Every finding on record at Complete Care at Marcella

Complaint #3001244 Based on interviews, review of medical records, and review of other pertinent facility documents on 5/6/26, 5/7/26 and 5/12/2026, it was determined that the facility failed to maintain a safe environment and to provide adequate supervision for a resident (Resident #2) who was assessed to have poor safety awareness, impaired cognition, and was identified as an elopement and fall risk. Resident #2 was also identified having a history of fall and required supervision with ambulation (walking).The deficient practice was identified for 1 of 4 residents (Resident #2) reviewed and was evidenced by the following: The facility policy titled: Fall Prevention Program, with a revised date of 10/7/25, revealed that residents would receive individualized care that would minimize their risk of falls, and that interventions will be monitored for effectiveness.The facility policy titled: Elopements and Wandering Residents, dated 9/1/24, revealed that residents at risk for elopements would be provided with adequate supervision to prevent accidents.1.) Resident #2 was not at the facility at the time of the survey. A closed record review was conducted as follows:According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: congestive heart failure, muscle weakness, schizophrenia, and difficulty in walking.According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 1/14/26, Resident #2 had a BIMs score of 11 out of 15, which indicated that the resident's cognition was moderately impaired. The MDS further revealed that the resident required assistance with all aspects of their activities of daily living (ADL), including supervision or touching assistance when walking.A review of Resident #2's Elopement Assessment - V 2, dated 3/23/26 at 4:08 PM, revealed that the resident scored 11 on the assessment which indicated high risk for elopement, and that Resident #2 had history of elopement attempt. The assessment further revealed that the resident had expressed a desire to leave, wandered, hovered at exits and that the resident had been observed standing near the elevator and was redirected by staff.A review of Resident #2's Care Plan (CP) revealed the following:- Resident is an elopement risk/wanderer, [related to] Impaired safety awareness, initiated 3/22/26. Interventions included the placement of a Wander Guard on the resident on 3/26/26, and to distract the resident from wandering by providing diversions, and to identify pattern of wandering.-Resident is a diuretic therapy initiated 1/8/26. Interventions included that staff monitor postural hypotension, dizziness and to encourage the resident to get up slowly and to sit before standing. Resident has increase risk for falls. -Resident used antidepressant and was to be monitored for adverse reactions which included falls and dizziness, initiated 1/8/26.--Activities of Daily Living (ADL) deficit, revised 1/23/26, which revealed that the resident required assistance with all aspects of their ADLs.A review of the secure care (Wander Guard's) section seven standard features and mode of operation of the manufacturer's instruction stated that the system allows free access of the door by staff members and visitors but quickly locks the door when a monitored, wandering resident approaches the door. The instruction stated that the code was used to reset an alarm or to escort a monitored resident through a door without creating an alarm .and that the code should only be given to authorized staff members.A review of Resident #2's Progress Notes (PN) revealed a nursing note dated 3/22/26 at 3:41 PM, created by Licensed Practical Nurse (LPN) #1. The PN stated that Resident #2 was observed attempting to go outside and was redirected and that the Nurse Practitioner was notified. The PN further stated that a wander guard (WG) was placed on the resident, .due to poor safety awareness., and that the resident's family was notified.A review of another (PN) revealed a nursing note dated 4/7/26 at 7:47 PM, that at 6:20 PM, Resident #2 had an unwitnessed fall. The NN stated, .the resident was found seated on a bench in the courtyard area with visible lacerations to the right cheek and lip. The nursing note further revealed that when staff asked the resident what happened, Resident #2 stated that they felt dizzy and fell on their face. The nursing noted also indicated that Resident #2 was sent to the hospital for further evaluation due to unwitnessed fall with head impact; and due to increased risk of bleeding due to being on anticoagulant therapy.A review of Resident #2's Order Summary Report revealed the resident had an active physician's order initiated on 3/23/26 for WG due to the resident's poor safety awareness.A review of Resident #2's Treatment Administration Record (TAR) for April 2026 revealed that a WG was placed on the resident due to poor safety awareness and it was to be checked for placement on every shift. The treatment was signed as completed on 4/7/26 by LPN #2.A review of the facility's document titled: Fall, dated 4/7/26 at 6:20 PM, revealed that Resident #2 was, .observed seated on courtyard bench with visible abrasions to right facial check, lip and chin. The fall document further stated that Resident #2 reported feeling dizzy and fell forward onto [their] face. The Fall document further stated that Resident #2 received first aid treatment, neurological checks initiated, and that the resident was sent out to the hospital for further evaluation due to fall with facial injuries and for being on anticoagulant medications. A witness statement written by the Licensed Nursing Home Administrator (LNHA) dated 4/7/26, stated that LNHA saw Resident #2 when the resident came out of the elevator on the first floor alone on 4/7/26; and that the LNHA allowed the resident access into the Courtyard. The facility did not provide evidence that Resident #2, who had poor safety awareness, was supervised while they were in the courtyard.A staff witness statement dated 4/8/26, revealed that while a Dietary Aide (DA) was walking past the area where Resident #2 had fallen, she heard the resident yelling for help. The DA stated that she went to the scene and found Resident #2 on the ground with bloody face and that she stayed with the resident till a nurse arrived.According to a staff statement from the nurse (Licensed Practical Nurse #2) dated 4/7/26, she heard someone yelling for help and stating that a resident fell. LPN #2 stated that she then went to the courtyard and found Resident #2 in the courtyard and observed blood on the resident's right cheek and lip, and that a doctor came into the courtyard and evaluated the resident. 2.) The surveyor reviewed the medical record of Resident #3, and according to the admission Record, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: cerebral infarction (stroke due to blocked blood vessel in the brain), type 2 diabetes, anxiety disorder, and hypertension.According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/11/26, Resident #3 had a BIMs score of 15 out of 15, which indicated that the resident's cognition was intact.An interview was conducted on 5/6/26 at 11:40 AM with Resident #3, who stated that at the first of each month, staff provided them with the elevator code. When asked who provided the code them, the resident stated: I have connections, and did not elaborate any further. The resident confirmed going downstairs regularly to smoke. The resident also stated that there were times when other residents wandered near the elevator which usually activated the elevator alarm. The resident stated that if staff were not around to turn off the alarm, it would keep ringing and that they had entered the code to turn off the alarm when it would be ringing and staff were not available.An interview was conducted on 5/6/26 at 10:18 AM with the Licensed Practical Nurse Unit Manager (LPN/UM), who stated that the facility had no locked units, but that the second-floor unit had a WG alarm system for the elevators. She stated that some of their residents were cognitively impaired and wandered on the unit and needed additional supervision to ensure their safety. LPN/UM explained that the wandering residents were provided with WG, and they were not to leave the unit without staff. As the surveyor and the LPN/UM toured the second-floor unit, LPN/UM showed the surveyor alarm panels located on both sides of the two elevators. She stated that if residents wearing WG were to go near the elevator, the alarm would sound; and as safety measure, the elevators would not move until a keypad code was entered. LPN/UM further stated that staff, and some residents who were alert and oriented, were provided with the keypad code. She confirmed that there was one resident, (Resident #3), who was provided with the code because the resident goes to smoke independently, and that having access to the elevator door code allowed the resident to move independently throughout the building. LPN/UM further stated that Resident #3 no longer resided on the second-floor unit because of an incident that occurred when Resident #3, took another resident with a WG onto the elevator, and to the first floor after entering the elevator keypad code that bypassed the WG alarm system. When asked about who provided the keypad code to the resident, LPN/UM stated that she was not sure who provided the code to the resident. When asked how they determined which resident should be given the code, she stated she was not the one that provided residents with the code, but she knows that the resident must be alert and oriented to have the code.An interview was conducted on 5/6/26 at 12:52 PM with LPN #1, who stated that Resident #2 was observed to have exit seeking behavior and had poor safety awareness and wore a WG. She further stated that any resident wearing a WG that wanted to leave the unit would need to be escorted by staff to ensure their safety.During a follow-up interview on 5/6/26 at 1:25 PM, LPN/UM stated that she was aware that Resident #2 was an elopement risk and had a WG in place. LPN/UM stated that Resident #2 should not have been able to get off the unit without an escort. She stated that there were residents, including Resident #3, who were alert and oriented and had access to the elevator door code, but she was unsure who provided the resident with the code and that the codes were changed monthly. She further stated that she had not observed Resident #3 enter the code to bypass the alarm, but she was aware that the resident had the code and could deactivate the alarm if they entered the code.An interview was conducted on 5/6/26 at 2:57 PM with the Maintenance Director (MD), who stated that his staff was responsible for checking the WG door alarm system for functionality weekly. The MD stated that the alarm system was in place to keep residents safe by alerting staff if a resident attempted to leave the facility. He further stated that the code was updated monthly, and that a week prior to the change of code, he would provide all department heads with the new code during their morning meeting. He stated that no resident should ever have the code and that if he was told that a resident had the code, he would immediately change it.A joint interview was conducted with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) on 5/6/26 at 2:22 PM. During the interview the DON stated that the purpose of the WG system was to keep residents safe by ensuring that residents who were identified to be at risk of an elopement were protected from exiting the building and that the WG alarm would alert staff if a resident was near the elevator. The DON and the LNHA further stated that there were residents that were awake, alert, and oriented, that were allowed to have the code. The surveyor asked about the facility criteria and protocol for providing the code to those residents, the DON stated that it was done verbally. When asked if there was a policy related to residents being allowed to have the code, they stated that they did not have one. When asked for a list of residents that had the code at that time, the DON stated she did not one.When asked about an investigation into the incident that Resident #2 had on 4/7/26, the DON and the LNHA stated that they recalled discussing the fall. When asked about how the resident was able to leave their assigned unit, the DON referenced that there was a statement provided by staff that Resident #3 allowed Resident #2 go down on the elevator. When asked what action the facility took in response to the incident to ensure that does not happen again the DON stated that she interviewed Resident #3; the team discussed the incident and decided that Resident #3 would be transferred to a different unit. When asked if any other actions were taken, both the DON and the LNHA stated that the incident was not an elopement, it was a fall that did not need to be reported, and Resident #3 had been moved to another unit. When asked if facility reported the incident to the department of health, both DON and LNHA stated that the incident was a fall and did not need to be reported, and that they moved Resident #3 to another unit. An interview was conducted on 5/6/26 at 4:33 PM, with the DON, the LNHA, the Regional Clinical Director (RCD), the [NAME] President of Operations (VPO), the Assistant Administrator (AA), and the Regional Director (RD). During the interview the LNHA stated that the incident was not treated as an elopement because Resident #2 remained within the line of sight of staff. The LNHA stated that he observed Resident #2 exit the elevator and motioned wanting to go into the enclosed courtyard. The LNHA stated that he escorted the resident to the courtyard and walked away. The LNHA did not indicate that there were staff members in the courtyard supervising the resident to ensure their safety.An interview was conducted on 5/7/26 at 10:59 AM with the resident's assigned nurse, LPN #2. She stated that the purpose of the WG was to alert staff when residents at high risk for elopement went near exit doors or elevators. She stated that residents were not allowed to leave the unit without staff knowledge to ensure that they were safe. She stated that staff were allowed to have the codes along with certain residents who were awake, alert, and oriented, and that she was aware that Resident #3 had the code. She stated that she did not know why they were provided the code, nor who provided them with it. She further stated that she observed the resident enter the code to deactivate the alarm in the past as she was on her way to respond to the alarm. During the same interview, LPN #2 stated that Resident #2's WG was in place on 4/7/26. She stated that she last saw the resident about ten minutes prior to being notified that the resident had fallen in the courtyard, and that she went to the courtyard and met the resident as the resident was being wheeled to the second floor by staff, and that she observed the resident to have facial abrasions. LPN #2 further stated that as the resident was wheeled to the elevator, the WG system alarmed. She stated further stated that she did not hear the alarm sound when the resident went down in the elevator to the first floor on 4/7/26. When asked how the resident got downstairs, she stated that Resident #3 had put in the elevator code for Resident #2. She further stated she assessed the resident and obtained an order to send Resident #2 out for further evaluation.An acceptable Removal Plan (RP) was received on 5/11/26 at 5:15 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice, including:Resident #2 was assessed at the time of the incident on 4/7/26 by RN, first aid rendered to the resident's right cheek and upper lip, the resident was transferred to the emergency room (ER) secondary to concerns that the resident hit their head during the fall and was on antiplatelet (anti-blood clot medications), in-servicing initiated with all staff on Wandering Residents, Elopement, and Door Code Security for all staff on 4/8/26 by the Assistant Director of Nursing (ADON)/designee and completed on 4/10/26. Re-education on door code security initiated on 5/7/26, by the Regional Clinical Director to all Management Staff, and continued with all staff by the ADON/designee and completed on 5/11/26. Codes for all doors and elevators were changed by the maintenance Director monthly and as needed. The monitoring plan will be overseen by the Administrator/designee. All new admissions will continue to be reviewed for wander/elopement risk, and facility ensures appropriate interventions are in place. All findings, education, and outcomes will be reviewed by the QAPI committee at the monthly QAPI meeting to determine the need for additional audits. The Administrator/Director of Nursing is responsible for completing the actions outlined in the removal plan by the target date of 5/11/26.The surveyor verified the implementation of the RP during the continuation of the on-site survey on 5/12/26. NJAC 8:39-27.1 (a)

Complaint # 185832, 186185 Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to administer medications within the scheduled medication administration times. The deficient practice was identified for 2 of 2 residents (Resident # 12, # 159) reviewed for significant medication errors. The deficient practice was evidenced by the following: 1.) On 07/16/2025 at 10:16 AM, the surveyor observed Resident # 12 in bed in their room. At that time, he/she declined to be interviewed due to experiencing pain. The resident displayed facial grimacing as he/she spoke. A review of Resident # 12's Electronic Medical Record (EMR) under Orders revealed that Resident # 12 was prescribed Morphine Sulfate (medication used to treat pain) ER (Extended Release) 15 milligrams (mg) tablet to be given one time a day for Chronic Pain. He/she was also prescribed gabapentin (medication used to treat nerve pain) capsule 300mg to be given at 9:00 AM and 1:00 PM for nerve pain. A review of Resident # 12's Care Plan located in the EMR revealed a focus that Resident # 12 has chronic pain related to physical disability, multiple wounds, and neuropathy that was initiated on 2/19/2025. The Care Plan revealed an intervention to, Administer analgesia (Morphine ER and Oxycodone IR; Tylenol) as per orders . A review of the Medication Audit Report for Resident # 12 revealed that Morphine Sulfate ER 15 mg to be given at 9:00 AM was given on the following date and times: 7/5/25 - 10:35 AM 7/12/25 - 11:32 AM 7/13/25 - 10:50 AM A review of the Medication Audit Report for Resident # 12 revealed that gabapentin 300 mg to be given at 9:00 AM and 1:00 PM was given on the following date and times: 7/5/25 - 10:32 AM 7/5/25 - 15:17 PM (1 PM dose) 7/7/25 - 2:12 (1PM dose) 7/10/25 - 2:27 PM 7/11/25 - 2:13 PM 7/12/25 - 11:32 (9 AM dose) 7/12/25 - 2:20 PM ( 1 PM dose) 7/13/25 - 10:51 AM (9:00 AM) 7/13/25 - 2:35 PM (1:00 PM) On 7/22/2025 at 11:04 AM during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) # 1 replied that the nurses may not document the medication as administered at the administration time due to various distractions. She confirmed that Resident # 12 does take their medications for pain. On the same date at 11:16 AM during an interview with the surveyor, the Director of Nursing (DON) replied, One hour before and one hour after when the surveyor asked how early and how late can a medication be administered past the scheduled time. A review of the facility policy titled, Medication Administration implemented on 9/1/2024 revealed that, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . The policy also reflected that, 10. Ensure that the six right of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time . 2.) A review of Resident # 159’s admission record revealed that he/she was admitted with but not limited to paroxysmal atrial fibrillation (an irregular heartbeat that starts and stops on its own), neuropathy (damage or disease affecting the nerves outside the brain and spinal cord), and asthma (inflammation and narrowing of airways that affects the lungs). A review of Resident # 159's Electronic Medical Record (EMR) under Orders revealed that Resident # 159 was prescribed gabapentin (medication used to treat nerve pain) 300 milligrams (mg) capsule to be given three times a day for neuropathy. He/she was also prescribed metoprolol succinate (medication used to treat high blood pressure) ER (extended release) 25 mg tab one time a day for hypertension. He/she was also prescribed dabigatran etexilate mesylate (a medication used to thin blood) 150mg two times a day for atrial fibrillation. He/She was also prescribed Advair diskus inhalation aerosol powder (a medication used to treat asthma) 500 MCT/ACT (micrograms that is given per activated clotting time) one puff two times a day for asthma. A review of Resident # 159's Care Plan located in the EMR revealed a focus that Resident # 159 was on anticoagulant therapy (dabigatran Etexilate Mesylate) related to a-fib was initiated on 04/22/2025. The Care Plan revealed an intervention to, Administer anticoagulant medication as per orders . A review of the Medication Audit Report for Resident # 159 revealed that Gabapentin 300 mg to be given at 2:00 PM was given on the following date and times: 4/23/23 – 3:10 PM 4/24/25 – 3:09 PM A review of the Medication Audit Report for Resident # 159 revealed that dabigatran etexilate mesylate150 mg to be given at 9:00 PM was given on the following date and times: 4/22/25- 11:30 PM 4/23/25- 2:03 AM 4/24/25-10:09 PM A review of the Medication Audit Report for Resident #159 revealed that Advair diskus inhalation aerosol powder 500-50 mcg/act to be give at 9:00 PM was given on the following date and times: 4/23/25-10:55 PM 4/24/25-10:10 PM On 7/22/2025 at 9:55 AM during an interview with the surveyor, the Licensed Practical Nurse said medications should be given within one hour before or after their scheduled time to ensure the effectiveness of the medications. On the same date at 10:01 AM during an interview with the surveyor, Director of Nursing (DON) said that medications could be given an hour before up to an hour after their scheduled time and signed out when given. The DON also said that if a medication was to be given late, the doctor was to be called, and an order would need to be given for that medication. A review of the facility policy titled, Medication Administration implemented on 9/1/2024 revealed that, “12, b. Administer with in 60 minutes prior to or after scheduled time unless otherwise ordered by physician.” N.J.A.C.§ 8:39-27.1(a)

Based on observation, interviews, record review, and review of facility documentation, it was determined that the facility failed to ensure infection control practices were followed for the handling and storage of respiratory equipment for 1 of 2 residents reviewed for respiratory care (Resident #92).On 7/16/2025 at 10:06 AM, during rounds the surveyor observed Resident #92 laying in bed in their room with the nasal cannula (a tube used to deliver oxygen through the nose). The tube was labeled 7/13/2025 and coiled directly on top of the oxygen concentrator (a medical device that delivers extra oxygen to the resident). The tube was not in a bag and exposed to air. On 7/17/2025 at 9:04 AM, during rounds the surveyor observed Resident #92 lying flat in bed. The oxygen tubing was now bagged, but continued to be labeled with the date 7/13/2025, indicating the tubing has been previously exposed and potentially reused.On 7/18/2025 at 12:18 PM, during rounds the surveyor observed Resident #92's nebulizer mask (a mask used to deliver aerosolized medication through the nose) and tubing was exposed and open to air on top of a stuffed animal on the windowsill. The nebulizer mask and tubing was not in a bag and exposed to air. A review of Resident # 92's admissions record revealed that, Resident # 92 was admitted with but not limited to atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of fatty deposits in the arteries of the heart, which can slow blood flow, however not having chest pain).A review of Resident #92's Electronic Medical Record revealed an active physician's order with a state date of 02/03/2025 for oxygen at 2 liters via nasal cannula as needed (PRN) for shortness of breath, wheezing, or if the SP02 (a device that measures oxygen level) falls below 93%.During an interview on 07/18/2025 at 11:06 AM with the surveyor, the Infection Preventionist (IP) said that all respiratory equipment should be kept in a bag when not in use and changed weekly for infection control. The IP further stated, if the respiratory equipment is found open to air, it should be thrown away and replaced. During an interview on 07/22/2025 at 10:04 AM with the surveyor, the Licensed Practical Nurse (LPN) #1 said that respiratory equipment should be stored in a bag and labeled with a date and name and kept in the resident's room. LPN # 1 further stated that oxygen tubbing is changed weekly on Wednesday night, and if it is found open to air, it would be discarded and changed for infection control.During an interview on 07/22/2025 at 12:02 PM with the surveyor, the Director of Nursing (DON) said the respiratory equipment should be kept in a plastic bag, not open to air, when not in use for infection control.A review of a facility provided policy titled Oxygen Administration, implemented on 09/01/2024 revealed under section, Policy Explanation and Compliance Guidelines: that, 5. b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. and 5. e. Keep delivery devices covered in plastic bag when not in use.8:39-19.4 (k)

Complaint #: NJ00180123 Based on interviews, medical record review, and review of other pertinent facility documents on 1/21/2025 it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the residents and to follow the Certified Nursing Assistant (CNA) job description and follow its policy titled Activities of Daily Living (ADLs). This deficient practice was identified for 4 of 4 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for ADL documentation. This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility with diagnoses that included but were not limited to: moderate protein calorie malnutrition; muscle weakness (generalized); unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; and adult failure to thrive (a process of physical and psychological decline associated with advanced age, manifesting as a pronounced overall deterioration). A review of Resident #1's Minimum Data Set (MDS), an assessment tool, revealed a Brief Interview of Mental Status (BIMS) score of eight out of 15, which indicated that the resident's cognition was moderately impaired. The MDS further revealed that the resident was dependent on a helper to eat, to roll left and right, and for personal hygiene. A review of Resident #1's Care Plan (CP) initiated on 08/20/2024 revealed a Focus that the resident had an ADL self-care performance deficit related to activity intolerance, fatigue, and limited mobility. The CP revealed that Resident #1 had potential/actual skin impairment related to incontinence, and pressure ulcers. The CP also revealed that Resident #1 had a history of unplanned weight loss and met the criteria for moderate malnutrition. A review of Resident #1's DSR (ADL Record) and the progress notes (PNs) for the month of December 2024 revealed no documented evidence to indicate that the resident's ADL care was provided, or that the resident refused care on the following dates and shifts: Eating: 7:00 AM- 3:00 PM shift on: 11/01/2024, 12/06/2024, 12/07/2024, 12/09/2024, 12/10/2024, 12/12/2024, 12/17/2024, 12/20/2024, 12/25/2024, 12/28/2024, and 12/29/2024 3:00 PM - 11:00 PM shift on: 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/20/2024, 12/24/2024, and 12/25/2024. Meal intake: 7:00 AM - 3:00 PM shift on: 12/01/2024, 12/06/2024, 12/07/2024, 12/09/2024, 121/10/2024, 12/12/2024, 12/17/2024, 12/20/2024, 12/25/2024, 12/28/2024, and 12/29/2024. 3:00 PM - 11:00 PM shift on: 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/20/2024, 12/24/2024, and 12/25/2024. Turned and repositioned: 7:00 AM-3:00 PM shift on: 12/01/2024, 12/06/2024, 12/07/2024, 12/09/2024, 12/10/2024, 12/12/2024, 12/17/2024, 12/20/2024, 12/25/2024, 12/28/2024, and 12/29/2024 3:00 PM-11:00 PM shift on: 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/20/2024, 12/24/2024, and 12/25/2024. 11:00 PM- 7:00 AM shift on: 12/01/2024, 12/02/2024, 12/04/2024, 12/05/2024, 12/07/2024, 12/10/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/22/2024, 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/29/2024, 12/30/2024, and 12/31/2024. Personal hygiene: 7:00 AM to 3:00 PM shift on: 12/01/2024, 12/06/2024, 12/07/2024, 12/09/2024, 12/10/2024, 12/12/2024, 12/17/2024, 12/20/2024, 12/25/2024, 12/28/2024, and 12/29/2024. 3:00 PM to 11:00 PM shift on: 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/20/2024, 12/24/2024, and 12/25/2024. 2. According to the AR, Resident #2 was admitted to the facility with diagnoses which included but were not limited to muscle wasting and atrophy (wasting or thinning of muscle mass), and moderate protein calorie malnutrition. A review of Resident #2's MDS revealed a BIMS of 11 out of 15 which indicated the resident's cognition was moderately impaired. The MDS further revealed that the resident required setup and/or cleanup assistance with eating. The MDS also revealed that the resident required touch assist or supervision with personal hygiene. A review of Resident #2's CP initiated on 03/22/2023 and revised on 09/12/2023 revealed under Focus, that the resident met the criteria for moderate malnutrition and had a history of downward trending weights. CP interventions included, monitor intake PRN [as needed]. Further review of the CP revealed a Focus, of potential/actual impairment to skin integrity initiated on 09/25/2024. Interventions included Encourage good nutrition and hydration in order to promote healthier skin. A review of Resident #2's DSR and PNs for the month of December 2024 revealed no documented evidence to indicate that the resident's meal intake or refusal of meals was monitored at the following mealtimes: 8:00 AM on: 12/02/2024, 12/05/2024, 12/07/2024, 12/08/2024, 12/10/2024, 12/11/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/21/2024- 12/23/2024, 12/28/2024, and 12/31/2024. 12:00 PM on: 12/02/2024, 12/05/2024, 12/07/2024, 12/08/2024, 12/10/2024, 12/11/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/21/2024, 12/22/2024, 12/23/2024, 12/28/2024, and 12/31/2024. 5:00 PM on:12/07/2024, 12/11/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/21/2024, 12/23/2024, 12/25/2024, 12/28/2024, 12/29/2024, and 12/31/2024. 3. According to the AR, Resident #3 was admitted to the facility with diagnoses that included but were not limited to dehydration; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; moderate protein-calorie malnutrition; muscle weakness; and need for assistance with personal care. A review of Resident #3's MDS revealed a BIMS of four out of 15 which indicated the resident's cognition was severely impaired. The MDS further revealed that Resident #3 was dependent on a helper for eating, personal hygiene, and to roll left and right. A review of Resident #3's CP initiated on 10/07/2024 revealed that the resident had an ADL self-care performance deficit and required assistance with bed mobility, and personal hygiene. Resident #3's CP contained a Focus related to Resident #3's refusal to eat and resistance to feeding initiated on 10/21/2024. Interventions included Explain importance of prescribed diet to the resident and the need for adequate nutritional intake, initiated on 10/21/2024. Resident #3's CP included a Focus related to the resident's potential for fluid deficit due to poor intake, initiated on 10/07/2024. Interventions included Notify Physician if [ .] persistent output exceeding intake past 48 hours, initiated on 10/07/2024. Resident #3's CP contained a Focus that the resident met the criteria for moderate protein calorie malnutrition and had a history of unintended significant weight loss, initiated on 10/03/2024 and revised on 11/11/2024. Interventions included assistance with meals PRN, monitor for signs of dehydration, and provide diet as ordered. Further review of Resident #3's CP revealed a Focus of impaired skin integrity initiated on 10/03/2024 and updated to reflect the presence of wounds and deep tissue injury (DTI) on 11/22/2024. Interventions included Encourage good nutrition and hydration in order to promote healthier skin. A review of Resident #3's DSR and PNs for the month of November 2024 revealed no documented evidence to indicate that the resident's meal intake and or refusal of meals were monitored at the following mealtimes: 8:00 AM on: 11/01/2024, 11/06/2024, 11/07/2024, 11/09/2024, 11/10/2024, 11/15/2024, 11/20/2024, 11/23/2024, 11/24/2024, and 11/29/2024. 12:00 PM on: 11/01/2024, 11/06/2024, 11/07/2024, 11/09/2024, 11/10/2024, 11/15/2024, 11/23/2024, 11/24/2024, and 11/29/2024. 5:00 PM on: 11/01/2024, 11/02/2024, 11/03/2024, 11/04/2024, 11/05/2024, 11/06/2024, 11/08/2024, 11/10/2024, 11/11/2024, 11/17/2024, 11/21/2024, and 11/22/2024. A review of Resident #3's DSR and PNs for the month of November 2024 revealed no documentation to indicate that the resident's ADL care was provided or that the resident refused care on the following dates and shifts: Eating: 7:00 AM to 3:00 PM on: 11/01/2024, 11/06/2024, 11/07/2024, 11/09/2024, 11/10/2024, 11/15/2024, 11/20/2024, 11/23/2024, 11/24/2024, and 11/29/2024. 3:00 to 11:00 PM on: 11/01/2024, 11/02/2024, 11/03/2024, 11/04/2024, 11/05/2024, and 11/06/2024, 11/08/2024, 11/10/2024, 11/11/2024, 11/17/2024, 11/21/2024, and 11/22/2024. Personal hygiene: 7:00 AM to 3:00 PM on: 11/01/2024, 11/06/2024, 11/07/2024, 11/09/2024, 11/10/2024, 11/15/2024, 11/20/2024, 11/23/2024, 11/24/2024, and 11/29/2024. 3:00 PM to 11:00 PM on: 11/01/2024, 11/02/2024, 11/03/2024, 11/04/2024, 11/05/2024, 11/06/2024, 11/08/2024, 11/10/2024, 11/11/2024, 11/17/2024, 11/21/2024, and 11/22/2024. 11:00 PM to 7:00 AM on: 11/01/2024, 11/05/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/10/2024, 11/13/2024, 11/20/2024, 11/21/2024, and 11/25/2024. Turned and repositioned: 7:00 AM to 3:00 PM shift on: 11/01/2024, 11/06/2024, 11/07/2024, 11/09/2024, 11/10/2024, 11/15/2024, 11/20/2024, 11/23/2024, 11/24/2024, and 11/29/2024. 3:00 PM to 11:00 PM shift on: 11/01/2024, 11/02/2024, 11/03/2024, 11/04/2024, 11/05/2024, 11/06/2024, 11/08/2024, 11/10/2024, 11/11/2024, 11/17/2024, 11/21/2024, and 11/22/2024. 11:00 PM to 7:00 AM on:11/01/2024, 11/05/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/10/2024, 11/13/2024, 11/20/202411/21/2024, and 11/25/2024. 4. According to the AR, Resident #4 was admitted to the facility with diagnoses that included but were not limited to hemiplegia (paralysis that affects either side of the body) and hemiparesis (loss of strength and mobility on one side of the body) following cerebral infarction affecting left non-dominant side; other lack of coordination; and need for assistance with personal care. A review of Resident #4's MDS revealed a BIMS of 12 out of 15 which indicated the resident's cognition was moderately impaired. The MDS revealed that Resident #4 required partial/moderate assistance with personal hygiene. The MDS revealed that the resident required substantial or maximal assistance with toileting hygiene. The MDS further revealed that Resident #4 required partial or moderate assistance to transfer to and from a bed to a chair or wheelchair. A review of Resident #4's CP initiated on 09/09/2024 revealed a Focus that the resident had self-care performance deficits related to fatigue and difficulties with using the right side of the body. Interventions included: assistance of one staff with personal hygiene, and one or two staff for toileting hygiene. The CP further revealed that Resident #4 required the assistance of one or two staff to move between surfaces as needed. A review of Resident #4's DSR and PNs for the month of October 2024 revealed no documented evidence to indicate that the resident's ADL care was provided or that the resident refused care on the following dates and shifts: Personal hygiene: 7:00 AM to 3:00 PM shift on: 10/08/2024, 10/23/2024, and 10/31/2024. 3:00 PM to 11:00 PM shift on: 10/02/2024, 10/03/2024, 10/08/2024, 10/09/2024, 10/12/2024, and 10/13/2024. Toileting Hygiene: 7:00 AM to 3:00 PM shift on: 10/08/2024, 10/23/2024, and 10/31/2024. 3:00 PM to 11:00 PM shift on: 10/02/2024, 10/03/2024, 10/08/2024, 10/09/2024, 10/12/2024, and 10/13/2024, 11:00 PM to 7:00 AM shift on: 10/03/2024, 10/14/2024, 10/15/2024, 10/17/2024, 10/18/2024, 10/19/2024, 10/20/2024, 10/21/2024, 10/22/2024, 10/24/2024, 10/25/2024, 10/26/2024, 10/27/2024, 10/28/2024, 10/29/2024, 10/30/2024, and 10/31/2024. Chair/bed-to-chair transfer: 7:00 AM to 3:00 PM shift on: 10/08/2024, 10/23/2024, and 10/31/2024. 3:00 PM to 11:00 PM shift on: 10/03/2024, 10/08/2024, 10/09/2024, 10/12/2024, and 10/13/2024. 11:00 PM to 7:00 AM shift on: 10/03/2024, 10/14/2024, 10/15/2024, 10/17/2024, 10/18/2024, 10/19/2024, 10/20/2024, 10/21/2024, 10/22/2024, 10/24/2024, 10/25/2024, 10/26/2024, 10/27/2024, 10/28/2024, 10/29/2024, 10/30/2024, and 10/31/2024. During an interview with the surveyor on 01/21/2025 at 1:55 PM, the CNA stated that care provided, including the assistance residents required to eat and the percentage of meals eaten were documented on the residents' ADL sheets. The CNA further stated that residents who stayed in bed were turned and positioned every two hours. During an interview with the surveyor on 01/21/2025 at 4:34 PM, the Director of Nursing (DON) stated that turning and positioning were standard care for residents who lacked bed mobility. The DON stated that turning and positioning was expected to occur every two hours and that CNAs and any staff could do position changes. During the same interview the DON stated that documentation was important in order to have a record of the care that was provided to residents. The DON stated that documentation was a way for staff to take accountability for their actions. The DON confirmed the presence of blank spaces on Resident #3's DSR. The DON stated that CNAs were responsible for completing ADL documentation in POC, (a computer system which enables CNAs to document ALDs). The DON further stated that documentation expectations was a part of the orientation that the facility provided to all employees. Review of the facility policy, Activities of Daily Living (ADLs), with a Date Implemented, of 9/1/2024, revealed, Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care; 2. Transfer and ambulation; 3. Toileting; 4. Eating to include meals and snacks. Further review of this policy revealed, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's undated job description document for the position Certified Nurse Assistant revealed that the following under Major Duties and Responsibilities, Assists residents with or performs activities of daily living for resident in accordance with care plans and established policies and procedures. This section of the CNA job description document further revealed, Completes flow sheets daily to indicate that the specified task was done. NJAC 8:39-35.2 (f)

COMPLAINT #NJ00174308 Based on interviews, review of medical records and other pertinent facility documentation on 06/07/24, it was determined that the facility failed to perform skin scrapings to confirm the presence of scabies (an infestation of the skin by a human itch mite). The deficient practice was identified for 2 of 4 residents (Resident #1 and Resident #4) sampled and was evidenced by the following: During a review of Resident #1's electronic medical record (EMR), a physician note, dated 02/22/24, at 08:53 A.M. revealed that one of the resident's chief complaints included a rash that had developed across his/her lower extremities, trunk and back. The note further revealed that Ivermectin (an oral medication effective in treating scabies) was ordered for Scabies. The surveyor reviewed the resident's Order Summary Report from 03/01/24, which revealed an active physician's order for Ivermectin 18 MG to be given for Scabies on 02/22/2024. The surveyor reviewed Resident #1's February 2024 Medication Administration Record (MAR), that revealed that Ivermectin was administered on 02/22/24. A review of Resident #1's progress notes and physician orders, did not contain an order for a skin scraping. During a review of Resident #4's electronic medical record (EMR), the surveyor reviewed the following progress notes: -Nursing note [signed by the Unit Manager], dated 02/15/24, at 01:40 P.M. that revealed that that the resident had returned from a dermatology appointment and that Permetherin External Cream 5% (a topical medication used to treat scabies) was prescribed. -Physician note, dated 02/20/24, at 12:00 A.M that contained, Nursing reports the patient did not have a scraping at dermatology to confirm diagnosis of scabies . The note further revealed that Ivermectin was then ordered. The surveyor reviewed the resident's Order Summary Report from 03/01/24, which revealed an active physician's order for Ivermectin 15 MG on 02/22/24. The surveyor reviewed Resident #1's February 2024 Medication Administration Record (MAR), that revealed that Ivermectin was administered on 02/20/24 and Permetherin Cream was administered on 02/15/24. A review of the Resident #1's progress notes and physician orders, did not contain an order for a skin scraping. During an interview with the Director of Nursing (DON), on 06/07/24, at 11:12 A.M. she stated that the Infection Preventionist Nurse was not available for interview. She further stated that she [the DON] would be able to assist the surveyor with any Infection Control concerns. The surveyor asked if there had been any positive cases of scabies in the facility since February 2024, the DON stated No. She further added that there had been multiple skin flare-ups with different presentations involving many residents, but that there was no pattern. She also added that residents had responded to different courses of treatments but that no confirmed case of scabies was reported. During an interview with the Unit Manager (UM), on 06/07/24, at 01:57 P.M. she stated that she had called the dermatology office to confirm whether a skin scraping had been done for Resident #4 and they told her that they had not performed one. She stated that she provided the facility physician with this information. She stated that there was no outbreak of scabies at the facility because there were no positive skin scrapings. When the surveyor asked if she was aware of any skin scrapings that had been done at the facility, she stated, Not that I was aware of. During a telephone interview with the treating Physician on 06/07/24, at 02:44 P.M., he stated that Ivermectin and Permetherin were commonly used in the treatment of scabies, and other conditions as well, and that no one at the facility was reported to have a positive scraping. When asked about the dermatology visit for Resident #4, the physician stated that the facility had called the dermatology office and confirmed that although the resident was given the diagnosis, the office had not performed a skin scrape and since they had not, the physician did not consider it as a confirmed diagnosis. The physician stated that although the skin scraping had not been completed the recommendation was to continue to follow the dermatologist's recommended course of treatment. The surveyor asked the physician about the diagnosis of scabies in the physician note for resident #1, to which the physician stated, This [scabies] was the working diagnosis at the time, since the other patient [Resident #4] had been seen by dermatology. He went on to state that since the scraping was confirmed as not being done, they went on to treat Resident #1 accordingly because, It could have been scabies. The surveyor asked if he had ordered skin scrapings for Resident #1 or Resident #4 to confirm whether they had scabies, and he stated that he had not. The surveyor reviewed the facility's Scabies Identification, Treatment and Environmental Cleaning, dated 12/06/23, which revealed that the purpose of the procedure was to treat infected residents and to prevent the spread of scabies to other residents and staff. The policy further explained the equipment and supplies needed, along with the steps to perform the skin scraping for microscopic identification. Under the Reporting section, the policy revealed that reporting should be, . in accordance with facility policy and professional standards of practice. During a follow-up interview with the DON at 04:04 P.M., the surveyor reviewed the scabies policy provided by her. The surveyor asked the DON if it was policy that skin scapings be conducted at the facility, to which the DON stated, Yes. The surveyor asked the DON if a skin scraping had been done for Resident #1, who had a written diagnosis in the chart for scabies and she stated, No. The surveyor asked the DON if a skin scraping had been done for Resident #4 who had been seen by the dermatologist and was diagnosed with scabies and she stated, No. When asked why these two aforementioned residents did not receive skin scrapings, she stated, I am not a doctor. The surveyor asked the DON if any resident had received a positive skin scraping result for scabies what would the facility have done, to which the DON stated, We would have notified the Department of Health. 8:39-19.4

Based on observation, interview, and document review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 11/13/23 from 09:25 AM until 10:35 AM the surveyor, who were accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1.A Food Service Worker (FSW) was observed with a hairnet on with the hair near her ears exposed. Another FSW was observed with a surgical mask on his face. His facial hair was exposed. The FSD stated that hairnets should cover all hair. He also stated that the FSW should be wearing a beard guard. 2. In the snack refrigerator there were five individual cartons of commercially prepared vanilla shakes with no use by date. The FSD stated the staff should place a use by date on them once they come out of the freezer. He furthered the shakes are not outdated but should have a used by date placed. 3. In the third refrigerator, there 2 hardboiled eggs 2 in a bin with no label and no date. The FSD stated the eggs should be dated. 4. In the third refrigerator there were individual cups of cream cheese in an opened box with a received date of 5/16. The FSD stated he will throw them out. 5. In the third refrigerator, there were fresh tomatoes in an opened box dated 10/31. The FSD stated the tomatoes are good for 10 days. There was a box of zucchini dated 10/17. The FSD stated they are good for 15 days. He said he will throw them out. 6. In the freezer, there were closed plastic sleeves of turkey burgers and vegetable burgers with no label and no date. The FSD stated his staff took them out of the box. He stated they should be labeled and dated. On 11/15/23 at 09:57 AM, the surveyor observed the Unit 200 ice machine with the Unit 200 Nurse Manager (NM). A black substance was observed on the plastic downspout. The NM is not sure who takes care of cleaning the machine but will get back to this surveyor. On 11/15/23 at 11:08 AM, the Licensed Nursing Home Administrator (LNHA) stated that the ice machine is cleaned quarterly. He stated that it is due at the end of this month. On 11/15/23 at 12:04 PM, the LNHA stated that he observed the Unit 200 ice machine and it needs to be cleaned. He stated that it will be cleaned tonight. The surveyor reviewed the 6/15/18 personal hygiene policy provided by the facility Administrator. The policy reflected 7. Hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. Facial hair coverings are used to cover all facial hair. The surveyor reviewed a 6/15/18 Refrigerated/Frozen Storage policy provided by the LNHA. The policy reflected 1.4 All foods are labeled with name of product and the date received and use by date once opened. Manufacturer use by dates are used until opened. 1.5 Prepared foods are labeled and dated with the name of product, date opened, and use by date. 1.9 Frozen, commercially prepared shakes are thawed under refrigeration; the date removed from the freezer is marked on the case. 1.9.2 Individual shakes are labeled with use by date when removed from the original container. The surveyor reviewed the Food Storage and Retention Guide provided by the LNHA. The policy reflected that cream cheese can be stored for two weeks. It reflected that fresh fruit and vegetables can be stored for one week or until visual decline is noted. The surveyor reviewed the Work History Report provided by the LNHA. It reflected that preventative maintenance was completed on the ice machines on 8/31/23. NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility records, it was determined that the facility failed to a.) ensure infection control practices were adhered to in a manner that would decrease the possibility of the spread of infection during wound care, and b.) medication administration. This deficient practice was observed with 1 of 2 residents (Resident# 5) reviewed for pressure ulcers, and for 1 of 2 nurses observed during the medication observation pass on 1 of 3 nursing units, (Second Floor). This deficient practice was evidenced by the following: a.) On 11/13/23 at 10:32 AM, during initial tour of the facility, the surveyor observed Resident #5 resting in bed in their room. On the wall outside of the resident's room door was an Enhanced Barrier Precaution sign and a plastic bin with three drawers containing disposable gloves and disposable gowns. The Clinical Supervisor (CS) informed the surveyor that this resident was on transmission-based precautions due to having a pressure ulcer. Review of Resident #5's Admission Record indicated the resident was admitted to the facility with diagnosis which included but not limited to multiple sclerosis (a long-lasting (chronic) disease of the central nervous system) and paraplegia (paralysis of the legs and lower body). Review of Resident #5's quarterly Minimum Data Set (MDS) (a comprehensive assessment tool) dated 9/14/2023, indicated the resident had a brief interview of mental status (BIMS) score of 14 out of 15 indicating intact cognition, was at risk for developing pressure ulcers, had a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) which was being treated with ointments/medication and application of nonsurgical dressings. Review of the resident's care plan indicated an active care focus area with an initiation date of 6/29/2021 for potential and actual impairment to skin integrity with a goal to have no complications related to stage four coccyx (tail bone) wound and will display improvement or will be healed through the review date. This care focus had intervention planning which included but was not limited to, follow facility protocols for treatment of injury. Review of the resident's physician's orders and the Order Summary Report included the following orders: Coccyx: cleanse with acetic acid 0.25% (a solution used to prevent bacterial growth), apply mix of medihoney and collagen powder (medications used to promote wound healing) to wound base, cover with calcium alginate (promotes wound healing and absorption of excess moisture) (cut to size), apply mix of zinc oxide paste and lotrisone 1% (medications used to prevent skin breakdown or irritation) to surrounding skin, cover with large bordered foam/silicone dressing daily and as needed, start date of 10/27/2023. Review of the November 2023 treatment administration record (TAR) revealed this wound care treatment was completed as ordered daily. On 11/17/23 at 9:23 AM, the surveyor observed the Licensed Practical Nurse/Wound Care Nurse (LPN/WC) perform the ordered wound care treatment. The following was observed: After bringing the wound treatment cart to the resident's doorway, (keeping it in the hallway outside the room door), washing her hands, and gathering all the required materials and medications to be used, donning (putting on) a disposable gown and gloves, the LPN/WC brought the mediations and dressings, which she had gathered on a clean barrier pad, [NAME] the pad with the supplies into the room and placed it on the resident's tray table, then proceeded with the wound care. The LPN/WC first doffed (removed) the gloves she was wearing while preparing the working area and the trash bag, without performing hand hygiene, donned new gloves. With the assistance of another nurse, they turned the resident onto their right side, removed the old wound dressing, disposed of it into the trash bag, doffed and disposed gloves, did not perform hand hygiene, donned new gloves, patted the wound with acetic acid soaked gauze, disposed of the gauze, doffed gloves, no hand hygiene, donned new gloves, patted the wound with more acetic acid gauze, disposed of the gauze, doffed gloves, no hand hygiene, donned new gloves, used clean dry gauze to pat the cleaned wound dry, disposed of that gauze, doffed gloves, no hand hygiene, donned new gloves, repeated pat dry with new clean gauze, doffed gloves, no hand hygiene, donned new gloves, went to the glove box hanging on the wall by the room door, obtained a handful of more clean gloves, placed them on the barrier pad, doffed gloves, no hand hygiene, donned new gloves, using a clean application stick she applied the zinc/lotrisone mixture to the resident's skin surrounding the wound, disposed of medication cup and stick, doffed gloves, no hand hygiene, donned new gloves, applied the medihoney/collagen mixture and the calcium alginate pad to the wound, doffed gloves, no hand hygiene, donned new gloves, applied the large foam dressing to the wound, replaced the resident's adult incontinence brief, repositioned the resident onto their back, doffed gloves, no hand hygiene, donned new gloves, disposed of all remaining supplies and barrier pad into trash bag, disposed the trash bag into a trash bin, doffed the gown, used hand sanitizer to perform hand hygiene, then proceeded to the bathroom to wash her hands. On 11/17/23 at 9:49 AM, once the LPN/WC returned to the treatment cart, the surveyor interviewed her. The LPN/WC informed the surveyor that she is the facility's wound care nurse and is usually the one performing wound care for residents requiring it. The LPN/WC informed the surveyor that she had reviewed the regs prior to this observed treatment and that just glove changes are required during care and there is no more sanitizer (hand hygiene) in between glove changes. The LPN/WC acknowledged she did not perform any hand hygiene in between glove changes during the process of wound care, and stated, there's supposed to be hand sanitizing, I apologize. At 10:25 AM, the LPN/WC provided the surveyor with the facility policy regarding wound care and stated, I should have been doing hand hygiene in between glove changes. On 11/17/23 at 10:50 AM, the surveyor interviewed the Infection Preventionist Registered Nurse (IP), who stated, regardless of what you're doing, if there is glove change, there should be hand hygiene in between glove changes. 41442 b.) On 11/15/23 from 08:48 AM to 9:12 AM, the surveyor observed Licensed Practical Nurse (LPN) #2 as she prepared medications for administration to two residents (an unsampled Resident and Resident #49) during the Medication Pass: On 11/15/23 at 8:50 AM, the surveyor observed LPN#2 as she came out of an unsampled resident's room with an Insulin pen in her gloved hands. LPN #2 then proceeded to reach into her uniform pocket, obtained keys and unlocked the medication cart. LPN #2 then opened the top drawer of the medication cart and proceeded to return the insulin pen to a plastic bag and closed the drawer. LPN #2 then doffed (removed) her gloves and did not perform hand hygiene before she responded to a resident's call light and reportedly assisted the resident to open their milk carton. The surveyor did not observe LPN #2 perform hand hygiene as she exited the resident's room with alcohol based hand rub (ABHR) that was present at the entrance of the room before she prepared and administered medications to an unsampled resident. On 11/15/23 at 8:58 AM, the surveyor observed LPN#2 who opened a new bottle of Vitamin D (supplement) and removed the protective foil with her bare hands before she poured the medication into a medication cup and and prepared additional medications which were then administered to Resident #49. On 11/15/23 at 8:57 AM, the surveyor observed LPN #2 perform hang hygiene with ABHR before she prepared medications for Resident #100. LPN #2 then proceeded to enter the supply room and touched the exterior of the door with her right hand. LPN #2 then returned to the medication cart and opened a new bottle of acetaminophen arthritis (pain reliever) and removed the protective foil with her bare hands before she poured the medication into a medication cup and prepared additional medications which were then administered to the resident. LPN #2 handed the resident a cup of water upon request then proceeded to touch the back of the resident's shirt when the resident complained that the tag inside the shirt needed to be cut as it reportedly caused the resident to complain of itching. LPN #2 then left the resident's room and failed to perform hand hygiene before she accessed the computer on top of the medication cart and charted the resident's medications. On 11/15/23 at 9:12 AM, the surveyor interviewed LPN #2 who stated that she was supposed to perform hand hygiene when she doffed her gloves after insulin administration for infection control reasons . LPN #2 stated that when she answered the resident's call bell and opened the resident's milk carton immediately after insulin administration it was also an infection control issue. LPN #2 stated that when she touched Resident #100's cup and back she should have performed hand hygiene prior to accessing both the computer and medication cart as failure to do so, could result in the spread of germs. On 11/16/23 at 10:37 AM, the surveyor interviewed the Licensed Practical nurse/Unit Manager (LPN/UM) who stated that staff must wash their hands when they doffed their gloves before they moved onto any other task for infection control purposes. The LPN/UM added that if the nurse administered medications and touched a resident without washing their hands afterward, they could spread germs. On 11/17/23 at 09:47 AM, the Infection Preventionist/Registered Nurse (IP/RN) stated that nursing could potentially contaminate all of the surfaces touched if hand hygiene was not performed. The IP/RN stated that hand hygiene should be performed when gloves were doffed to prevent the spread of infection. On 11/20/23 at 11:27 AM, the surveyor interviewed the Director of Nursing (DON) who stated that hand hygiene should be performed after gloves were doffed to avoid cross-contamination. The DON stated that contamination was possible if you did not wash your hands after you have doffed your gloves and accessed the medication cart. The DON stated that nursing should perform hand hygiene before opening a new bottle of medications and pouring them. The DON further stated that hand hygiene should be performed after touching a resident to prevent contamination. On 11/20/23 at 12:20 PM, the DON and the Administrator were made aware of the surveyor's concerns related to Medication Administration. The LPN/ADON/Educator provided the surveyor with an in-service sign-in sheet which indicated that LPN #2 received education on COVID-Handwashing/PPE (personal protective equipment, equipment worn to protect the body from harm or disease) on 11/16/23. Review of the facility's Handwashing/Hand Hygiene policy Reviewed 1/2023, revealed the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .before and after direct contact with residents . before handling clean or soiled dressings, gauze pads, etc, . before moving from contaminated body site to a clean body site during resident care, . after contact with a resident's skin, after contact with blood or body fluids, after handling used dressings, contaminated equipment, etc . after removing gloves .before and after assisting a resident with meals; The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility's Wound Care policy with a review date of 1/2023 included: .put on clean gloves. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene. Put on gloves . NJAC 8:39-19.4(a)(b)(c)(d); 27.1(a)

Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to provide an appropriately sized bed for 1 of 28 residents (Resident #44) reviewed for accommodation of needs and was evidenced by the following: On 11/13/23 at 11:10 AM, during initial tour of the facility, the surveyor observed Resident #44 resting in bed in their room. The resident was laying diagonally in bed, had both knees bent to keep their legs and feet on the mattress. The resident's feet were up against the foot board while the resident's head was propped on a pillow extending past the edge of the mattress. Resident #44 informed the surveyor that their legs hurt from being bent and that he/she is seven feet tall and in a short bed and is uncomfortable. The resident further stated that they asked the facility staff for a longer bed, to which they informed the resident that this was the longest the bed can go as it is already extended and is the biggest one they have. On 11/16/23 at 11:34 AM, the surveyor observed the resident in bed in the same position as previously observed. This time the footboard of the bed had a type of padding material on it to keep the resident's feet off the wood of the footboard, which the resident confirmed was placed to keep my feet from rubbing on the wood, but they rub anyway because the bed is too small. The resident stated they requested a longer bed over a year ago from a previous social worker, who has since left the facility, and had requested a couple times for a longer bed. The resident stated they had been at the facility for a couple of years and does not sleep well at night due to discomfort in bed. The resident also stated that when the nursing aids provide care, they make comments such as, you must not be comfortable in that bed. On 11/16/23 at 11:44 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) and asked her to accompany the surveyor to Resident #44's room to check on the bed size, and if it is appropriate for the resident's needs. Upon inspecting the bed in the presence of the surveyor, the LPN/UM confirmed that the bed was extended and that it may still be too short for the resident, and will bring it to the attention of the interdisciplinary team (IDT) to request a longer bed to accommodate the resident's needs. On 11/16/23 at 11:59 AM, the surveyor and the Director of Nursing (DON) went to the resident's room and the DON confirmed the need for a longer bed. The DON stated they have had tall residents in the past and typically the administrator automatically orders equipment needed to accommodate resident needs. Review of Resident #44's Admission Record revealed the resident was initially admitted to the facility in March of 2021 with diagnosis which included but was not limited to hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side (paralysis and weakness of the left side due to nontraumatic brain bleed), insomnia (inability or difficulty getting to sleep), and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) (a comprehensive assessment tool) dated 9/6/23, indicated the resident had a brief interview of mental status (BIMS) score of 14 out of 15 indicating intact cognition, and a height of 82 inches (six feet ten inches). On 11/16/23 at 12:56 PM, in the presence of the survey team, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated he visits this resident almost every day, and confirmed the resident appeared to be a bit tight in the bed. The LNHA informed the surveyor that when medical equipment is ordered, they typically are delivered the same day from the facility's vendor. The LNHA informed the surveyor that he ordered a longer bed for Resident #44, and it will be delivered by the end of the day. On 11/17/23 at 9:56 AM, the surveyor observed Resident #44 laying in the newly ordered bed. The resident was laying on their back with legs straight and their entire body fitting within the limits of the mattress without resting or rubbing on the head or footboards. The Resident stated this is so much better; I can actually stretch my legs out in this bed now. I was in the last bed for two years, this is so much more comfortable, thank you. On 11/17/23 at 11:43 AM, the surveyor asked the Facility Maintenance Director (FMD) to measure and compare the two beds. The FMD, using his own tape measure, in the presence of the surveyor measured the new bed to be 88.5 inches, while the extended previous bed measured 78 inches. The LNHA provided the surveyor a Mechanical and Electrical Information sheet indicating the new bed was delivered with specifications to meet the needs of the resident. NJAC 8:39- 31.8 (c)(1)

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 2 residents (Resident #63) reviewed for smoking. This deficient practice was evidenced by the following: On 11/13/23 at 10:23 AM, during the tour of the facility, Resident #63 was identified by the Licensed Practical Nurse/Nurse Manager LPN/UM as a smoker. At that time the surveyor observed Resident #63 ambulating in his/her room. The resident stated that he/she went out to smoke four to five times a day. The surveyor reviewed the Admission Record for Resident #63 which reflected that the resident was admitted with diagnoses that included diabetes (high blood sugar) and depression. The surveyor reviewed the nursing quarterly assessment dated [DATE], which indicated that Resident #63 currently smokes. The surveyor reviewed the smoking assessment dated [DATE], which indicated that Resident #63 currently smokes. The surveyor reviewed the care plan initiated 10/22/19, which reflects that this resident may smoke independently. The surveyor reviewed Resident #63's Annual Minimum Data Set (MDS), an assessment tool, dated 8/22/23. The section for current tobacco use was coded as zero (0) indicating that Resident #63 does not currently use tobacco. On 11/16/23 at 01:45 PM, the surveyor interviewed the MDS Coordinator. She stated the process to identify the resident's that smoke was to look into policy to identify smokers, to look at the notes, orders and care plans to determine if the resident smokes. She stated that she would have to look to determine if Resident #63 smokes. It should be on the MDS if the resident does smoke, and the information was on the chart. She reviewed the August Annual MDS and stated that Resident #63 was not coded for tobacco use. She stated that the purpose of coding resident would be to paint a picture of the patient, the care plan development, and review. She stated that from what she sees, Resident #63 should have been coded as a smoker in the August MDS dated [DATE]. A review of the facility provided policy Resident Assessment (RAI) Policy and Procedures reflects It is the policy of the facility that the completion of the RAI shall be based on the guidelines of the RAI manual. On 11/20/23 at 12:15 PM, the Director of Nursing and Licensed Nursing Home Administrator were made aware of the Annual MDS dated [DATE] for Resident # 63 not having tobacco use documented as required. NJAC 8:39-2(e)1

Based on interview and review of pertinent facility documentation it was determined the facility failed to develop a person-centered baseline care plan for a fall risk resident within 48 hours of admission to a facility. This deficient practice was identified in 1 of 28 residents reviewed for baseline care plans (Resident #185) and was evidenced by the following: On 11/13/23 at 11:15 AM, the surveyor reviewed facility documentation which revealed the resident left the facility against medical advice (AMA) on 03/07/23. Review of the Admission Record indicated that the resident was admitted to the facility with medical diagnoses which included but were not limited to heart failure, diabetes (high blood sugar), difficulty in walking, and muscle weakness. Review of the entry Minimum Data Set (MDS), an assessment tool dated 03/07/23 the resident had a Brief Interview of Mental Status of 8, meaning Resident #185 had moderate cognitive impairment. Review of section J of the MDS, Health Conditions showed that the resident had a fall in the last month prior to admission to the facility. On 11/16/23 at 01:57 PM, the surveyor reviewed Resident #185 incidents and accidents. The incidents revealed that on 03/05/23 the resident had a fall and was found on the floor next to the bed. The resident was alert, confused, and suffered no injury. Following the investigation, the resident was not able to verbalize the incident. On 11/17/23 at 09:00 AM, the surveyor reviewed Residents #185 Admission Nursing Comprehensive assessment dated [DATE]. Under the mobility section it indicated the resident was total dependence for walking in the room or in the corridor. Under the section for fall risk it revealed the resident had a fall in the last month prior to admission to the facility and the resident had sustained a fracture in the 6 months prior to admission to the facility. The score of the assessment indicated Resident #185 was at risk for falls. On 11/17/23 09:44 AM, the surveyor reviewed Resident #185 care plan which showed a focus of falls was initiated on 03/06/23, following the fall at the facility. Prior to the resident falling on 03/05/23 the resident did not have a fall care plan in place or fall prevention interventions. The fall care plan was initiated on 03/06/23 and interventions of bed and chair alarms, frequent monitoring for 72 hours, neurological checks, and physical therapy were put in place on 03/06/23. On 11/17/23 at 11:23 AM, the surveyor met with the Director of Nursing (DON). The DON provided surveyor with the resident's care plan. The DON told the surveyor, I'm going to be honest, the baseline care plan and regular care plan were completed on the 6th. The surveyor asked if it was in the time frame to complete a baseline care plan and the DON responded, no. On 11/22/23 at 01:28 PM, the surveyor reviewed the care plan titled, Managing Falls and Fall Risks. The policy had a reviewed date of 01/2023. Under the section titled, Resident Centered Approaches to Managing Falls and Fall Risk, number one indicated the staff, with the input of the attending physician will implement a resident centered fall prevention plan toreduce specific risk factors for falls for each resident at risk or with a history of falls. NJAC 8:39-11.2 (d)

Based on observation, interview, and review of pertinent facility documentation it was determined the facility failed to 1. Obtain physician orders to change oxygen tubing on a resident who was ordered nasal cannula (a devices that delivers oxygen through a tube into the nose) oxygen and 2. Obtain physician orders for care of a Percutaneous endoscopic gastrostomy (PEG) tube (tube passed through abdominal wall into the stomach to provide a means of feeding) site for a resident. This was identified in 1 of 2 residents reviewed for PEG tubes (Resident #61) and 1 of 2 residents reviewed for oxygen (Resident #31 ) and was identified by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing a 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 with in the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.On 11/13/23 at 11:11 AM, during initial tour of the facility the surveyor observed Resident #31 in bed. Resident #31 was wearing nasal cannula oxygen being delivered via concentrator (medical devices that separates nitrogen from the air around you so you can breathe up to 95 percent pure oxygen) at two liters per minute. The oxygen tubing and humidity bottle was dated 11/13/23. Review of Resident #31 admission record revealed the resident had medical diagnoses which included but were not limited to heart disease, diabetes (high blood sugar), hypertension (high blood pressure), and muscle weakness. Review of the quarterly Minimum Data Set (MDS), an assessment tool dated 08/24/23 indicated the resident had severe cognitive impairment and the Brief Interview of Mental Status could not be completed. On 11/14/23 at 09:58 AM, the surveyor reviewed the physician orders which showed an order for oxygen at two liters per minute for shortness of breath. It was an active order dated 07/03/23. On 11/14/23 at 10:16 AM, the surveyor reviewed Resident # care plan which included a focus of respiratory and shortness of breath and one intervention was to apply oxygen as prescribed by the doctor. On 11/14/23 at 10:27 AM, the surveyor reviewed the physician orders and could not locate an order to change nasal cannula oxygen tubing. On 11/16/23 at 10:10 AM, the surveyor observed the resident in bed, eyes closed wearing oxygen at two liters nasal cannula. The oxygen tubing and the humidity bottle were dated 11/16/23. On 11/17/23 at 10:14 AM, the surveyor interviewed the subacute unit Registered Nurse (RN) regarding nasal cannula tubing changes. The RN told the surveyor the tubing was changed once per week. The surveyor asked who was responsible and how would we know it was changed and the RN stated, (it is hanged by whoever is on shift, and they sign it off on the Treatment Administration Record (TAR) or the Medication Administration Record (MAR). The surveyor asked if there was a specific day they were changed on the unit and she told the surveyor the days are different based on when the resident was admitted to the facility. The surveyor then asked the RN to look on the MAR and TAR and show the surveyor where it was signed. The RN could not locate the tubing changes on the MAR or TAR. On 11/17/23 at 1030 AM the surveyor interviewed unit LPN ([NAME]) who told the surveyor, It should it be on the Mar or Tar, yes it should be and we will fix it. On 11/22/23 at 11:12 AM, the surveyor reviewed the policy titled, Oxygen Administration with an updated date of 10/2019. The purpose of the policy was to provide guidelines for safe oxygen administration. The policy did not include changing of nasal cannula tubing. 41442 2. On 11/14/2023 at 12:34 PM, the surveyor observed Resident #61 lying in bed with his/her eyes closed. The surveyor observed that the head of the bed was elevate in an upright position and the resident was being administered enteral tube feeding formula via a feeding pump through a tube inserted in the resident's abdomen. A review of Resident Quarterly Minimum Data Set (an assessment tool) dated 09/19/2023, revealed that Resident #61 had a feeding tube while a resident in the facility. A review of Resident #61's November 2023 physician orders located in the electronic medical record (EMR) revealed an order for Jevity 1.5 (nutritional formula) to be administered at 40 milliliters (mL) /hour with a total volume of 800 mL's. There were no additional orders for the care of the gastrostomy site. On 11/16/2023 at 10:36 AM, the surveyor interviewed the resident's Hospice aide and observed Resident #61 during morning care. The resident had an abdominal binder in place and on request of the surveyor, the binder was removed to reveal the gastrostomy tube site. The tube entrance site on the abdomen did not have a dressing, was clean and intact. The Hospice aid stated that the nurse takes care of the gastrostomy site. Shortly later, the nurse came into the room and cleaned the abdominal site with normal saline solution (NSS) and then placed a gauze pad at the tube site. When the surveyor asked the nurse what the physician orders were for the gastrostomy site, the nurse was unable to confirm, stating she wasn't sure, but she believed it was protocol to use NSS and place gauze at the gastrostomy site. Review of the Resident #61's November Care Plan (CP) indicated that the resident required tube feeding (Gastrostomy tube (G-Tube) that was placed 7/3/2023). The CP included nursing interventions to care of the feeding tube that included: Provide local care to G-Tube site as ordered. Report results to MD and follow up as indicated. Review of the November 2023 Treatment Administration Record (TAR) as well as the Medication Administration Record (MAR), did not reveal documentation of the assessment, care, or treatment of the feeding tube site. During an interview with the Director of Nursing (DON), she acknowledged that a physician order for the care of the gastrostomy tube site as well as documentation of the care, is required as per facility policy. Review of the facility's policy for enteral feeding, titled, Enteral Feedings-Safety Precautions, with a review date of 1/2023, found under Preventing Skin Breakdown, # 2: Assess for leaking around the gastrostomy or jejunostomy frequently during the first 48 hours after tube insertion, and then with each feeding or medication administration. In addition, under #3: Observe for signs of skin breakdown, infection and irritation; and Document all assessments, findings and interventions in the medical record. NJAC 8:39-27.1 (a)

Based on observations, interviews, review of medical records (MR) and other pertinent facility documentation, it was determined that the facility failed to administer medications in accordance with the medication's cautionary statement, and manufacturer specifications. This deficient practice was identified for 1 of 2 nurses who administered medications to 2 of 4 (Residents #27 and #98) observed during medication pass and was evidenced by the following: On 11/15/2023 at 08:18 AM, the surveyor observed Licensed Professional Nurse (LPN) #1 who prepared seven medications, which included Potassium Chloride ER (extended release) tablet 10 Milliequivalents (meq) give one tablet by mouth one time a day for hypokalemia (deficiency of potassium in blood stream), for Resident #27. LPN #1 reviewed the Potassium Chloride ER label that was on the bingo card (blister pack) in the presence of the surveyor and failed to acknowledge a pharmacy cautionary statement that specified, Take with food . prior to administration. On 11/15/23 at 8:31 AM, the surveyor observed LPN #1 who prepared nine medications, which included Potassium Chloride ER tablet 20 meq give one tablet by mouth two times a day for supplement and Carvedilol Oral tablet 6.25 mg give one tablet by mouth two times a day for HTN (hypertension, high blood pressure), for Resident #98. LPN #1 reviewed the Potassium Chloride ER label and the Carvedilol labels that was on the bingo card in the presence of the surveyor and failed to acknowledge a pharmacy cautionary statement that specified, Take with food . prior to administration. On 11/15/23 at 8:41 AM, the surveyor interviewed LPN #1 who stated that she did not note the cautionary labels which cautioned that both Potassium Chloride ER and Carvedilol were required to have been administered with food. LPN #1 stated she thought that breakfast would have been served by now. LPN #1 further stated that she could have given the resident's medications with an oral supplement or a snack, if the breakfast trays were not yet provided. LPN #1 then continued to prepare medications for the next resident without first providing Resident #27 and #98 with nourishment post-medication administration as she had described. On 11/16/2023 at 10:37 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that it was standard practice for nursing to review the medication label for cautionary instructions which indicated that the medication was required to have been given with a meal. LPN/UM further stated that LPN #1 should have either waited for meal delivery or obtained something comparable to a meal from the pantry prior to medication administration. On 11/17/2023 at 09:28 AM, the surveyor interviewed the Licensed Practical Nurse/Assistant Director of Nursing/ Educator (LPN/ADON/Ed) who stated that she told nursing to perform three checks prior to medication administration. She further stated that if a cautionary label indicated to give the medication with food then the resident's tray should be in front of the resident or the nurse should wait to give the medication until the meal arrived prior to medication administration. She stated that if a cautionary label was not observed, and the medication was not given with food, the resident could experience upset stomach or irritation of the lining of the stomach. The LPN/ADON/Ed further stated that Potassium should be separated and given with food and a full glass of water to avoid stomach upset or nausea may result. On 11/17/23 at 10:36 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone. The CP stated that both Carvedilol and Potassium Chloride should be given with a meal. The CP explained that with Potassium Chloride there was a potential for upset stomach. The CP further stated that she was not sure with Carvedilol, though the manufacturer specified to take it with food as a matter of timing. On 11/20/23 at 11:27 AM, the surveyor interviewed the Director of Nursing (DON) who stated that nursing was required to review and follow the cautionary statements as directed. The DON further stated that if the cautionary statement directed to give a medication with food, then the nurse should wait until the resident's meal tray arrived prior to medication administration. Review of the facility's policy titled, Administering Medications, did not address medication cautionary instructions. NJAC 8:39-29.2(d)

Complaint: #NJ155583 and #NJ156394 Based on record review, interviews, and facility policy review, the facility failed to ensure mail was delivered unopened to protect a resident's right to private communications for 1 (Resident #8) of 3 sampled residents who received mail at the facility. Findings included: A review of an Admission Record revealed the facility admitted Resident #8 on 01/20/2021 with diagnoses that included idiopathic aseptic necrosis (a condition that occurs when there is loss of blood supply to the bone, resulting in bone death) of the right femur (long bone between the hip and the knee), rheumatoid arthritis, and chronic pain syndrome. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident required extensive assistance with bed mobility. Review of a facility investigation revealed on 07/01/2022, the facility completed an investigation indicating Resident #8's mail was accidentally opened due to improper labeling of mail and unintentional opening due to being in the wrong stack of mail. During an interview on 11/17/2022 at 11:32 AM, Resident #8 reported that during the beginning of the year 2022, the resident's mail was delivered opened more than once. During an interview on 11/18/2022 at 9:24 AM, the Office Manager (OM) stated she was responsible for opening the facility's mail but not mail addressed to residents. She reported in July of 2022, she accidentally opened Resident #8's mail. She stated she was in the process of opening the facility's mail, and Resident #8's mail was mixed up in the facility's pile of mail. She reported she apologized to the resident, and she was in-serviced regarding providing residents' mail unopened. During an interview on 11/18/2022 at 9:56 AM, the Admission Coordinator (AC) indicated she was working on a weekend as the receptionist and offered to help with opening the facility's mail. She reported she accidentally opened Resident #8's mail. The AC indicated she was in-serviced regarding a resident's right to receive mail unopened. She indicated that since her in-service, she had not opened any resident's mail. During an interview with the Administrator on 11/18/2022 at 10:49 AM, he indicated Resident #8's mail was accidentally opened on more than one occasion by the staff at the facility. The Administrator indicated the staff who accidentally opened the mail were in-serviced. Review of an undated facility policy titled, Mail, email and package distribution, revealed, Mail is to be delivered unopened. The policy also indicated residents were to be provided with, the choice of privately opening the mail or receiving assistance from the staff. Keep all reading materials confidential unless the resident specifies. New Jersey Administrative Code S 8.39-4.1

Based on observation, interview, review of medical records, and other facility documentation, it was determined that the facility failed to follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was evidenced by: On 08/06/2021 at 8:25 AM, the surveyor observed Resident #44 lying in bed. With the resident's permission, the resident pulled the blankets off his/her feet to reveal he/she was wearing non-skid socks and his/her heels were resting directly on the mattress. There was no pillow or offloading device in the vicinity of the foot of the bed. On 08/09/2021 at 9:00 AM, the surveyor observed Resident #44 lying in bed. With the resident's permission, the resident pulled the blankets off his/her feet to reveal he/she was wearing non-skid socks and his/her heels were resting directly on the mattress. There was no pillow or offloading device in the vicinity of the foot of the bed. According to the Admission Record, Resident #44 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Quarterly Minimum Data Set (MDS), an assessment tool, dated 06/09/2021, included the resident had a Brief Interview for Mental Status of 3 which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident had a stage 4 pressure ulcer. Review of the resident's Care Plan included, Pressure wound to heel, with an intervention to Off Load/Float heels while in bed with pillows as tolerated, with a date initiated of 03/13/2021. Review of the resident's August 2021 Order Summary Report included a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's August 2021 Treatment Administration Record (TAR) included the aforementioned order was recorded as complete by the nurse on 08/06/2021 and 08/09/2021 for the day shift. Review of the resident's August 2021 Progress Notes did not include any progress notes related to the resident's refusal or non-compliance with offloading heels. Review of the resident's Wound Care Consult, dated 08/05/2021, included that the resident's Left Heel Stage 4 Pressure Injury was improving. During an interview with the surveyor on 08/10/2021 at 08:45 AM, the Certified Nursing Assistant assigned to Resident #44 stated she was uncertain if the resident had a wound and that the resident did not have any positioning devices while in bed. During an interview with the surveyor on 08/10/2021 at 8:49 AM, the Licensed Practical Nurse (LPN) assigned to Resident #44 stated she was unsure if the resident had a wound. The LPN then checked the TAR and stated the resident had a left heel wound. When asked if the resident had any positioning or offloading devices for the bed, the LPN stated she would have to go to the resident's room to check. In the presence of the surveyor, the LPN entered Resident #44's room, pulled the resident's blanket of his/her feet, and revealed the resident was wearing non-skid socks, with heels resting directly on the mattress. The LPN then took one of the pillows at the head of the resident's bed and placed it under the resident's legs to offload the heels. During an interview with the surveyor on 08/10/2021 at 8:57 AM, the Unit Manager (UM) stated that Resident #44 had a left heel wound and that staff encourage the resident to offload heels using a pillow under the resident's legs. The UM further stated the resident could remove the pillows, but that staff are expected to reapply the pillow throughout the shift. During an interview with the surveyor on 08/10/2021 at 9:17 AM, the Assistant Director of Nursing (ADON) stated that Resident #44 had a foot wound and to her knowledge, the resident did not refuse offloading. The ADON further stated if a resident refuses a treatment, the nurse should document no on the TAR which would also initiate a corresponding progress note to explain why the order was not completed. Review of the facility's Wound Care policy, updated 5/2021, included, The following information should be recorded in the resident's medical record: . Any problems or complaints made by the resident related to the procedure . If the resident refused the treatment and the reasons why. NJAC 8:39-27.1(a)

Based on observation, interview, review of medical records, and other facility documentation, it was determined that the facility failed to maintain a medication error rate of less than 5%. This deficient practice was identified for 1 of 3 nurses, on 1 of 2 units (Unit 3), who administered medication to 1 of 5 residents. There were 2 medication errors out of 31 medication opportunities (Resident #50), which resulted in a medication error rate of 6%. This deficient practice was evidenced by the following: On 08/06/2021 at 8:40 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medications to Resident #50. The LPN dispensed seven oral (by mouth) medications, including a [MEDICATION(S)] 5,000 mcg (microgram) capsule and one [MEDICATION(S)] 100 mg (milligram) capsule. The LPN recorded the medications were administered in the electronic Medical Administration Record (eMAR). Review of the August 2021 Order Summary Report for Resident #50 included the following orders: [MEDICATION(S)] Capsule 300 mg Give 1 capsule by mouth two times a day for Diabetic [CONDITION(S)], (Error #1) and [MEDICATION(S)] Capsule Give 1,000 IU (International Units) by mouth one time a day for supplement, (Error #2). Review of the August 2021 eMAR for Resident #50 revealed that the LPN recorded the aforementioned orders as administered. On 08/06/2021 at 11:12 AM, in the presence of two surveyors, the LPN removed all medications from the medication cart that were administered during the morning medication observation for Resident #50, which included [MEDICATION(S)] 100 mg capsules and [MEDICATION(S)] 5,000 mcg capsules. The LPN confirmed that she administered one capsule of the [MEDICATION(S)] 100 mg, and that according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN then checked the medication cart and showed the surveyors the resident's [MEDICATION(S)] 300 mg capsules. The LPN also confirmed the order for [MEDICATION(S)] was 1,000 IU and did not know if the [MEDICATION(S)] 5,000 mcg she administered that morning was equivalent to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the surveyor on 08/09/2021 at 11:03 AM, the Unit Manager (UM) stated that nurses should be checking the residents' medications during medication pass, to ensure the medication and dose match the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the surveyor on 08/09/2021 at 12:13 PM, the Assistant Director of Nursing (ADON) stated nurses should be checking the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON further stated that the LPN should have clarified the order for [MEDICATION(S)] before administering the [MEDICATION(S)] 5,000 mcg capsule and administered [MEDICATION(S)] 300 mg, as ordered. Review of the facility's policy Administering Medications, revised 10/2019, included, Medications must be administered in accordance with the orders, and, The individual administering the medication must check the label against the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . NJAC 8:39 - 29.2(d)

Based on interview and record review, it was determined that the facility failed to complete a comprehensive Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care for residents, for Resident #8. This deficient practice was identified for 1 of 11 residents reviewed for Resident Assessment and was evidenced by the following: A review of the MDS section of the Electronic Medical Record (EMR) for Resident #8 revealed that the Quarterly MDS on 03/30/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/07/21, revealed that the 03/30/21 Quarterly MDS was completed. The EMR did not reflect that the facility initiated the Annual Comprehensive Assessment as the next MDS assessment. During an interview with the surveyor on 08/10/21 at 10:04 AM, the MDS Coordinator stated that the facility was under new ownership as of 04/01/21. During the transfer of the MDS records from the former company, there was a glitch in the transition of files and about eight residents, completed during the last week of March 2021, did not transfer over correctly. The MDS Coordinator confirmed that the resident did not trigger for the next Annual Comprehensive Assessment MDS until the June schedule. During an interview with the surveyor on 08/10/21 at 1:42 PM, the Administrator stated that the next MDS should have been completed three months after March 2021. A review of the facility's MDS Completion and Submission Timeframes undated policy reflected that Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, in Chapter 2, on page 2-21, The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) N.J.A.C. 8:39-11.1

Based on interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care for residents, for Residents #1, #2, #3, #4, #5, #6, #7, #9, #10 and #11. This deficient practice was identified for 10 of 11 residents reviewed for Resident Assessment and was evidenced by the following: A review of the MDS section of the Electronic Medical Record (EMR) for Resident #1 revealed that the Quarterly MDS on 03/22/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/05/21, that revealed the 03/22/21 Quarterly MDS was completed. The EMR did not reflect that the facility initiated the next quarterly MDS assessment. A review of the MDS section of the EMR for Resident #2 revealed that the Annual MDS on 03/23/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/06/21, that revealed the 03/23/21 Annual MDS was completed. The EMR did not reflect that the facility initiated the next quarterly MDS assessment. A review of the MDS section of the EMR for Resident #3 revealed that the Quarterly MDS on 03/23/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/06/21, that revealed the 03/23/21 Quarterly MDS was completed. The EMR did not reflect that the facility initiated the next quarterly MDS assessment. A review of the MDS section of the EMR for Resident #4 revealed that the Admission MDS on 03/30/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/02/21, that revealed the 03/30/21 Admission MDS was completed. The EMR did not reflect that the facility initiated the next quarterly MDS assessment. A review of the MDS section of the EMR for Resident #5 revealed that the Quarterly MDS on 03/24/21 in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/07/21, that revealed the 03/24/21 Quarterly MDS was completed. The EMR did not reflect that the facility initiated the next quarterly MDS assessment. A review of the MDS section of the EMR for Resident #6 revealed that the Quarterly MDS on 03/30/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/15/21, that revealed the 03/30/21 Quarterly MDS was completed. The EMR did not reflect that the facility initiated the next quarterly MDS assessment. A review of the MDS section of the EMR for Resident #7 revealed that the Quarterly MDS on 03/31/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/15/21, that revealed the 03/31/21 Quarterly MDS was completed. The EMR did not reflect that the facility initiated the next quarterly MDS assessment. A review of the MDS section of the EMR for Resident #9 revealed that the Quarterly MDS on 03/30/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/15/21, that revealed the 03/30/21 Quarterly MDS was completed. The EMR did not reflect that the facility initiated the next quarterly MDS assessment. A review of the MDS section of the EMR for Resident #10 revealed that the Quarterly MDS on 03/30/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/15/21, that revealed the 03/30/21 Quarterly MDS was completed. The EMR did not reflect that the facility initiated the next quarterly MDS assessment. A review of the MDS section of the EMR for Resident #11 revealed that the Quarterly MDS on 03/30/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/15/21, that revealed the 03/30/21 Quarterly MDS was completed. The EMR did not reflect that the facility initiated the next annual MDS assessment. During an interview with the surveyor on 08/10/21 at 10:04 AM, the MDS Coordinator stated that the facility was under new ownership as of 04/01/21. During the transfer of the MDS records from the former company, there was a glitch in the transition of files and about eight residents, completed during the last week of March 2021, did not transfer over correctly. The MDS Coordinator confirmed that the residents did not trigger for the next MDS until the June schedule. During an interview with the surveyor on 08/10/21 at 1:42 PM, the Administrator stated that the next MDS should have been completed three months after March 2021. A review of the facility's MDS Completion and Submission Timeframes undated policy reflected that Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, Chapter 2, on page 2-33, the Quarterly assessment is a non-comprehensive assessment for a resident that must be completed at least every 92 days N.J.A.C. 8:39-11.1

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices and handle soiled personal protective equipment in a safe and sanitary manner during a COVID-19 Focused Survey. This deficient practice was identified for 2 of 3 nursing units (Unit #2 and Unit 3), as was evidenced by the following: On 05/19/20 at 11:03 AM, during the initial tour of the facility, the surveyor interviewed the Unit Manager (UM) of Unit #2 regarding Personal Protective Equipment (PPE) (specialized clothing or equipment worn by employees for protection against safety hazards) required to care for residents who tested positive for COVID-19. The UM stated that all staff was required to wear an N-95 mask (a mask that filters out 95% of airborne particles), gown, protective eyewear, and gloves when entering the room of a COVID-19 positive resident and were not permitted to wear gowns in the hallway. At 11:16 AM, the surveyor observed signage outside of a resident room, which revealed that the resident was on Extended Contact and Airborne Precautions for particular respiratory circumstances. Further review of the signage revealed that staff was required to perform hand hygiene before and after patient contact, contact with the environment, and after removal of PPE. The surveyor observed a female caregiver open the closed door of the resident's room before removing her gloves and discarding them in a trash can. She exited the room without first performing hand hygiene or removing an orange gown that covered her uniform. She pulled back the outside curtain that covered the front of the linen cart and obtained a blanket from the shelf. When interviewed, the caregiver identified herself as a Hospice Aide (health care professional who provided personal care to the terminally ill ) who was employed by an outside agency. She stated that she already provided AM (individual) care to the resident. She further said that she removed her gloves and just stepped out into the hall for a second to get a blanket from the linen cart. She stated that she was not supposed to wear a gown outside of the resident's room. She further noted that she was required to remove her gown and dispose of it in the trash can inside the room when she finished with the care of the resident. At 11:21 AM, the surveyor interviewed the UM of Unit #2, who stated that the Hospice Aide should have removed both her gown and her gloves and performed hand hygiene before exiting the resident's room and accessed the linen cart. She stated that the linen cart was contaminated. She further noted that the linen cart would be removed from the unit, decontaminated, and exchanged to prevent the potential spread of infection. At 11:26 AM, the surveyor observed the Hospice Aide come out of the room with two bags of trash, which she placed in the soiled utility room. She then turned on the faucet, wet her hands, applied soap, and washed her hands for 15 seconds. When interviewed, the Hospice Aide stated that she was required to wash her hands for 15 to 20 seconds. At 11:32 AM, the surveyor interviewed the UM of Unit #2, who stated that staff was required to turn on the faucet, wet their hands, apply soap, and scrub for 20 seconds. At 11:35 AM, the surveyor observed CNA #1, who wore an orange gown over her uniform as she walked through the hallway. She entered a resident room that contained external signage and cautioned that the resident was on Extended Contact and Airborne Precautions. The surveyor interviewed CNA #1, who stated that the resident was presumed to be positive for COVID-19 due to refusal of testing. She noted that the facility required her to doff her gown and place the disposable gown in a plastic bag, tie the bag shut and dispose of it in the designated area near the nurse's station. CNA #1 removed her gown and accessed a plastic PPE cart in the hallway that contained plastic bags but did not obtain a plastic bag. She stated that she needed a small bag and closed the cart. She then proceeded to the soiled utility room and disposed of the orange gown directly into a bin within the room without first placing it in a secured plastic bag as described. The surveyor noted a sign affixed to the door of the soiled utility room, which cautioned that all discarded gowns must be put in a clear garbage bag, tied, and placed in the bins. At 11:49 AM, the surveyor interviewed the UM of Unit #2, who stated that all gowns should be bagged, tied, and disposed of in the bins provided in the soiled utility room. At 12:26 PM, the surveyor toured Unit #3 of the facility and observed CNA #2 exit the room of a resident who had signage outside of the room to indicate that Extended Contact and Airborne Precautions were required. The surveyor observed that CNA #2 placed a pair of gloves into a trash bag located in the hallway. When interviewed, CNA #2 stated that she performed hand hygiene with alcohol-based hand rub before she left the resident's room but then carried her gloves to the trash bag in the hall to discard them. She then applied gloves without performing hand hygiene and pushed the lunch truck down the hall. At 12:45 PM, the surveyor interviewed the Unit Manager In-Training of Unit #3, who stated that once gloves were removed, staff were required to perform hand hygiene and before the application of new gloves. She further noted that handling soiled gloves after hand hygiene was performed would make your hands dirty again. At 2:01 PM, the surveyor interviewed the Center Nurse Executive (CNE), who stated that hand hygiene was required after resident care was provided, and gloves were to be discarded. She further noted that failure to do so before accessing a linen cart would render the cart contaminated. She stated that after glove removal, the staff was required to throw them in the trash and wash their hands for 20 seconds. When the staff changed their gloves, they were also required to perform hand hygiene. The CNE stated that extended use gowns were permitted to be worn from room to room, providing that all residents were positive for COVID-19. She said that when staff finished with resident care, they should doff their gowns, place them in a plastic bag, tie it shut and place it in the receptacle provided. She further stated that all gowns should be bagged and tied shut when carried through the hallway; and that the purpose of bagging soiled gowns was to prevent transmission of infection. The surveyor reviewed the facility policy, IC203 Hand Hygiene (Reviewed 11/15/19) which revealed the following: Purpose: To improve hand hygiene practices and reduce the transmission of pathogenic microorganisms. Process: Perform hand hygiene: Before resident care .after patient care, after contact with the patient's environment. Hand hygiene techniques: To wash hand with soap and water: Wet hands with warm (not hot) water, apply soap to hands and rub hands vigorously outside the stream of water for 20 seconds covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with a disposable towel. Use a clean, dry, disposable towel to turn off the faucet. Surveyor review of the facility policy titled, IC303 Droplet Precautions and Respiratory Hygiene/Cough Etiquette (Revised 06/15/19) which revealed the following: 4.3 Before exiting the room, remove and bag PPE and wash hands. 4.3.1 Remove bagged PPE from the room and discard in soiled utility. NJAC 8:39-19.4 (a) 1 and 2

COMPLAINT # NJ 4 Based on interviews, review of the Medical Record (MR), and other pertinent facility documentation on 9/20/2019, it was determined that the facility staff failed to notify a resident's #1 contact of a change in condition (Fall), as well as follow their own facility policy titled Accidents/Incidents, and Change in Condition: Notification of for 1 of 5 sampled residents (Resident #3). This deficient practice is evidenced by the following: 1. According to the facility Admission Record, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 9/4/2018, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3/15, indicating that Resident #3 had severely impaired cognition. The MDS documentation included that Resident #3 required assistance for Activities of Daily Living (ADLs). Review of a Care Plan (CP) dated 6/6/2016,with a revision date of 9/13/2018, under Focus revealed Resident is at risk for falls: cognitive loss, lack of safety awareness, Goal : Resident will have no falls with injury x 90 days. Interventions included but were not limited to: Assess for changes in medical status, pain status, mental status and report to MD (Medical Doctor) as indicated. Remind and encourage to use call light for assistance. Review of a Change in Condition Evaluation form dated 9/12/2018, revealed that Resident #3 had a fall on 9/12/2018. Found Resident in the bathroom sitting on the floor next to a empty ice cream cup and spoon. Under Name of family/healthcare agent notification, it was noted that the Emergency Contact #2 had been notified of the fall at 14:15 (2:15 p.m.) and not the Emergency Contact #1 POA (Power of Attorney). Review of Progress Notes dated 9/12/2018 at 12:30, revealed A change in condition has been noted. The symptoms include: falls 09/12/2018, in the afternoon. Name of family/Healthcare agent notified: Emergency Contact #2. During an interview on 9/20/2019 at 11:20 a.m., the Licensed Practical Nurse Unit Manager (LPNUM) stated that when a resident sustains a fall the family is notified immediately, as soon as possible notifying the Doctor (DR) first then the emergent contacts. The LPNUM further stated call the first contact, run all contacts until I get someone. During an interview on 9/20/2019 at 11:43 a.m., the Assistant Director of Nursing (ADON) stated that Once the patient is assessed notify the Dr, then notify family immediately. The ADON further stated the POA is the first contact you call. Review of a facility policy titled Accidents/Incidents with a review date of 5/2/2018, under 2. Assessment, Medical Assistance, Documentation: under 2.1.5 revealed The patients responsible party/family will be notified of the accident/Incident and any follow -up treatment needed. Review of a facility policy titled Change in Condition: Notification of effective date 11/28/2016, revealed under Policy: A center must immediately inform the patient, consult with the patients physician, and notify, consistent with his/her authority, the patient's Health Care Decision Maker (HCDM), where there is: An accident involving the patient which results in injury and has the potential for requiring physician intervention . NJAC 8:39 -13.1 (c)

Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 8:35 AM to 9:36 AM, the surveyor, accompanied by the Cook and Dining Room Director (DRD), observed the following in the kitchen: 1. Upon entry to the kitchen the surveyor observed a Food Service Worker (FSW) working on the breakfast tray-line. The FSW had a lengthy mustache/goatee. The FSW had no beard guard and the mustache/goatee was exposed. The FSW's hair was in a dreadlock style and had a hairnet that only partially covered his hair, leaving the front third of the hair exposed. 2. The surveyor observed the cook perform handwashing at the designated handwashing sink after removing her disposable gloves. The cook proceeded to wet her hands and then apply soap. The cook performed vigorous handwashing for three seconds and then placed her hands under the running water and rinsed her hands. The cook then proceeded to grab a hand towel, dried her hands, and threw the hand towel into the trash can. 3. On a lower shelf in the Dry Storage area a can of Fancy Sliced Beets had a noticeable dent on the side seam of the can. The cook removed the can to the designated dented can bin. On a middle shelf a sealed plastic container contained coconut shavings. The container was labeled ,[DATE] and had an additional date of ,[DATE]. The cook stated, that should be thrown away, it was supposed to be used by ,[DATE]. The cook threw the coconut in the garbage. 4. In the Walk-In Refrigerator on a middle shelf an opened plastic gallon container of Ventura French Dressing had an open date of ,[DATE]. When interviewed by the surveyor, the cook stated, they are good for 30 days after opening. That is expired and is going in the trash. The cook threw the dressing into the trash. 5. The surveyor observed the DRD perform handwashing upon entry to the kitchen. The DRD applied soap to her hands then proceeded to wash her hands vigorously for 13 seconds under the running water, effectively removing the soap from her hands. The DRD then proceeded to turn off the faucet with her bare hand and grabbed a hand towel to dry her hands. The DRD then threw the hand towel in the trash next to the sink. 6. On a shelf in the cooks prep area, an opened bottle of[NAME]and Seasoning Sauce was labeled open on ,[DATE] and had a use by date of ,[DATE]. The DRD stated, The manufacturer's date is one year but I use 30 days as my policy. This should have been thrown away. I know it's still good but I'm gonna have to toss it. The DRD threw the bottle of Seasoning and[NAME]Sauce in the trash. On [DATE] from 9:33 AM to 10:33 AM, the surveyor, accompanied by the DRD and District Manager (DM), observed the following in the kitchen: 1. Upon entry to the kitchen, the surveyor observed a FSW in the dishroom. The FSW was observed to have a goatee type beard on his chin. The FSW had no beard guard and the goatee type beard was exposed. In addition, the FSW's hair braids extended past his shoulders in the back. The FSW's hairnet did not cover the lower ,[DATE] of the FSW's braids which were exposed. 2. In the Cooks Fridge, a third pan contained fresh roasted garlic and was covered with plastic wrap. The plastic wrap was dated ,[DATE] and had a use by date of ,[DATE]. When interviewed, the DRD stated, That's expired on the fourteenth, its trash. The DRD threw the roasted garlic in the trash. On [DATE] from 9:30 AM to 9:34 AM, the surveyor, accompanied by the DM, observed the following in the Main Dining Room: 1. The surveyor observed a wheeled cart adjacent to the kitchen door in the dining room. The cart contained 11 stacks of cleaned and sanitized bowls and dessert plates. The plates and bowls were not inverted or covered and were exposed. The plates and bowls were utilized to serve resident meals. When interviewed, the DM stated, Those should be stacked inverted. I will have them rewashed and sanitized and we will stack them in the inverted position to protect from contamination. The surveyor reviewed the Healthcare Services Group, Inc. and its subsidiaries policy titled Staff Attire, HCSG Policy 024, Revised ,[DATE]. The policy stated the following under the Procedures section: 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. The surveyor reviewed the Healthcare Services Group, Inc. and its subsidiaries policy titled Receiving, HCSG Policy 017, Revised ,[DATE]. The policy stated the following under the Procedures section: 4. All canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. 6. All food items will be stored in a manner that ensures appropriate and timely utilization based on the principles of first in - first out (FIFO) inventory management. The surveyor reviewed the Healthcare Services Group, Inc. and its subsidiaries policy titled Warewashing, HCSG Policy 022, revised ,[DATE]. The policy stated the following under the Procedures section: 4. All dishware will be air dried and properly stored. The surveyor reviewed the Healthcare Services group Handwashing Procedure For Dining Services, Inservice & Policy Training v1. The procedure revealed the following: The hand washing procedure is as follows: 1. Wet hands 2. Apply soap thoroughly. Get under nails and between fingers. 3. If necessary, use a brush to remove resistant particles. 4. With a rotating frictional motion, rub hands for at least 20 seconds. Wash at least 3 to 4 inches above the wrist. 5. To wash fingers and spaces between them, interlace and rub up and down. 6. Rinse well. 7. Dry thoroughly. Be sure not to use the paper towel to wipe down surfaces or turn water off before drying your hands. 8. Turn water off with a paper towel. Make certain the sink is clean before exiting. NJAC 8:,[DATE].2(g)

Based on interview and the review of medical record, it was determined that the facility failed to provide an identified fall/injury prevention intervention for resident transfer. The resident fell and sustained a fracture of the left leg. The resident was transferred to the hospital and underwent surgical intervention and a long leg cast. This deficient practice was identified in 1 of 10 residents, Resident #1 reviewed for falls/accidents and was evidenced by the following: 1. On 8/26/13, the surveyor reviewed the medical record of Resident #1. According to the Admission Record, Resident #1 was admitted to facility with [DIAGNOSES REDACTED]. A 1/22/13 Minimum Data Set (MDS), an assessment tool, indicated that Resident #1 was cognitively impaired, non-ambulatory, and dependent on staff for transfer out of bed and wheelchair. Upon review of the Resident Incident Report (IR), the surveyor noted that on 12/21/12 at 9 a.m., Resident #1 sustained injury to the right great toe during a transfer from wheelchair onto the toilet by a Certified Nursing Assistant (CNA). According to the IR, Resident #1's right great toe got stuck under the leg of the commode and caused the toe nail to lift up off the nail bed. Further review of the investigation revealed that the facility instituted a Sit-to-Stand Lift for resident transfers, as a measure to prevent further incidents/injuries. The surveyor reviewed another Incident Report which indicated that Resident #1 slipped to the floor on 12/26/12 at 8 p.m., as a CNA transferred him/her from wheelchair to the bed. The report indicated that Resident #1 sustained bruises to the left calf and left mid back and the resident complained of knee pain. The facility notified the physician who then ordered an X-ray. The preliminary report of the X-ray revealed no fracture. The surveyor reviewed a nurse Progress Note dated 12/27/12 at 9:28. This revealed that Resident #1 was observed in bed in the morning with left leg bruised and swollen and the "resident crying throughout a.m." It was further stated in the Progress Note that two percocet (narcotic analgesics) were administered to the resident and that the resident was then sent out to the hospital for evaluation. The X-ray report dated 12/27/12 indicated that Resident #1 sustained fractures of the left Tibia and Fibula. The facility then changed the resident's plan of care to include use of a Hoyer lift (mechanical lift) for transfer. The facility's Summary & Conclusion report concluded that the fracture occurred during the transfer from chair to bed. It was also indicated in the Summary & Conclusion that Resident #1 was able to perform stand and pivot transfer until 12/21/12 and that the CNA transferred the resident using a stand and pivot system on 12/26/12. The report indicated that the CNA had been off the schedule until 12/26, thus unaware of the change in transfer equipment. The surveyor reviewed the CNA's Care Cardex but did not see any information regarding the use of a Sit-to-Stand device. The surveyor interviewed the Registered Nurse Unit Manager (RN/UM) on 8/27/13 at 12:30 p.m. She stated to the surveyor that CNAs should be looking at the Care Cardex for information on resident's care needs and that CNAs also give end of shift reports to each other. When interviewed on 8/28/13 at 1:30 p.m., the Director of Nursing (DON) she told the surveyor that the CNA followed a restorative plan of care for Resident #1, which did not involve use of a Sit-to-Stand device. She also told the surveyor that the use of the Sit-to-Stand was Resident #1's family request to which the facility did not agree. The facility did not have any documented evidence of discussion with the resident's family or the rehabilitation department regarding a transferring device. The resident's care plan dated 12/21/12 indicated to use Sit-to-Stand Hoyer for all transfers. On 8/29/13 at 9:30 a.m., the DON told the surveyor that the CNA used the resident Restorative care book and "probably did not check the CNA Care Cardex." However, surveyor review of the Care Cardex revealed it had not been updated for the CNAs. NJAC 8:39 - 27.1(a)

C# NJ Based on observation, interviews, review of the medical records and pertinent documents; it was determined that the facility failed to consistently document daily wound monitoring, weekly skin assessments, and treatment administration in accordance with acceptable nursing standards of practice, and in accordance with the New Jersey Board of Nursing Statutes for 1 of 3 sampled residents (Resident #4). In addition, the facility failed to consistently follow their own facility policy to "document the treatment on the TAR (Treatment Administration Record)" for 1 of 3 sampled residents (Resident #4). Resident #4's pressure wound progressed to a Stage IV which required hospitalization . Resident #4 underwent surgical intervention on two occasions, and received intravenous antibiotics for six weeks. In addition, the hospital records (Wound Consult) dated 2/15/13 showed the wound measured approximately 4 X 5 centimeters(cm) in diameter and 3 cm deep with bone exposure. Malodorous yellow green drainage was noted. The wound was described as infected (osteo[DIAGNOSES REDACTED]) with tissue necrosis. This deficient practice is evidenced by the following: Reference: New Jersey Board of Nursing Statutes states: "The practice of nursing as a registered professional nurse is defined as ... executing medical regimens as prescribed by a licensed or otherwise legally authorized physician..." Reference: New Jersey Board of Nursing Statutes states: "The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding;..provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist." REFER TO EXAMPLE #1 F279 and F314 NJAC 8:36-27.1(a)(e)

C# NJ Based on observation, interviews, review of the medical records and pertinent documents; it was determined that the facility failed to consistently do weekly skin assessments, and administer prescribed treatments for 1 of 3 sampled residents (Resident #4). Resident #4's pressure wound progressed to a Stage IV which required hospitalization . Resident #4 underwent surgical intervention on two occasions, and received intravenous antibiotics for six weeks. In addition, the hospital records (Wound Consult) dated 2/15/13 showed the wound measured approximately 4 X 5 centimeters(cm) in diameter and 3 cm deep with bone exposure. Malodorous yellow green drainage was noted. The wound was described as infected (osteo[DIAGNOSES REDACTED]) with tissue necrosis. This deficient practice is evidenced by the following: The surveyor reviewed the medical records on 6/26/13 and 7/10/13. Resident #4 was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Sheet (MDS) an assessment tool dated 12/19/12 indicated that the resident was cognitively impaired and totally dependent on staff for activities of daily living (ADL). One Stage II wound was documented. The revised Care Plan dated 9/27/12 identified actual skin breakdown related to limited mobility. In addition, a small granulated area was noted to the right buttock/sacrum. Interventions included but were not limited to daily wound evaluation, including the surrounding tissue. Weekly wound assessments done by the licensed nurse; were to include measurements and a description of the wound. The Physician order [REDACTED]. The POS dated 12/25/12 showed orders to clean the sacrum with wound cleanser and apply [MEDICATION NAME] and a dry dressing daily. ([MEDICATION NAME] is used as an adjunct to prevent and treat [MEDICAL CONDITION] in patients with 2nd and 3rd [MEDICAL CONDITION](pdr.net)). There was no description of the sacrum in the Nurse's Notes (NN) from 12/4/12-2/14/13; in addition to the Skin Integrity Report. The December 2012 Treatment Administration Record (TAR) indicated that weekly skin assessments were done on Monday; 12/3 and 12/10, and were coded as a "1". According to the TAR; "1" indicated that there was no skin injury/wound present. The weekly skin assessments were not documented as signed and/or completed on 12/17, 12/24, and 12/31. There were no staff initials for the Bag Balm treatment at 10:00 a.m. on 12/18, 12/19,12/20, 12/26, 12/27, 12/28 and at 10:00 p.m. on 12/7, 12/28, and 12/31; totaling 9 out of 31 days; which indicated that the treatment was not done. The January 2013 TAR revealed that the weekly skin assessments were done every Monday on 1/7, 1/14, 1/21, and 1/28. Each assessment was coded as "3" on the TAR; which indicated that the skin injury/wound was previously identified. In addition, "yes" was checked indicating that a wound was present. The wound site was initialed for monitoring the status of the dressing, surrounding tissue, and wound pain. There were no staff initials indicating the wound site was monitored on 1/3, 1/4, 1/5, 1/6, 1/11, 1/17, 1/26, and 1/27; totaling 8 out of 31 days; which indicated that wound monitoring was not done. The physician progress notes [REDACTED]. The POS dated 1/28/13 indicated orders to cleanse the sacral wound with Microclenz and to apply Santyl with a dry dressing daily. (According to the Drug Information Handbook for Nursing 8th edition (2007) pg. 301; Santyl promotes debridement of necrotic tissue in dermal ulcers and severe burns.) There was no documentation on the Skin Integrity Report, "Wound Care Monthly Progress and Tracing Sheet", or NN that described the sacral wound. The February 2013 TAR indicated that weekly skin assessments were done on 2/1, 2/8, and 2/14. "1" was coded on 2/1 and 2/8 which reflected that there was no skin injury or wound. However, the "yes" was checked which signified that a wound was present. In addition, the wound site was initialed for monitoring the status of the dressing, surrounding tissue, and wound pain daily. Omissions for monitoring the wound site were noted on 2/7 and 2/13. The "Wound Care Monthly Progress and Tracing Sheet" dated 2/7 and 2/14 showed a sacral wound that measured 4 X 3. There was no indication of which type of measurement was used; i.e.. centimenters or inches. There were no initials for the Bag Balm, [MEDICATION NAME], and Santyl treatments on 2/7 and 2/13 at 9:00 a.m; which indicated that the treatments were not applied. The Skin Integrity Report dated 2/14/13 did not identify the initial date, location or stage of the wound. However, the Skin Integrity Report showed that the area measured 4 X 3 cm and 0 cm (depth). There was 50% slough and granulation with moderate serosanguineous drainage. There was no documentation in the odor section of the Skin Integrity Report. In addition, there was no documentation in the NN that described the wound or when the sacral wound was identified. The POS dated 2/7/13 showed orders for a Gastrointestinal Consultation for possible tube feeding placement. The NN dated 2/14/13 showed that the resident left the facility via stretcher at 11:50 a.m. for peg tube placement. On 7/19/13 at 1:14 p.m. and 7/23/13 at 1:24 p.m., the Director of Nursing (DON) faxed statements to the Department of Health (DOH). The documents indicated that on 12/25/12 the sacral wound was not open. "They used preventive cleansers and treatments trying to keep it closed." The physician progress notes [REDACTED]. However, the DON's faxed statements to DOH indicated that the wound was not open "(more dry like a scab)". The DON confirmed that there were no skin integrity reports for December 2012 and January 2013 or documentation on the 24 hour report; because there were no open areas. Further documentation in the DON's faxed statement showed that the wound opened on 2/7/13; when the GI consult for the tube feeding was ordered. However, the same document revealed that the wound did not re-open until 2/14/13. There was a discrepancy as to when the wound re-opened in February 2013. The hospital records revealed that the 2/14/13 Anesthesiologist's History and Physical report indicated that a foul smelling odor emanated from the sacral wound. The Wound Consult dated 2/15/13 showed that the sacral area measured approximately 4 X 5 centimeters (cm) and 3 cm deep. There was a layer of necrotic tissue and malodorous yellow drainage. The sacral ulcer was debrided at the bedside following an examination of a small amount of necrotic tissue. Santyl ointment was ordered for a few days and redebridement was required the following week. On 2/18/13 the preoperation [DIAGNOSES REDACTED]. The operative findings showed the sacral wound measured 5 X 6 cm; osteo[DIAGNOSES REDACTED] involved the coccyx which was detached from its attachment to the sacral bone. Excision of coccyx and debridement of the sacral bone was done. The Infectious Disease Consult dated 2/22/13 revealed that the pathology report was positive for acute and chronic osteo[DIAGNOSES REDACTED]. The resident required six weeks of intravenous antibiotics. An interview was conducted by the surveyor on 7/10/13 at 2:29 p.m. with the Unit Manager (UM). She stated that [MEDICATION NAME] was ordered when the sacral area was reddened. The UM explained that the primary nurse was responsible for documenting that the weekly skin assessment was done. The UM further explained that Skin Integrity Report was used when the resident had actual skin breakdown. She stated that she completed the Skin Integrity Report on 2/7/13. However, the document was never presented to the surveyor. She continued to explain that she did the wound measurements on 2/14/13 because she knew the resident was scheduled to have a gastrostomy tube placed on 2/15/13. The UM stated that she believed that the resident's wound was a Stage 3 on 2/14/13; but was not 100% sure. The UM further stated that Santyl was ordered because the resident's wound was a Stage 3. An interview was conducted by the surveyor on 7/10/13 at 3:00 p.m., with the Licensed Practical Nurse (LPN) that received orders from the physician on 1/28/13. The LPN explained that the previous treatment was not effective. She further explained that the wound was not open on 1/28/13. She continued to explain that a nurse's note would be written if there was a change in the wound's appearance. The LPN stated that she did not write a note because there was no change. Post-survey telephone interviews were conducted by the surveyor on 7/18/13 at 2:18 p.m. & 3:00 p.m. and on 7/25/13 at 10:17 a.m., with the Director of Nursing (DON). The DON stated that on 12/25/12 and 1/28/13 the sacral wound was closed. She further stated that the treatment order was written as a [MEDICATION NAME] treatment. The DON explained that it would be better nursing practice for the nurse to document in nurse's note when a doctor's order was obtained. She further explained that she was in the process of educating the nursing staff to write the reason an order was obtained. She stated that monitoring the wound site on the TAR was a "FYI" (for your information). She further stated that the nurses did the treatments daily and would observe the wound. The DON explained that the Skin Integrity Reports were done when a wound was discovered. She further explained that the primary nurse was responsible for doing the weekly skin assessments and documenting on the TAR. The DON continued to explain that the wound did not open until early February 2013. She stated that she did not know where the Skin Integrity Report for 2/7/13 was. She further stated that the depth of the wound determined the stage of the wound. She said that the measurements (4 X 3) was indicative of a Stage 2 wound. The DON explained that the monthly wound tracking forms did not reflect the actual day of the skin breakdown. However, she further explained that the Skin Integrity Forms showed the actual date of the wound assessment. The facility policy titled, "Skin Integrity Management" included but was not limited to "...Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with any deterioration of wound. Perform daily monitoring of wounds or dressings for any presence of complications or declines. Document on TAR and/or Nurse's Note...For wounds requiring daily dressing change, monitor for any signs of decline in wound status. If any decline in wound, surrounding tissue, or wound pain, complete the Skin Integrity Report and notify physician... Document appearance and condition of the wound weekly and with deterioration in wound condition on Skin Integrity Report...Evaluate the patient and the wound progress through routine, ongoing review and revision...Adjust plan of care, as indicated..." The facility policy titled, "Treatments" included but was not limited to documenting the treatment on the TAR. "If a treatment is omitted, circle your initials and indicate on back of treatment sheet the date, time, and reason for omission;..." The facility policy titled, "Dressing: Aseptic" included but was not limited to documenting the "appearance of the wound on Skin Integrity Report (Smartworks #GHC-692R); as indicated with weekly evaluations, or with any wound decline and/or complications;"..."Treatment in Nurse's Notes and/or on TAR..." There was no evidence that the aforementioned policies were consistently followed. NJAC 8:39-27.1(a)(e)