Every finding on record at Complete Care at St Vincents LLC

Complaint #s: 3031703, 3054815 Based on interviews, medical record review, and review of pertinent facility documents it was determined that the facility failed to a) develop a wound care Care Plan (CP) for a resident who had a heel wound on admission and received wound care in the facility (Resident #3) and b) update the CP of a resident who alleged that they were sexually assaulted in the facility (Resident #4). This deficient practice was identified for 2 of 3 residents reviewed for care plans. This deficient practice was evidenced by the following:Resident #3 was no longer at the facility, a closed record review was conducted. According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses including but not limited to: aftercare following joint replacement surgery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (total paralysis or partial weakness caused by a blocked blood vessel in the brain), muscle weakness (generalized), and need for assistance with personal care. A review of Resident #3's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 03/03/2026, was conducted. The MDS revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed that Resident #3 had an unstageable pressure injury on admission. A review of the progress notes (PNs) for Resident #3 was conducted. A wound care PN dated 03/03/2026 at 5:01PM, revealed that Resident #3 was evaluated by the wound care Nurse Practitioner on 03/02/2026. The PN revealed that Resident #3 had right heel discoloration on admission and had a pre-existing ulcer of the right heel. The wound care PN further revealed the following treatment recommendations for the wound on Resident #3's right heel:1. Cleanse with soap and water, pat dry.2. Apply skin prep to the base of the wound.3. Leave the area open to air.4. Change twice a day and as needed. A review of a wound care progress note dated 03/23/2026 at 2:13 PM, revealed that Resident #3's right heel wound appeared boggy (soft or spongy) from an opened blood-filled blister. The wound care PN revealed the following treatment recommendations for the wound on Resident #3's right heel:1. Cleanse with soap and water, pat dry.2. Apply calcium alginate (highly absorbent, seaweed-derived material used in wound care) and medical grade honey (sterilized, clinically tested honey used to promote wound healing) to base of the wound.3. Secure with bordered foam (specialized wound dressing).4. Change twice a day and as needed. A review of a wound care progress note dated 04/13/2026 at 8:04 PM, and 04/20/2026 at 12:32 PM, revealed that a surgical wound debridements (removal of dead, damaged, or infected tissue from a wound to assist with healing) were performed on Resident #3's right heel wound. The wound care PNs revealed the following treatment recommendations for the wound on Resident #3's right heel:1. Cleanse with normal saline.2. Apply Dakins (solution is used to kill and prevent the growth of bacteria or germs in wounds) moistened fluffed gauze, skin prep surrounding tissue or peri wound to base of the wound.3. Secure with bordered gauze.4. Change daily, and as needed. A review of Resident #3's CP revealed a Focus of Resident requires enhanced barrier precautions [EBP] right heel Resident has any skin opening requiring a dressing, Interventions related to this focus revealed instructions for use of EBP. Further review of the CP for Resident #3 revealed no foci, goals, or interventions related to Resident #3's right heel wound or its treatments. According to the AR, Resident #4 was admitted to the facility with diagnoses including but not limited to; encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, adjustment disorder with mixed anxiety and depressed mood (strong reaction to stress or trauma including signs of both sadness and worry), and unspecified mood [affective] disorder (mental health condition that primarily affects the emotional state). A review of Resident #4's comprehensive MDS dated [DATE] revealed that Resident #4 had a BIMS score of 14 out of 15 which indicated that the resident's cognition was intact. A facility reportable event (FRE), a form used by facilities to communicate reportable events to the New Jersey Department of Health (NJDOH), dated 06/25/2026, was reviewed. Under Narrative the FRE revealed that on 06/23/2026 at approximately 10:50 AM, Resident #4 reported that a female hospice aide touched them inappropriately during care. A Summary of Investigation (SOI) dated 6/23/2026, was reviewed. Under Investigation/Statements the SOI revealed that Resident #4's CP was updated to include having two caregivers present during bathing and changing activities. A review of Resident #4's CP revealed no foci, goals or interventions related to Resident #4's sexual assault allegation, or two caregivers being present for bathing and changing. On 07/15/2026 at 11:10 AM, the surveyor attempted to interview Resident #4. The resident could not be interviewed due to their cognitive status. On 07/15/2026 at 4:07 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that CPs are the plan of how care is managed for residents in the facility. The DON stated that Resident #3's heel wound should have been included in the resident's CP with treatments and interventions as ordered. On 07/16/20206 at 2:16 PM, a follow up telephone interview was conducted with the DON. The DON stated that she could not find the intervention of two caregivers to be present for bathing and changing on Resident #4's CP. The DON stated that Unit Managers or the Assistant Director of Nursing or anyone from the nursing team were responsible for updating CPs. On 07/16/2026 at 2:59 PM, a follow up telephone interview was conducted with the DON. The DON stated that she did not see the sexual abuse allegation on Resident #4's CP. The DON further stated that the allegation may not have been added to the CP because it was investigated and ruled out. The facility policy Comprehensive Care Plans with an implementation date of 09/01/2024 and a reviewed/revised date of 03/01/2025 was reviewed. Under Policy: the policy revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Under Policy Explanation and Compliance Guidelines: the policy revealed .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. NJAC 8:39-11.2 (e)2

Complaint #: 3054815Based on interviews, record reviews, and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) and failed to notify law enforcement agencies of an allegation of resident sexual abuse against a hospice Certified Nursing Assistant (CNA #1) working in the facility. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #4).This deficient practice is evidenced by the following:A facility reportable event (FRE), a form used by facilities to communicate reportable events to the New Jersey Department of Health (NJDOH), dated [DATE], was reviewed. The FRE revealed Yes under Was this a Significant Event? and Yes under Was Significant Event Called in?. The FRE further revealed the event was called in on [DATE] at 4:00 PM. Under Narrative revealed that on [DATE] at approximately 10:50 AM, Resident #4 reported that a female hospice aide touched them inappropriately during care. The FRE revealed that an immediate investigation was initiated. The FRE revealed that the facility implemented the following after the allegation was made: assessment of the resident; pain assessment; physician and family notification; correlation with the hospice agency investigation; review of the resident's medications; evaluation by psychiatry and psychology; assessment of Resident #4's mental status; and conducting interviews. There was no indication that the police were notified. The Summary of Investigation (SOI) dated [DATE], was reviewed. The SOI did not indicate that the police were notified. A review of the admission Record face sheet for Resident #4 revealed that the resident was admitted to the facility with diagnoses including but not limited to; encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, adjustment disorder with mixed anxiety and depressed mood (strong reaction to stress or trauma including signs of both sadness and worry), and unspecified mood [affective] disorder (mental health condition that primarily affects the emotional state). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated [DATE], revealed that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated that the resident's cognition was intact. A review of Resident #2's Care Plan Report (CPR) revealed a Focus initiated on [DATE] that Resident #4 was lethargic. Interventions related to this focus included but were not limited to, Staff/Hospice will provide a safe environment. On [DATE] at 11:10 AM, the surveyor attempted to interview Resident #4. The resident could not be interviewed due to their cognitive status. On [DATE] at 11:17 AM, an interview was conducted with the Unit Manager (UM #1). UM #1 stated that she was informed by Resident #4's hospice nurse that the resident alleged that they were touched inappropriately during care by the lady who cleans them. UM #1 stated that she informed the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA), and Social Worker (SW) right away. UM #1 further stated that she and the DON assessed Resident #4 within 15 minutes of becoming aware of the allegation and at that time Resident #4 stated that a finger was rubbed on [their] butt. On [DATE] at 5:07 PM, an interview was conducted with the LNHA. The LNHA stated that on [DATE] at approximately 11:00 AM, Resident #4 reported the sexual abuse allegation to HN #1. The LNHA stated that CNA #1 was told to leave the building and report to the hospice office and CNA #1's other residents were interviewed, or skin checks were performed. The LNHA further stated that Resident #4's allegation of sexual assault was not reported to the police because the facility's investigation found the allegation to be invalid. The LNHA stated she could not recall the date she notified the NJDOH of the sexual assault allegation made by Resident #4. The LNHA further stated that the date on the FRE ([DATE]) was the date notification to the NJDOH was made. On [DATE] at 2:25 PM, a follow up telephone interview was conducted with the LNHA. The LNHA stated that the sexual assault allegation made by Resident #4 was not reported to the police because the facility investigation revealed that CNA #1 provided incontinence care and that Resident #4 was not sexually assaulted. The LNHA stated the facility abuse policy did not require allegations to be reported to the police. The facility policy Abuse, Neglect and Exploitation with an implementation date of [DATE] and reviewed/revised date of [DATE] was reviewed. Under Policy the policy revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Under Definitions: the policy revealed that an alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse. The Definitions: section of the policy further revealed that law enforcement is the full range of potential responders to elder abuse, neglect, and exploitation including: police, sheriffs, detectives, public safety officers; corrections personnel; prosecutors; medical examiners; investigators; and coroners. Under Reporting/Response: the policy revealed The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse [.] or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. NJAC 8:39-4.1(a)(5);

Based on observation, interview, and record review, it was determined that the facility failed to a.) ensure that there was an order for the administration of oxygen being provided to Resident # 189 and b.) failed to accurately document a medication being administered per Physicians order for Resident # 35. 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: 1. The surveyor reviewed the electronic medical record (EMR) of Resident # 189 which revealed the following: According to the Resident Face Sheet, Resident #63 was admitted with diagnoses that included Chronic Systolic (Congestive) Heart Failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of the resident's progress notes revealed the following: On 4/23/23 a progress noted revealed 4 L (liters) oxygen via nasal cannula, on 4/25/23 oxygen via nasal cannula, on 5/3/23 oxygen at 2 LPM (liters per minute), on 5/7/23 on 4 L oxygen. A review of the 02 (oxygen) saturation summary in the the vitals section of the EMR, revealed that there were documented methods of oxygen via nasal cannula on the following dates: 4/23/34, 4/24/23, 4/25/23, 4/27/23, 4/28/23, 4/29/23, 4/30/23, 5/1/23, 5/2/23, 5/3/23, 5/4/23, 5/5/23, 5/6/23, and 5/7/23. On 1/23/24 at 1:25 PM, the surveyor discussed the above concerns with the Administrator and Director of Nursing (DON). A review of the facility's Oxygen Administration policy and procedure updated 1/2024, revealed Verify that there is a physician's order for this procedure. review the physician's orders for oxygen administration. 2. The Surveyor reviewed the electronic medical record (EMR) of resident #35 which revealed the following: According to the Resident Face Sheet, the resident was admitted with a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain, Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions, your general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function. an emotion characterized by feelings of tension, worried thoughts). A review of the resident's electronic medication record revealed the following: An order dated 4/25/23 for clonazepam .5mg twice a day (a medication used to treat anxiety). An order dated 8/8/23 to discontinue lorazepam .5mg as needed every 4 hours for anxiety/agitation (a medication used to treat anxiety). A review of the resident's paper medical record and electronic medical record revealed the following: A Psychiatric Consult dated 12/11/23 that reflected a recommendation to maintain Ativan (lorazepam). A Hospice of New Jersey Plan of Care dated 1/9/24 with a medication list that included Ativan (lorazepam) .5mg PRN every 4 hours as needed for anxiety/agitation. On 1/24/24 at 12:10 PM the surveyor interviewed the Hospice RN who stated that she has personal clinical notes that reflected the change in medication orders, but they were not in the resident's medical record as they are no longer putting hard copies in the resident's chart. On 1/24/24 at 12:41 PM the DON provided to the surveyor a copy of an email from the Psychiatric Advance Practice Nurse stating the 12/11/23 consultation report omitting clonazepam and documenting lorazepam was an error in transcription. 49078 2. The Surveyor reviewed the electronic medical record (EMR) of resident #35 which revealed the following: According to the Resident Face Sheet, the resident was admitted with a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain, Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions, your general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function. an emotion characterized by feelings of tension, worried thoughts) A review of the resident's electronic medication record revealed the following: An order dated 4/25/23 for clonazepam 0.5mg twice a day (a medication used to treat anxiety). An order dated 8/8/23 to discontinue lorazepam 0.5mg as needed every 4 hours for anxiety/agitation (a medication used to treat anxiety). A review of the resident's paper medical record and electronic medical record revealed the following. A Psychiatric Consult dated 12/11/23 that reflected a recommendation to maintain Ativan (lorazepam). A Hospice of New Jersey Plan of Care dated 1/9/24 with a medication list that included Ativan (lorazepam) 0.5mg PRN every 4 hours as needed for anxiety/agitation. On 1/24/24 at 12:10 PM, the surveyor interviewed the Hospice RN who stated that she has personal clinical notes that reflected the change in medication orders, but they were not in the resident's medical record as they are no longer putting hard copies in the resident's chart. On 1/24/24 at 12:41 PM, the DON provided to the surveyor a copy of an email from the Psychiatric Advance Practice Nurse stating the 12/11/23 consultation report omitting clonazepam and documenting lorazepam was an error in transcription. NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in three (3) of four (4) medication carts inspected on four (4) of four (4) units. This deficient practice was evidenced by the following: On 1/18/23 at 11:37 AM, the surveyor inspected 1st floor South Cart High in the presence of LPN#1 and an additional surveyor and observed one (1) foil package of Budesonide (Pulmicort) nebulizer solution (a steroid inhalant liquid used with a mechanical nebulizer to treat asthma) with no date documented on the foil package when opened. The surveyor also observed one (1) box of Ipratropium/Albuterol (DuoNeb) nebulizer solution (an inhalant liquid used with a mechanical nebulizer to treat asthma), which contained one (1) open foil packet. There was no indication of when the foil pouch or box was opened. On 1/18/23 at 11:47 AM, the surveyor interviewed LPN#1 who stated that she could not find any dates when opened on the Budesonide package or the Ipratropium/Albuterol package. The surveyor with LPN#1 reviewed the Budesonide and Ipratropium/Albuterol manufacturer label and packaging which specified for Budesonide, once the foil pouch was opened, use ampules within (two) 2 weeks, and specified for the Ipratropium/Albuterol to be used within one (1) week of removal from foil package. The LPN#1 acknowledged the lack of dates, and the undated items were removed from the medication cart. On 1/18/24 at 11:55 AM, the surveyor inspected 1st floor South Cart Low in the presence of RN#1 and an additional surveyor and observed one (1) vial of PPD Tubersol (Tuberculin Purified Protein Derivative-Mantoux, an injectable solution used to aid diagnosis of tuberculosis infection in persons at increased risk of developing active disease). The surveyor observed a date of 1/10/24 written on the box and vial. On 1/18/24 at 11:56 AM, the surveyor interviewed RN#1 who stated the vial of PPD Tubersol should have been stored in the refrigerator. Review of the PPD Tubersol labeling and package information reflected: Store at 2 to 8 C (35 to 46 F). Do not freeze. Discard product if exposed to freezing. Protect from light. Tuberculin PPD solutions can be adversely affected by exposure to light. The product should be stored in the dark except when doses are actually being withdrawn from the vial. A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. On 1/18/24 at 12:07 PM, the surveyor inspected the 1st floor South Cart Subacute in the presence of RN#2 and an additional surveyor and observed one (1) vial of Insulin Aspart (an injectable medication used to treat diabetes) that was unopened. The surveyor also observed one (1) box of Ipratropium/Albuterol nebulizer solution, which contained one (1) open foil packet and two (2) loose vials. There was no indication of when the foil pouch or box was opened. On 1/18/24 at 12:09 PM, the surveyor interviewed RN#2 who stated the Insulin Aspart should be stored in the refrigerator. The surveyor with RN#2 reviewed the Ipratropium/Albuterol manufacturer label and packaging which indicated for the Ipratropium/Albuterol to use within one (1) week of removal from foil package. The medication nurse acknowledged the lack of dates on the Ipratropium/Albuterol. On 1/18/24 at 12:15 PM, the surveyor inspected the 2nd floor North Cart Low in the presence of RN#3 and an additional surveyor observed twenty-three (23) various unidentified loose tablets on the bottom of the 2nd drawer of the medication cart. The surveyor interviewed RN#3 who stated she could not identify the loose tablets. On 1/18/24 at 12:25 PM, the surveyor inspected the 2nd floor South medication room in the presence of RN#3 and an additional surveyor. The surveyor observed a temperature log for the medication refrigerator located in the medication room. The refrigerator was observed to contain vials of influenza vaccine. The temperature log reflected monitoring of the refrigerator once a day. On 1/18/24 at 1:15 PM, the Administrator provided a copy of the facility policy on medication storage. The facility policy reflected The facility shall store all medications and biologicals in a safe, secure, and orderly manner. In addition, the facility policy reflects at line 1 Medications and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. A review of CDC guidelines for vaccine storage reflected for Monitoring Vaccine Temperatures, To ensure the safety of vaccines, the storage unit minimum and maximum temperatures should be checked and recorded at the start of each workday. If using a TMD that does not display minimum and maximum temperatures, then the current temperature should be checked and recorded a minimum of two times (at the start and end of the workday). NJAC 8:39-29.4(d)(g)

Reference: The American Heart Association (AHA) 2010 . guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). These guidelines reflect global resuscitation science and treatment recommendations . In the guidelines, AHA has established evidenced-based decision-making guidelines for initiating CPR when cardiac or respiratory arrest occurs in or out of the hospital. AHA urges all potential rescuers to initiate CPR unless: 1) a valid Do Not Resuscitate (DNR) order is in place; 2) obvious clinical signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers, and the general public. Based on interview, review of facility records, and other pertinent facility documents on [DATE], it was determined that the facility failed to initiate life saving measures for a resident who was found unresponsive and was designated by the facility as a full code (Initiate Cardiopulmonary Resuscitation if the heart stops and respirations cease), as well as failed to follow the facility policy titled; Cardio Pulmonary Resuscitation. This deficient practice was identified for 1 of 3 residents for closed records review (Resident #122), when on [DATE] at 3:40 PM, Resident #122 was found by the Registered Nurse (RN #1) with no pulse or respirations. RN #1 failed to initiate CPR and pronounced the resident dead at 3:40 PM, without attempting to resuscitate the resident. This was not in accordance with the resident's wishes as documented in the medical record, as stated by the resident's physician, or according to the facility's policy. In addition, there was no documentation in the medical record to explain RN #1's decision to not attempt resuscitation. The facility's failure to honor the code status of a resident and initiate life saving measures (CPR) posed a serious and immediate threat to the safety and well being of Resident #122 and all other residents in the facility who were designated as full code status. This resulted in an Immediate Jeopardy (IJ) determination. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were notified of the IJ and provided the IJ template on [DATE] at 1:29 PM. The IJ began on [DATE] at 3:40 PM when Resident #122 was found unresponsive by the Registered Nurse (RN #1) assigned to the resident and continued until [DATE] at 2:38 PM when the facility provided an acceptable removal plan. The removal plan was verified on-site on [DATE], during survey. The evidence was as follows: On [DATE] at 9:00 AM the surveyor reviewed the Electronic and Hard copy medical records of Resident #122 which revealed the following: The nurses admission note was dated [DATE] 5:31 AM. The note read At 0100 AM receive a [AGE] year old [male] patient from [an acute care hospital] via ambulance on a stretcher accompanied by 2 MT [medical technician] staff, with a DX [diagnosis] OF S/P [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . s/p IM [intramedullary-inside of a bone] nailing wound vac.[vacuum]. Pt is awake alert and oriented x3 (with no cognitive deficits) denied pain at this time breathing even and easy unlabored, abdomen bowel sounds present in all quadrants with bulging hernia skin warm to touch with multiple bruises to both upper extremities surgical incision with 24 staples all intact with mild oozing, closed blister near the incision pitting [CONDITION(S)] to bilateral feet. Dry dressing applied to the surgical site APN [Advanced Practice Nurse] made aware of the admission and verified all the medication orders carried out and faxed to the pharmacy Covid rapid test done Negative. PPD [a test to evaluate exposure of a person to [CONDITION(S)]] Given To The Left Forearm . Patient cleaned and made comfortable. A review of the note by the APN dated [DATE] at 12:21 PM, revealed Resident #122 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The note also included the code status of the resident. Under Code Status it read: Resuscitation status-ordered-[DATE] 1:56:00 EDT-Full Code. A review of the nurses note by RN #1 dated [DATE] 6:38 PM, read: Patient found in a supine position with NC [nasal cannula] in place, wound vac [vacuum assisted device to help close a wound] functioning, bed lowered, HOB [head of bed] up, no response to name or stimulus, no respiration, no pulse, no S1S2 on auscultation [sounds heard when listening to the heart]. Patient pronounce [sic] by this nurse at 3:40 pm. [The physician] informed immediately and ordered to inform the family. She was also going to follow up with a call to the family . This note was electronically signed by RN #1 at 7:40 PM. On [DATE] at 9:31 AM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #122 had been a full code. The Vice President of Operations and the LNHA were also present. The surveyor asked the DON what she remembered about the death of Resident #122. The DON stated I learned that the resident had expired the day after it happened, I spoke with the nurse involved, because when I read the note it looked like nothing had been done. The nurse involved said when he saw the resident earlier in the shift it looked like the resident was asleep, he checked the resident later and it appeared that the resident was far gone so he called the family. The surveyor asked the DON what she would expect the nurse to do if they came upon a resident who was unresponsive and a full code. The DON stated I would expect that they would call an emergency. There is someone assigned to arrive to the unit when there is an emergency. The surveyor asked the DON what she would expect the nurse to do if they found the resident unresponsive. The DON stated To start CPR and start the code [Cardiopulmonary Resuscitation]. The nurse said the resident looked far gone so he called the family he called the family and said your loved one just died . We did an in-service (education) and explained that CPR should have been initiated for a resident who was a full code and found unresponsive. The DON provided an in-service sign in sheet dated [DATE], (the DON said the year 2022 was an error). The topic was Code Status/CPR. Under Summary it read; If a resident is found unresponsive and upon assessment needs to be coded, Licensed Nurse needs to check first if resident has an advance directive. If resident is full code, CPR should be started immediately and 911 should be alerted. There were 11 signatures on the sign in sheet to indicate they attended the in-service. RN #1 was not one of the 11 people that signed to indicate they attended the in-service. The surveyor asked the DON why they did not provide the in-service training to all of the staff. The DON said they didn't have time. The DON also provided a form that she identified as an in-service that was conducted the day after the incident but it did not document the in-service that she conducted with RN #1. The DON stated that RN #1 was called in to the facility the morning the current survey was being conducted ([DATE]) and asked RN #1 to sign that he had been spoken to the day after he failed to initiate CPR for Resident #122. The topic was listed as Protocol on code status. Under Agenda it read: In-service with [RN #1]. The Nurse (RN#1) stated that resident was far gone when he assessed resident and had expired. No HR [heart rate], RR [respiratory rate], O2 Sat [oxygen level measured in the blood], Skin was cold, Notified family resident had expired and pronounced resident. Protocol on code status and how to address was reviewed with [RN #1]. Start CPR no matter how far gone unless family indicates beforehand that they did not want CPR. Always better to get a witness to family statement. It was signed by RN #1 and dated [DATE]. On [DATE] at 10:37 AM, the surveyor interviewed RN #1 who stated Doing rounds the patient was in bed and looked okay at around 3:,d+[DATE]:30 [pm]. I did a quick sweep through. Then during the second round about 3:40 pm, the patient wasn't responding, the patient was cold, the feet were cold, the patient had no respirations, pulse, was not responding to their name. I called the doctor and asked if I should start CPR. I told her the patient was cold, looked like [the resident] was dead for a while. The doctor said no do not start CPR. Then I called the family. The family did not want to come in. The surveyor asked RN #1 if he was aware the resident was a full code. RN #1 stated Yes, I checked. I've been a nurse for [AGE] years. This patient was [AGE] years old, the patient was fragile, the patient was dead cold. It wasn't that I neglected that part of the CPR but the patient was really gone. The surveyor asked why he did not initiate CPR. RN #1 stated. The patient's history and the patient was already gone. I would have started CPR, there is a procedure that you would follow but I called the doctor and told her the resident was gone and cold. It looked like the resident was dead for a while, the feet were purple, the patient was cold, the eyes were shut, there was no carotid pulse, O2 (oxygen) saturation was zero. The resident had changed, the color, the resident was cold, not responding, what caught my attention the patient was cold. The surveyor asked RN #1 if he felt he honored the resident's wishes to be a full code. RN #1 stated No I didn't do that. I was thinking the resident was [AGE] years old, frail, do we want to crack the ribs, I called the doctor. Moving forward I would start CPR right away. I wouldn't care about the age I would just do it. RN #1 also stated that the failure to initiate resuscitative measures was due to the fact that the resident was [AGE] years old and frail, and additionally stated the resident was cold and it looked as if the resident had been dead for a while. RN #1 did not report any of the following as a reason for not initiating Cardiopulmonary Resuscitation; rigor mortis, dependent lividity, decapitation, transection, or decomposition, which are the conditions under which a health care professional would not initiate Cardiopulmonary Resuscitation according to the American Heart Association. In addition, there was no documentation in the medical record to explain RN #1's decision to not attempt resuscitation. On [DATE] at 11:00 AM, the surveyor reviewed the certification card of RN #1 from the American Heart Association which verified that RN #1 was certified as a Basic Life Support Provider. The issue date was [DATE], and the renewal date was ,d+[DATE]. On [DATE] at 12:32 PM, the surveyor interviewed the Physician who stated He [RN #1] called me and said [the resident] expired not unresponsive, I don't remember what time, in the afternoon, he told me [the resident] expired, after the resident expired I called the family and they said [the resident] said that [the resident] didn't want to live anymore. In the past I had the conversation with the family about [the resident's] code status and they said they didn't want any aggressive measures but they did want [the resident] to be a full code. I wasn't in the building so I could not assess for myself, if I was in the building then I would assess but I was not there and the nurse said the resident was expired. You can't perform CPR on a dead person. On [DATE] at 12:45 PM, the surveyor reviewed the facility's policy and procedure titled Cardio Pulmonary Resuscitation date implemented [DATE], and date reviewed/revised [DATE]/21. Under Policy it read; In the absence of a Do Not Resuscitate Order by a licensed MD or APN or in accordance to resident's advance directive or if resident does not show signs of clinical death, a witnessed respiratory or cardiac arrest at [the facility], basic Cardio Pulmonary Resuscitation (CPR) will be initiated on all persons by CPR trained staff. CPR is provided as per the current American Heart Association and Emergency Cardiovascular Care (ECC) guidelines. Under Procedure bullet point one read: Initiate CPR and have someone page code blue and the emergency team will respond. Bullet point two read: The Supervisor is notified immediately. The MD/APN is notified and 911 is called. Bullet point three read: CPR continues until the Mobile Intensive Care Unit (MICU) arrives, or the licensed MD/APN is present to discontinue resuscitation. Bullet point number four read: After the resident is transferred, the following must be documented: a. Time the resident was found to be totally unresponsive and by whom. b. Time CPR was initiated and outcome of CPR. c. Time MICU arrived and transported the resident. d. Use of resuscitation bag and/or O2. e. MD/APN notified. f. Relative notified and time of call. The surveyor asked the DON if the facility had a separate policy for an unwitnessed respiratory or cardiac arrest. She said they did not, but moving forward they would add that to the policy. The IJ was identified on [DATE], and the LNHA was notified of the IJ at 1:29 PM. A removal plan was received the same day at 2:38 PM, which included: that the facility updated the pre-admissions process to include; the admissions staff requesting a copy of the advance directive from the sending facility and providing a copy to the admitting nurse, verification of the code status by the admitting nurse, applying a code status identifier on the resident, daily audits of identifiers by the Unit Managers and House Supervisor on all shifts. The code status of residents will be reviewed the first day after admission, at the first clinical meeting about the resident, quarterly, at care plan meetings, and during family meetings. Education started on [DATE], after the LNHA was notified of the IJ situation. All staff were being educated on how to identify a resident who required a code, their responsibilities during a code, and how to document the event. Mock codes will be re-instated at the facility that were halted due to the Covid-19 Pandemic. The implementation of the Removal Plan was verified on-site on [DATE], through observations, interviews with facility staff, and a review of in-service education and revised facility's Cardio Pulmonary Resuscitation policy. NJAC 8:,d+[DATE].1(31)iii NJAC 8:,d+[DATE].6(g) )

Based on observation, interview and record review, it was determined that the facility failed to accurately develop and implement a person-centered comprehensive care plan for care and service needs. This deficient practice was observed for 6 of 27 residents reviewed, Residents # 7, # 25, # 38, # 94, # 98, and # 112, as evidenced by the following: 1. On 9/15/21 at 1:04 PM, the surveyor observed Resident #94 in the resident's room. Resident # 94 informed the surveyor that he/she was receiving an anticoagulant medication. The surveyor reviewed Resident #94's Electronic Medical Records. Resident #94's face sheet revealed that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) an assessment tool dated 8/21/21 indicated the facility performed a Brief Interview for Mental Status (BIMS) and the resident scored a 5 out of 15 which indicated the resident had moderate cognitive impairment. A review of the LTC Active Medication Orders (LTCAMO) revealed the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed the resident's current care plans. There was no comprehensive care plan developed regarding the resident's for the anticoagulant medication. On 9/20/21 at 10:30 AM, the surveyor interviewed the Registered Nurse #1 (RN #1) assigned to the resident who stated that a care plan for the anticoagulant medication should have been created. RN#1 was unable to locate a care plan. 2. On 9/16/21 at 1:24 PM, the surveyor observed Resident #98 in the resident's room. Resident #98 informed the surveyor that he/she was receiving an anticoagulant medication. The surveyor reviewed the EMR of Resident #98. The resident's face sheet revealed that Resident #98 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) an assessment tool dated 9/2/21 indicated the facility performed a Brief Interview for Mental Status (BIMS) and the resident scored a 15 out of 15 which indicated the resident was cognitive intact. The LTCAMO revealed that Resident #98 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed the resident's current care plans. There was no care plan developed regarding the resident's use of the anticoagulant medication. On 9/20/21 at 10:30 AM, the surveyor interviewed the RN #1 assigned to the resident who stated that a care plan for the anticoagulant medication should have been created. RN #1 was unable to locate the care plan. 3. The surveyor observed RN #2 feeding Resident #7 on 9/15/21 at 1:14 PM in the resident's room. The surveyor interviewed RN #2 on 9/17/21 at 12:14 PM. RN #2 stated, depending on the resident's cognition, the resident must either be closely supervised during meals or fed. RN #2 stated the resident does better with breakfast, but for lunch the resident must be fed since he/she tends to be more confused at lunchtime. A review of the resident's EMR revealed the following. The Quarterly MDS dated [DATE] indicated the resident had moderate cognitive impairment evidenced by a Brief Interview for Mental Status (BIMS) score of 8 of a possible 15 (indicating moderate cognitive impairment). The resident was assessed to be independent with eating after receiving assistance setting up the food tray. The Registered Dietician (RD) documented a Progress Note on 8/9/21 regarding the resident's recent weight loss. The RD indicated that she had discussed with the Unit Manager RN (RMUM) the need to begin to supervise or, if needed, feed the resident during mealtimes. The RD documented that since the resident's mental status and/or mood varies throughout the day, the resident would need to be more closely monitored during meals to provide optimal oral intake. On 9/17/21 the RNUM provided the surveyor with the facility care plan dated 11/23/20 addressing nutritional risk listed dementia as one causal factor leading to weight loss. Interventions included, but were not limited to, provide dining room/meal accommodations: 'I fill out my own select menu with help from staff; allow adequate tie to eat; provide a quiet, calm setting.' The surveyor interviewed RNUM on 9/22/21 at 10:00 AM. RNUM stated new interventions should be added to the care plan within 1 - 2 days. RNUM did not offer an explanation as to why the care plan had not been updated after the 8/9/21 RD recommendation to supervise or feed the resident. 4. The surveyor observed Resident #38 awake in bed on 9/16/21 at 12:12 PM. The resident's right hand wrist was bandaged in white gauze. At that time the surveyor asked RNUM why the resident's hand was bandaged. She replied that she sustained a skin tear. RNUM stated the resident can get combative during care. RNUM stated the resident is on hospice and has fragile skin. A review of the resident's EMR revealed the following information: The Significant Change in Status MDS dated [DATE] indicated the resident had short and long-term memory impairment along with moderately impaired decision-making skills. Additionally, on 1 - 3 days during the past seven days, the resident exhibited behaviors such as hitting or scratching self, rummaging, pacing, among other behaviors listed. The September 2021 LTCAMO contained an 8/24/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RNUM provided the surveyor with a copy of the resident's care plan on 9/17/21 at 10:00 AM. The care plan's most recent revision date was listed as 6/14/21. The care plan did not reflect the 8/24/21 right hand skin tear. The care plan did not include interventions to protect the resident's extremities from future skin tears nor did the care plan reflect the resident's behavior of injuring self. The surveyor interviewed RNUM on 9/22/21 at 9:50 AM. RNUM stated the care plan should be updated 1 - 2 days after changes in the resident's status occurs. She provided no explanation as to why interventions were not added to the care plan on methods to prevent injury to the resident's skin due to her self-injurious behavior and fragile skin. 5. On 9/16/21 at 10:35 AM, the surveyor observed Resident #112 sitting in a wheelchair with eyes closed and a home health aide sitting in a chair beside the resident. A review of the EMR revealed the following: The Quarterly MDS dated [DATE] indicated that the resident had short term and long term memory problems and severe cognitive impairment. In addition, the assessment indicated that the resident had no unhealed pressure ulcers. The Skin Impairment care plan, revised on 8/12/21, indicated that the resident had actual skin impairment as indicated by a left hip wound. The most recent wound care consult was dated 5/4/2020 and indicated that the stage four pressure ulcer of the resident's left hip resolved. On 9/17/21 at 9:48 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the condition of Resident #112's skin. The LPN stated that the resident does not have any wounds. She stated that the resident was on skin precautions and received skin preparation treatment to prevent wounds but that there were no wounds at this time. At 9:58 AM, the surveyor interviewed RNUM regarding the status of the pressure ulcer and the care plan. RNUM stated that the pressure ulcer was now healed fully. The surveyor showed RNUM the care plan which indicated that the resident had an actual wound. RNUM stated that this was inaccurate and that she would change the care plan to indicate that it was a history of a wound and not an actual wound. 6. On 9/21/21 at 11:48 AM, the surveyor observed Resident #25 lying in bed with eyes closed. There was an indwelling catheter drainage bag hanging at the side of the bed in a privacy bag. The resident had AM care provided by the hospice home health aide. The surveyor reviewed Resident #25's EMR and Hospice records located in the resident's hard copy chart that revealed the following: The Quarterly MDS dated [DATE] indicated that a BIMS was performed by the facility and the resident scored an 8 out of 15, which indicated that Resident #25 had moderate cognitive deficit. The resident was placed on hospice care on 6/20/20 for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospice nurse's plan of care interventions included but not limited to providing a home health aide, indwelling urinary catheter care needs and to collaborate with the facility nurses any changes. The facility's nursing care plans for Resident #25 did not include a separate hospice care plan that would indicate that there was coordination of care between the hospice nurse and the facility nurse. In addition, there was no care plan to address Resident #25's indwelling urinary catheter needs for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/21/21 at 12:22 PM, the surveyor interviewed the RNUM about the missing care plans. The surveyor and RNUM reviewed all the care plans located in the care plan book. The RNUM then checked the computer and stated she must of missed them. On 9/22/21 at 1:13 PM, the survey team discussed the above care plan concerns with the Administrator and Director of Nursing (DON). The DON provided the survey team with requested facility policies. The facility's policy titled Hospice indicated under Policy the following: The facility and hospice are jointly responsible for developing a coordinated plan of care for the resident that guide both providers and is based upon their assessments and the resident's needs and plans. The facility's policy titled Foley Catheter Care did not include a procedure to develop a comprehensive care plan to address a resident's indwelling urinary catheter needs. A review of the 2021 facility policy titled Interdisciplinary Care Plan/ MDS Assessment indicated that care plans should be revised and updated as per resident care needs. NJAC 8:39- 11.2 (e)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to provide full visual privacy for 2 of 24 residents reviewed, Resident #96 and Resident #85. The deficient practice was evidenced by the following: 1. On 9/15/2021 at 10:15 AM, Resident #85 was observed lying in bed with eyes open. The resident was pleasant when spoken to. The surveyor reviewed Resident #85's Electronic Medical Records (EMR) that revealed the following: The 7/30/21 Quarterly Minimum Data Set (MDS) an assessment tool indicated the resident had short term and long term memory problems and moderate cognitive impairment, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/21/21 at 9:35 AM, the surveyor observed the pressure ulcer in the presence of the Registered Nurse Unit Manager (RNUM) and the hospice home health aide (HHA) during morning care. The wound was on the resident's sacrum, so the resident's buttocks was exposed. The resident's roommate was present in bed on the other side of the room. The resident's privacy curtain was pulled partway, obscuring the view from the doorway and the hallway but not obscuring the view of the resident's roommate. The roommate's privacy curtain was also pulled partway in the same fashion, not obscuring the view to Resident #85. On 9/21/21 at 10:44 AM, the surveyor interviewed the HHA who stated that when she provided morning care for Resident #85 that the privacy curtain was fully closed and that when the RNUM and the surveyor came into the room that it must have been pulled back. The HHA stated that she always ensures resident privacy. On 9/22/21 at 10:40 AM, the surveyor interviewed the RNUM. The RNUM stated that she did not notice that the privacy curtain was not fully closed, and that Resident #85 was exposed to the roommate. The RNUM stated that she was focused on the task at hand of showing the surveyor the wound. She stated that the privacy curtain should have been closed all the way. 2. On 9/15/21 at 10:51 AM, the surveyor observed Resident #96 in bed awake. The resident was alert and oriented and watching television. The surveyor asked the Registered Nurse (RN) who was assigned to the resident if the resident had a urinary catheter. The RN said the resident had a nephrostomy (a tube surgically inserted through the skin and into the kidney to divert urine into a drainage bag). The surveyor asked the RN if she could assist the surveyor to see the nephrostomy, the tube, and the drainage bag. The RN entered the resident's room, washed her hands, went to the resident's bedside, and uncovered the resident while she explained to the resident what she was doing. She turned the resident over and showed the surveyor the nephrostomy tube from the right nephrostomy and the urinary drainage bag that was attached to the resident's right ankle, exposing the resident's legs. She lifted the resident's top as well to show me the resident's back where the tube was inserted. She did not close the privacy curtain. The resident's roommate was awake and sitting in the next bed. On 9/15/21 at 11:20 AM, the surveyor reviewed the EMR of Resident #96 which revealed the following: An Admission MDS dated [DATE] which included a Brief Interview of Mental Status with a score of 14 of a possible 15. This indicated that the resident was cognitively intact. The MDS also indicated that the resident had the following active diagnoses, Cancer, [CONDITION(S)], Urinary Tract Infection (last 30 days), [CONDITION(S)], and Malignant Neoplasm of Bladder. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order date was 8/20/21. On 9/22/21 at 2:09 PM, the surveyors spoke with the Administrator and the Director of Nursing (DON) about the concern with the lack of physical privacy for Resident # 96 and Resident #85. They both acknowledged that the nurses should have provided privacy. The surveyor asked for the facility's list of Resident Rights. On 9/23/21 the surveyor reviewed the facility's list of resident's rights. Under Patient Rights, a. read: Each patient shall be entitled to the following rights: Number 16 read: To have physical privacy. The patient shall be allowed, for example, to maintain the privacy of his or her body during medical treatment and personal hygiene activities, such as bathing and using the toilet, unless the patient needs assistance for his or her safety. 8:39-37.4(b)

Based on observation, interview, and record review, it was determined that the facility failed to reassess and provide care for pressure ulcers in accordance with professional standards of practice for 1 of 3 residents reviewed for pressure ulcer care, Resident #85. The deficient practice is evidenced by the following: On [DATE] at 10:15 AM, Resident #85 was observed lying in bed with eyes open. On [DATE] at 9:35 AM, the surveyor observed the pressure ulcer (an injury to the skin and underlying tissue primarily caused by prolonged pressure on the skin) in the presence of the Registered Nurse Unit Manager (RNUM) and the hospice home health aide (HHA) during the resident's morning care. The surveyor observed an open wound on the sacrum with redness around the outside of the wound and yellowness inside of the wound bed. The surveyor reviewed Resident #85's Electronic Medical Record (EMR) which revealed the following: The Quarterly Minimum Data Set an assessment tool dated [DATE], indicated the resident had short term and long term memory problems and moderate cognitive impairment, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the assessment indicated that the resident had one stage three pressure ulcer. The Skin Breakdown care plan, revised on [DATE], indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Weekly Skin Assessments dated [DATE], [DATE], and [DATE] revealed no documentation that the resident had a sacral wound. The nurse's documented on the Weekly Skin Assessments the following: On [DATE] it was documented that the resident had skin color usual for ethnicity and that the resident's skin was warm. On [DATE] and [DATE] the Weekly Skin Assessment indicated that the resident's skin was usual for ethnicity. The [DATE] LTC Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had a stop date for the treatment that was [DATE]. The [DATE] Electronic Treatment Administration Record (ETAR) had no documentation after the stop date of [DATE], from [DATE]-[DATE], that the nurses had performed a treatment to the sacral pressure ulcer. The Nursing Progress Notes from [DATE]-[DATE] revealed no documentation that the nurses had reassessed the sacral pressure ulcer once the treatment had ended on [DATE]. On [DATE] at 9:40 AM, the surveyor interviewed the RNUM regarding the treatment order for the pressure ulcer that had a stop order for [DATE]. The RNUM stated that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor stated that there were no active treatment orders on the ETAR and that there was no documentation on the ETAR from [DATE]-[DATE] that the nurses had performed the treatment. The RNUM stated that when treatment orders expire, the nurses need to contact the resident's physician. On [DATE] at 9:45 AM, the surveyor spoke with the Registered Nurse (RN) assigned to the resident. The RN stated that the sacral pressure ulcer was closed and that she had been placing a dry dressing on the area according to her professional nursing judgment. The RN stated that no medicated ointment or treatment was applied to the wound since when the order expired on [DATE]. At 9:50 AM, The RN returned to the surveyor and stated that the resident's wound was still a little bit open and that she was contacting the doctor resume the treatment order to the sacral wound. On [DATE] at 9:07 AM, the surveyor reviewed the Nursing Progress Note dated and timed [DATE] at 2:39 PM, that indicated the RN documented that she observed a small opening on the sacrum and that she cleansed the wound with normal saline and applied a dry sterile dressing. On [DATE] at 9:54 AM, the Assistant Director of Nursing (ADON) provided the surveyor with Weekly Skin Assessments from [DATE], [DATE], and [DATE], which had documentation indicating the measurements and exudate (drainage) of the sacral pressure ulcer. The [DATE] Weekly Skin Assessments provided by the ADON were different from the [DATE] Weekly Skin Assessments the surveyor had obtained from the resident's EMR. On [DATE] at 10:40 AM, the surveyor interviewed the RNUM about the difference in the Weekly Skin Assessments that were obtained from the EMR and the Weekly Skin Assessments that the ADON provided the surveyor. The RNUM stated that she backdated the Weekly Skin Assessments from [DATE], [DATE], and [DATE] and that they were all completed on [DATE]. On [DATE] at 1:20 PM the surveyor discussed the above concerns with the Administrator and the Director of Nursing (DON). The DON stated that there should have been a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 2020 facility policy on Wound Assessment and Treatment indicated that wound assessments should be documented weekly including the measurement and description of the wound. The facility policy also indicated that nursing documentation should include notification to the physician regarding wound or treatment changes. 8:,d+[DATE].1(e)

Based on observation, interview, and record review, it was determined that the facility failed to provide care and services for a nephrostomy in a manner that would decrease the possibility of infection. This was found with Resident #96, who was 1 of 1 resident reviewed for nephrostomy care. The deficient practice was evidenced by the following: On 9/15/21 at 10:51 AM, the surveyor observed Resident #96 in bed awake. The resident was alert and oriented and watching television. The surveyor asked Registered Nurse #1 (RN) who was assigned to the resident if the resident had a urinary catheter. RN #1 said the resident had a nephrostomy (a tube surgically inserted through the skin and into the kidney to divert urine into a drainage bag). The surveyor asked RN #1 if she could assist the surveyor to see the nephrostomy, the tube, and the drainage bag. RN #1 entered the resident's room, washed her hands, went to the resident's bedside, and uncovered the resident while she explained to the resident what she was doing. She turned the resident over and showed the nephrostomy tube from the right nephrostomy and the urinary drainage bag that was attached to the resident's right ankle. On 9/15/21 at 11:20 AM the surveyor reviewed the record of Resident # 96 which revealed the following: An admission Minimum Data Set (MDS) assessment dated [DATE] which included a Brief Interview of Mental Status with a score of 14 of a possible 15. This indicated that the resident was cognitively intact. The MDS also indicated that the resident had the following active diagnoses, Cancer, [CONDITION(S)], Urinary Tract Infection (last 30 days), [CONDITION(S)], and Malignant Neoplasm of Bladder. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order date was 8/20/21. An Interdisciplinary Care Plan dated 8/18/21 that read: [The resident] has a nephrostomy in place due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The approach read: Will check for redness on stoma site, Will check for proper functioning and placement, Will monitor output, and Change nephrostomy dressing daily. On 9/16/21 at 11:57 AM, the surveyor observed the resident in bed watching television. The resident was fully dressed and clean. The resident was laying on the bed. There was a urinary drainage bag from the nephrostomy tube attached to the resident's right ankle with a strap. The surveyor asked the resident if the staff changed the bag when the resident was in bed at night. The resident said No, this is it. This is what I use. On 9/21/21 at 11:15 AM, the surveyor asked the Unit Manager/Registered Nurse (UM/RN) for a new urinary drainage bag for the nephrostomy tube that was used by Resident #96. She provided one for the surveyor to inspect. The surveyor asked the UM/RN if the facility had a different drainage bag they used at night when the resident slept in bed. The UM/RN said no, they used the leg bag when the resident was in bed. The surveyor asked the UM/RN when the resident's last Urinary Tract Infection ([CONDITION(S)]) was. She said the resident was admitted with the nephrostomy tube and the resident hadn't had a [CONDITION(S)] since the resident had been at the facility. She further stated that the resident did have a history of UTIs. On 9/21/21 at 11:22 AM, the surveyor went to interview the resident again. The surveyor observed the resident asleep in bed on top of the bed fully dressed with the nephrostomy bag on the right ankle. On 9/21/21 at 12:53 PM, the surveyor called the manufacturer for the urinary drainage bag that the resident had been observed wearing. The surveyor asked the customer service representative (CSR) if the leg bag should have been used for the resident when the resident was in bed. The CSR said no, that is a leg bag and not meant to be used while in bed. The CSR informed the surveyor that there was nighttime drainage bag for use when the resident would have been in bed. On 9/21/21 at 1:44 PM, the surveyor spoke with RN #2 who identified herself as a part time nurse who had worked at the facility for 6 years. RN #2 said she filled in for the regular nurse when she was off and worked every other weekend. She said she was unaware if the urinary drainage bag should have been changed to a large bag when the resident was in bed. She said when a resident had a foley catheter they changed the collection bag, but she was unsure about the process for a resident with a nephrostomy. On 9/21/21 at 12:00 PM, the surveyor reviewed the facility's policy and procedure titled Nephrostomy and Cystostomy Tube Care and Maintenance. Under Policy it read: Resident's with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. On 9/21/21 at 2:09 PM, the surveyor spoke with the Administrator and the Director of Nursing (DON). The DON acknowledged that the resident should not have been in bed with a leg bag on because of the risk of infection. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility nurse failed to consistently assess the [CONDITION(S)] vascular access site before transport to the hemodialysis clinic for 1 of 1 resident (Resident #118) reviewed for hemodialysis. The deficient practice was evidenced by the following: The surveyor observed the resident on 9/15/21 at 10:46 AM. The resident was seen lying in bed in a hospital gown. A review of the resident's Electronic Medical Records (EMR) which revealed the following: The 8/18/21 Admission Minimum Data Set (MDS) an assessment tool, indicated the resident had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 of a possible 15. Additionally, the resident was assessed to have dependence on Renal [CONDITION(S)] and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan addressed two areas related to hemodialysis. 1) The need for [CONDITION(S)] three times a week for [CONDITION(S)]. Interventions included: arrange appointment and transportation as needed; provide a communication book to monitor compliance and pertinent information that [CONDITION(S)] center provides. 2) The potential for infection due to the presence of an internal jugular catheter for [CONDITION(S)] access. Interventions included: monitor catheter site for redness, drainage, and foul odor; perform laboratory testing as needed; administer antibiotics if indicated; follow up with vascular or primary physician if warranted. The September 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The [CONDITION(S)] Communication Sheet, a form traveling with the resident to the [CONDITION(S)] center, provided spaces for the [CONDITION(S)] center staff to complete. At the bottom of the form was a signature line for the long-term care (LTC) facility nurse to sign. There were six completed forms in the communication binder. None of the six forms included documentation from the LTC facility nurse indicating the [CONDITION(S)] access site was assessed before or when returning to the facility from the [CONDITION(S)] center. The surveyor interviewed the Registered Nurse Unit Manager (RNUM) on 9/22/21 at 9:30 AM regarding nurses' documentation of resident's [CONDITION(S)] access site assessment prior to and upon returning from the [CONDITION(S)] center. The RNUM stated it was located on the [CONDITION(S)] Communication Sheet. The surveyor and the RNUM reviewed the sheet together. The RNUM confirmed the assessments were not documented on the [CONDITION(S)] Communication Sheet. She stated, I have to change that sheet. The surveyor interviewed the unit Registered Nurse (RN #1) assigned to Resident #118 on 9/22/21 at 9:40 AM. RN #1 stated the resident leaves for [CONDITION(S)] on her shift (7 AM - 3 PM) and returns on the 3 PM - 11 PM shift. RN #1 stated the access site is monitored once each shift and is documented on the Electronic Treatment Administration Record. RN #1 was unable to provide documentation of monitoring at the time the resident was transported to the [CONDITION(S)] center. The surveyor interviewed the 3 PM - 11 PM Registered Nurse (RN #2) on 9/22/21 at 11:10 AM via telephone. RN #2 stated when the resident returns from [CONDITION(S)], she checks the access site for bleeding and to be sure the dressing is intact. RN #2 stated she documents the assessment in the Nursing Notes in the EMR. The surveyor interviewed the Director of Nursing (DON) on 9/22/21 at 1:41 PM regarding nursing assessments of the resident's [CONDITION(S)] access site pre and post [CONDITION(S)]. The DON provided to the surveyor on 9/23/21 copies of eight Nursing Progress notes written in September 2021 documenting access site monitoring upon return from the [CONDITION(S)] clinic. Three of the notes were marked late entry written on 9/22/21 for previous dates. The DON did not provide documentation of assessments done prior to the resident leaving the facility for the [CONDITION(S)] center. On 9/23/21 the DON provided the surveyor with the facility policy for [CONDITION(S)] Transport and Communication, implemented 9/2017 and reviewed/revised 2020. The policy did not address monitoring the access site before or after returning from [CONDITION(S)]. NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to complete a Comprehensive Admission 14-day Minimum Data Set (MDS) assessment according to the Resident Assessment Instrument (RAI) for 1 of 27 residents (Resident #323) reviewed. Reference: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. At a minimum, facilities are required to complete a comprehensive assessment for each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident's status and not less than once every 12 months while a resident, where 12 months refers to a period within 366 days. The deficient practice was evidenced by the following: On 9/21/21 at 12:27 PM, the surveyor reviewed the Electronic Medical Records for Resident #323 which revealed the following: According to the MDS Intelligence form, the facility set a target date for the Admission MDS on 9/9/21. As of 9/21/21, Under the MDS status column, it indicated that the MDS was still open. The Nursing Home Comprehensive (admission) MDS dated [DATE] had Section A, Identification Information, completed and the remaining areas Section B through Section V were not completed with in the 14 calendar days after admission. On 9/21/21 at 1:29 PM, the surveyor interviewed the MDS Coordinator who confirmed that she did not complete the MDS. She stated she's been busy with the long term care unit and doesn't currently have help. On 9/22/21 at 1:26 PM, the surveyor discussed the above concern with the Administrator and Director of Nursing (DON). The DON stated that the Department Heads are responsible for their part in completing the MDS and should have done so. NJAC 8:39-11.2

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) follow appropriate isolation precaution protocols for residents on Transmission-Based Precautions (TBP) on a unit for Persons under investigation/observation (PUI) from potential exposure to COVID-19 for 1 of 2 units toured; b.) ensure staff perform appropriate handwashing to prevent the spread of COVID-19; and, c) follow appropriate isolation precaution protocols for entering a COVID-19 positive unit. This deficient practice was evidenced by the following: Reference: CDC guidelines titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 3/29/21, included the following: Identify Space in the Facility that Could be Dedicated to Monitor and Care for Residents with Confirmed [CONDITION(S)]-CoV-2 Infection .To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit. Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. Residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure . HCP (Health Care Personnel) should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents .Residents can be transferred out of quarantine if they remain with no fever and without symptoms for 14 days . Reference: NJDOH guidelines titled, Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities, updated 3/25/21, included the following: Cohorting is only one element of infection prevention and control measures used for outbreak control . a) Cohort 1 - COVID-19 Positive: This cohort consists of both symptomatic and asymptomatic patients/residents who test positive for COVID-19, regardless of vaccination status, including any new or readmitted patients/residents known to be positive who have not met the criteria for discontinuation of Transmission-Based Precautions. If feasible, care for COVID-19 positive patients/residents on a separate closed unit. Patients/residents who test positive for COVID-19 are known to shed virus, regardless of symptoms; therefore, all positive patients/residents would be placed in this positive cohort. b) Cohort 2 - COVID-19 Negative, Exposed: This cohort consists of symptomatic and asymptomatic patients/residents who test negative for COVID-19 with an identified exposure (i.e., close contact) to someone who was positive, regardless of vaccination status. This includes new or readmitted patients/residents who have tested negative and have been identified as a close contact in the past 14 days. Exposed individuals should be quarantined for 14 days from last exposure, regardless of negative test results or vaccination status . Patients/residents who test negative for COVID-19 could be incubating and later test positive . Frequently asked questions . What types of precautions should be used in each cohort? Full Transmission-Based Precautions and all recommended COVID-19 PPE should be used for all patients/residents who are: .Close contacts to a suspected or confirmed COVID-19 positive person (e.g., HCP, visitor, roommate). On a wing/unit (or facility-wide), regardless of presence of symptoms, when transmission is suspected or identified . What types of precautions should be used in each cohort? Regardless of cohort, all HCP should adhere to Standard Precautions and any necessary Transmission-Based Precautions according to clinical presentation and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Close contacts to a suspected or confirmed COVID-19 positive person (e.g., HCP, visitor, roommate); On a wing/unit (or facility wide), regardless of presence of symptoms, when transmission is suspected or identified . HCP should wear eye protection and an N95 respirator or higher (or well-fitting facemask if unavailable) at all times while in the COVID-19 Positive (Cohort 1) area. 1. On 7/26/21 at approximately 9:30 AM, during entrance conference and in the presence of the other surveyors, the Director of Nursing (DON) stated that the facility had one staff member and four residents that tested positive for COVID-19 in the facility, and they were located in the COVID-19 unit. She stated that three of the four residents were from the same unit and under the care of the one staff member that tested positive for COVID-19. She further noted that the fourth resident that tested positive for COVID-19 was tested that morning and was from a different unit of the other three residents and was not under the care of the one staff that tested positive for COVID-19. The DON stated that all residents on the unit where the staff member worked were placed on TBP, and that unit was considered the PUI unit. At 10:30 AM, the surveyor toured the first part of the PUI unit, first floor south A. At 10:36 AM, the surveyor observed Housekeeper #1 (HK #1), who wore an N95 mask with a surgical mask over it, don (put on) a gown and gloves. HK #1 entered Resident #1's room. Resident #1 was on TBP, and there was a bin containing PPE located outside the room entrance. HK #1 was not wearing goggles or a face shield to protect her eyes. At 10:37 AM, the surveyor observed a Certified Nursing Assistant (CNA), who wore an N95 mask with a surgical mask over it, obtain a blue disposable gown from the PPE bin located outside the entrance of Resident #2 's room. Resident #2 was on TBP. The CNA entered the resident's room with the gown in her hand and closed the door. The CNA did not don eye goggles or a face shield for eye protection prior to entering the resident's room. The CNA did not don the blue disposable gown or gloves prior to entering the resident's room. At 10:43 AM, the surveyor observed HK #2 exiting Resident #3's room. Resident #3 was on TBP. HK #2 was wearing an N95 mask with a surgical mask over it, eye goggles, a blue disposable gown, and gloves. At the doorway, HK #2 doffed (to take off) her blue disposable gown and gloves, rolled it up, walked out of the room, and discarded the gown and gloves into a garbage can located on the other side of the hallway in an alcove area. HK #2 then proceeded to wash her hands appropriately. The surveyor then asked HK #2 why she did not discard the gown and gloves into the covered garbage can that was located inside the room. HK #2 stated that the garbage can inside the resident's room was full, so she put it in the garbage can that was in the hallway. At 10:50 AM, the surveyor observed HK #1 exiting Resident #1's room. At the doorway, she doffed the blue disposable gown and gloves and discarded it in a clear plastic garbage bag attached to the housekeeping cart that was located outside the resident's room. HK #1 did not discard the blue disposable gown and gloves in the covered garbage can located inside the resident's room. The surveyor then asked HK #1 why she did not discard the gown and gloves into the covered garbage can that was located inside the room and why she was not wearing eye protection. HK #1 stated that she doesn't use the garbage can in the room like others do and that she always takes the garbage bag directly to the dumpster. She then stated that she usually wears eye protection but that she forgot to put it on. At 11:08 AM, the surveyor observed the CNA exit Resident #2's room wearing an N95 mask with a surgical mask over it, holding a bag of garbage. The CNA discarded the garbage bag into the garbage can located in the alcove area of the hallway and then performed hand hygiene using an alcohol-based hand rub. The surveyor asked the CNA why she did not don the gown and gloves prior to entering the resident's room and why she did not wear eye protection. The CNA stated that she dons the gown and gloves after she enters the room. The CNA also said that she never wears eye protection and that there was no reason why. She further stated that the facility offers eye protection. 2. On 7/26/21 at 10:52 AM, the surveyor observed the Registered Nurse (RN) exit through a zippered clear plastic area which provided a barrier to another section of the PUI unit, first floor south C. The RN then zipped the eco-barrier closed. The surveyor asked the RN her name, and the RN attempted to show the surveyor her ID badge using the back of her hands. The RN then went down the hall to talk to another staff member without touching anything. The RN then put in a code on the kitchenette door, opened the door, and entered the kitchenette. Through the door window, the surveyor observed the RN perform handwashing outside the flow of water for 5 seconds. The RN then rinsed her hands under the flow of water for 1 second and proceeded to turn off the water by turning the faucet handle with her hand. The RN then exited the kitchenette, and the surveyor asked the RN why she performed handwashing for 5 seconds. The RN stated that she knew she should wash her hands for 30 seconds but that she was in a rush to get back to her resident. 3. On 7/26/21 at 10:55 AM, the surveyor entered a zippered plastic eco-barrier to tour the section of the PUI unit, first floor south C. The surveyor observed that after room [ROOM NUMBER], there was a second zippered plastic eco-barrier which provided a barrier to the COVID-19 unit. Outside of the zippered barrier was a bin that contained PPE. At 11:03 AM, the surveyor observed a Maintenance worker (MW) enter the first-floor south C PUI unit through the first zippered plastic eco-barrier. The MW wore an N95 mask and was observed pulling a four-wheeled flatbed cart with an opened plastic bag that contained approximately ten blue filters. The MW was also observed changing the blue filter in the air-filtering device located in the hallway of the PUI unit. The MW then donned a blue disposable gown, gloves, and a bouffant cap (to cover hair). The MW unzipped the second zippered plastic ecobarrier, which led to the COVID-19 unit. The MW put his hand on the flatbed cart, which contained the opened plastic bag of blue filters, and started to pull the cart to enter the COVID-19 unit through the unzipped entrance of the eco-barrier. The MW stopped at the entrance of the unzipped ecobarrier. The surveyor then asked the MW why he was not wearing eye protection and why he was taking a cart full of filters into the COVID-19 unit. The MW could not provide a reason why he was not wearing eye protection. The MW then stated that he would only bring in the filter that he needed to change on the unit. The MW did not bring the cart onto the COVID-19 unit. At 11:06 AM, the surveyor asked the Unit Manager (UM), who was in the area, if the MW should enter the COVID-19 unit without eye protection and with the cart containing supplies. The UM stated the MW should have donned eye protection and should not bring in a cart if entering the COVID-19 unit. On 7/26/21 at 11:30 AM, the surveyor asked the DON why the first floor south A residents were on TBP. She stated that when a resident from that subacute unit, who was fully vaccinated, tested positive for COVID-19, the facility decided to place all the residents, on that unit, on TBP as a precaution for possible exposure to COVID-19. She further stated that all the residents in that section of the unit were fully vaccinated. At 11:37 AM, the surveyor interviewed the Infection Preventionist (IP) about the facility procedures for TBP and handwashing. The IP stated that staff is expected to don gown and gloves and eye protection prior to entering an isolation room or the COVID-19 unit. She noted that staff is expected to doff their gown and gloves prior to exiting an isolation room and discarding it in the garbage can located in the room. She then stated that staff is expected to wash their hands for 20 seconds after they exit the PUI unit. She further noted that the COVID-19 unit had dedicated equipment that does not leave the unit and that nothing should be brought in or out. At 12:00 PM, during the surveyor interview, the DON confirmed that HK #1, CNA, and MW should have worn eye protection before entering PUI rooms or the COVID-19 unit. The DON confirmed that the CNA should have donned the gown and gloves before entering a PUI room. The DON confirmed that HK #1 and HK #2 should have discarded the gown and gloves in the garbage can located inside the resident's room. The DON confirmed that the MW should not enter into the COVID-19 unit with a cart full of supplies. The DON then stated that the facility provides eye protection and that the facility in-services staff about donning and doffing. She further stated a dedicated housekeeping cart is kept on the COVID-19 unit [as an example] and does not leave. If something is brought on that unit, it needs to be disinfected if it comes out. The surveyor then asked if an open bag of filters could be disinfected. The DON stated, No. A review of the facility provided in-services included the following: HK #1 and HK #2 received an inservice on 7/20/21 titled Environmental Cleaning/Room, which included PPE required and where to doff and discard PPE. The CNA and MW received an untitled inservice on 4/26/21, which included what PPE is required to be donned upon entering an isolation room. The RN had a hand hygiene competency performed on 6/9/21, which indicated she was competent. A review of the facility provided policy titled, Appropriate use of PPE: Coronavirus prevention, with a reviewed/revised date of 11/19/2020, included the following: Definition: Transmission Based Airborne Isolation-Isolation of residents that are infected with pathogens that can be transmitted by the airborne route. Requires the use of the N95 mask, face shield, gown, and gloves when taking care of resident . Full PPE: N95 mask, goggles/face shield, gown, gloves. Hair cover is optional. PUI-Person Under Investigation for COVID 19. Policy Explanation and Compliance Guidelines Residents with active signs and symptoms of COVID 19 or PUIs, will test for COVID 19 and will be placed on Transmission-based Airborne Isolation for 14 days or linger until symptoms resolve and or until the resident has met the criteria for de-isolation. Staff will wear full PPE during this period of isolation. The policy did not include where to don or doff the PPE. A review of the undated facility provided policy titled Hand Hygiene included the following: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 5. Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water to prevent drying skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use a clean towel to turn off the faucet. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Hand Hygiene Table [attached to policy]; Before applying and after removing personal protective equipment (PPE), including gloves. Either soap and water or alcohol-based hand rub (ABHR is preferred). NJAC: 8:39-19.4 (a)

Based on observation, interview, and review of records, it was determined that the facility failed to: a) provide disinfectant wipes and sanitize the equipment used by visitors in the COVID-19 screening process; b) practice appropriate hand hygiene for 1 of 4 staff; c) ensure proper use of personal protective equipment (PPE) for 2 of 2 staff; and, d.) ensure that workers sanitize the table used for staff testing in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: A review of the U.S. CDC's Cleaning and Disinfecting Your Facility, updated on 7/28/20, included, Practice routine cleaning of frequently touched surfaces. High touch surfaces include tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, sinks, etc. Disinfect with a List N: disinfectants for use against [DIAGNOSES REDACTED]-CoV, [MEDICAL CONDITION] that causes COVID 19. For electronics, such as tablets, touch screens, keyboards, remote controls, and ATMs, consider putting a wipeable cover on electronics. Follow the manufacturer's instructions for cleaning and disinfecting. If no guidance, use alcohol-based wipes or sprays containing at least 70% alcohol. Dry surface thoroughly and wear appropriate PPE when cleaning or disinfecting frequently touched surfaces and electronics. The U.S. CDC's Preparing for COVID-19 in Nursing Homes updated on 11/20/20, indicated, Environmental Cleaning and Disinfection: develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. Ensure HCP are appropriately trained on its use. According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/20 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene, which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. According to the U.S. CDC guidelines Responding to Coronavirus (COVID-19) in Nursing Homes, Considerations for the Public Health Response to COVID-19 in Nursing Homes, updated 4/30/20 included, Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes the use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. According to the U.S. CDC's Interim Infection Prevention and Control Recommendations for HCP During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 11/4/20 included guidelines to Collection of Diagnostic Respiratory Specimens It specified that, Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. 1. At 9:00 AM, the surveyors entered the front lobby and observed a security guard seated at a desk behind a protective barrier. The surveyors introduced themselves and explained the intention for the visit. The surveyors asked for guidance regarding the screening process; The security guard pointed towards the computer. The surveyors asked the security guard to explain the screening process. At that time, the guard approached the computer screen and instructed the surveyors on the process. The guard did not sanitize the computer used to take temperatures and answer screening questions for Covid-19 symptoms and exposure. The security guard instructed the surveyors to type their information into the computer but did not disinfect the computer screen in between the surveyors use. There were no disinfecting wipes available at that time. On that same day, at 10:15 AM, during an interview, the Assistant Director of Nursing (ADON) stated that the facility usually had a staff member monitoring the front screening area but that the staff member had called out sick. The ADON noted that the computer screen should have been disinfected between use. The surveyor told the ADON that there were no disinfectant wipes observed at the screening station. The ADON replied, yes, they are right on the table. Come with me now, and I will show you. The surveyor accompanied the ADON, who acknowledged that there were no disinfectant wipes on the screeing table. The ADON went behind the protective barrier and reached under the security guard's desk, and removed two disinfectant wipes containers. The ADON instructed the security guard not to remove them from the table. On that same day, at 10:30 AM, during an interview, the security guard stated that her job did not include screening and that she had not been trained on the screening process. On that same day, at 11:00 AM, the ADON provided the surveyor with the facility's policy and procedure for the screening process dated 4/13/20, revised 11/27/20, which indicated: A staff member will be assigned to disinfect any writing materials and the screening machine at the front desk with disinfectant wipes in-between staff, vendors and visitors touching the device. 2. On 11/27/20 at 10:35 AM, the Registered Nurse/Unit Manager (RN/UM) informed the surveyor that 2 South had two new admissions from home on observation for 14 days. The RN/UM stated that both new admissions were tested upon entry, and results were negative for COVID-19, and staff were mandated to wear an N95 mask, an eye protector, gown, and gloves when inside the rooms of new admissions. At 10:45 AM, the surveyor observed the room of new admit with red signage that indicated, Attention Please see the Nurse before entering this room [ROOM NUMBER]/25-12/9/20. There was no PPE bin outside of the room. At 10:47 AM, the surveyor observed the Certified Nursing Aide (CNA) touch the door with her ungloved hands as she entered the room of the new admission. The CNA was wearing a headcover, N95 mask, and a surgical mask. The CNA did not wear a gown or gloves when she entered the resident's room. Afterward, the surveyor observed the CNA exit the room without performing hand hygiene. Simultaneously, the surveyor observed the CNA went to the bathroom of another resident and immediately performed hand washing for 9 seconds under the stream of running water. The surveyor interviewed the CNA, who stated that she should have washed her hands before leaving the resident's room for at least 20 seconds outside of the water, according to the in-service provided by the Infection Preventionist Nurse (IPN). She stated that the gown was available outside the Unit Manger's office, and she should have worn a gown before going inside the resident's room. 3. At 11:04 AM, the IPN who was on 2 South informed the surveyor that new admissions were on Observation for 14 days, which meant that residents were on transmission-based precautions (TBP). The staff were mandated to wear full PPE, which included eye protectors, N95 masks, gloves, and gowns when inside resident rooms. She stated that there should be a PPE bin outside the rooms of Observation residents. At that same time, the surveyor and the IPN observed Observation rooms with no PPE bins outside. At 11:11 AM, the surveyor and the IPN observed a resident on the Observation Unit came out of the room without a mask and walked unsteadily in the hallway. The surveyor and the IPN observed the RN immediately assisted and guided the resident back to their room. The RN was not wearing a gown or gloves when she was in direct contact with the resident. Afterward, in the presence of the IPN, the RN stated that she should have worn a gown and gloves before entering the resident's room and that she had direct contact with the resident and had to walk the resident close to her because the resident was unsteady. 4. On 11/27/20 at 9:28 AM, the surveyor, met with the ADON and the Infection Control Preventionist Nurse (ICPN). They stated that the facility had a current Covid-19 outbreak in which 8 Residents tested positive for Covid-19. On that same date and time, the ICP stated that staff was being tested 2x/week on Tuesday and Friday due to the outbreak. On 11/27/20 at 1:05 PM, during Covid-19 nasopharyngeal (back of the nose and throat) swab collection, the surveyor observed that after completing a swab collection for the Registered Nurse (RN), the RN/ MDS coordinator did not sanitize the table that was used for specimen collection. During an interview, in the presence of the Infection Preventionist Nurse (IPN), the surveyor asked the RN/ MDS coordinator why she did not sanitize the table between testing. The RN/MDS coordinator replied, I should have. On that same day, at that same time during an interview, the IPN stated that she had trained the RN/MDS coordinator on the Covid-19 staff testing procedure and had instructed the RN/MDS coordinator to disinfect the work table after each test was performed. At 2:23 PM, the survey team met with the LNHA, DON, and IPN. There was no additional information provided by the facility. A review of the undated facility's Nursing/Infection Control Policy of Hand Hygiene that was provided by the IPN included, Hand hygiene technique when using soap and water: wet hands with water, apply to hands the amount of soap recommended by the manufacturer, rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers, rinse hands with water, dry thoroughly with a single-use towel and use a clean towel to turn off the faucet. A review of the facility's Cohorting of Residents: Coronavirus Prevention Policy with a revised date of 11/29/2020 that was provided by the DON included, All new admission who have never been tested /status unknown, or have tested negative prior to admission, will be admitted to a single occupancy room and will be monitored for 14 days for symptoms of COVID 19. They will be tested for COVID 19 on admission and weekly thereafter. All COVID-19 recommended PPE should be worn during resident care. NJAC 8:39-19.4 (a) NJAC 8:39-27.1

Based on observation, interview and review of other facility documentation, it was determined that the facility failed to use disposable kitchen products on the COVID isolation unit. This deficient practice was identified for 1 of 2 COVID isolation units (1st floor South), in a facility experiencing a COVID-19 outbreak and was evidenced by the following: During a tour of the 1st floor South unit (COVID positive), on 06/02/2020 at 11:24 AM, the surveyor observed a food cart in the hallway between rooms [ROOM NUMBERS]. The cart had one washable hard-plastic tray, hard-plastic plate liner, plate, a dome lid, a hard-plastic bowl, hard-plastic coffee cup, and silverware. On 06/02/2020 at 12:30 PM, the surveyor observed the following on the 1st floor South unit (COVID positive): A food cart outside of room [ROOM NUMBER] which contained two washable hard-plastic trays, two hard-plastic plate liner, two plates, two dome lids, one hard-plastic coffee cup and silverware on both trays. Visible inside room [ROOM NUMBER] on the overbed table, there was a washable hard-plastic tray, plate, hard-plastic plate liner, dome, hard plastic cup, and silverware. Visible inside room [ROOM NUMBER] on the overbed table, there was a washable hard-plastic tray, plate, hard-plastic plate liner, dome, hard plastic cup, and silverware. During an interview with the surveyor on 06/02/2020 at 11:29 AM, the Registered Nurse (RN #1) on the 1st floor South unit stated both halls on the 1st floor South were for the COVID positive residents only. RN #1 stated all meals came on disposable products and were thrown out on the unit after the resident had finished eating. During an interview with the surveyor on 06/02/2020 at 12:23 PM, the Food Service Director (FSD) stated COVID positive residents received disposable paper products. The FSD stated he was not aware of a COVID unit on the 1st floor. RN #1 and the surveyor walked the 1st floor South unit and RN #1 confirmed a total of five resident lunches were served on non-disposable trays, plates, plate liners, dome lids, cups, and silverware. During an interview with the surveyor on 06/02/2020 at 12:30 PM, RN #1 stated the meals should not have been served on non-disposable products. RN #1 stated disposable products were used so they could be thrown out on the COVID unit and prevent the spread of infection. During an interview with the surveyor on 06/02/2020 at 12:38 PM, the Certified Nursing Assistant (CNA #1) stated that the meals should have been on disposable kitchen products but that some meals came up on non-disposable, washable kitchen products. CNA #1 stated she had reported this to RN #1. CNA #1 stated disposable kitchen products were important to prevent the spread of infection outside the COVID unit. During an interview with the surveyor on 06/02/2020 at 12:40 PM, the 1st floor South RN unit manager (RN/UM) stated she had reported the non-disposable kitchen products to the FSD and that the FSD told her he was unaware the 1st floor South unit was a COVID positive unit. During an interview with the surveyor on 06/02/2020 at 12:46 PM, the Director of Nursing (DON) stated COVID positive residents were communicated to the dietary department by email with the resident name and room number so the kitchen may supply disposable kitchen products. The DON stated the facility used disposable kitchen products because they don't know if even after a resident was 14 days without any symptoms, how the COVID disease may spread. The DON stated that all COVID positive residents were made known to the dietary department by email and the dietary department also would know from the weekly department head meetings. During an interview with the surveyor on 06/02/2020 at 12:48 PM, the FSD stated when he received an e-mail, he would note on the dietary slip paper products and that the facility had a sufficient amount of disposable kitchen products available. During an interview with the surveyor on 06/02/2020 at 1:10 PM, the cook stated that the COVID positive resident's meal tickets will display paper products on them so the staff know to use disposable kitchen products. During an interview with the surveyor on 06/02/2020 at 1:16 PM, the kitchen supervisor stated there were two COVID positive units. The kitchen supervisor stated she would be responsible for checking the trays before they left the kitchen but if the resident's meal ticket did not indicate paper products, she would follow the ticket instructions. During an interview with the surveyor on 06/02/2020 at 1:35 PM, the Dietary Aide (DA #1) stated that nursing informed the kitchen of any special instructions. DA #1 stated she was aware of two COVID positive units in the facility and that those units should have had all disposable kitchen products. DA #1 stated she would not know if any non-disposable meal trays that returned to the kitchen were from the COVID positive unit and that she wouldn't know of anything different that would need to be done for those trays. During an interview with the surveyor on 06/02/2020 at 1:39 PM, DA #2 stated that there were two COVID units in the facility. DA #2 stated that paper disposable kitchen products were used on the units because they can be thrown out and stop the spread of infection from leaving the COVID units. DA #2 stated that if any non-disposable meal trays returned to the kitchen from the COVID positive unit, she would not know of anything different to do to those meal trays and that she was unaware of any policy to do anything different for those meal trays. During an interview with the surveyor on 06/02/2020 at 1:52 PM, the RN Infection Control and Employee Education nurse stated both COVID positive units opened in March 2020. She stated she had been in-servicing the staff on Personal Protective Equipment (PPE) and hand hygiene but had not specifically in-serviced the dietary staff on the use of the disposable kitchen products because it was part of the facility policy and procedure for isolation. During an interview with the surveyor on 06/02/2020 at 2:35 PM, the Administrator stated the dietary department should have known about the two COVID positive units within the time from when they opened in March 2020. Review of the facility, Generalized Cleaning and Sanitizing of Foodservice Trays policy and procedure, dated April 2020, revealed residents that were identified by nursing to be COVID positive would receive isolation trays. Foodservice will deliver meals to the identified residents on paper good to be discarded on the nursing units after the meal was complete. Review of the facility, Use of Disposable trays for COVID Residents policy and procedure, dated 05/14/2020, revealed that the facility would ensure that all meals would be served on disposable kitchen products until a resident who was COVID positive was no longer considered infectious; when a resident tested positive for COVID-19, nursing shall notify the kitchen staff to advise the resident needed disposable trays. Review of the facility, Transmission based precautions procedures, dated 10/09, revealed Nutrition Services: All meals will be served using disposable kitchen products until the resident is no longer considered infectious. NJAC 8:39-19.4(a)(2); 19.4(l)

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain the kitchen environment and equipment in sanitary conditions to prevent contamination and the potential for the development of foodborne illness. This deficient practice was evidenced by the following: On 10/1/19 at 8:45 AM, during the initial tour of kitchen in the presence of the Director of Dietary Services (DDS) the surveyor observed the following: 1. The seven oven knobs on oven #1 had a buildup of a brown grease like substance on and around the knobs and the edges of the oven door. The outside door of the oven and the left side of the oven had multiple streaks of a dried white substance and dried food particles on it. The bottom half of the backsplash had a buildup of a brown, black dried grease like substance on it. 2. The four knobs on oven #2 had a buildup of a brown grease like substance on and around the knobs and the edges of the oven door. The inside floor of the oven had a buildup of black charred particles and white dried particles. The corner of the outside of the oven had a large amount of food crumbs imbedded in it. 4. A metal spacer cabinet that the DDS stated was used to store cleaning supplies was covered with multiple dried white particles on the outside right hand side. The cabinet interior contained cleaning supplies and a bucket without a lid that contained salt. The DDS confirmed it was salt and stated, This doesn't belong here, and added, I'm going to throw this out. 5. A plastic knife holder station that was on the wall of the kitchen contained 6 large knives. The DDS stated the knives were clean and ready for use. On the edge of the knife holder, where the knifes entered the plastic container, there was a large amount of food crumbs and a dried grease like substance. There was also a large amount of food crumbs on the floor of the plastic container where the knives were being stored. 6. The sides of the fryer cabinet had a layer of multiple dried white streaks going down the front of it. 7. The two inside glass doors and edging of the convection oven #1 had a large buildup of a dried brown, black grease like substance. 8. The two inside glass doors and edging of the convection oven #2 had a large buildup of a dried brown, black grease like substance. The floor of the oven had multiple black charred particles on it. 9. The metal tilt skillet had multiple dried white streaks going down the outside of it. The two control knobs had a buildup of dust and dried white particles. 10. The metal doors underneath the kettle had multiple dried white streaks going down it. The DDS stated that all the above equipment was cleaned weekly. The DDS showed the surveyor the cleaning schedule that was posted on the wall in the kitchen. The surveyor noted that there was no place on the form for the kitchen staff to sign when they completed their assignments. The DDS stated, the staff do not sign anything when they complete their assignments and added they just know what they are supposed to do. 12. The shelf under the steam table had a dried puddle of a brown substance and also had dried white and brown particles on it. All seven of the metal covers on the two steam tables had multiple dried food particles on them and the oven knobs had a buildup of a brown grease like substance. There was also dried brown, grease like drippings on the side of the steam table. The DDS stated that the steam table and knobs are cleaned weekly. 13. In one of the corners of the kitchen's walls where the staff hang their aprons there was a large amount of dried orange and brown food particles splattered on either sides of the corner. The DDS stated that the walls of the kitchen are cleaned monthly. 14. The walls above the food prep area was spattered with orange, brown dried food particles. The DDS stated that the cleaning of the food prep wall was not included on the cleaning schedule. The DDS further stated that the staff working at this station were responsible to clean the area daily when food preparation was completed. 15. Three of eight adaptive plates that the DDS stated were clean and ready for use had dried yellow, red and brown food particles on them and the shelf the adaptive plates were being stored on had dust particles on it and loose food particles on it. 15. The metal plate warmer had dried white streaks going down the outside of it and there was a large buildup of dust on the rubber corners above the wheels. 16. Two large plastic containers used to dispense cold liquids were being stored on a shelf. The DDS stated the containers were clean and ready for use. The outside of the two large plastic containers had a large amount of dried orange, brown drippings on them. The containers were opened by the DDS in the presence of the surveyor. There was approximately two inches of pooled water on the bottom of one the containers. 17. Three closed metal containers used for ice cream were being stored on a shelf. The DDS stated the ice cream containers were clean and ready for use. The inside and outside of the containers had droplets of dried ice cream on them and the tops of the containers had a buildup of dust. 18. Two large metal thermal coffee dispensers that DDS stated were clean and ready for use were being stored on a shelf. The covers of the coffee dispensers were being stored upside down on top of the coffee pots and had a layer of dust particles on them. A review of the facility's policy and procedure titled, Generalized Cleaning and Sanitizing indicated under the under the title Procedure #5, All food contact surfaces will be kept clean and sanitized throughout all shifts. NJAC 8:39-19.7(d)

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to ensure that ready-to-serve food was protected from contamination during food preparation, service and storage to prevent potentially hazardous foods from food borne illness as evidenced by the following: During the initial tour of the kitchen on 10/29/18 at 8:55 AM in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. The tilt top skillet was filled with water and ready to serve lunch food items. The cook stated she took the food items from refrigerator and placed them into the tilt top at 8:30 AM after the tray line was finished so they could heat up. The FSD stated lunch service starts at 11:30 AM. The FSD was informed of the surveyor's observations and all the items were removed and discarded. The cook stated that her normal routine to reheat food was to place it in the tilt top skillet after the tray line is finished about 8:30 AM and if the food doesn't get hot enough before lunch service starts she transfers it to the steamer to finish the reheating process. 2. The walk-in freezer was stacked too high and over-crowded that inhibited adequate air circulation. 3. Soiled meal trays and plate lids from the dining room lunch service were returned to the open food carts while it was filled with ready-to-eat plated meal trays. This was observed from both the large and the small closed food trucks on 10/28, 10/29 and at breakfast on 10/30. The large food trucks have three rows with 10 trays per row for a total of 30 meal trays per food truck. The small closed food trucks had two rows with five trays in each row for a total of 10 meal trays per truck. On 10/30/18 at 12:45 PM the Administrator and Director of Nurses were informed of the surveyor's observations. The surveyor reviewed the facility's undated Production Policy and Procedure for food and nutrition service that indicated food and nutrition products are prepared and handled in a manner that is in compliance with acceptable regulatory guidelines. To identify appropriate cooking methods as per set recipes and to identify proper methods of food storage, labeling and dating to help ensure that food and nutrition products are stored and prepared under proper conditions. According to Chapter 24 (NJAC 8:24-3.4 (g4)) Sanitation in Retail Food Establishments and Food and Beverage Vending Machines stated reheating for hot holding shall be done rapidly and the time the food is between refrigeration temperatures and 165 degrees Farenheit (F) may not exceed two hours. Steam tables, bain maries (method of cooking with water), warmers and similar hot holding facilities are prohibited for the rapid reheating of potentially hazardous foods. NJAC 8:39 19.7(g)

Based on observation, interview and record review, it was determined that the facility failed to: a.) properly store, label and dispose medications in 1 of 7 medication carts and 2 of 3 medication refrigerators, b.) properly secure narcotic storage box in 1 of 3 medication refrigerators inspected. This deficient practice was evidenced by the following: On [DATE] at 8:45 AM, the surveyor inspected 1 South medication cart in the presence of a License Practical Nurse (LPN). The surveyor observed two opened [MEDICATION NAME] Insulin Pens with an expiration date of [DATE]. The surveyor interviewed the LPN who stated that the two opened pens of [MEDICATION NAME] Insulin were expired and should be removed from the medication cart. On [DATE] at 9:10 AM, the surveyor inspected 1 South medication room refrigerator in the presence of LPN #2. The surveyor observed 5 vials of unopened [MEDICATION NAME] 20% stored in the refrigerator. The surveyor interviewed LPN #2 who stated that unopened vials of [MEDICATION NAME] should be stored at room temperature. On [DATE] at 9:30 AM, the surveyor inspected 2 South medication room refrigerator in the presence of a Register Nurse (RN). The surveyor observed an opened vial of [MEDICATION NAME] Purified Protein Derivative (PPD) that had an open date of [DATE] on the vial. The surveyor also observed an unlocked Narcotic storage box that was affixed to the refrigerator that contained two bottles of [MEDICATION NAME] solution. The surveyor interviewed the RN who stated that the opened vial of PPD was expired and should be removed from the medication refrigerator. The RN stated that the Narcotic box should be locked. A review of the Manufacturer's Specifications for the above medications indicated the following: 1. [MEDICATION NAME] Insulin Pens once opened had an expiration date of 28-days. 2. Unopened vials of [MEDICATION NAME] should be stored at room temperature. 3. PPD vial once opened had an expiration date of 30-days. A review of the facility's policy titled Medication Storage indicated the following under section one entitled Narcotics and Controlled Substances; Schedule II and back- up stock of Schedule III, IV and V medications are stored under double-lock key. NJAC: 8:,[DATE].4 (a) (h)(d)

Based on observation, interview and record review, it was determined that the Consultant Pharmacist (CP) failed to identify medication discrepancies for 4 of 26 residents (#1, 5, 15 and 16) reviewed from January 2016 through August 2016, as evidenced by the following: 1. The surveyor reviewed the record of Resident #5 and observed that on 05/15/16 the Advanced Practice Nurse wrote an order to decrease Zyprexa 2.5 mg from every night to every other night. A review of the June 2016 Medication Administration Record (MAR) revealed that Zyprexa 2.5 mg was given every night. The surveyor observed the Consultant Pharmacist Progress Notes (CPPN) dated 06/07/16. The CP did not note this error. 2. The surveyor reviewed the record of Resident #15 and observed a current physician's orders [REDACTED]. The surveyor observed the CPPNs dated 06/18/16, 07/07/16 and 08/08/16. The CP did not note this discrepancy. 3. The surveyor reviewed the record of Resident #16 and observed a physician's orders [REDACTED]. Humalog Insulin was to be administered based on the blood sugar reading. This resident went out for dialysis treatments on Tuesdays, Thursdays and Saturdays from 1:30 p.m. to 6:30 p.m. The surveyor reviewed the May 2016 and June 2016 MARs which revealed that the nurses were documenting blood sugar results and insulin administration at 4:30 p.m. daily even though the resident was not in the facility at 4:30 p.m. on Tuesdays, Thursdays and Saturdays. The surveyor observed a clarification of the order dated 06/29/16 which indicated that the blood sugars with insulin coverage were to be done on non-dialysis days at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m. Blood sugars with insulin coverage were to be done at 6:30 p.m. and 10:30 p.m. on dialysis days. The order for dialysis days did not include the 6:30 a.m. and 11:30 a.m. dose. The nurses were documenting those readings under the non-dialysis days order. The surveyor reviewed the July 2016 MAR and observed that the nurses continued to document the blood sugar results and insulin administration incorrectly. The days for each order were not clearly plotted on the MAR when the order was transcribed. The surveyor observed the CPPNs dated 05/08/16, 07/07/16 and 08/08/16. The CP did not note this discrepancy. On 08/24/16 at 11:30 a.m. the surveyor brought these findings to the attention of the Administrator and Director of Nursing. No additional information was provided. 4. On 8/23/16 at 9:35 a.m. the surveyor reviewed the record of Resident #11. The surveyor noted that the MAR documented the administration of Oxybutynin Chloride ER 10 mg tablet at 9 a.m. and Potassium Chloride ER 20 milliequivalents (meq) at 8 a.m. daily since the Physician ordered them on 1/14/16. The manufacturer of Oxybutynin Chloride ER 10 mg tablet recommended that when administering Potassium supplementation, the liquid formula of Potassium be administered rather than the long acting, Potassium Chloride ER 20 meq formula. The administration of these two medications was contraindicated due to the fact that solid Potassium passage may be delayed through the gastrointestinal tract, increasing the risk of ulcerative lesions. The surveyor observed the Consultant Pharmacist Progress Notes (CPPN) documenting review of the resident's medication monthly from 2/8/16 to 8/8/16. The CP did not comment about this interaction in any of the monthly reports. NJAC 8:39-29.3(a)

Based on observation, interview and record review, it was determined that the facility failed to provide supportive rationale for increasing the dose of an antipsychotic medication, [MEDICATION NAME], and the use of the medication [MEDICATION NAME] 20/10 mg, a medication used to treat Pseudobulbar Affect (PBA). This deficient practice was observed for 1 of 7 residents reviewed for antipsychotic use, Resident #4; and 6 of 6 facility residents reviewed for [MEDICATION NAME] use, Residents #8, #11, #18, #19, #20 and #21 as evidenced by the following: 1. On 8/22/16 at approximately 8:10 a.m. during the initial tour, the Unit Manager (UM) stated that Resident #4 was oriented to self. The surveyor reviewed the resident's records. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the August 2016 physician's orders [REDACTED]. The surveyor reviewed the Psychiatric Follow Up (PFU) dated 5/15/16 which documented that the Psychiatric Nurse met with a family member who reported that the resident may not be taking the medication because of the bitter taste related to crushing the medication. Continued review of the PFU documented Patient with increase paranoia, disorganization-wants to return to Italy. Further documentation on the PFU dated 5/15/16 documented weight loss, depression, anxiety, delusion. The surveyor reviewed the nursing Psychoactive Medication Monitor (PMM) dated 12/2015 through 04/2016 which documented episodes of auditory hallucinations. The surveyor observed only 5 entries in December 2015 and 1 entry in January 2016. The surveyor reviewed the Consultant Pharmacist Progress Notes (CPPN) dated 6/8/16 which documented increase [MEDICATION NAME] 0.25 mg at bedtime as per Psych Consult for change in behavior, no behaviors noted on Behavior Monitoring Sheet (BMS). 2. On 8/22/16 at 8 a.m. during the initial tour of the facility, the UM stated that Resident #11 was treated with [MEDICATION NAME] (a medication that the Federal Drug Agency (FDA) approved for PBA. PBA - characterized by emotional lability or emotional incontinence referring to a neurologic disorder expressed by involuntary crying or uncontrollable episodes of crying and/or laughing.) The surveyor reviewed the resident's records. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the August 2016 POS whch revealed that [MEDICATION NAME] was ordered on [DATE] for PBA. The surveyor reviewed the Admission/Readmission assessment dated [DATE] which documented no behavioral issues noted. The surveyor reviewed the Initial Psychiatric Consultation/Evaluation dated 2/2/16 which documented mild depression and anxiety. The resident also complained of being full of aches and pain (legs). The Psychiatrist recommended to increase [MEDICATION NAME] (an antidepressant) to 60 mg. The surveyor reviewed the Psychiatric Follow Up dated 5/15/16 which documented I'm happier here. I like talking to people. The Psychiatric Follow Up dated 8/20/16 documented all I really want is a companion, I am lonely. Continued review of the nursing Inter-Disciplinary Progress Note from 5/11/16 to 8/21/16 did not present any documentation for involuntary crying or laughing for Resident #11 that might be interpreted as PBA. 3. On 8/22/16 at approximately 8:10 a.m., during the initial tour, the UM did not state that Resident #20 was treated with [MEDICATION NAME], only that the resident was oriented to self. The surveyor reviewed the resident's records. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the August 2016 POS which revealed that [MEDICATION NAME] 20/10 mg was ordered on [DATE] for Dementia with Behaviors that was crossed out and PBA was entered. The surveyor reviewed the CPPN dated 4/7/16 which documented new order [MEDICATION NAME]-change [DIAGNOSES REDACTED].#20 that might be interpreted as PBA. On 8/25/16 at 11:10 a.m. the surveyor interviewed the resident's medication nurse who stated the resident is happy, has a new friend. The resident used to be sad and cry. 4. On 8/22/16 at approximately 8:15 a.m., during the initial tour, the UM did not state that Resident #20 was treated with [MEDICATION NAME], only that the resident was oriented to self. The surveyor reviewed the records of Resident #21. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the August 2016 POS which revealed that [MEDICATION NAME] 20/10 mg was ordered on [DATE] for PBA. A review of the Initial Psychiatric Consultation / Evaluation dated 2/21/15 documented crying intermittantly, a history of [MEDICAL CONDITION], and crying PBA?. Continued review of the nursing Inter-Disciplinary Progress Note from 12/1/15 to 7/27/16 did not present any documentation for involuntary crying or laughing for Resident #21 that might be interpreted as PBA. On 8/25/16 at 11:15 a.m. the surveyor interviewed the resident's medication nurse who stated the resident gets frustrated sometimes and cries. It's better now, we know the resident's routine. The resident cries sometimes because of difficulty expressing needs. On 8/23/16 at 9:00 a.m. the surveyor reviewed the contraindications listed by the manufacturer of [MEDICATION NAME]. [MEDICATION NAME] was contraindicated in patients with heart failure and [MEDICAL CONDITION]. 5. On 8/22/16 at 8 a.m. the surveyor observed Resident #8 in bed with eyes closed. The Assistant Director of Nursing (ADON) told the surveyor that the resident was receiving [MEDICATION NAME], because the resident repeated the same thing over and over. The surveyor reviewed the resident records. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the August 2016 POS which revealed the resident had an order for [REDACTED]. The surveyor reviewed the Inter-Disciplinary Progress Note (IDPN) from 5/24/16 to 8/20/16 revealed the resident's documented behaviors included constantly calling out and repeating words. The surveyor reviewed the resident's care plans which revealed a care plan problem titled Cognition deficit as evidenced by history of calling out and screaming out and a care plan problem titled use of [MEDICATION NAME] which had interventions that included monitor for increase in behavior (screaming, calling out and repetitive words.) The surveyor reviewed the Psychiatric Follow-up Form (PFUF) dated 6/1/16 - 7/21/16 revealed the Psychiatric Advanced Practice Nurse (PAPN) had diagnosed the resident with Dementia with anxiety, mood labilty, [MEDICAL CONDITION], and behavioral disturbance and PBA. The resident's behaviors were documented on the PFUP by the PAPN as anxious, agitated, requesting to go home, yelling, crying, screaming, restless, paranoia, confused and pleasant. After reviewing the IDPN, care plans and PFUF, there was no documentation that included any behaviors of involuntary crying or laughing that might by interpreted as PBA to support the use of the medication [MEDICATION NAME]. On 8/23/16 at 11 a.m. the surveyor spoke to the nurse assigned to the resident who said the resident has behaviors of calling out, but usually could be calmed down. 6. On 8/22/16 at 8:30 a.m. the surveyor observed Resident #18 in bed with eyes closed. The ADON said the resident was alert and oriented with some confusion. The surveyor reviewed the resident's records. The resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the August 2016 POS which revealed the resident had an order for [REDACTED]. The surveyor reviewed the IDPN dated 10/2015 - 8/2016 which revealed the resident had documented behaviors of screaming, yelling and being uncooperative with care. Further review of the Care Plan Conference Summaries by the Interdisciplinary Care Plan team (IDCP) from 9/3/15 to 8/23/16 describe the resident's behavior of anxiety, screaming, yelling, sundown behavior, talking to his/herself and resistive to care. The surveyor reviewed the PFUF from 9/15/15 - 8/22/16 which revealed that the PAPN documented a [DIAGNOSES REDACTED]. The [MEDICATION NAME] medication was initially started on 10/12/15 and approximately 1 month later [MEDICATION NAME] for Anxiety and [MEDICATION NAME] for Dementia with Behavior Disturbances were added to the resident's list of medications. A review of the resident's care plans revealed a care plan problem titled (the resident) at risk for symptoms of decline as it relates to dementia with cognition loss .takes [MEDICATION NAME]. An update on the care plan dated 8/16 indicated that the resident remains with occasional calling out. After surveyor review of the IDPN, care plans and PFUF, there was no documentation that included any behaviors of involuntary crying or laughing that might by interpreted as PBA to support the use of the medication [MEDICATION NAME]. 7. On 08/25/16 at 10:15 a.m. the surveyor observed Resident #19 in bed with glasses on, awake and pleasant when greeted. The surveyor reviewed the resident's records. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the August 2016 POS revealed that the resident had a medication order for [MEDICATION NAME] 20 mg-10 mg 1 cap by mouth two times a day. The medication was ordered on [DATE] which was indicated for Dementia with Behaviors, rewritten on the May 2016 POS as PBA. The resident was also taking the medication [MEDICATION NAME] 15 mg 1 tab by mouth daily for a [DIAGNOSES REDACTED]. The surveyor reviewed the Progress Notes dated 02/06/16 - 03/26/16 for documentation that lead to the decision for the [MEDICATION NAME] to be started. There was no documentation that supported the adequate indication for use of [MEDICATION NAME]. On 08/25/16 at 12:15 p.m. the surveyor spoke to the nurse assigned to the resident who said that the resident does not have behaviors. She further stated, sometimes she'll cry because she misses her family. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to follow an Advanced Practice Nurse's (APN) orders for a gradual dose reduction for a psychoactive medication as ordered for Resident #5, 1 of 7 residents reviewed. This deficient practice was evidenced by the following: On 08/22/16 at 8 a.m. during the initial tour of the facility with the Unit Manager (UM), the resident was out of bed in a wheelchair. The resident smiled when greeted and responded to questions appropriately. The surveyor reviewed the resident's record. The resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with an order for [REDACTED]. The surveyor observed a Psychiatric Follow-Up Form dated 05/15/16 which revealed that the APN determined that the resident's thought process showed no evidence of [MEDICAL CONDITION] (a mental illness that made one behave strangely or believe things that are not true). The APN indicated that this improvement in the resident's condition warranted a gradual dose reduction of the [MEDICATION NAME]. The surveyor observed that on 05/15/16 the APN wrote an order on the physician's orders [REDACTED]. A review of the June 2016 Medication Administration Record [REDACTED]. On 08/24/16 at 11:30 a.m. this was brought to the attention of the Administrator and Director of Nursing. They did not dispute these findings. NJAC 8:39-27.1(a)