Resident #9's) clothes, I have no idea. In a 1:02 P.M. interview on 4/29/16, the Director of Nursing (DON) stated Resident #9 would smell of smoke and when passing the resident in the hall she would smell smoke. When the surveyor asked how Resident #9 had ash on the bed on 3/5/16, the DON stated she could not say where the ash came from but that it could have fallen off the smoke apron when it was removed from the resident. A 3/5/16 PN, timed at 8:26 P.M., documented The smell of smoke emitted from the pts (resident's) room at 8:15pm. Entered the room to find no contraband, with the pt (resident) denying smoking. There were no further PNs documenting the smell of smoke in Resident #9's room. On 4/18/16 and 4/29/16 the facility was unable to provide the surveyor with an investigation into the 3/5/16 incident involving the smell of smoke in Resident #9's room. A review of a 3/14/16 PN, written by the Director of Social Services (DSS), documented This writer accompanied DON to pt's (Resident #9) room to discuss non compliance with plan of care and smoking policies. Pt (resident) was advised that (he/she) is now on 1 to 1 supervision due to (his/her) failure to comply with safe smoking. Cigarettes and lighter were removed from the room. In addition (he/she) had multiple bags/boxes of medications and medical items brought from home to (his/her) room (He/She) would not converse in regards to where the items came from or who brought them to (him/her). The facility was unable to provide the surveyor with an investigation concerning the 3/14/16 discovery of cigarettes, a lighter, and multiple bags/boxes of medications found in Resident #9's room. In interviews with Residents #12, #13, #14, and #15 conducted on 4/18/16 and 4/29/16, residents stated they were unaware of other residents smoking in rooms or the facility. All residents denied smelling smoke in the halls or in the facility. In a 10:31 A.M. interview on 4/18/16 Unit Manager (UM) #1 stated the facility policy is no smoking in the building. UM #1 went on to state there is a designated smoking area in front of the building where residents can smoke. UM #1 stated they have had problems with some residents with smoke supplies in room, Resident #9, but she has never had any residents smoking in their rooms. UM #1 stated resident's smoking supplies are stored in the medication cart. UM #1 did state staff would complain Resident #9 smelled of smoke, but there was no evidence of the resident smoking in the room. UM #1 went on to state the 3/5/16 incident involving the smell of smoke from Resident #9's room was investigated, however no investigation was provided to the surveyor. Interviews with the DON on 4/18/16 and the Director of Maintenance (DOM) on 4/29/16, revealed that if Resident #9 smoked in the facility, the smoke alarm would sound and since it never sounded, Resident #9 didn't smoke in the facility. During an interview on 4/18/16 at 2:37 P.M., when asked about the smell of smoke in Resident #9's room, the DON stated I feel confident (Resident #9) wasn't smoking (in the room) due to the smoke alarms not going off. During an interview on 4/29/16 at 11:20 A.M. the DOM stated that since shaken baby powder set off alarm, he feels that if a resident was smoking, it would set off the alarm as the sensors are relatively sensitive. The DOM denied that any alarms went off in the facility in April 2016. The surveyor notified him that a security guard found Resident #15 smoking on the side of the bed in his/her room on 4/19/16 at 4:30 A.M. and the DOM replied that he'd look into it since there was no failed reports and he was not aware of the smoking incident. The DOM then went into the lobby vestibule to the alarm panel and verified that no alarm sounded in Resident #15's room on 4/19/16. In a 4/18/16 interview at 1:08 P.M., the DOM stated there were no alarms in the last 3 months due to smoking. In a 4/18/16 interview at 11:39 A.M., Certified Nursing Assistant (CNA) #11 denied being aware of any residents smoking in rooms or halls smelling of smoke. CNA #11 went on to state that resident's smoking supplies are stored on the medication carts. In a 9:55 A.M. interview on 4/29/16, UM #1 stated when Resident #9 was first admitted to the facility the resident was supervised while smoking. UM #1 further stated I always saw (Resident #9) wearing smoking apron. UM #1 denied Resident #9 sustained any burns, to self or clothing, while in the facility. In a 3:39 P.M. interview on 4/29/16, UM #1 stated incident reports are filled out for anything out of the ordinary involving a patient. UM #1 denied recent inservicing on the type of incidents that would require the completion of any incident report form. In a 4:20 P.M. interview on 4/29/16, Licensed Practical Nurse (LPN) #8 stated an Incident is anything, including a resident doing something they shouldn't be doing or the smell of smoke in the room. In a 4:30 P.M. interview on 4/29/16, Registered Nurse Supervisor (RNS) #1 stated things considered to be an incident include smoking in the facility and finding medications in resident rooms. In a 4:40 P.M. interview on 4/29/16, LPN #7 stated there was one time she smelled smoke in the hallway but the smoke was outside and came in through an open window from the back parking lot. LPN #7 further stated that Resident #9 smoked but had no incidents, but if there was an incident involving a resident, a smoking assessment would be done and the care plan changed. A review of the medical record revealed a Safe Smoke Assessment for Resident #9, dated 3/7/16, 2 days after staff smelled smoke in the resident's room. There was no change in the Safe Smoking Assessment from the prior assessment on 2/24/16. A review of a facility document titled Smoking Rules, dated 3/9/16 and signed by Resident #9 lists under 2. You may NEVER smoke in your room or any other non-designated smoking area., 4. For the safety of all staff and residents, you may not retain your lighter, matches, or other source of ignition. If you have been evaluated as an independent smoker, you will be given your lighting materials before going out to smoke, and you must return them to the nurse when you return from smoking., 5. .you must inform a staff member before you go out to smoke, and are required to check in and out each time you go out and return from smoking. A review of the facility policy, Smoking Policy - Residents, Revised April 2012, revealed under Policy Interpretation and Implementation, 3. Smoking restrictions shall be strictly enforced in all nonsmoking areas and 8. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. A review of the facility policy, Accidents and Incidents - Investigating and Reporting revealed under Policy Statement, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation revealed under 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident, 2. The following data, as applicable, shall be included on the Report of Incident/Accident form k. Any corrective action taken, and 5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. During survey on 4/18/16 and 4/29/16 the facility was observed to be free of the smell of smoke. NJAC 8:39-9.3(a)

Part A C#NJ Cross Reference F 323 Based on interviews and review of medical records and other facility documentation, it was determined the facility failed to ensure that a Care Plan (CP) with problems, goals, and interventions was initiated for 1 of 15 sampled residents (Resident #9). On 1/1/16, Resident #9, a newly admitted resident was found unresponsive and was administered [MEDICATION NAME] with positive results. There was no CP initiated and on 2/8/16, Resident #9 was found a second time, unresponsive and was administered [MEDICATION NAME] with positive results. The physician's note indicated drug overdose, illegal use. There was no CP initiated with interventions to prevent a reoccurrence of unauthorized/unordered/illegal drugs in the resident's possession. On 3/14/16, Resident #9's room was searched and non facility medications, [MEDICAL CONDITION] and foley supplies were found in the resident's room. Two non facility pharmacy bottles containing medication that was not prescribed or authorized by the resident's physician were found by staff in the resident's closet. On 3/15/16 Resident #9 was found with an illegal drug and paraphernalia. A CP was not initiated after the 3/14/16 or 3/15/16 incidents. The failure to initiate a CP with interventions placed Resident #9 in Immediate Jeopardy (IJ) and had the potential to place future residents with similar behaviors in an IJ situation. The IJ to Resident #9's health and wellbeing began on 2/8/16, the facility Administrator was notified on 4/29/16 at 5:10 P.M. and was lifted the same day at 8:05 P.M. when the facility implemented an acceptable plan of correction (POC). This deficient practice is evidenced by the following: 1. See Example #1 The IJ to Resident #9's health and wellbeing began on 2/8/16, the facility Administrator was notified on 4/29/16 at 5:10 P.M. and was lifted the same day at 8:05 P.M. when the facility implemented an acceptable plan of correction (POC). 1. Resident #9 was discharged home on[DATE]. 2. The facility will audit current residents receiving narcotics for a change in mental status. 3. The facility will monitor residents with change in mental status or change in condition of unknown origin to determine etiology and initiate a plan of care. The facility will initiate care plans and review and revise as necessary to include interventions such as: room searches and alert staff to new interventions. Residents experiencing a change in mental status and change in condition will be referred to the physician for medical follow up and treatment. On an ongoing basis, staff will be inserviced on reporting and addressing changes in resident condition and mental status. 4. The DON or her designee will conduct weekly audits for 1 month then bi weekly audits for 2 months of residents with a change in mental status or a change in condition to ensure that a care plan has been initiated and reviewed and revised as needed. Audit results will be reported to the QAPI committee monthly for 3 months for further interventions as needed. This deficiency continues at a scope and severity of D based Part B Part B C#NJ Based on interviews and review of medical records and other facility documentation, it was determined the facility failed to initiate an appropriate Care Plan (CP), based on the initial 12/31/15 Safe Smoking Evaluation nor update the CP on 3/14/16 after cigarettes and a lighter were found in the resident's room, for 1 of 15 sampled residents, Resident #9. This deficient practice is evidenced by the following: 1. A record review revealed Resident #9 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. A review of the 2/8/16 Minimum Data Set (MDS), an assessment tool, documented Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. A further review revealed Resident #9 required extensive staff assistance by two staff with all Activities of Daily Living (ADLs), except eating. In a 10:31 A.M. interview on 4/7/16, Unit Manager (UM) #1 stated the facility policy is no smoking in the building. UM #1 went on to state there is a designated smoking area in front of the building where residents can smoke. UM #1 stated they have had problems with some residents with smoke supplies in room and 1 resident was Resident #9, but there have never been any residents smoking in their rooms. UM #1 stated residents' smoking supplies are stored in the medication cart. UM #1 stated staff would complain Resident #9 smelled of smoke, but there was no evidence of the resident smoking in the room. In a 9:55 A.M. interview on 4/29/16, UM #1 stated when Resident #9 was first admitted to the facility the resident was supervised while smoking. UM #1 further stated I always saw (Resident #9) wearing smoking apron. A review of a Safe Smoking Evaluation with an effective date of 12/31/15, revealed Resident #9 was determined to be an At risk smoker, meaning the resident requires staff, family or friend for physical support or supervision to smoke. The Smoking Evaluation further documented the resident shall be supervised by staff while smoking. The evaluation documented the resident was not free of physical limitations interfering with the ability to perform safe smoking techniques, e.g., able to grasp and handle cigarette, lighter or matches without assistance, nor was the resident able to maintain balance while sitting or standing. Additionally the evaluation documented the resident was unable to demonstrate safe smoking techniques: holding cigarette, lighting cigarette, extinguishing matches, lighter and cigarette after use and disposal of ashes nor was the resident free from evidence of burn injuries or holes noted on clothing or wheelchair. Despite this evaluation Resident #9 was care planned as an independent smoker on 12/31/15. A review of the CP initiated on 12/31/15 revealed Resident #9 had a focus of Safe Smoking which included interventions to educate family and visitors not to leave smoking materials in patient's room, educate resident to interventions and center smoking policy and procedures, resident independent smoking with apron, secure smoking materials (cigarettes, matches, lighters, etc.) at nursing station, and wear smoking apron when smoking. The goal was to have no adverse events related to smoking during stay and the resident would adhere to facility smoking policy during stay. A review of subsequent Safe Smoking Evaluations, dated 2/24/16 and 3/7/16, revealed the resident to be an Independent Smoker, requiring no supervision. A review of the physician's orders [REDACTED].#9: 12/31/15 Smoking apron to be on while outside smoking with supervision. A review of Progress Notes (PN) revealed a 12/30/15 PN, timed at 11:27 A.M., which documented Identified as a current smoker. Smoking evaluation shows (Resident #9) to be an at risk smoker requiring staff, family or friend for physical support or supervision to smoke. A review of PN revealed a 3/5/16 PN, timed at 10:08 A.M., documented This nurse was asked to come to resident's (Resident #9) room because of the smell of smoke. Upon my entrance into the room the smell is over powering I found black ash on his bed and cigarette tobacco. Resident denies smoking and denies having cigarettes. Resident refuse to allow me to check his space. A 3/5/16 PN, timed at 8:26 P.M. documented The smell of smoke emitted from the pt's (resident's) room at 8:15pm. Entered the room to find no contraband, with the pt (resident) denying smoking. There were no further PNs documenting the smell of smoke in Resident #9's room. In a 3:39 P.M. interview on 4/29/16, UM #1 stated that Resident #9's CP should have been updated following the 3/5/16 incident. A review of a 3/7/16 PN timed at 1:23 P.M. documented informed patient that all smoking materials will be given (to) nurse and locked in cart, patient (resident) said 'someone already took my lighter and locked it in the cart'. No smoking materials noted with patients (resident's) belongings. A review of a 3/12/16 PN timed at 2:17 P.M. documented supervisor gave this writer three cigarettes and a lighter to be kept on the med cart. resident will asked (ask) for it when going outside to smoke and will return it to nurse when (he/she) return to the unit. resident is aware. A review of a 3/14/16 PN, written by the Director of Social Services (DSS), documented This writer accompanied DON to pt's (Resident #9's) room to discuss non compliance with plan of care and smoking policies. Pt (resident) was advised that (he/she) is now on 1 to 1 supervision due to (his/her) failure to comply with safe smoking. Cigarettes and lighter were removed from the room (He/She) would not converse in regards to where the items came from or who brought them to (him/her). The CP was not updated to reflect cigarettes and lighter were found in the resident's room nor were there any interventions added to the CP. In a 4/18/16 interview at 4:07 P.M. the DSS revealed Resident #9 stated the cigarettes and lighter found in the resident's room on 3/5/16 were brought in by the resident's visitor. The DSS further stated Resident #9 was outside smoking a lot. She went on to state that was why the resident always smelled of smoke and that there was a very heavy odor of smoke on Resident #9. Although there was no documentation that Resident #9's visitor was spoken to about leaving smoke supplies with the resident, in a 9:55 A.M. interview on 4/29/16 UM #1 stated she spoke with Resident #9's visitor, though she could not remember when, about smoking supplies left in the resident's room and the visitor agreed not to bring smoking supplies to the facility for the resident. In a 1:02 P.M. interview on 4/29/16, the Director of Nursing (DON) stated Resident #9 would smell of smoke and when she passed the resident in the hall she would smell smoke. When the surveyor asked how Resident #9 had ash on the bed on 3/5/16, the DON stated she could not say where the ash came from, but it could have fallen off the smoke apron when it was removed from the resident. In a 4:20 P.M. interview on 4/29/16, Licensed Practical Nurse (LPN) #8 stated resident CPs are done by the UM and changes would be made concerning smoking because it would need to be addressed in the care plan. In a 4:30 P.M. interview on 4/29/16, Registered Nurse Supervisor (RNS) #1 stated the nurse initiates a resident care plan upon admission and nurses make updates if there are any changes or things are added. In a 4/18/16 interview at 11:39 A.M., Certified Nursing Assistant (CNA) #11 denied being aware of any residents smoking in their rooms and halls smelling of smoke. CNA #11 went on to state that residents' smoking supplies are stored on the medication carts. CNA #11 stated she would alert the nurse if a resident or family member complained of another resident smoking in the room. In a 4:40 P.M. interview on 4/29/16, LPN #7 stated there was one time she smelled smoke in the hallway but the smoke was outside and came in through an open window from the back parking lot. LPN #7 further stated that Resident #9 smoked but had no incidents, but if there was an incident involving a resident, a smoking assessment would be done and the care plan changed. A review of a facility document titled Smoking Rules dated 3/9/16 and signed by Resident #9 listed under 2. You may NEVER smoke in your room or any other non-designated smoking area., 4. For the safety of all staff and residents, you may not retain your lighter, matches, or other source of ignition. If you have been evaluated as an independent smoker, you will be given your lighting materials before going out to smoke, and you must return them to the nurse when you return from smoking., 5. .you must inform a staff member before you go out to smoke, and are required to check in and out each time you go out and return from smoking. A review of the policy Smoking Policy - Residents, Revised April 2012, revealed under Policy Interpretation and Implementation, 3. Smoking restrictions shall be strictly enforced in all nonsmoking areas and 8. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. A review of the Care Plan Policy, Revised February 2014, revealed under Policy Statement, Our facility's Care Planning Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Resident #9 was discharged from the facility prior to survey and was unavailable for interview. During survey on 4/18/16 and 4/29/16 the facility was observed to be free of the smell of smoke. NJAC 8:39-11.2 (I) NJAC 8:39-27.1 (a)

Part A C#NJ Based on interviews and review of medical records and other facility documentation it was determined the facility failed to provide adequate supervision and other interventions to prevent potential and actual life threatening situations for 1 of 15 sampled residents, Resident #9. On 1/1/16 at approximately 10:50 P.M., Resident #9 was found to be unresponsive, with respirations of 4, and was administered Narcan with positive results. A second incident on 2/8/16 at approximately 7:50 A.M. occurred. Resident #9 was found unresponsive and was administered Narcan. On 3/14/15 and 3/15/16 Resident #9 was found with unauthorized/unordered medications and/or an illegal drug and paraphernalia. The immediacy of the Immediate Jeopardy (IJ) was lifted on 3/14/16 when Resident #9 was placed on 1:1 until discharge. The IJ to Resident #9's health and wellbeing which began on 2/8/16 was identified by the surveyor on 4/29/16, the facility Administrator was notified on 4/29/16 at 5:10 P.M. and the IJ was lifted the same day at 8:05 P.M. when the facility implemented an acceptable plan of correction (POC). This deficient practice is evidenced by the following: Reference: http://stopoverdoseil.org/narcan.html Narcan (naloxone) is an opiate antidote. Opioids include heroin and prescription pain pills like morphine, codeine, oxycodone, methadone and Vicodin. When a person is overdosing on an opioid, breathing can slow down or stop and it can very hard to wake them from this state. Narcan is a prescription medicine that blocks the effects of opioids and reverses an overdose. It cannot be used to get a person high. If given to a person who has not taken opioids, it will not have any effect on him or her, since there is no opioid overdose to reverse. Reference: http://www.drugabuse.gov/publications/drug/drugfacts/heroin Heroin can be injected, inhaled by snorting or sniffing, or smoked. All three routes of administration deliver the drug to the brain very rapidly, which contributes to its health risks and to its high risk for addiction, which is a chronic relapsing disease caused by changes in the brain and characterized by uncontrollable drug-seeking no matter the consequences. 1. A record review revealed Resident #9 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. A review of the 2/8/16 Minimum Data Set (MDS), an assessment tool, documented Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. A further review revealed Resident #9 required extensive staff assistance by two staff with all Activities of Daily Living (ADLs), except eating. A 1/8/16 Care Plan (CP) focus of at risk for adverse effects related to use of antianxiety/anxiolytic, hypnotic medication included interventions to notify physician of decline in ADL ability or mood/behavior related to a dosage change, provide patient education to risks and benefits of medications as needed, and psychiatrist consult and follow-up as needed. The CP did not have a care focus for Pain Management or narcotic use. Resident #9 was discharged from the facility prior to survey and was unavailable for interview. a. A review of Physician order [REDACTED]. On 12/30/15 Oxycodone IR (immediate release) 15 mg (milligrams) PO (by mouth) Q (every) 6 hours PRN (as needed) pain. On 12/31/15 Increase Oxycodone IR 15 mg Q 4 hours PRN breakthrough (pain); Oxycontin ER (extended release) 40 mg PO Q 12 hours. A review of the Medication Administration Records (MARS) dated 12/2015-3/2016 revealed Resident #9 was administered medications as ordered. A further review revealed Resident #9 was administered Oxycodone IR 15 mg PRN 2 times on 12/31/15 and Resident #9 was administered Oxycodone IR 15 mg PRN 58 times from 1/1/16-2/8/16. A review of Progress Notes (PN) revealed a PN dated 1/1/16 documenting At 10:50 P.M., Pt (Resident #9) noted to have RR (regular respirations) of 4, pt (resident) not opening eyes, did not respond to chest rub, Narcan given via IV and non rebreather mask was placed on pt. (resident). The PN further documented the resident responded and the physician was made aware. A review of a 1/4/16 Internal Medicine Progress Note (IMPN) documented Resident #9 was examined by the advanced practice nurse (APN). Under SUBJECTIVE was documented Pt. (resident) required Narcan administration over weekend (secondary to) unresponsiveness (with) depressed resp. (respirations). A review of POS dated 1/2016-2/2016 revealed the following orders: On 1/1/16 Naloxone (Narcan) 0.4 mg IV (intravenous) X1 now D/C (discontinue) Oxycontin 40 mg Q 12 hours Oxycontin 20 mg PO Q12 hours, hold for sedation. On 1/4/16 D/C Oxycontin 20 mg BID (2 times a day), change to Oxycodone 20 mg Q 4 hours, 1 tab (tablet) crushed PO Crush all pain meds and give with applesauce Clarification - Oxycodone 20 Q 4 (hours) standing; Oxy IR (Oxycodone) continue as PRN. On 2/6/16 D/C Oxycodone 20 mg Q 4 hours ATC (around the clock) Oxycodone 20 mg IR Q 6 hours ATC 1 tab. On 2/7/16 Telephone Verbal Order (TVO) Crush all narcotics place in applesauce. On 4/18/16 and 4/29/16 the facility was unable to provide the surveyor with an investigation or evidence that the change in Resident #9's condition, which required the administration of Narcan, was due to medication dosages. A review of a 5/9/16 Witness Statement, sent to the surveyor, revealed the rationale behind decreasing Resident #9's narcotic medications on 1/1/16, after the administration of Narcan, was related to the resident experiencing respiratory compromise. The statement further documented that on 1/4/16 the patient (Resident #9) verbalized the dosing was effective. After the 1/1/16 administration of Narcan there was no change made to the resident's CP. b. A review of the MARS and PN revealed that on 2/7/16 at 12 A.M. and 6 A.M. Oxycodone IR 20 mg was held due to Resident #9 being lethargic. The physician was notified and an order to crush all narcotics place in applesauce was obtained. A review of a 2/8/16 PN, timed at 7:50 A.M., revealed resident (Resident #9) was found this morning unresponsive. resident was pale and could not wake, a sternal rub was done and resident could not wake up. respirations were about 8-10. Narcone (Narcan) was administered and resident woke up. The PN further documented Resident #9 was searched and 2 empty 10 cc syringes and a green pill in a napkin were found. A 2/8/16 PN, timed at 8:21 A.M., documented went in to room at 7am to assess pt (resident) w/nurse. Pt. (resident) unresponsive, pale, did not respond to sternal rubs. pulse ox 64%. I administered Narcan via IV (intravenous) and pt (resident) woke up quickly. Pts (resident's) O2 (oxygen) increased to 97%. Pt (resident) found to have syringes in bed w/(him/her) and a pill wrapped in a napkin stuffed in (his/her) leg brace. pill given to DON (Director of Nursing). Pt (resident) alert at this time and will continue to monitor. A review of a 2/8/16 IMPN documented Resident #9 was seen by the physician. Under SUBJECTIVE was documented Called in to see pt (resident) emergently (with decreased) pulse ox cyanosis. Pt (resident) given Narcon (Narcan) (with) good response. Illegal substances found in pt's (resident's) possession. Under ASSESSMENT was documented AMS (altered mental status) (secondary to) drug overdose (illegal use). A review of a 2/11/16 IMPN revealed the APN (Advanced Practice Nurse) examined Resident #9 and under SUBJECTIVE, documented states (he/she) has not taken (his/her) own supply of narcotics since Monday (2/8/16). Under ASSESSMENT was documented 1. Narcotic Withdrawal. A review of the POS dated 2/2016-3/2016 revealed the following orders: On 2/8/16 Naloxone (Narcan) 0.4 mg IV X1 dose now D/C Oxycodone 20 mg D/C Oxycodone 15 mg Motrin two 200 mg tabs PO Q 6 hours; TVO. On 2/11/16 Percocet (Oxycodone) 5/325 mg 1 PO BID, hold for sedation. On 3/4/16 Percocet (Oxycodone) 5/325 mg BID decreased to Q AM 3/4 and 3/6 then D/C on 3/7. A review of the APN's IMPN dated 2/11/16 revealed Resident #9 stated he/she had (his/her) own supply of narcotics. On 4/29/16 the facility was unable to provide the surveyor with an investigation concerning the 2/8/16 incident when Resident #9 was unresponsive and Narcan was administered and the APN's IMPN dated 2/11/16 which revealed that Resident #9 stated he had own supply of narcotics. The DON sent to the DOH (Department of Health) a conclusion dated 4/18/16 of the 2/8/16 incident. The Conclusion documented, On 2/8/16 (Resident #9) was found in (his/her) bed unresponsive, patient (resident) was receiving physician prescribed narcotic medication for pain management. Physician was contacted, Narcan administered per physician's orders [REDACTED]. Patient's (resident's) room was searched and 2 capped 10cc syringes and what appeared to be a crushed pill and an unknown tablet were found in patient's (resident's) room. The syringes found were empty needless (needleless) saline flushes. The physician's progress note states illegal substances found in patient's (resident's) possession and unresponsiveness reversed with Narcan 'illegal use'. The investigation never actually concluded that the substances found were illegal and it was not determined that the patient's (resident's) episode of unresponsiveness was caused by illegal use. The patient (resident) had been receiving physician prescribed narcotics at the time of the incident. After the 2/8/16 administration of Narcan the facility did not investigate the incident or make any changes to the resident's CP. Despite the documentation by the APN that unauthorized medication was found in Resident #9's room on 2/8/16 and on 2/11/16, the resident told the APN he/she had own supply of narcotics, there was no care plan initiated with interventions to prevent a reoccurrence. In a 4/29/16 interview, at 1:02 P.M.,when the surveyor asked if the facility had investigations for the 1/1/16 and 2/8/16 incidents involving the administration of Narcan to Resident #9 the DON stated the facility can't find them. In a 4/29/16 interview, at 3:39 P.M., Unit Manager (UM) #1 stated inservicing on CP updates was received a couple of months ago, maybe mid January and inservicing on residents smoking around February or March, around the time we were having issues with (Resident #9). UM #1 denied recent inservicing on situations that require an incident report or inservicing on unusual items such as syringes or pills being found in resident's rooms. The UM further stated that Resident #9's CP should have been updated following the 1/1/16 and 2/8/16 incidents. c. A review of a 3/14/16 PN, written by the Director of Social Services (DSS), documented This writer accompanied DON to pt's (Resident #9's) room to discuss non compliance with plan of care and smoking policies. Pt (resident) was advised that (he/she) is now on 1 to 1 supervision due to (his/her) failure to comply with safe smoking. Cigarettes and lighter were removed from the room. In addition (he/she) had multiple bags/boxes of medications and medical items brought from home to (his/her) room (He/She) would not converse in regards to where the items came from or who brought them to (him/her). A review of staffing assignments dated 3/14/16 - 3/24/16, the day of Resident #9's discharge, revealed a 1:1 staff member was assigned every shift. There was no CP initiated for medication that was found in Resident #9's room on 3/14/16, which was not ordered or authorized by the resident's physician. On 4/29/16 the facility was unable to provide the surveyor with an investigation concerning the 3/14/16 incident involving unauthorized medications in Resident #9's room. In a 4:19 P.M. interview on 4/18/16 the DON stated that when Resident #9's room was searched home medications as well as colostomy and foley supplies were found. In a 4/29/16 interview at 12:40 P.M. the DON stated there was no incident report for the 3/14/16 incident when cigarettes, a lighter, and unauthorized medications and medical supplies were found in Resident #9's room. d. Information received by the Department of Health (DOH) on 5/9/16 via fax from another state agency revealed that on 3/15/16 the state agency responded to the facility for a narcotics investigation. The report documented Upon my arrival I met with (DON) who stated that they had found suspected narcotics in the room of one of their residents. (DON) said that they had went into the room of (Resident #9) after an incident between an employee and (Resident #9). After speaking with (Resident #9) they realized that there may be narcotics on (his/her) persons. (DON) stated that they then had (Resident #9) remove a glove that was on (his/her) hand. At this time (Resident #9) removed the glove and a small baggie fell out of the glove .staff then took the bag and called police. I then made contact with the resident, (Resident #9). On the foot of (his/her) bed was a clear baggie with blue wax paper and residue inside of it. I then asked (Resident #9) what was inside of the baggie and (he/she) advised me that (he/she) was not sure. (Resident #9) explained that (he/she) did not realize that the baggie was in (his/her) glove. After asking (Resident #9) several times about the contents of the residue, I was advised that the residue was heroin. I then seized the baggie for evidence. At this time I asked (DON) to turn over any contraband that they have seized from (Resident #9). (DON) turned over two plastic straws that were used to snort the heroin. I then advised (Resident #9) that (he/she) would be charged with the paraphernalia and for being in possession of heroin. The report further documented, under Property/Evidence, the seizure of heroin and 2 straws with residue. There was no CP initiated for the illegal drug and paraphernalia which was found in Resident #9's room on 3/15/16. In a post survey telephone interview on 5/9/16 at 11:39 P.M., the DON stated that there were no other incidents pertaining to smoking or drug use and will verify if there were any other incidents and get back to the surveyor. The DON also was not sure if police were called in concerning Resident #9 and the use of drugs. The DON called the DOH on 5/10/16 at 11:50 A.M. and spoke to the Supervisor of Inspections. She stated that although there was no incident report, on 3/15/16, CNA #10 was assigned to do the 1:1. Resident #9 was touching/manipulating the suprapubic tube and CNA #10 told (the resident) not to as the tube disconnected and urine splashed into CNA #10's eye. Although an investigation was done and it was determined it was an accident, no incident report was done nor was the incident documented in the PNs. Another CNA called the police. The police arrived at the facility and spoke to Resident #9 and CNA #10 declined to press charges and the police left the facility. The DON further stated that there were no other incidents such as falls, skin tears or anything else. The DON did not mention the police were called to the facility concerning Resident #9. A review of a 3/15/16 Investigation Report emailed to the surveyor on 5/10/16 documented the police were notified of potential intentional splashing of urine on staff by Resident #9. A summary of the incident, dated 3/15/16, documented the DON was present in Resident #9's room upon police arrival. A further review revealed a 3/15/16 Witness Statement, signed by LPN # 6, documented I dont (don't) remember who relayed the information to me., (sp.)however, I recall the urgency in their voice giving me the impression that it (the splashing of urine) was done on purpose so i (I) called the police. A review of the Accidents and Incidents - Investigating and Reporting policy, revised February 2014, revealed, under Policy Statement, All accidents and incidents involving residents, employees, visitors, vendors. etc., occurring on our premises shall be investigated and reported to the Administrator. Under Policy Interpretation and Implementation is documented 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. A review of the Change in a Resident's Condition or Status policy, Revised February 2014, revealed under Policy Statement, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Under Policy Interpretation and Implementation documented, 3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychosocial status. A review of the Care Plan Policy, Revised February 2014, revealed under Policy Statement, Our facility's Care Planning Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The Immediate Jeopardy (IJ) to Resident #9's health and wellbeing began on 2/8/16 and was identified by the surveyor and the facility Administrator was notified on 4/29/16 at 5:10 P.M. and was lifted the same day at 8:05 P.M. when the facility implemented an acceptable plan of correction (POC). 1. The resident no longer resides at the facility. 2. All Residents have the potential to be affected 3. The DON/designee will audit current residents that require supervision related to non prescribed medication use and provide the needed supervision that is required. Incident report will be initiated. The DON/designee will inservice licensed nursing staff on initiating an incident report and completing the investigation timely to include an intervention at time of incident. The DON/designee will inservice licensed nursing staff on implementing a plan of care or initiating a new intervention based on the incident. The IDCT (interdisciplinary care team) will review the 24 hour report and incident reports in clinical meeting and review residents care plans for updates to determine which residents need supervision. 4. The DON/designee will conduct random audits weekly for one month and bi weekly for 2 months of incident reports for use of non prescribed medication use for a completed investigation and updated care plan/interventions for supervision. Results of these audits will be forwarded to the center QAPI Committee for 3 months for review and action as appropriate NJAC 8:39-27.1(a) This deficiency continues at a scope and severity of G based on Part B. Part B C# NJ , NJ , NJ Based on interviews, observation and review of medical records, it was determined that the facility failed to provide adequate supervision according to the facility protocol to prevent falls for 1 out of 7 residents (Resident #1). On 2/22/16, Resident #1 fell and sustained skin tears. On 3/19/16 Resident #1 fell and sustained a left hip fracture which required surgical intervention and a hospital stay. This deficient practice is evidenced by the following: 2. According to the facility Admission Record, Resident #1 was admitted in 1/2016 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 1/29/16 identified Resident #1 with short and long term memory problems, and severely impaired cognition. He was not able to stand without physical assistance of two staff members and required extensive assistance of one for most activities of daily living. Fall risk assessments indicated that a total score of 10 or higher may represent a high fall risk. Fall risk assessment dated [DATE] stated that resident #1's score was 14, on 2/22/16, Resident #1's score was 20, on 3/1/16, Resident #1's score was 15, on 3/19/16 Resident #1's score was 14, and on 3/28/16 Resident #1's score was 20. Resident #1 fell five times from January 2016- April 2016. A facility care plan, initiated on 1/23/16 revealed that Resident #1 was at risk for falls due to impaired balance, poor coordination, noncompliance with use of assisted devices, unsteady gait, involuntary movements and a history of falls. Interventions included but were not limited to; Physical Therapy and fall mat. During an interview with the surveyor on 4/7/16 at 9:15 p.m., Certified Nurses Aides (CNA's) #2 and #3 stated that along with resident assignments, CNA's are also scheduled to monitor residents in the day room at 30 minute intervals. CNA #2 stated she was scheduled from 9:00-9:30 p.m. and would not leave the day room until another staff member came to relieve her. Both CNA's stated the daily shift assignment sheet indicated the CNA's name and the time he/she had to monitor the day room. Review of the 4/7/16 Long Term Care Unit 3-11 shift assignment sheet by the surveyor, confirmed that at 30 minute intervals, from 3:00 p.m. through 11:00 p.m., a CNA was scheduled in the day room to monitor residents. During an interview with the surveyor on 4/7/16 at 9:25 p.m., the 3-11 shift Registered Nurse on the Long Term Care Unit confirmed that the CNA's monitored the day room for the entire shift. During interview with the surveyor on 4/7/16 at approximately 9:55 p.m., the RN Staff Educator stated that the day room is never left unattended and when awake all residents go to the day room which is monitored 24/7 (all the time). The RN Staff Educator confirmed the monitoring sheet and indicated which CNA is responsible to monitor the day room. In another interview on 4/14/16 at 12:15 p.m., the RN Staff Educator stated that the day room is monitored 24 hours a day and confirmed that the staff responsible is indicated on the CNA assignment sheets. During an interview with the surveyor on 4/14/16 at approximately 9:35 a.m., CNA #4 stated that they never leave the day room unattended. CNA's #4, #5 and #6 stated that their assignment sheets tell them what times they are in the day room and they do not leave until the next CNA comes in to relieve them. CNA #4 and #5 showed the surveyor their assignment sheet that confirmed the day room monitoring schedule. a. Review of Resident #1's medical record progress notes dated 3/19/16 at 4:26 p.m. revealed Resident #1 was laying on the floor in the day area (day room). Resident #1 fell out of his chair and was found lying on his left side. He had a hematoma to his left temple as well as pain to his left hip. He was guarded with his hip, grimacing in pain. The medication administration record revealed an order for [REDACTED]. The Medical Doctor (MD) was notified and Resident #1 was sent to the hospital for evaluation. Review of the hospital records revealed that Resident #1's discharge [DIAGNOSES REDACTED]. The resident was discharged to the facility on [DATE] with the recommendation he remain on Tylenol and Hydrocodone for pain as needed. Review of the Facility Incident/Accident Report dated 3/19/16 indicated that the resident was observed lying on the floor in the day room on his left side at 12:05 p.m. The Supervisor Review section indicated there was no staff in the day area (day room) at the time of the fall. Review of the Investigation Report conclusion, dated 3/21/16, indicated Patient (Resident #1) was seated in the day room with activity staff present. Activities were concluded and activity staff was in the process of transporting residents to their respective lunch areas in the day room. The activity aide responded to another resident's call for assistance and turned away from the resident at which time he fell from his wheelchair. While walking down the hall, the Unit Manager (LPN #1) observed resident on the floor. Review of the untitled staffing sheet for the 7a.m.-3 p.m.shift, dated 3/19/16 indicated that monitoring was done from 1:00 p.m. until 3:00 p.m., however, the untitled staffing sheet showed no documentation that CNA's were to monitor the room from 7:00 a.m. - 1:00 p.m. During interview with the surveyor on 4/14/16, LPN #1 stated that monitoring was scheduled on the afternoon that day. Review of the facility Witness statement from CNA #4, dated 3/19/16 indicated she was CNA assigned. The resident was last seen at 10:30 a.m. and was sitting in the day room. Review of the facility Witness statement from Activity Assistant (AA #1), dated 3/19/16 revealed that prior to the fall, the resident was in the activity room. When the activity ended at 11:30 a.m, activity staff began to transport residents to the dining room. We left (Resident #1) at the table in the day room .we continued to transport residents to dining room. AA #1 thought someone was aware .activities ended. AA #1 and AA #2 were in the process of transporting residents to the dining room. AA #1 had saved (Resident #1) for last to move .so we could keep an eye on him till we had to go to the dining room and stay in there Review of the facility Witness statement from AA #2 revealed that I was watching (Resident #1) in the day room until 11:50 a.m., then (AA #1) and I (AA #2) set him up at a table and transported the rest of the residents to lunch. During an interview with the surveyor on 4/14/16 at 9:30 a.m., LPN #1 stated that on 3/19/16, he went to assist another resident in his room and while walking by, he observed staff in the day room. When he came back from assisting the resident, Resident #1 was on the floor in the day room and no one was in the day room. Interview with the Activities Director on 4/14/16 at 10:45 a.m., confirmed the activity aides left the area to assist another resident and transported that resident down the hall. The Activities Director verified that the day room should not have been left unattended. During an interview with the surveyor on 4/14/16 at 11:30 a.m., LPN #1 stated activity staff are aware not to leave the room before someone is there. During an interview with the surveyor on 4/14/16 at approximately 12:00 p.m., the Director of Nursing confirmed that the day room should be continuously monitored. b. Review of Resident #1's medical record progress notes, dated 2/22/16 at 8:16 a.m. revealed Resident #1 was found sitting on the floor in front of the geri chair with 3 skin tears on the right outer arm. Review of the Facility Incident/Accident Report dated 2/22/16 indicated that Resident #1 was found in day room sitting on floor at 5:40 a.m. in front of geri chair with 3 skin tears to the right arm. Review of the Fall Investigation indicated it was unknown what the resident was doing at the time of the fall. Review of the untitled assignment sheet dated 2/22/16 for the 11-7 shift indicated two CNA's (CNA #1 and CNA #9) were assigned to the unit. The untitled assignment sheet revealed monitoring from 11:00 p.m. - 7:00 a.m CNA #8 was scheduled to be in the day room from 5:00 a.m.- 6:00 a.m. There was no Facility Witness Statement from CNA #9 who was assigned to monitor the day room from 5:00 a.m. - 6:00 a.m. Review of the Facility Witness Statement dated 2/22/16, for CNA #1's reflected that prior to the incident, he (Resident #1) was sleeping in the chair, and at 5:35 a.m., incontinent care was provided. Resident (Resident #1) was found sitting on the floor at 5:40 a.m. Review of the Facility Witness Statement dated 2/22/16, for LPN #2 revealed that prior to the incident, Resident # 1 was sleeping in the gerichair in the day room and last seen five minutes before found sitting on floor in day room in front of geri chair. During a telephone interview on 4/14/16, at 12:15 p.m., CNA # 1 stated that she was in another resident's room and left the room. While walking by the day room, she observed Resident #1 partially in the geri chair. She went to notify the nurse. The nurse was not at the nurse's station and she found her in a room. She did not remember seeing anyone in the day room. The nurse and CNA # 1 placed Resident #1 back in the geri chair. CNA #1 revealed if a resident is in the day room, someone should be with him. Review of progress notes dated 2/23/16 at 11:42 a.m. revealed IDCP met to review the fall .Resident (Resident #1) in day room sitting in front of his recliner chair 3 skin tears on right arm .treatment was rendered .therapy will evaluate seating when OOB (out of bed) .care plan was reviewed and updated. There was no indication that a CNA was in the day room at the time of the fall. On 3/1/16, a care plan intervention of a Broda chair was added to prevent falls. During a tour of the facility on 4/14/16 during the 3-11 shift at 9:15 p.m., the surveyor observed Resident #1 on the Long Term Care Unit in the day room sitting in a Broda chair awake, but the resident did not respond to questions. Additionally, two other residents (Resident #2 and #3) were in the day room along with two staff members, CNA #2 and CNA #3 who were monitoring the day room. NJAC 8:39-27.1(a)