Every finding on record at Complete Care at Phillipsburg, LLC

Repeat DeficiencyBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain cleanliness of resident care equipment for 3 of 4 enteral feeding (TF) residents (Resident #3, #4, and #36) and b.) maintain infection control standards and procedures during wound care for 1 of 1 resident (Resident #31). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 6/15/26 at 10:51 AM, the surveyor observed Resident 36's enteral feeding machine (medical devices designed to safely deliver nutrition directly into the gastrointestinal tract) with droplet-shaped yellowish substances.On 6/15/26 at 11:20 AM, the surveyor reviewed the electronic medical record (E-mar) for Resident #36.A review of the resident's admission record (AR, an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; gastrostomy (g-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food), type 2 diabetes mellitus (a chronic condition characterized by insulin resistance and high blood sugar levels), and gastro-esophageal reflux disease (a chronic digestive disorder where stomach acid flows back into the esophagus).A review of the quarterly Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), with a reference date 5/30/26 indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #36 scored 9 out of 15, which indicated the resident had moderate cognitive impairment. The MDS further revealed that Resident #36 had an enteral feeding.A review of the physician order summary report (OSR) revealed a physician order (PO) dated 11/11/25, Enteral feeding order every day shift continuous Tube Feeding (TF) via g-tube of Glucerna 1.2 at (@) 75 milliliter per hour (ml/hr.) up at 6PM and down once total volume (TV) of 1500 ml infused to provide 1500 calories (kcal).On 6/16/26 at 8:34 AM, the surveyor observed Resident #36's TF machine with droplet-shaped yellowish substances. 2. On 6/15/26 at 11:02 AM, the surveyor observed Resident #3 in bed with their eyes closed. Surveyor further observed Resident 3's TF machine with droplet-shaped yellowish substances.On 6/15/26 at 11:25 AM, the surveyor reviewed the E-mar for Resident #3.A review of the Resident #3's AR, revealed the resident was admitted to the facility with diagnoses that included but were not limited to; gastrostomy, dysphagia (difficulty swallowing), and adult failure to thrive (the gradual decline in health and functional abilities in older adults).A review of the quarterly MDS, with a reference date 4/15/26 indicated the facility was unable to perform a BIMS test related to Resident #3 not being able to be understood. The MDS further revealed that Resident #3 had an enteral feeding.A review of the physician OSR revealed a PO dated 3/29/26, Enteral feeding order one time per day Jevity 1.2 calories, administered continuous via pump at 75ml per hour until total volume 1250ml delivered, providing 1500 kcal.On 6/16/26 at 8:39 AM, the surveyor observed Resident #3's TF machine with droplet-shaped yellowish substances.3. On 6/15/26 at 10:54 AM, the surveyor observed Resident #4's enteral feeding machine with droplet-shaped brown-yellowish substances.On 6/18/26 at 12:30 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #4.A review of the resident's AR revealed the resident was admitted to the facility with diagnoses that included but were not limited to; gastrostomy, essential hypertension (high blood pressure), and gastro-esophageal reflux.A review of the quarterly MDS, with a reference date 5/16/26 indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #4 scored 9 out of 15, which indicated the resident had moderate cognitive impairment. The MDS further revealed that Resident #4 had an enteral feeding.A review of the OSR revealed a PO dated 5/12/26, Enteral Feed Order one time a day Jevity 1.5 CAL up at 4 pm Administer continuous via Pump_85___ML per hour until TV 1365 ml reached, providing 2047 kcal/d .On 6/18/26 at 10:50 AM, the Regional Registered Nurse (RRN) provided the surveyor with the facility policy, Cleaning and Disinfection of Resident-Care Equipment, dated 9/3/25. The policy revealed, Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current Centers for Disease Control recommendations in order to break the chain of infection. The compliance guideline section of the policy further revealed, Direct care staff are responsible for cleaning single-resident equipment when visibly soiled. On 6/18/26 at 11:02 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated that the TF machines are to be cleaned by housekeeping and nursing staff. LPN#1 observed both Resident #3 and #36's TF machine and acknowledged that both TF needed to be cleaned and sanitized. 4. On 6/16/26 at 10:00 AM, the surveyor observed Resident #31 in bed. The resident did not respond to the surveyor. On 6/16/26 at 11:00 AM, the surveyor reviewed the medical record for Resident #31.A review of the AR reflected Resident #31 was admitted to the facility with diagnoses that included, but were not limited to; gangrene (the death of body tissue caused by a lack of blood flow), peripheral vascular disease ( a progressive circulation disorder), and vascular dementia (a decline in thinking and memory caused by conditions that block blood flow to the brain).A review of the quarterly MDS dated [DATE] indicated that Resident #31 had short and long-term memory problems.A review of the current order summary report (OSR) included a physician's order (PO) to cleanse the [NAME] ulcer (unavoidable skin breakdown that often appears in the final weeks or days of life) sacral wound with wound cleanser, apply calcium alginate with silver dressing (sterile wound care product designed for moderate to heavily exuding or infected wounds) to the wound base and cover with bordered gauze every day shift and as needed for soiled or dislodged dressing dated 6/10/26. A review of the quarterly MDS dated [DATE], indicated that the resident's cognitive skills for daily decision making were severely impaired. A review of Resident #31's CP reflected that the resident had impairment to their skin integrity r/t multiple wounds on admission, including frostbite and a sacral Kennedy ulcer, with interventions that included but were not limited to; weekly wound treatment and documentation to include measurement of each area of skin breakdown dated as initiated 6/15/26. A review of the weekly Wound Assessment Report indicated that the Sacral end-of-life skin failure wound was evaluated on 6/9/26. On 6/18/26 at 1:10 PM, the surveyor observed the Licensed Practical Nurse (LPN) perform the treatment to Resident #31's sacral wound and observed the following:The LPN disinfected the overbed table (OBT), applied a clean barrier, and gathered wound care supplies, which included 4x4 gauze pads, wound cleanser, calcium alginate with silver, and a border dressing. The surveyor observed the LPN and LPN/Unit Manager (who assisted with the resident's positioning) donned (put on) disposable gowns and gloves and entered the resident's room. The LPN placed the supplies on the OBT.The surveyor observed the LPN remove the soiled dressing, which contained copious purulent and serosanguineous drainage. The LPN discarded the soiled dressing, removed her gloves, performed hand hygiene, and donned a new pair of gloves. The surveyor observed the LPN, then cleansed the wound and opened the sterile calcium alginate dressing. Without disinfecting the scissors prior to use, the LPN cut the calcium alginate dressing with the scissors and touched the entire sterile dressing with her gloved hands before applying it to the wound bed. The LPN covered the wound with the border dressing. After completing the wound treatment, the LPN did not disinfect the OBT.Immediately following the treatment, the surveyor discussed the infection control breaches with the LPN in the presence of the LPN/UM. The LPN acknowledged that she should have disinfected the scissors prior to use and should only have touched the edges of the sterile calcium alginate dressing to minimize the risk of transferring bacteria into the wound bed. The LPN confirmed that she should have disinfected the OBT after she completed the treatment. On 6/22/26 at 12:00 PM, the surveyor discussed the above observations and concerns with the Director of Nursing (DON) and the RRR. On 6/23/26 at 9:30 AM, the surveyor reviewed the facility's, Wound Treatment Management policy dated 9/1/25 reflected.To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence based treatment in accordance with current standards of practice and physician order On 6/23/26 at 12:10 PM, the surveyor met with the covering LNHA, DON, VPO, and RRN for the exit conference; no further pertinent information was provided. NJAC 8:39- 27.1 (a)

Based on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms and common areas. The deficient practice was observed on 1 of 1 resident units during facility tour. The deficient practice was evidenced by the following: On 6/15/26 at 10:45 AM, during initial tour, the surveyor observed the following: 1. room [ROOM NUMBER] observed with multiple stained and buckled ceiling tiles. 2. room [ROOM NUMBER] observed with multiple stained and buckled ceiling tiles in the bathroom. 3. room [ROOM NUMBER] observed with multiple damaged floor tiles. 4. room [ROOM NUMBER] window track was observed dirty and had buckled ceiling tiles. 5. room [ROOM NUMBER] observed multiple stained ceiling tiles. 6. room [ROOM NUMBER] observed with multiple ceiling tile frames damaged and buckled ceiling tiles. 7. room [ROOM NUMBER] observed with multiple areas of wall damage. 8. room [ROOM NUMBER] observed with multiple areas of wall damage and multiple stained ceiling tiles in the room and adjoined bathroom. 9. Outside the first-floor bathroom, the surveyor observed stained ceiling tiles. 10. In the kitchen, the surveyor observed multiple stained and broken ceiling tiles. 11. Throughout the facility hallways and dining room the surveyor observed multiple stained and buckled ceiling tiles. On 6/18/26 at 10:50 AM, the Regional Registered nurse (RRN) provided the survey with a facility policy titled, Safe and Homelike Environment with a revised date 9/3/25. The policy revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. On 6/18/26 at 12:04 PM, the surveyor toured the above-mentioned rooms with the Director of Maintenance (DM), who stated that he had not been made aware of the above concerns and that his expectation was that the staff would inform him verbally. He has recently been familiarizing himself with the electronic Total Environmental & Life Safety system (TELS, a building management platform developed specifically for senior living communities, that integrates asset management, life safety, and maintenance solutions to help facilities operate efficiently, maintain compliance, and ensure resident safety) but is not proficient yet so he doesn't use it regularly. On 6/18/26 at 12:51 PM, the surveyor met with the Licensed nursing Home Administrator (LNHA), Director of Nursing (DON), [NAME] President of Operations (VPO), and RRN. The LNHA stated they are aware of the environmental concerns. On 6/23/26 at 12:10 PM, the surveyor met with the covering LNHA, DON, VPO and RRN for the exit conference, no further pertinent information provided. NJAC 8:39-4.1 (a)12

Based on observation, interview and record review, it was determined that the facility failed to update and revise the comprehensive care plan of a resident. This deficient practice was identified for 3 of 15 residents reviewed, Resident #4, Resident #5 and Resident #12.The deficient practice is evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.On 6/16/26 at 11:35 AM the surveyor interviewed the Certified Nurses Aide (CNA) who cared for and was familiar with Resident #4. The surveyor asked the CNA if the resident was able to use their call bell. The CNA stated yes, the resident could use it at times. On 6/18/26 at 11:29 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who cared for and was familiar with Resident #4. The surveyor asked the LPN if Resident #4 was able to use their call bell. The LPN stated that they never saw the resident use the call bell and they didn't think they would be able to.On 6/18/26 at 11:45 AM, the surveyor interviewed the Director of Nursing (DON) about Resident #4's call bell. The DON stated that they were very doubtful the resident would be able to use the call bell.On 6/18/26 at 12:30 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #4 which revealed the following:An admission Record (AR; an admission summary) that reflected the resident was admitted to the facility with diagnoses which included but not limited to; essential hypertension (high blood pressure) and hemiplegia / hemiparesis following cerebral infarction (paralysis or weakness following a stroke).A review of the Quarterly Minimum Data Set (QMDS), (an assessment tool used to facilitate the management of care), with an assessment reference date (ARD) of 5/16/26, had a Brief Interview Mental Status (BIMS) score of 9 out of 15, which indicated the resident has moderate cognitive impairment.A review of Section B of the QMDS revealed section Hearing, Speech, and Vision which reflected that the resident had an absence of spoken words.A review of Section GG of the QMDS revealed section Functional Abilities which reflected that the resident was totally dependent on caregivers.A review of the resident's Comprehensive Care Plan (CCP), a document that outlines a patient's healthcare needs and the nursing interventions required to meet those needs, dated revised 11/14/25, revealed, under the interventions area, an entry reflecting, that the resident's call light is within reach and encourage use.On 6/23/26 at 9:45 AM, the Regional Registered Nurse (RRN) provided the surveyor with an updated CCP with an intervention dated 6/18/26 reflecting that the resident is unable to use their call bell. 2.On 6/15/26 at 11:26 AM, the surveyor observed a handwritten paper sign attached to a wall below the television. The sign reflected to leave TV on at night due to (Res #12 name redacted) anxiety.On 6/18/26 at 11:36 AM, the surveyor interviewed the LPN who cared for and was familiar with Resident #12. The surveyor asked the LPN about the sign. The LPN stated that a family member put it there and the family member often does things on their own or makes requests to the staff.On 6/18/26 at 12:45 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #12, which revealed the following:An AR which reflected that Resident #12 was admitted to the facility with medical diagnoses that included but were not limited to; Type 2 Diabetes with hyperglycemia (a chronic condition of high blood sugar), hypothyroidism (the thyroid gland does not produce enough thyroid hormones resulting in slow metabolism) and hyperlipidemia (high levels of cholesterol and triglycerides in the blood). A Comprehensive Minimum Data Set (cMDS), with an ARD of 4/2/26, reflected that the resident had a BIMS score of 7 out of 15 indicating the resident had severe cognitive impairment. A CCP, dated revised 6/15/26, revealed a focus area, that the resident had an anxiety disorder. The CCP did not reflect under any section that the resident required a TV on at night for anxiety, a placement of a sign that revealed the resident had anxiety or that the family had placed a sign on the wall. 3. On 6/16/26 at 10:24 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #5 which revealed the following:An AR that reflected that Resident #5 was admitted to the facility with medical diagnoses that included but were not limited to; essential hypertension (high blood pressure), Type 2 Diabetes with hyperglycemia (a chronic condition where the body can not maintain normal blood sugar levels resulting in high blood sugar) and retention of urine (the inability to completely empty the bladder). A QMDS, with an ARD of 3/17/26 that reflected that the resident had a BIMS score of 15 out of 15 indicating the resident had no cognitive impairment. A review of Section H, Bladder and Bowel, revealed that the resident was assessed as occasionally incontinent. An Order Summary Report (OSR), a listing of the resident's current active physician orders, which reflected the following order: Tamsulosin HCl Oral Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth one time a day for urinary retention dated 8/20/25.A CCP, dated revised 10/8/24, revealed, a focus area that reflected the resident had incontinence and with an intervention that reflected to check and change brief as needed with incontinence care. The CCP did not reflect under any section that the resident had urinary retention or was being treated with medication. On 6/22/26 at 11:48 AM, the surveyor interviewed the Unit Manager (UM) LPN about Resident #5. The UM LPN stated that Resident #5 was not incontinent and able to toilet themselves. The UM LPN stated that the resident had not voiced any complaints of urinary retention and felt the medication made them go more frequently.On 6/22/26 at 1:00 PM, the DON provided an updated CCP to the surveyor that reflected the following: The resident had urinary retention.On 6/22/26 at 12:00 PM, the surveyor reviewed the facility policy titled Comprehensive Care Plans, dated revised 3/1/25, that was provided by the RRN. The policy reflected under 3. The .care plan will describe.services that are to be furnished to attain or maintain.highest practicable.well-being. Under 3.f. Resident specific interventions. Under 5. The comprehensive care plan will be reviewed and revised.after each comprehensive and quarterly MDS assessment. On 6/23/26 at 12:10 PM, the surveyor met with the covering Licensed Nursing Home Administrator (LNHA), DON, [NAME] President Operations (VPO) and Regional Registered Nurse (RRN) for the exit conference, no further pertinent information was provided. NJAC 8:39-11.1, 11.2(h)(i)

Based on interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication, by failure to correctly document a diagnosis, indication, or reason for use for one (1) of five (5) residents reviewed for unnecessary medication (Resident #12).The deficient practice was evidenced by the following: On 6/22/26 at 12:00 PM, the surveyor reviewed Resident #12's electronic medical record (EMR) which revealed the following: An admission Record (AR)(a summary of admission documents), that reflected that Resident #12 was admitted to the facility with medical diagnoses that included but were not limited to; Type 2 Diabetes with hyperglycemia (a chronic condition where the body does not maintain normal blood sugar levels resulting in high blood sugar), hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormones to meet your body's needs resulting in slow metabolism) and hyperlipidemia (high levels of cholesterol and triglycerides in the blood). A Comprehensive Minimum Data Set (cMDS) an assessment tool, with an assessment reference date (ARD) of 4/2/26, reflected that the resident had a brief interview for mental status (BIMS) score of 7 out of 15 indicating the resident had severe cognitive impairment. A review of Resident #6's Order Summary Report (OSR), a listing of the resident's physician orders, revealed the following medication order: Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for mild pain, moderate pain and sever pain, headaches or fever, dated 6/17/26. A review of the resident's electronic medication administration record (eMAR) revealed the order Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed formild pain, moderate pain and sever pain, headaches or fever, dated 6/17/26. On 6/22/26 at 1:18 PM, the surveyor interviewed the Director of Nursing (DON) about the as needed acetaminophen order. The surveyor asked if a medication order (med), specifically an order that is to be given only when needed by the resident, should have a specific reason or indication for giving the med at that time and that is not left open to misinterpretation as to why the med was initially given. The DON stated, yes, as needed orders should be specific and not have several different reasons. The surveyor also asked the DON if the term fever should be more specific with a certain temperature. The DON agreed that the acetaminophen order should have been separated into different as needed orders along with a specific temperature to identify a fever. The DON stated that the acetaminophen order would be changed to correctly reflect when to administer. On 6/23/26, at 10:35 AM, the surveyor reviewed the policy titled Medication Orders, dated revised 9/3/25, that was provided by the Regional Registered Nurse (RRN). The policy reflected, under 3. Elements of the Medication Order: k. PRN (as needed) orders should also specify the condition, for which they are being administered. On 6/23/26 at 12:10 PM, the surveyor met with the covering Licensed Nursing Home Administrator (LNHA), DON, [NAME] President Operations (VPO) and RRN for the exit conference, no further pertinent information provided. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to a.) maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey, and b.) failed to ensure that sufficient and competent staff were available to provide appropriate incontinence care to dependent residents for 2 of 3 residents (Resident #25 and #52) on 1 of 1 Nursing Unit. This deficient practice was evidenced by the following: Refer to F677 Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. Direct care staff member means any registered professional nurse, licensed practical nurse, or certified nurse aide who is acting in accordance with that individual's authorized scope of practice and pursuant to documented employee time schedules. The following ratio(s) were effective on 02/01/2021: 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) One certified nurse aide to every eight residents for the day shift. (2) One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be certified nurse aides, and each staff member shall be signed in to work as a certified nurse aide and shall perform certified nurse aide duties, and (3) One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a certified nurse aide and perform certified nurse aide duties 1.A review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the two weeks of staffing from 5/31/26 through 6/13/26 prior to the Standard survey of 7/1/26, revealed the facility was deficient in staffing hours as evidenced by the following: 1.The facility was deficient in Certified Nursing Assistant (CNA) staffing for residents on 8 of 14 day shifts and deficient in total staff for residents on 1 of 14 overnight shifts as follows: -05/31/26 had 3 CNAs for 56 residents on the day shift, required at least 7 CNAs.-06/02/26 had 3 total staff for 56 residents on the overnight shift, required at least 4 total staff.-06/03/26 had 6 CNAs for 56 residents on the day shift, required at least 7 CNAs.-06/05/26 had 6 CNAs for 56 residents on the day shift, required at least 7 CNAs.-06/07/26 had 5 CNAs for 56 residents on the day shift, required at least 7 CNAs. -06/07/26 had 5 CNAs for 56 residents on the day shift, required at least 7 CNAs.-06/09/26 had 5 CNAs for 59 residents on the day shift, required at least 7 CNAs.-06/10/26 had 6 CNAs for 59 residents on the day shift, required at least 7 CNAs.-06/13/26 had 4 CNAs for 58 residents on the day shift, required at least 7 CNAs. On 6/22/26 at 11:30 AM, the surveyor interviewed the staffing coordinator (SC), who stated that they were aware of the staffing ratios for CNAs for the day and evening shift, but not sure about the CNA to resident ratios for the night (11:00 PM-7:00 AM) shift. The SC also stated that if she was unable to meet staffing requirements, she would inform the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). 2. On 6/16/26 at 8:15 AM, the surveyor conducted an incontinence care tour and observed the following:a. On 6/16/26 at 8:15 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #1), observed Resident #25 in bed. CNA #1 exposed Resident #25's incontinence brief and observed that the brief was saturated with urine. CNA #1 confirmed that the brief was saturated and stated that incontinence care should be done every 2 hours. b. On 6/16/26 at 8:30 AM, the surveyor, accompanied by CNA #2 observed Resident #52 in bed. CNA #2 exposed the resident's incontinence brief and observed that the brief was saturated with urine. CNA #2 confirmed that the brief was saturated. On 6/22/26 at 11:15 AM, the surveyor reviewed the 11:00-7:00 AM assignment sheet, which revealed that the Nursing Unit had a census of 58 residents with 3 assigned CNAs. CNA # 3 (who was assigned to Resident #25's care) and CNA #4 (who was assigned to Resident #52's care) each had an assignment of 15 residents on that 11-7 AM shift. The LPN/UM confirmed that the census was 58 and that CNA #3 and CNA #4 each had 15 residents assigned to them. On 6/22/26 at 12:00 PM, the survey team met with the DON and the Regional RN to discuss the above observations and concerns. The DON confirmed that the CNAs should be providing incontinence care every 2 hours on all shifts. On 6/22/26 at 12:17 PM, the 11:00 PM-7:00 AM CNAs were not available for interviews. On 6/22/26 at 12:30 PM, the surveyor reviewed the facility's policy, Activities of Daily Living dated 7/3/25, which reflected. 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. On 6/23/26 at 10:15 AM, the surveyor reviewed the facility's Staffing policy dated 10/15/25, which reflected.Facilities will provide qualified and appropriate staffing levels to meet the needs of the resident population. The staffing plan will include all shifts, seven days a week.The facility meets or exceeds the staffing levels mandated by state and federal staffing requirements. to assure that residents are safe and their needs are met. On 6/23/26 at 12:15 PM, no further information was provided. NJAC 8:39-27.1 (a), (e), 27.2 (h)

Based on observation, interview, record review, and review of facility policies it was determined that the Consultant Pharmacist (CP) failed to clarify medication route for a resident during the monthly medication reviews for 1 of 4 Residents, (Resident #36). This deficient practice was evidenced by: 1. On 6/15/26 at 10:51 AM, the surveyor observed Resident 36's enteral feeding machine (TF, medical devices designed to safely deliver nutrition directly into the gastrointestinal tract) in their room. On 6/15/26 at 11:20 AM, the surveyor reviewed the electronic medical record (E-mar) for Resident #36.A review of the resident's admission record (AR, an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; gastrostomy (g-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food), type 2 diabetes mellitus (a chronic condition characterized by insulin resistance and high blood sugar levels), and gastro-esophageal reflux disease (a chronic digestive disorder where stomach acid flows back into the esophagus).A review of the quarterly Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), with a reference date 5/30/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #36 scored 9 out of 15, which indicated the resident had moderate cognitive impairment. The MDS further revealed that Resident #36 had an enteral feeding.A review of the June physician order summary report (OSR) revealed a physician orders (PO) for Resident #36. PO dated 5/21/26, NPO (nothing by mouth) diet, NPO texture, NPO consistency, PO dated 11/14/25, Risperdal oral tablet 0.5 milligram (mg) (Risperidone), give 1 tablet by mouth at bedtime for bipolar, and PO dated 11/24/25, Risperdal oral tablet 0.5 mg (Risperidone), give 1 tablet by mouth one time a day for bipolar. A review of Resident #36's progress notes revealed a note from the Consultant Pharmacist (CP) dated 5/24/2026, Medication Regimen Reviewed (MRR) completed. No recommendations noted.On 6/16/26 at 10:43 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1), who revealed they are the usual 7AM to 3PM nurse for Resident #36. LPN #1 further revealed, Resident #36 takes all meds through g-tube and when the resident had trialed po diets, the orders would still be to give the medications through the g-tube. LPN#1 reviewed the current PO and acknowledged the Risperdal PO was written by mouth. LPN#1 stated the CP comes at least monthly and the medication discrepancy should have been noted and corrected.On 6/18/26 at 10:23 AM, the surveyor conducted a phone interview with the CP, who revealed his company had been working with the facility for less than a year. The CP stated he would come in monthly and would review the medication storage room, medications carts, answering any questions the nurses had with medications, and would review resident charts for any medication discrepancies. The surveyor reviewed Resident #36 medications that were ordered by mouth despite NPO. CP stated those discrepancies should have been caught and corrected.On 6/18/26 at 10:50 AM, the Regional Registered Nure (RRN) provided the surveyor with a facility policy, Addressing Medication Regimen Review Irregularities with a revised date of 5/12/26. The compliance guidelines revealed, 4. The pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing, and reports must be acted upon.On 6/18/26 at 12:51 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), [NAME] President of Operations (VPO), and RRN. The DON stated the medication discrepancy has been addressed.On 6/23/26 at 12:10 PM, the surveyor met with the covering LNHA, DON, VPO and RRN for the exit conference, no further pertinent information provided. NJAC 8:39- 29.3 (a)

Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 2 of 3 residents (Residents #25 and #52) observed for incontinence care on 1 of 1 Nursing unit.This deficient practice was evidenced by the following: On 6/16/26 at 8:15 AM, the surveyor conducted an incontinence care tour on the Nursing Unit and observed the following:1. On 6/16/26 at 8:15 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #1), observed Resident #25 in bed. CNA #1 exposed Resident #25's incontinence brief and observed that the brief was saturated with urine. CNA #1 confirmed that the brief was saturated and stated that incontinence care should be done every 2 hours. On 6/16/26 at 11:00 AM, the surveyor reviewed the medical record for Resident #25. A review of the admission Record (AR) reflected Resident #25 was admitted to the facility with diagnoses that included but were not limited to; chronic kidney disease (kidneys are damaged and lose their ability to filter waste from the blood) and diabetes mellitus (high blood sugar). A review of the quarterly minimum data set (MDS), an assessment tool dated 3/16/26, reflected that the resident had a brief interview for mental status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. The MDS further assessed that Resident #25 was frequently incontinent of bowel and bladder and was dependent on staff for toileting. A review of Resident #25's Care Plan (CP) indicated the resident was at risk for impairment to their skin integrity related to incontinence, with interventions that included but were not limited to; offer toileting prior to meals, at bedtime, and when needed, perform brief changes and perineal care when incontinent. 2. On 6/16/26 at 8:30 AM, the surveyor, accompanied by CNA #2, observed Resident #52 in bed. CNA #2 exposed the resident's incontinence brief and observed that the brief was saturated with urine. CNA #2 confirmed that the brief was saturated. On 6/16/26 at 11:00 AM, the surveyor reviewed the medical record for Resident #52. A review of the AR reflected Resident #52 was admitted to the facility with diagnoses that included but were not limited to; history of urinary tract infections, and diabetes mellitus. A review of the annual MDS dated [DATE], reflected that Resident #52's cognitive skills for daily decision making were moderately impaired. A further review of the MDS indicated the resident was always incontinent of bladder, frequently incontinent of bowel, and was dependent on staff for toileting. A review of Resident #52's CP reflected that the resident had an Activities of Daily Living (ADL) self-care deficit with interventions that included but were not limited to; requires total assistance with ADL care. On 6/22/26 at 11:15 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) confirmed that incontinence care should be provided every 2 hours across all shifts. On 6/22/26 at 12:00 PM, the survey team met with the Director of Nursing (DON) and Regional Registered Nurse (RRN) to discuss the above observations and concerns. The DON confirmed that incontinence care should be provided every 2 hours. On 6/22/26 at 12:17 PM, the 11:00 PM-7:00 AM CNAs assigned to care for Resident #25 and Resident #52 were unavailable for interviews. On 6/22/26 at 12:30 PM, the surveyor reviewed the facility's policy, Activities of Daily Living dated 7/3/25, reflected. 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.On 6/23/26 at 12:15 PM, the survey team met with the administration for an exit conference. No further information was provided. NJAC 8:39-27.1 (a), (e), 27.2 (h)

Based on observation, staff interview, and facility policy review, the facility failed to ensure kitchen staff properly air-dried pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 49 of 51 residents who resided in the facility and who received dietary services. There were two residents receiving tube feedings. The facility had a census of 51 residents. Findings include: Review of the facility's policy titled, Manual Ware washing, dated 10/2024 (sic), revealed, Policy Statement: All cookware, dishware, and service ware that is not processed through the dish machine will be manually washed and sanitized. Procedures: . 3. All service ware and cook ware will be air dried prior to storage. Review of the facility's undated policy titled, Pots and Ware washing, revealed, .9. Air-dry all items on a clean, sanitized drain board or rack. Take care not to stack items to avoid wet nesting . Wet Nesting: Wet nesting occurs when clean pans, plates, cups, bowls, etc. (et cetera, and other things), are stacked together as they are coming out of the dish machine, or 3 (sic) compartment sink without completely drying first. This action will cause water to pool and, if not dried properly or quickly, can create a breeding ground for bacteria even on clean items. To prevent wet nesting, store clean items in properly filled glass, dish or 3 (sic) compartment racks. Make sure there is no standing water in rims of trays or hotel pans. Always make sure silverware is completely dried and stored in a proper storage bin with lid. During an observation and interview on 02/17/25 at 10:30 AM, the Dietary Manager (DM) confirmed three pans, 10 inches by 12 inches by 3 inches deep; two pans, 6 inches by 12 inches, by 2 inches; four pans 6 inches by 12 inches, by 8 inches; four pans 12 inches by 24 inches by 3 inches that had been cleaned and stacked for use that were still wet and had food particles on them when they were unstacked. The pans were found to have been stacked wet and not allowed to airdry. The DM stated, They should be dry; they weren't completely dry when they were put away. When they're wet it increases the chance of contamination. They need to be rewashed. During an observation and interview on 02/17/25 at 10:35, the DM confirmed the can opener had paper and a black substance located on the blade. The DM stated, The can opener is dirty and needs to be cleaned, it shouldn't have anything on it. NJAC 8:39-17.2(g)

Based on interview, record review, and facility policy review, the facility failed to ensure one out of one resident (Resident (R) 42) reviewed for Pre-Admission Screening and Resident Review (PASRR) had accurate screenings and/or were referred for a Level II review as required following a positive Level I screening. This had the potential to cause delays in receiving necessary mental health services. Total sample was 23. Findings Include: Review of the facility Preadmission Screening and Resident Review (PASARR) policy updated on 07/01/24, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include a. A resident who exhibits behavioral, psychiatric, or mood-related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment. Review of R42's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R43 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, recurrent, severe with psychotic symptoms. Review of R42's Pre-Admission Screening and Resident Review (PASRR) Level I Screening, dated 06/16/23 and located under the Misc (Miscellaneous) tab of the EMR, revealed documentation R43 has a serious mental illness, did not have significant impairment in functioning related to the diagnosis of a mental illness, and had experienced one psychiatric treatment episode that was more intensive than routine follow-up care in the last two years. Review of R43's entire EMR and hard chart revealed no documentation a Level II resident review had been completed for R42. Review of Psychiatric Hospital Discharge Summary Notes, Located under the Misc tab of the EMR, dated 12/31/24, revealed multiple medical conditions and perinatal depression with major depression disorder features and Major Neurocognitive Disorder, prior psychiatric admissions one prior Suicide Attempt via Overdose on medication years ago, no h/o [history of] self-injurious behavior, currently on Zoloft 50 milligram (mg) daily and Melatonin 6 mg nightly. The resident was sent to the emergency department on 12/13/24 reportedly due to worsening depression and Suicidal ideation. The patient was admitted to the inpatient psychiatry unit for further psychiatric stabilization. R43 was in the psychiatric unit for 14 days and released on new medications. During an interview on 02/19/25 at 1:39 PM with the Social Service Director (SSD), revealed R43 had been out of the facility for fifteen days in a psychiatric facility for suicidal ideation. When asked about the PASARR in needing a PASARR II, the SSD revealed having some questions as to when to do the PASARR. When asked about another PASRR I to see if R43 needed a PASRR II, the SSD stated I never thought about the repeat of the PASRR I. During an interview on 02/20/25 at 2:57 PM with the Administrator and Regional Director of Social Services, the Administrator stated they had requested to appropriate PASARR to be completed on R43, and they will be reviewing their process. NJAC 8:39-5.1(a)

Based on observation, interview, and policy review, the facility failed to ensure a catheter bag was kept off the floor for one of one resident (Resident (R) 48) reviewed for catheters in a total sample of 23 residents. The failure to keep a catheter bag off the floor increased the risk for R48 developing a urinary tract infection. Findings include: Review of the facility's policy titled, Indwelling Catheter Care, dated 02/20/25, revealed, Policy: It is the policy of this facility to ensure that residents with indwelling catheter receive catheter care and maintain their dignity and privacy when indwelling catheters are in use. Procedure . 3. Privacy bags will be changed out when soiled, with a catheter change or as needed .5. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. Drainage bag should not be touching the floor. Review of R48's undated Admission Record, located in R48's electronic medical record (EMR) under the Profile tab revealed R48 was admitted to the facility on [DATE]. Review of R48's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/25 indicated R48 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact, and indicated R48 had an indwelling catheter. Observation on 02/17/25 at 3:23 PM, revealed, R48 lying supine (on his back) in bed. R48's catheter bag was observed lying on the floor next to his bed. Observation on 02/18/25 at 3:20 PM, revealed, R48 seated in a wheelchair in the hallway while working with therapy and his catheter bag resting on the floor under the wheelchair. During an observation and interview on 02/20/25 at 12:20 PM, Licensed Practical Nurse (LPN) 1 confirmed that R48 was lying in his bed supine, and his catheter bag was lying on the floor next to his bed. LPN1 stated, The catheter bag should not be touching the floor, it should never be on the floor. If it is on the floor that increases the risk of infection. NJAC 8:39-19.4

Based on observations, record review, interviews, and review of facility policies, the facility failed to ensure a respiratory assessment was completed prior to initiating a breathing treatment and failed to monitor the resident's respiratory condition, including response to therapy provided, and any changes in the respiratory condition during the breathing treatment. This involved one of 28 sampled residents (Resident (R) 29). Findings include: Review of a policy provided by the facility titled Nebulizer Therapy undated.5.Obtain baseline vital signs . 13. Observe resident during the procedure for any change in condition . Documentation record the following information in the residents medical record . 3.Resident lung sounds 4. Resident's response to treatment. Review of R29's Admission Record in the electronic medical record (EMR) under the Admissions Record tab indicated R29 was admitted on [DATE] with diagnoses including Respiratory Failure. Review of R29's care plan located in the EMR under the Care Plan tab dated 08/21/24 indicated R29 was care planned for altered respiratory status/difficulty in breathing . The care plan did not address self-administration of the nebulizer. Review of Medication Administration Record (MAR), dated 08/19/24, indicated R29 had an order for nebulizer treatment Ipratropium-Albuterol solution 0.5-2.5/3 milliliters inhalation orally every six hours as needed for shortness of breath. During observation of the medication pass on 02/20/25 at 9:33AM, Licensed Practical Nurse (LPN) 1 administered R29's morning medications in his room. LPN1 started R29's nebulizer treatment and returned to the medication cart. LPN1 began to prepare the next resident's medications. LPN1 returned to R29's bedside at 10:05AM and removed R29's nebulizer mask, rinsed it out with water and laid it on a towel to air dry. R29 was asleep. LPN1 exited the room. LP1 did not complete a respiratory assessment prior to beginning the treatment. During an interview on 02/20/25 at 10:10 AM, LPN1 confirmed she started R29's nebulizer treatment before leaving the room at 9:33 AM. LPN1 confirmed she did not complete a respiratory assessment prior to beginning the treatment, and did not assess R29's lung sounds, pulse, or respirations and returned to R29's bedside to complete a respiratory assessment checking oxygen saturation and lung sounds. LPN1 stated, the respiratory assessment should be done prior to the breathing treatment and at the end of the treatment. LPN1 stated the respiratory assessment use to be on the MAR with the nebulizer order, indicating the assessment needed to be done. Review of R29's MAR on 02/20/25 at 11:31 AM, a respiratory assessment order was added by Regional Clinical Nurse (RCN) to the MAR as follows: Before treatment obtain lung sounds (LS) oxygen saturation (O2) and respirations. After treatment, obtain LS,O2, respirations and number of minutes spent completing treatment. During an interview on 02/20/25 at 10:31 AM, with Infection Preventionist (IP) and (RCN) present, stated that a resident's lung sounds and O2 saturations should always be assessed prior to a nebulizer treatment with the expectations to be assesses before and after treatment . NJAC 8:39-25.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to clean and disinfect three of three shower chairs observed in the shower room. This deficient practice was as evidenced by the following: On 12/22/22 at 10:40 AM, the surveyor interviewed five residents during a resident council meeting. At the end of the resident council meeting, the surveyor asked the residents if they had any other concerns and two of five residents stated that the shower chairs in the shower room were not clean and that the shower chairs had black and brown substances on them. On 12/22/22 at 12:15 PM, the surveyor went into the shower room and observed three shower chairs stored inside the room. The surveyor observed one shower chair's four metal legs were each soiled with a black colored substance and the plastic seating bench of the chair had a brown colored substance in the holes of the bench and a brown colored substance on the entire under side of the bench. The surveyor observed two of two white Polyvinyl chloride (PVC) plastic shower chairs with mesh seat backings in the shower room as well. Each of the four legs on the two PVC plastic shower chairs were soiled with a black colored substance and the mesh seat backings were both soiled with a black colored substance as well. At 12:18 PM, the surveyor asked the Director of Nursing (DON) to come to the shower room and to observe the three shower chairs. The DON stated that the three chairs were soiled and should not be like this. The DON stated that the chairs need to be cleaned. At 12:32 PM, in the presence of the DON, the surveyor interviewed the Housekeeping Director, who stated that the chairs had never been cleaned by the housekeeping department and it was never on their cleaning schedule to do so. The DON stated that the nursing staff were also not cleaning the shower chairs. The surveyor reviewed the Cleaning and Disinfecting Critical and Non-Critical Resident Equipment policy, dated 6/2022, which revealed that non-critical and reusable resident care equipment will be decontaminated and/or sterilized between residents. N.J.A.C. 8:39-19.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to date medication when opened and stored for continued use. This was found in 2 of 3 medication carts and 1 of 1 medication refrigerator. The deficient practice was evidenced by the following: On [DATE] at 9:35 AM, the surveyor inspected the annex medication cart with Licensed Practical Nurse #1 (LPN #1). Inside of the annex medication cart there was one vial of Humalog insulin that was open and dated [DATE] and one vial of Humalog insulin that was open and dated ,d+[DATE]. LPN # 1 confirmed the dates then took them and said they were out dated and he didn't know why they were in the medication cart. According to manufacturer specifications Humalog insulin should be discarded 28 days after opening. On [DATE] at 9:55 AM, the surveyor inspected the medication refrigerator with the Unit Manager/LPN (UM/LPN). Inside of the medication refrigerator there was a vial of Influenza vaccine that was open and undated. The UM/LPN confirmed that there was no date and there should have been. According to the manufacturer specifications the vial should be discarded 28 days after opening. On [DATE] at 10:16 AM, the surveyor inspected the west hall medication cart with LPN #2. Inside of the west hall medication cart there was a Levalbuterol Inhalation Solution package of vials that was open and undated. According to manufacturer instructions once opened the vials must be used within 2 weeks. LPN #2 confirmed that the package should have been dated when it was opened. On [DATE] at 1:30 PM, the survey team spoke with the Administrator and the Director of Nursing (DON) and made them aware of the concerns with the undated or expired medication found in the medication carts and refrigerator. The DON confirmed that the vials and package should have been dated when opened and the expired vials of insulin should have been discarded. On [DATE] at 1:18 PM, the surveyor reviewed the facility's policy and procedure titled Labeling of Medication Containers. Under Policy Statement it read All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations, and reviewed the policy and procedure titled Administering Medications dated ,d+[DATE]. Under Policy it read The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. NJAC 8:,d+[DATE].4 (h)

Based on observation, interview and policy review it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development of a food borne illness. This deficient practice was evidenced by the following: On 12/19/22 at 9:15 AM, in the presence of the Food Service Manager (FSM) and the Regional Food Service Director (RFSD), the surveyor observed the following: 1. In the food preparation area, the surveyor observed grey colored material stuck on the blade of the can opener. 2. On a shelf in the Cook's refrigerator, the surveyor observed a container of cranberry sauce, which had a written date in marker of 11/16/21 and a stamped manufacturer expiration date of 7/23/22. The FSM stated he was not sure what the written date on the item or the manufacturer's date on the item was indicating, and disposed of the cranberry sauce. 3. The surveyor observed four of six stovetop burners were soiled with a black grease-like substance. FSM stated the stove was cleaned once a week. 4. Above the stove top, the surveyor observed the overhead sprinklers which were soiled with grey dust-like particles. On 12/19/22 at 10:42 AM, the surveyor informed the Licensed Nursing Home Administrator, the Director of Nursing, and the Regional Nurse of the above concerns. The surveyor reviewed the facility's policy titled, Equipment with a revised date of September 2022. The policy read All foodservice equipment will be clean, sanitary, and in proper working order. Under Procedures, it read 3. All food contact equipment will be clean and free of debris. The surveyor reviewed the facility's policy titled, Environment with a revised date of September 2022. The policy indicated that all food preparation areas, food service areas will be maintained in a clean and sanitary condition. The surveyor reviewed the facility's policy titled, Food Storage: Cold Foods with a revised date of September 2022. The policy indicated that all foods should be labeled and dated. The policy did not further address checking food item expiration dates. NJAC 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to revise a comprehensive care plan to include monitoring of injuries sustained during a fall for Resident #35, 1 of 3 residents reviewed for falls and was evidenced by the following: On 10/26/20 at 10:15 AM, the surveyor observed Resident #35 in the resident's room awake and alert, seated on top of a canvas lift pad in the geri chair. The surveyor reviewed Resident #35's medical records that revealed the following: According to the Admission Record, Resident #35 had [DIAGNOSES REDACTED]. The Progress Notes dated 1/15/20 at 15:26 indicated the resident had a fall in the afternoon and was sent to the Emergency Department for evaluation, and at 23:10 the documentation indicated the resident was admitted to the hospital with [REDACTED]. The Event Summary Report dated 1/15/20, obtained from the Regional Clinical Quality Specialist, revealed that Resident #35 had a fall in the resident's room. There was bleeding from the nose and the resident had a bump to the right forehead. The resident stated that he/she wanted to get a nightgown from the closet. Under the Summary of Investigation: Root cause/conclusion revealed a summary of the incident and that the resident returned from the hospital with follow up for monitoring post non-displaced nasal bone fractures. In addition the summary included monitor for changes due to a hematoma over the right eyebrow. Remains on [MEDICATION NAME] (a blood thinner medication). Resident #35 had a care plan initiated on 11/10/09 indicating (the resident) was at risk for falls and had a revised date of 4/15/18 and a target date of 11/29/20. There was no documentation on the care plan regarding the fall on 1/15/20 and injuries the resident sustained [REDACTED]. On 10/29/20 at 12:15 PM, the surveyor interviewed the Unit Manager (UM) and asked who was responsible for creating and updating residents care plans. The UM stated either she or the Director of Nursing (DON). The surveyor inquired about an update to the careplan to reflect the date of the fall, include the injuries sustained, and include interventions to monitor for changes. The UM stated she didn't know, but stated there was a care plan evaluation written in the Progress Notes. She stated that was how the care plans were updated. The UM showed the surveyor the Care Plan Evaluation note dated 1/21/20 in the Progress Notes. However, there was no documentation in that note to monitor for changes as the Summary of Investigation indicated. The DON was present at the time of the interview and agreed that there was no update on the fall care plan regarding the actual fall. A review of the facility's Person Centered Care Plan Policy with a revision date of 7/1/19 included under Practice Standards #7.2 Care plans will be: Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. NJAC 8:39-11.29 (i)

PART A: Based on observation, interview, a review of records and other pertinent facility documents, it was determined that the facility failed to: a.) ensure their written policy for extending the use of gowns was devised in accordance with nationally accepted guidelines for infection prevention and control to prevent the spread of COVID-19, b.) implement mitigation strategies to prevent the spread of COVID-19 for five days by not appropriately identifying four residents (Resident #1, #2, #3, and #4) exposed to COVID-19 as persons under investigation for [MEDICAL CONDITION] and c.) ensure gowns were not continuously worn from resident to resident while providing care in accordance with the U.S. Centers for Disease Control and Prevention. This deficient practice was identified on 1 of 2 cohort units (non-COVID unit) during a tour conducted on [DATE]. Upon observation and interview, it was identified that the facility practice included that all residents in the facility were placed on transmission-based precautions which allowed for the extended use of personal protective equipment (PPE) to be shared from resident to resident that had tested baseline negative for COVID-19. The facility became aware on [DATE] that two residents had tested positive for COVID-19, and the facility failed to identify their roommates as exposed to COVID-19 as persons under investigation (PUI) in an effort to mitigate the spread of [MEDICAL CONDITION]. During the survey conducted on [DATE], the surveyors observed facility staff wearing the same single-use long sleeve gowns entering and exiting the room of the exposed PUI residents and going into and out of other resident rooms that were not-ill without discarding their gowns after use. In accordance with facility provided documents as of [DATE], the surveyor noted that the facility had a COVID-19 outbreak that began on [DATE]. Two residents tested positive for COVID-19 and one had expired. The facility had a second COVID-19 outbreak that began on [DATE] when two staff members tested positive, and additonally on [DATE] when two residents tested positive for COVID-19. The facility's failure to appropriately implement extended use of PPE guidelines for COVID-19 in accordance with the U.S. Centers for Disease Control and Prevention (CDC), and their failure to identify four residents as exposed to COVID-19 and implement strategies to prevent the spread of COVID-19, posed a serious and immediate threat to the safety and wellbeing of all non-ill residents. This resulted in an Immediate Jeopardy (IJ) situation that began on [DATE] at 8:15 PM when the facility was notified of the two confirmed positive COVID-19 cases, and continued until [DATE] when the facility alleged complete implementation of the elements of the removal plan. The facility administration was notified of the immediate jeopardy situation on [DATE] at 2:30 PM. The evidence was as follows: On [DATE] from 9:35 AM to 10:25 AM, two surveyors interviewed the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Registered Nurse/Infection Preventionist (RN/IP) in a conference room. The RN/IP stated that she worked full time as an Infection Preventionist, but her days were split between this facility and other sister-facilities. She stated that she only worked approximately two days a week in this facility. The RN/IP explained to the surveyors that the facility recently had a second COVID-19 outbreak that began on [DATE], in which two staff members tested positive for COVID-19, and it continued on [DATE] when two residents were swabbed and subsequently tested positive for COVID-19. She stated that the two residents recently diagnosed with [REDACTED]. The RN/IP further stated that in addition to the two residents that tested positive for COVID-19, the facility had two residents identified as Persons Under Investigation (PUI) for COVID-19, one of which went to the [MEDICAL TREATMENT] center and another resident had a community physician visit and would be on the AQU unit for 14 days. The RN/IP stated that the entire facility has been on full PPE since March and added that everybody in the building was on droplet precautions and .even if all residents test negative, they are still on droplet precautions. The surveyor asked the RN/IP if the facility was extending the use of any PPE, including gowns, face shields, masks. The RN/IP stated that gowns were reused in non-COVID areas and the same gowns are used when going from room-to-room between residents that have all tested negative for COVID-19. The RN/IP and DON stated that the facility utilized two sets of signs outside the resident rooms. She stated that a resident who tested negative for COVID-19 and was not a PUI, would have a white sign posted on their door with a stop sign that would read, Extended Contact Plus Droplet Precautions. The RN/IP stated that this white sign meant that the staff must wear a gown, gloves, face mask, and eye protection upon entering the room. She added that eye protection and a face mask was universally mandated on the units as part of the facility policy and staff just had to wear a gown and gloves when entering the room. The RN/IP elaborated that the white sign for Extended droplet precautions meant that staff could go room-to-room wearing the same gown to extend the use of the gowns, but that they could only re-use the gowns between residents that had the white sign posted on their door. The DON added that any resident that had a white sign outside the door meant they had tested negative for COVID-19. The RN/IP confirmed that all the residents on the non-COVID hallway had white signs for Extended droplet precautions on their door except one PUI resident on that side (Resident #7). The DON stated that gowns could be shared between the residents within the negative COVID-19 cohort group. The surveyor inquired if or how that process differed for identified PUI and COVID-19 residents, and the RN/IP confirmed that both the identified PUI residents and COVID-19 positive residents had a yellow sign on their door which indicated Patient-Specific Contact plus Airborne precautions. She stated this meant that staff must wear a respirator mask, gown, gloves and eye protection when entering the room. The RN/IP added that the difference was, when exiting a room of a COVID-19 positive or identified PUI room, that all PPE must be discarded at the exit of the room and could not be extended or shared between different residents. The DON and RN/IP confirmed there was no method to delineate the positive COVID-19 from the PUI residents, but stated that staff are informed upon report who had tested positive for COVID-19 and who was PUI. The surveyor asked the RN/IP and the DON when they would consider a resident a PUI. The RN/IP stated the facility would identify a resident as a PUI, if: 1.) a resident went to the [MEDICAL TREATMENT] center, 2.) if a resident went to another community appointment or special treatment appointment, 3.) a new admission to the facility, and 4.) if a resident had signs or symptoms of COVID-19. She stated if a resident met any of that criteria they would be placed in a private room to the extent possible, and have a yellow sign posted on their door to indicate, Patient-Specific airborne precautions. She stated that this sign would remain on their door for at least 14 days. She stated that the PPE, specifically the gown, would be discarded upon exiting the room. The surveyor asked if there were any other circumstances in which a resident would be considered PUI, and the RN/IP stated she could not think of any other scenarios. The DON and LNHA were unable to speak to any other PUI scenarios as well. The surveyor asked how the facility identifies and manages roommates of residents that test positive for COVID-19, and the RN/IP stated that we move the positive resident away from their roommates and put the positive residents on the AQU unit, and we test the roommates for COVID-19. She continued that the facility would also assess and monitor those roommates for signs or symptoms of COVID-19 and that all residents in the building were on transmission-based precautions already, so there was no need to do anything differently for the roommates of positive residents, except to monitor and test them. She added that in addition, all residents get tested for COVID-19 weekly. The RN/IP confirmed that the facility only had two residents who were confirmed positive for COVID-19 (Resident #5 and #6) and two residents who were identified as PUI residents (Resident #7 and Resident #8). The surveyor asked the DON if the residents who tested positive for COVID-19 had roommates, and the DON stated yes. The surveyor requested a list of the roommates of the two residents who were confirmed positive for COVID-19. The RN/IP stated that the facility follows the US CDC guidelines and corporate policies for infection control and prevention related to COVID-19. The DON and LNHA stated that they have adequate supply of PPE and reported no shortages throughout the outbreaks. The surveyor reviewed the COVID-19 outbreak line list dated [DATE] and compared it to the Daily Census report dated [DATE] which reflected a total in-house census of 49 residents. The reports indicated that three (3) residents resided in private rooms in the AQU/COVID-19 unit, including the two (2) residents that tested positive for COVID-19 (Resident #5 and Resident #6), and one (1) resident that had recently had a community physician visit and was a PUI (Resident #8). The other 46 residents were on the non-COVID hallway. The Daily Census report reflected that the other resident that the facility identified as a PUI (Resident #7) resided in a private room on the non-COVID hallway. At 11:10 AM, the surveyors entered the non-COVID section of the U-shaped hallway and began to make general observations throughout the unit. The surveyors observed that all but one of the resident rooms had a white sign posted on the door that read to Stop and Please see the Nurse before entering the Patient's room! It further specified, Extended Contact plus Droplet Precautions. The surveyor continued to observe the one PUI resident room (Resident #7) on the non-COVID unit that did not have a white sign, but instead had a yellow sign on the door that indicated to Stop and Please see the Nurse before entering the Patient's room. The yellow sign specified, Patient-Specific Contact plus Airborne Precautions. There were no other resident rooms with the yellow sign posted on the door on the non-COVID unit. The surveyors also observed, located at various accessible points in the hallway, large plastic storage bins of PPE which included single-use long sleeve gowns, face masks, boxes of gloves in various sizes, and disinfecting wipes. At 11:24 AM, the surveyor observed an Activities Aide (AA) assisting with a music activity from outside of each resident room. The AA was wearing a face mask, eye protection and a gown in the hallway. The AA stated that since the COVID-19 outbreaks, they had stopped any activity that required shared items, such as magazines or picture books. She stated that all items brought into the resident rooms were left there for the residents to use indefinitely. The AA stated that she had been in-serviced on COVID-19 including donning and doffing of PPE and hand hygiene. She also stated that she utilized a well-to-ill activity schedule for 1:1 room visits in which she visited all the residents with white signs on their door first. The surveyor asked the AA about the use of PPE in the facility. The AA stated that PPE was worn when interacting with all the residents in the building. She further stated that all staff wore a face mask and eye protection throughout the building, and if the residents have a white sign on their door for Extended droplet precautions, it meant that PPE could be shared between those residents because they had all tested negative for COVID-19. The surveyor asked what the difference was between the yellow sign posted on the door of Resident #7 that read, Patient-Specific Contact plus Airborne precautions and the white sign posted on all the other resident rooms in the hallway that read Extended Contact plus Droplet precautions. The AA stated that Resident #7 went to the [MEDICAL TREATMENT] center, therefore due to the resident's possible unknown exposure to COVID-19, the resident needed to have the yellow sign for patient-specific PPE. The surveyor asked for clarification of what patient-specific PPE meant on the yellow sign posted on the door of Resident #7, and she stated that it meant, We don't share PPE in that room. We take it off before exiting the room and put on new PPE if going to another resident room. She stated that the white signs on doors mean PPE can be shared between residents that all have the same white signs, but if a resident had a yellow sign it meant that everything comes off and the PPE cannot be shared between residents after exiting that room. The AA confirmed there was only one resident on the non-COVID section that had a yellow sign posted on their door, and that was Resident #7. The surveyor continued to interview the AA, and the AA stated that there were two residents that had tested positive for COVID-19 last week, (Resident #5 and Resident #6.) She stated those residents were temporarily moved to the AQU/COVID-19 unit at the end of the U-shaped hallway behind the double doors. The surveyor asked if Resident #5 and Resident #6 had roommates at the time they tested positive for COVID-19, and the AA replied yes. She then brought the surveyor to the room of an unidentified PUI resident, Resident #1. She stated that Resident #1 shared a semi-private room with Resident #6, before Resident #6 tested positive for [MEDICAL CONDITION]. The AA showed the surveyor the room of Resident #1 which had a white sign posted on the door indicating Extended droplet precautions. She confirmed that because Resident #1 had a white sign on the door, it meant that PPE could be shared between all the other residents that also had a white sign on their doors. At that time, the AA took the surveyor to the former room of Resident #5 who had tested positive for COVID-19 last week. The AA stated that Resident #2, Resident #3, and Resident #4 had all shared a quad-room with Resident #5 at the time Resident #5 tested positive for COVID-19. The surveyor observed a white sign indicating Extended droplet precautions on the door of the three roommates. The surveyor asked the AA if the facility had informed her to do anything different for the roommates of the residents that had tested positive for COVID-19, and she stated she was not told to do anything different for them or follow any different procedures. She confirmed that because Resident #2, #3 and #4 had a white sign on their door, she and other staff could wear the same gown between the other 42 residents on the unit, because they all had the white signs indicating Extended droplet precautions. At 11:26 AM, a second surveyor observed the Registered Nurse/Unit Manager (RN/UM) in the hallway. The RN/UM was wearing a gown, face mask and eye protection. At that time the surveyor interviewed the RN/UM who stated that if a resident tested positive for COVID-19, all PPE must be discarded prior to exiting the room using a receptacle located inside the resident's room. The RN/UM elaborated that in the non-COVID unit, the staff must wear gown, gloves, eye protection and at a minimum a surgical mask. She stated that the staff on the unit may use the same gown to care for different residents as long as they tested negative for COVID-19. She confirmed that residents that tested negative for COVID-19 had white sings on their door that indicated Extended droplet precautions. At 11:41 AM, the surveyor observed the DON wearing a face mask and eye protection standing outside a resident room that had a white sign for Extended droplet precautions. The surveyor observed the DON open a PPE storage bin located in the hallway and don a long sleeve, single-use gown and a pair of gloves. The DON stated to the resident in the room that she was coming into the room to assist them with toileting needs. The DON then closed the resident's door behind her upon entering the resident room. At approximately 11:45 AM, a second surveyor observed a Certified Nursing Aide (CNA #3) wearing a single-use long sleeve gown, face mask and eye protection exit the room of the exposed PUI Residents #2, #3, and #4 without discarding the gown. The surveyor observed CNA #3 obtain a mechanical lift (a two-person surface-to-surface transferring device) from the hallway and proceed to another resident room. At 11:46 AM, the surveyor observed a Licensed Practical Nurse (LPN) wearing a single-use long sleeve gown, gloves, eye protection and a face mask exit a room where three residents resided. Posted on the outside of that door was a white sign for Extended droplet precautions. The LPN walked to a medication cart at the end of the hallway wearing the same PPE. She removed her gloves and discarded them into the medication cart trash can. While wearing the same gown, she then took a cup of apple sauce and went into another resident room that had a white sign for Extended droplet precautions posted on the door and donned gloves inside the resident room. At approximately 11:48 AM, the two surveyors observed CNA #3 and the LPN still wearing the same single-use long sleeve gown, face mask and eye protection enter the room of a resident that was negative for COVID-19 with the mechanical lift. The CNA #3 then closed the door behind her. After they finished in the room, the surveyors observed both the LPN and CNA #3 exit the room without doffing the PPE. After storing the mechanical lift, CNA #3 then proceeded to enter the room of Residents #2, #3 and #4 wearing the same gown. The CNA #3 informed the surveyor that she and the LPN were transferring a resident who had tested negative for COVID-19. The second surveyor then observed the CNA #3 exit the room of Resident #2, #3, and #4 wearing the same gown and then entered another resident room across the hallway that had a white sign for Extended droplet precautions. At 11:52 AM, the surveyor observed the DON exit the room of the resident she was earlier assisting to use the bathroom. While wearing the the gown, face mask and eye protection, the DON walked down the hallway to the medication cart and poured a glass of water from the water pitcher on the cart. She re-entered the same resident room that had the white Extended droplet precaution sign. At 11:57 AM the surveyor observed the DON exit the room wearing the same single-use long sleeve gown. The DON continued to walk down the hallway wearing the gown that she had worn while in the resident room. At 12:00 PM, the DON confirmed that Resident #1 was the roommate of Resident #6 who had tested positive for COVID-19, and Resident #2, #3, and #4 were the roommates of Resident #5 that tested positive for COVID-19. This corresponded with the interview with the AA at 11:24 AM. The DON confirmed the room numbers of the residents, and acknowledged all the residents had white Extended droplet precaution signs on their doors except for the Resident #7 because he/she went to the [MEDICAL TREATMENT] center. She informed the surveyor that We can wear the same PPE in the rooms of each resident that had a white sign, and there was nothing different done regarding how PPE was used for the Residents #1, #2, #3 and #4. At 12:17 PM, the surveyor observed CNA #1 deliver lunch trays into the room of Residents #2, #3, and #4 which had the white Extended droplet precaution sign outside the door. The CNA #1 was wearing a single-use long-sleeve gown, face mask, gloves and eye protection. The CNA #1 placed the tray next to Resident #3, exited the room and wearing the same gown returned to the meal truck to continue passing trays. The surveyor stopped and interviewed the CNA #1 at that time. She stated she had just passed out the tray to Resident #3 and was going room-to-room to pass out all the lunch trays. She added that after the trays were all passed she would return to the rooms assigned to her to assist the residents with their meals. The surveyor asked for information about Residents #2, #3, and #4. The CNA #1 confirmed that they were all roommates of Resident #5 who tested positive for COVID-19 last week. The surveyor asked if she was informed to do anything different upon entering or exiting the room of Residents #2, #3, and #4 and the CNA #1 stated that they do nothing different. The CNA #1 added that the facility tested all the residents in the facility every week for COVID-19, and if a resident developed signs or symptoms of COVID-19 they would be moved to a private room and given a yellow sign for Patient-specific airborne precautions. She confirmed that the yellow sign meant that PPE would have to be discarded upon exiting a room of a resident that was under suspicion for COVID-19, because it could not be shared. She confirmed PPE would be discarded even if she didn't touch anything in the room. The surveyor asked why it should not be shared, and the CNA #1 stated because it could spread [MEDICAL CONDITION]. The CNA #1 stated that Resident #2, #3, and #4 had no known signs or symptoms of COVID-19 and therefore a white Extended droplet precaution sign was in place for those residents. The surveyor asked if the facility considered the resident's exposed to [MEDICAL CONDITION] if they had a roommate that tested positive for COVID-19, the CNA #1 acknowledged that the residents should be considered exposed because they were in the same room. The CNA #1 re-iterated to the surveyor that even if the residents are considered exposed, we don't do anything different because PPE is worn for all the resident's in the building. She confirmed that the gowns were shared between residents that had white Extended droplet precaution signs on their door, but not shared between residents that would have a yellow Patient-Specific airborne precaution sign on their door. While still wearing the same gown, she then proceeded to take another tray from the meal truck and deliver it to another resident room across the hallway that had a white Extended droplet precaution sign on their door. At approximately 12:22 PM, the surveyor observed the AA wearing a single-use long sleeve gown, face mask and eye protection exit the room of Resident #3. The surveyor stopped the AA in the hallway and she confirmed she had just exited the room of Resident #3 because she had to drop off an item. The AA did not discard the gown upon exiting the resident room and proceeded down the hallway. From 12:22 PM to 12:40 PM, the surveyors observed CNA #1, CNA #2 and the DON entering and exiting different resident rooms wearing their same gowns, delivering and setting up lunch trays to the residents on the non-COVID unit all with white Extended droplet precaution signs on the room doors. The surveyor reviewed the records for the two residents that had tested positive for COVID-19 (Resident #5 and #6). A review of the lab reports for Resident #5 and Resident #6 indicated that nasal swab specimens were collected on [DATE] and the result read, abnormal Positive (Detected) for [DIAGNOSES REDACTED]-CoV-2 (COVID-19) on [DATE]. The lab results indicated that the two positive COVID-19 case results were reported to the facility on [DATE] at 8:15 PM. A review of the Primary Payer report dated [DATE] for Residents #5 and #6 reflected that the resident's rooms were changed to private rooms on the AQU/COVID unit on [DATE]. At 1:14 PM, the surveyor interviewed the RN/IP and the Regional Clinical Coordinator (RCC). The RN/IP provided the surveyor a copy of the U.S. CDC guidelines, Preparing for COVID-19 in Nursing Homes updated [DATE], marked in red to highlight the section where the U.S. CDC guidelines addressed the extended use of PPE in nursing homes. The U.S. CDC guidelines document included, If extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility and these residents are not known to have any co-infections (e.g. (multi-drug resistant organisms)). The RN/IP stated that this was what the facility had been implementing. The surveyor asked if the facility was using the same gown when caring for different residents, and the RN/IP acknowledged yes the facility was sharing the same gown for different residents that had the white Extended droplet precautions sign on the door. The RN/IP acknowledged those residents with the white sign on the door had tested negative for COVID-19. The RN/IP confirmed that in accordance with CDC guidelines, they should not be sharing the same gown between residents that had tested negative for COVID-19. She acknowledged that the guidelines addressed an exception for sharing gowns between different residents and that was if the residents had a confirmed COVID-19 [DIAGNOSES REDACTED]. The RN/IP confirmed that the facility was not sharing gowns between residents that had tested positive for COVID-19 because they had the yellow sign that indicated Patient-Specific airborne precautions, whereby PPE would get discarded upon exit of the room. The RN/IP and RCC stated based on the review of the U.S. CDC guidelines, they would stop Extended droplet precautions with the sharing of the gowns between residents that tested negative for COVID-19. According to the U.S. CDC guidelines, Responding to Coronavirus (COVID-19) in Nursing Homes updated [DATE], included, Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for (COVID-19) 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. A review of the facility's Infection Control Policies and Procedures for COVID-19 revised on [DATE] included, In addition to Standard precautions, Contact and Airborne precautions will be implemented for patient's suspected or confirmed to have COVID-19 based on the Centers for Disease Prevention & Control (CDC) guidance. It further included, implement universal use of facemasks/respirator and eye protection while in the Center. The policy provided did not address identifying roommates of residents that test positive for COVID-19 as exposed and PUI. A review of the Personal Protective Equipment (PPE): Use, Reuse and Extended Use of PPE for All Staff policy dated [DATE] included in a section titled, Buildings Where COVID-19 is Confirmed, Staff who are directly providing care to a patient who is suspected, presumed or confirmed for COVID-19 should use an N95 or approved KN95 respirator. It further included that, Staff must use gowns in caring for all patients and must follow extended use guidance. Staff on patient units who will not be entering patient rooms should NOT wear a gown. During a COVID-19 outbreak, gowns must be worn by all employees in patient care areas who are entering patient rooms. The facility defined Extended Use in their policy as, The same gown is worn by the same healthcare worker when interacting with more than one patient known to be infected with the same infectious disease when these patients housed in the same location (i.e. COVID-19 patients residing together in dedicated wings/units). Reuse of gowns can be considered only if there are no additional co-infectious [DIAGNOSES REDACTED].Diff) (infectious diarrhea)) among patients. Staff must remove and discard the gown if it becomes visibly soiled. The policy further included, When caring for patients with NO infectious process: Patients/residents who have tested negative for COVID-19 and are asymptomatic are considered non-infectious. Staff member may wear the same gown to go in and out of those patients rooms and into the hallway. Do not touch the front or sleeves of the gown. (This practice does not correspond with the U.S. CDC guidelines for extending the use of gowns). When caring for people with the same infectious process (e.g. COVID-19 .) Staff member may wear the same gown between patients. Gown must be removed in the room and discarded after leaving the room unless going directly to the room of another patient with the same infectious process. Staff member must change gowns when caring for patients with different infectious processes: Staff member may wear gown upon entering the room of a patient with an infectious process IF coming from room of patient(s) with no infectious process. Change gown between patients who have different infectious processes. In order to extend the use of a gown, cluster patient care around common infectious processes to decrease the number of times the gown has to be changed. At 1:21 PM , a second surveyor toured the central supply room with the LNHA who stated this was where they stored their PPE. The LNHA stated that the nursing supervisors for each shift have the key to the central supply room in the event they need to get more PPE for the units. He confirmed they had adequate PPE and showed the surveyor a form by the door titled, Central Supply Sign Out Log which served as an accountability system and a burn list used to identify what PPE and how much was removed from the central supply room during restocking of the units. The surveyor observed a large quantity of respirator masks, surgical masks, goggles, boxes of gloves of various sizes, multiple hand sanitizers, and multiple boxes of gowns. At that time, a central supply (CS) staff member informed the surveyor that there were even more gowns stored inside another locked cabinet but that all units and the front central supply area was well stocked. At 1:50 PM, the RCC informed the surveyors that all the residents were tested for COVID-19 on Monday [DATE] as part of their weekly testing program including Resident #5 and #6. The RCC stated the facility was notified of the confirmed positive results for Resident #5 and #6 on Thursday [DATE], and their rooms were changed that day to the AQU/COVID-19 unit. The RCC acknowledged the roommates of the confirmed positive residents did not have yellow signs on their doors to reflect Patient-Specific airborne precautions. The facility was notified of the IJ situation on [DATE] at 2:30 PM. The facility's LNHA, DON, RN/IP, and RCC were informed that the facility failed to identify the roommates of the confirmed positive residents as exposed and potentially infected with COVID-19, and failed to avoid the re-use of single-use gowns between the unidentified exposed PUI residents and the residents that tested negative for COVID-19. This failure placed the non-ill residents in an Immediate Jeopardy situation that began on [DATE] at 8:15 PM. The Removal plan was accepted on [DATE] at 12:48 PM and the immediacy was removed on [DATE] based on the accepted implemented elements of that Removal Plan. The Removal Plan was verified by the surveyors during an onsite visit on [DATE]. The plan included the following: All residents that are not COVID positive are being treated as PUI's and have been placed on patient specific contact and airborne precautions. The affected residents will be retested weekly x 2 weeks for COVID and will be ruled out as Person's Under Suspicion if they remain asymptomatic for 14 days ([DATE]) after the positive test and then test negative for COVID. Extended use of gowns has been discontinued fo (TRUNCATED)

Based on observation, interview, record review and policy review, it was determined that the facility failed to perform proper hand hygiene during a [MEDICAL CONDITION] treatment. This deficient practice was observed for Resident #26 and evidenced by the following: Review of the Resident's Admission Record (AR) showed that Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 2/6/2019, showed that Resident #26 required total assistance from staff with Activities of Daily Living (ADL). The physician's orders [REDACTED]. Review of Resident's Care Plan (CP), initiated on 4/30/2017, showed that Resident #26 exhibits alteration in respiratory status related to Trach; s/p (status/post) pneumonia, dx (diagnosis) MDRO (multi drug resistant organisms) infections respiratory tract with interventions that included but were not limited to:[MEDICAL CONDITION] every shift an prn (as needed) for excessive secretions. On 4/10/19 at 10:02 a.m., the surveyor observed Licensed Practical Nurse (LPN) #1 provide [MEDICAL CONDITION] care to Resident #26. The resident was lying in bed, awake. The surveyor observed LPN #1 wash her hands for a duration of 10 seconds before putting on clean gloves. The LPN was observed to take off soiled gloves 4 times during the above procedure and did not cleanse her hands before putting on clean gloves. After the procedure was complete, the surveyor observed LPN #1 wash her hands for a total duration of 6 seconds. Review of the facility's policy titled [MEDICAL CONDITION] Care, revised 2/1/19, indicated remove gloves and cleanse hands under the numbers 11, 14 and 35. Review of the facility's policy titled Hand Hygiene, reviewed 11/28/17, indicated to 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. On 4/10/2019 at 1:29 p.m., the Administrator and Director of Nursing were made aware of the surveyors' observations. No further information was provided. NJAC 8:39-19.4 (a)1

Based on observation, interview, record review and policy review, it was determined that the facility failed to observe, monitor, assess and document the care of a [MEDICAL TREATMENT] resident's access site for one of one residents (Resident # 33) reviewed for [MEDICAL TREATMENT] care. This deficient practice was evidenced by the following: The surveyor reviewed the facility's policy titled, [MEDICAL TREATMENT] Graft and Fistula care, revised 10/01/18. The policy indicated to evaluate the access site daily, on completion of [MEDICAL TREATMENT] treatment and to observe for signs of complications. On 04/09/19 at 01:15 PM, the surveyor observed Resident # 33 in the resident's bedroom. Resident # 33 informed the surveyor that the resident was receiving [MEDICAL TREATMENT]. Review of Resident # 33's medical record showed that the resident was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed as cognitively intact according to the Quarterly MDS, an assessment tool used to facilitate the management of care, dated 02/16/19. The resident's (MONTH) 2019 physician's orders [REDACTED].# 33's [MEDICAL TREATMENT] left arm Arteriovenous (AV) fistula access site for pulse, bruit and thrill to assure adequate blood flow. The surveyor reviewed the resident's current care plan titled At risk for complications related to [MEDICAL CONDITION] which revealed an intervention to Monitor [MEDICAL TREATMENT] access for bruit and thrill every shift. During an interview on 04/11/19 at 12:00 PM, the Registered Nurse (RN) who cared for Resident # 33, stated that there should have been bruit and thrill assessments done daily and was unable to locate a physician's orders [REDACTED].>During an interview on 04/11/19 at 01:30 PM, the surveyor brought the above concerns to the attention of the Administrator and Director of Nursing, who stated that the bruit and thrill should have been assessed and monitored for this resident. NJAC 8:39- 27.1 (a)

Based on observation, interview, record review and review of other facility documents, it was determined that the facility failed to provide supportive documentation for the continued use of an antipsychotic medication for 1 of 5 residents (Resident #37) reviewed. The deficient practice was evidenced by the following: On 4/20/18 at 11:00 AM the surveyor observed Resident #37 in the Main Dining Room seated in the wheel chair using their lower extremities to move around. The surveyor reviewed Resident #37's medical records. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#37 had severe cognitive impairment. The surveyor reviewed the (MONTH) (YEAR) physician's orders [REDACTED]. The surveyor reviewed Resident #37's behavior care plan which included behavior problems related to episodes of hitting, kicking and cursing at staff, resistance to care and wandering in hallways. Interventions intended to address the behavior issues included allowing the resident to propel self around, monitoring of medications, observing for non-verbal signs of physical aggression, approaching in an unhurried manner and providing opportunities of choice during care and activities. The surveyor reviewed the (MONTH) and (MONTH) (YEAR) Behavior Monitoring and Interventions Flow Records which reflected the resident had 1 episode of kicking and 1 episode of wandering documented on (MONTH) 1, (YEAR). There were no episodes of behaviors documented on the (MONTH) (YEAR) Behavior Monitoring Flow Sheets. The surveyor reviewed the Psychiatric progress notes from 05/31/17 - 04/13/18. There was no recommendation for a gradual dose reduction to eventually discontinue the residents use of the antipsychotic medication [MEDICATION NAME] during this time period. The Psychiatrist indicted the resident was depressed, psychotic and paranoid, not lethargic, agitated or suicidal. The Psychiatrist indicated in the progress note dated 4/13/18 the nurse reports that (the resident) needed the medications, could be difficult at times, had no side effects of [MEDICATION NAME] continue with the same medications. On 4/25/18 at 11:35 AM the surveyor interviewed the Certified Nursing Assistant(CNA) who was assigned to Resident #37. The CNA stated the resident did not have behaviors of hitting or cursing for about one month or two. She further stated when the resident wandered into other residents rooms, the resident was easily redirected. On 4/25/18 at 11:45 AM the surveyor interviewed the Licensed Practical Nurse (LPN) who stated they had not observed the resident exhibiting behaviors of hitting or cursing for about a month or two. The LPN also stated the resident was easily redirected. On 4/25/18 at 12:05 PM the surveyor interviewed the activity assistant who was familiar with Resident #37. She stated that the resident was easily redirected when wandering around. On 4/26/18 at 12:30 PM the surveyor reviewed the Behavior Flow Sheets and the Psychiatric progress notes with the Unit Manager (UM) who stated she informed the Psychiatrist that the resident still needed their current antipsychotic medications because the resident wanders in and out of other residents rooms and was combative at times. The Unit Manager informed the surveyor that she observed Resident #37 swinging at a CNA the afternoon before (4/25/18). The UM told the surveyor she forgot to record the episode on the behavior monitoring flow sheet. The surveyor asked the UM how or if she intervened when Resident #37 was swinging at the CNA. The UM stated she went over to the resident and took their hand and the resident followed the UM and was calm and cooperative. The surveyor reviewed the facility's policy titled [MEDICAL CONDITION] Medication Use under procedure #8 indicated [MEDICAL CONDITION] medications used to treat Behavioral or Psychological Symptoms of Dementia must be clinically indicated, be supported by an adequate rational for use, and may not be used for a behavior with an unidentified cause. Also included in the policy under 8.2 indicated Gradual dose reduction is used in an effort to discontinue antipsychotics. On 4/27/18 at 9:00 AM, the surveyor addressed the continued use of the antipsychotic medication without documented behaviors with the Director of Nursing (DON) and Administrator. The DON stated she was aware that when the staff approached the resident from the front and took the resident's hand to redirect the resident it worked well. No further information or documentation was provided. NJAC 8:39-27.1 (a)

Based on observation, interview, record review and other facility documents, it was determined that the facility failed to provide treatment to a pressure sore as ordered by the physician. This deficient practice as observed for 1 of 3 residents reviewed for Pressure Ulcers, Resident # 27, and was evidenced by the following: This deficient practice was evidenced by the following: On 4/23/18 at 10:30 AM, the surveyor observed Resident # 27 in bed positioned on their left side. The resident was alert and confused and did not respond verbally to the surveyor. The surveyor reviewed Resident #27's medical records. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the (MONTH) (YEAR) physician's orders [REDACTED]. The order was to cleanse the left heel with normal saline solution and apply skin prep. On 4/23/18 at 11:30 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound treatment to Resident #27. The LPN performed hand hygiene and donned a pair of gloves. The LPN removed the resident's heel protector and sock from the left foot. She then reached into her pocket with the gloved hand. She removed and opened the skin prep pad. She proceeded to wipe the wound from the center outward without changing her gloves. She then reapplied the sock and heel protector and washed her hands. At that time the surveyor asked the LPN to review the treatment order on the TAR. The order on the TAR indicated that the treatment to the left heel was to cleanse the left heel with normal saline solution before applying the skin prep twice daily at 10 AM and 10 PM. The LPN agreed she did not follow the physician's treatment orders and infection control procedures. On 4/27/18 at 9:00 AM, the surveyor spoke with the Director of Nursing(DON) and Administrator and discussed concerns observed during the treatment. There was no additional information provided. NJAC 8:39-27.1(e)

Based on observation, interview and record review, it was determined that the facility failed to provide adequate supervision to prevent falls; complete thorough fall investigations to determine the root cause of falls; and determine if the equipment/interventions in use were effective in preventing the resident from falling again and/or sustaining an injury. This deficient practice was identified for 1 of 2 residents, Resident #6, reviewed for falls. Resident #6 had 8 falls and sustained a fracture of the right hip from the 7th fall requiring surgical intervention. This deficient practice was evidenced by the following: On 04/14/14 at 9:45 a.m. during the initial tour of the facility with the Unit Manager (UM), the surveyor observed the resident sitting in a wheelchair with an alarming seat belt in use. The UM stated that the resident was a fall risk and self- propelled around the facility. She added that the resident had behaviors that included kicking and grabbing. The surveyor observed a beveled mattress on the resident's bed, a floor mat at the bedside and a bed alarm attached to the bed. On 04/14/14 at 12:15 p.m. the surveyor reviewed the medical record for Resident #6. The resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 06/24/13 and 09/03/13 the Interdisciplinary (IDC) team assessed Resident #6 as being severely cognitively impaired utilizing the Minimum Data Set (MDS), an assessment tool. The IDC team further assessed the resident as requiring extensive assistance for transfers, ambulation and toilet use. The Balance During Transitions and Walking Section of the MDS indicated that the resident was "not steady, but only able to stabilize with staff assistance" for moving from seated to standing position; walking; turning around; moving on and off the toilet; and surface to surface transfer. On 03/24/13 the resident was identified as a high fall risk on the Facility Nursing Assessment and Fall Risk Evaluation. The resident had a Care Plan in place for being at risk for falls due to cognitive loss and lack of safety awareness. On 04/15/14 at 12 p.m. the surveyor reviewed the resident's 8 Fall Investigation reports: 1. On 04/20/13 at 3:15 p.m. the resident was found on the floor by his/her bed in a full lying position on his/her left side. There was no apparent injury. The resident stated "I rolled out of bed." A new intervention to prevent further falls was to change the bed mattress to a beveled edge mattress. The Fall Investigation Form indicated that an alarm was "not applicable" at the time of this fall. A review of the April 2013 physician's orders [REDACTED]. A review of the April 2013 Treatment Administration Record (TAR) revealed that the orders for bed alarm and wheelchair alarm were being documented as being used until 04/07/13. The bed alarm was reinstituted on the TAR on 04/21/13. On 04/21/14 at 10:50 a.m. the surveyor spoke with the Director of Nursing (DON) regarding the orders for wheelchair and bed alarms. The DON stated the alarms were discontinued on 04/04/13 when the Safety Committee determined that the "resident continues to transfer self from bed/chair independently multiple times a day. Alarms have had no effect and tend to aggravate resident and those around her. Will do a trial d/c of alarms and continue interventions of slipper socks, anti-roll back brakes and keeping chair at bedside." The DON was unable to provide any documentation regarding the placement of the wheelchair alarm on 04/21/13. 2. On 06/05/13 at 10 p.m. the nurse heard the resident yelling from his/her room and found Resident #6 on the floor next to the bed and wheelchair. There was no apparent injury. The resident stated "I fell ." The Fall Investigation Form indicated that the resident had been noted with increased confusion earlier in the shift. In addition, the resident's wheelchair with anti-roll back brakes was broken and the resident was using another wheelchair until it was repaired. A new intervention was to obtain a urine specimen to check for a possible Urinary Tract Infection. On 04/16/14 at 9:40 a.m. the surveyor spoke with the DON regarding the result of the urine test. The DON was unable to provide a report or any documentation to show that the test had been performed. A review of the June 2013 POS and TAR revealed that there were no orders for a bed or chair alarm. 3. On 07/04/13 at 2:45 a.m. the resident was found sitting on the floor of another resident's room. The nurse documented that the resident was apparently trying to get into another resident's bed. There was no apparent injury. The Fall Investigation Form indicated that the resident had been sitting in his/her wheelchair in the hallway prior to the fall. The Certified Nursing Assistant (CNA) that was assigned to care for him/her went on a break and did not inform others that she was leaving the resident unattended in the hallway. The new intervention put into place was to monitor when awake at night and to bring the resident to the nurse when the CNA goes on break. 4. On 07/27/13 at 1:50 a.m. the resident was found at the foot of his/her bed on the floor. There was no apparent injury. The Fall Investigation Form indicated that s/he was last toileted at 1 a.m. At the time of the fall, the resident's brief was soiled. The intervention put into place was to obtain a urine specimen to check for a possible Urinary Tract Infection. On 04/16/14 at 9:40 a.m. the surveyor spoke with the DON regarding the results of the urine test. She was unable to provide a report or any documentation that the test had been performed. The resident had a Physical Therapy (PT) Evaluation done on 08/01/13 due to the recent fall, decline in ambulation, balance impairment, and impaired muscle strength. The resident was discharged from PT on 09/03/13 with instructions for restorative nursing to ambulate with resident in the hallway with a rolling walker, knee support, and contact guard assist of one person for walker direction and cues for safety. 5. On 08/12/13 at 11:40 a.m. the resident was found on the floor in another resident's room in front of his/her wheelchair at the end of the bed. There was no apparent injury. The Fall Investigation Form concluded that the resident wandered, went into another resident's room and tried to get out of his/her wheelchair to get into bed. The resident's legs weakened and he/she fell to his/her buttocks. The new interventions put into place were to resume use of pad alarm in the wheelchair, have physician review anti-hypertensive medications and to obtain a urine specimen for a possible Urinary Tract Infection. On 04/16/14 at 9:40 a.m. the surveyor spoke with the DON regarding the results of the urine test. The DON provided a copy of the laboratory report dated 08/14/13 that indicated the resident did not have a Urinary Tract Infection. 6. On 09/17/13 at 12:55 a.m. the resident's roommate alerted staff that the resident had slipped to the floor while transferring from the bed to the wheelchair. The resident was found sitting on the floor in front of the wheelchair. There was no apparent injury. The Fall Investigation Form indicated that the roommate stated the resident grabbed for the wheelchair, it moved and he/she slipped to the floor. The new intervention put into place was to have maintenance check the anti-roll back brakes to ensure proper functioning. On 09/22/13 an entry in the Progress Notes regarding Restorative Transfers indicated that the resident demonstrated a deficit in transferring due to cognitive loss/dementia and functional deterioration. The resident transfered with extensive assistance. On 04/16/14 at 9:40 a.m. the surveyor spoke with the DON regarding whether maintenance checked the wheelchair brakes and what the finding was. The DON was unable to provide any answer. 7. On 10/25/13 at 10:10 p.m. the resident was found lying in the hallway. The nurse assessed the resident as having the right leg rotated out and shorter in length than the left leg. The resident complained of severe pain to the right hip. The physician was notified and the resident was sent to the emergency room for evaluation. The resident was admitted to the hospital with [REDACTED]. The Fall Investigation Form did not come to a conclusion as to how the fall occurred. It indicated that the resident's behavior had escalated within the past few days and he/she was more disruptive and difficult to redirect. A urine specimen had been obtained and had been sent to the laboratory to check for a possible Urinary Tract Infection. (Addendum to the Investigation Report indicated the urine results were negative.) The investigation indicated that the resident had last received care at 9:30 p.m. and the resident was in bed. The Certified Nursing Assistant (CNA) was in the charting room which was across from the resident's room. The CNA stated she looked up and saw the resident falling to his/her right side partially inside the charting room but was unable to reach her. The nurse noted the care plan would be revised when the resident returned from the hospital. The resident was readmitted on [DATE] and the care plan was revised to utilize bed and chair alarms, high impact mat on the floor and the wheelchair to be kept out of the room. 8. On 01/05/14 at 10:45 p.m. the resident was found on the floor sitting on the floor mat next to the bed. There was no apparent injury. The Fall Investigation Form indicated that the resident had been toileted 5 minutes prior to the fall. The new intervention was to provide hip protectors, ensure beveled mattress was on the bed and resident should be on a toileting schedule. On 04/16/14 at 9:40 a.m. the surveyor spoke with the DON regarding whether the beveled mattress had been on the bed and what the toileting schedule was to be. The DON did not have an answer. A review of the Facility Accidents, Incidents, and Adverse Reactions Policy and Procedure stated "the Administrator, DON or designee will review all incidents to determine if required documentation has been completed; interventions to prevent further accidents/incidents have been identified and implemented; and, further investigation is needed." On 04/16/14 at 9:40 a.m. and 04/21/14 at 10:50 a.m. the surveyor spoke with the Director of Nursing (DON) regarding Resident #6's falls. The resident had 6 falls prior to the 10/25/13 fall when s/he fractured his/her hip. The facility failed to identify that 4 of the 6 falls had occurred between the hours of 10 p.m. and 2:45 a.m. and failed to put new interventions or increased supervision into place to specifically address this pattern. The facility also failed to identify that all 8 falls involved the resident trying to get in or out of bed or chair. NJAC 8:39-27.1 (a)