Every finding on record at Dwelling Place at St Clares

Based on observation, interview, and record review, it was determined that the facility failed to maintain and document respiratory care and equipment for a resident who was receiving humidified, oxygen-enriched air via a medical ventilator (a machine that mechanically supports or entirely replaces a patient's breathing) for 12 of 12 residents reviewed (Residents #1, #2, #3, #4, #5, #6, #7, #8, #11, #17, #23, #25). This deficient practice was evidenced by the following: 1.) On [DATE] at 10:40 AM, the surveyor observed resident #1 in bed with a ventilator in place. The ventilator did not have a dated label or a written date on the circuit tubing or filters. On [DATE] at 10:00 AM, the surveyor reviewed the medical records for resident # 1, which revealed the following: A review of the admission record (AR) (an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to: chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood) and tracheostomy status. A review of the Physician Order (PO) Summary Report, dated [DATE], reflected a ventilator setting order of PRVC/AC (Pressure Regulated Volume Control/ Assist Control); RR (Respiratory Rate) =12, TV (total Volume) =450, PEEP (positive end-expiratory pressure) =5, FI02 (fraction of expired oxygen) = 30%. 2.) On [DATE] at 10:45 AM, the surveyor observed resident #3, in bed with a ventilator in place. The ventilator did not have a dated label or written date on the circuit tubing or filters. On [DATE] at 10:15 AM, the surveyor reviewed the medical record for resident # 3, which revealed the following: A review of the admission record reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to; acute and chronic respiratory failure with hypoxia (where blood oxygen levels remain consistently low) and tracheostomy status. A review of the PO Summary Report, dated [DATE], reflected a ventilator setting order of PRVC/AC; RR=20, TV=500, PEEP=5, FI02= 30%, Titrate FI02 to keep SP02(peripheral oxygen saturation) = 92% and above. 3.) On [DATE] at 10:50 AM, the surveyor observed resident #5, in bed with a ventilator in place. The ventilator did not have a dated label or written date on the circuit tubing or filters. On [DATE] at 10:30 AM, the surveyor reviewed the medical record for resident # 5, which revealed the following. A review of the admission record reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to: acute and chronic respiratory failure with hypoxia, and tracheostomy status. A review of the PO Summary Report reflected a ventilator setting order, dated [DATE], of CMV (continuous mandatory ventilation); RR=20, TV=500, PEEP=8, FI02= 50%, Titrate FI02 to keep Spo2 =92% and above. 4.) On [DATE] at 10:55 AM, the surveyor observed resident #8 in bed with a ventilator in place. The ventilator did not have a dated label (or written date on the circuit tubing or filters. On [DATE] at 10:45 AM, the surveyor reviewed the medical records for resident #8, which revealed the following. A review of the admission record reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to: acute and chronic respiratory failure, unspecified hypoxia, and tracheostomy status. Review of the PO Summary Report reflected a ventilator setting order, dated [DATE], of PRVC/AC; RR=16, TV=450, FI02= 30%, Titrate FI02 to keep FI02 =92%. 5.) On [DATE] at 11:00 AM, the surveyor observed resident #17 in bed with a ventilator in place. The ventilator did not have a dated label or written date on the circuit tubing or filters. On [DATE] at 11:00 AM, the surveyor reviewed the medical records for resident #17, which revealed the following: A review of the admission record reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to: chronic respiratory failure, and tracheostomy status. A review of the PO Summary Report reflected a ventilator setting order, dated [DATE], of PRVC/AC; RR=14, TV=400, PEEP= +5, FI02= 40%. 6.) On [DATE] at 11:10 AM, the surveyor observed resident #25 in bed with a ventilator in place. The ventilator did not have a dated label or a written date on the circuit tubing or filters. On [DATE] at 11:15 AM, the surveyor reviewed the medical record for resident #25, which revealed the following: A review of the admission record reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to; acute and chronic respiratory failure with hypoxia and tracheostomy status. A review of the PO Summary Report reflected a ventilator setting order, dated [DATE], of AC; RR=16, TV=450, PEEP= 5, FI02= 30%. 7.) On [DATE] at 11:30 AM, the surveyor observed Resident #23 in his/her room, seated in a chair with a ventilator in place. The ventilator did not have a dated label or a written date on the circuit tubing or filters. On [DATE] at 10:00 AM, the surveyor reviewed the medical record for Resident #23, which revealed the following: A review of the AR reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to; acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood) and tracheostomy status. A review of the OSR dated [DATE] reflected a ventilator setting of CPAP/PS (Continuous Positive Airway Pressure with Pressure Support) mode =12, PEEP=6, and F102 =30 % as tolerated. 8.) On [DATE] at 11:35 AM, the surveyor observed Resident #7 in bed with a ventilator in place. The ventilator did not have a dated label or a written date on the circuit tubing or filters. On [DATE] at 10:15 AM, the surveyor reviewed the medical record for Resident #7, which revealed the following: A review of the AR reflected that the resident was admitted to the facility with a diagnosis that included, but was not limited to, chronic respiratory failure and tracheostomy status. A review of the OSR dated [DATE] reflected a ventilator setting order SIMV (Synchronized Intermittent Mandatory Ventilation) ; RR=20, TV =330; PEEP =5, FI02 = 28%. 9.) On [DATE] at 11:40 AM, the surveyor observed Resident #2 in bed with a ventilator in place. The ventilator did not have a dated label or a written date on the circuit tubing or filters. On [DATE] at 9:47 AM, the surveyor reviewed the medical record for Resident #2, which revealed the following: A review of the AR reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to; acute respiratory failure with hypoxia and tracheostomy status. A review of the OSR dated [DATE] reflected a ventilator setting order VC/SIMV; RR=15, TV =420; PEEP =5, FI02 = 40%; speaking valve use PRN (when needed) and per the patient's request. 10.) On [DATE] at 11:45 AM, the surveyor observed Resident #6 in bed with a ventilator in place. The ventilator did not have a dated label or a written date on the circuit tubing or filters. On [DATE] at 10:45 AM, the surveyor reviewed the medical record for Resident #6, which revealed the following: A review of the AR reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to; respiratory failure and tracheostomy status. A review of the OSR dated [DATE] reflected a ventilator setting of CPAP/PS TV:450 PEEP: + 5 F102 =30 % PS:12 Titrate FIO2 to keep SpO2:90 back up vent PRVC 20/450/+5/35% PSV/SPONT every shift. 11.) On [DATE] at 11:50 AM, the surveyor observed Resident #11 in bed with a ventilator in place. The ventilator did not have a dated label or a written date on the circuit tubing or filters. On [DATE] at 11:00 AM, the surveyor reviewed the medical record for Resident #11, which revealed the following: A review of the AR reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to; chronic respiratory failure and tracheostomy status. A review of the OSR dated [DATE], reflected a ventilator setting order of PRVC/AC; RR 26, TV 500 PEEP: +7, FI02= 40% titrate FIO2 to keep SpO2:92 every shift. 12.) On [DATE] at 12:00 PM, the surveyor observed Resident #4 in bed with a ventilator in place. The ventilator did not have a dated label or a written date on the circuit tubing or filters. On [DATE] at 11:00 AM, the surveyor reviewed the medical record for Resident #4, which revealed the following: A review of the AR reflected that the resident was admitted to the facility with a diagnosis that included, but was not limited to, chronic respiratory failure and tracheostomy status. A review of the OSR dated [DATE], reflected a ventilator setting order of PRVC/AC; RR 12, TV 450 PEEP: 5, FI02= 30% PSV +10peep +5 up to 8 hours as tolerated daily. On [DATE] at 9:54 AM, the surveyor interviewed the floor respiratory therapist who stated, if any equipment would be changed the date would be written on the white filter that was attached to the ventilator. If the enclosed suction setup was changed that would be labeled with a next change date sticker (i.e . change Sunday or another specific day of the week) and then would be documented in the electronic medical record (eMR) under equipment change. On [DATE] at 10:18 AM, the surveyor interviewed the Respiratory Director (RD), who stated the suction setup is changed weekly and labeled on the closed suction catheter system with the day of the week. Circuits are changed every 28-30 days by the RD and two supervisors, to alleviate using the Respiratory therapist on the unit. The RD further stated that they do not document the change in the chart, and do not date the tubing because there was a schedule (RRC 2026 Ventilator Circuit change schedule). On [DATE] at 12:25 PM, the survey team met with the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA) and the Risk Management Nurse and were made aware of the surveyor's concern of the ventilator circuit changes. On [DATE] at 11:56 AM, the surveyor interviewed RD who provided a monthly schedule RRC 2026 Ventilator Circuit Change and no documentation about the previous month's circuit changes could be provided. A review of the RRC 2026 Ventilator Circuit change schedule, provided by the RD, revealed that ventilator circuits were changed on the following dates in 2026. February 3rd [DATE]nd [DATE]th [DATE]th [DATE]th [DATE]nd A review of the electronic record respiratory progress notes documentation for the RRC 2026 Ventilator Circuit change schedule dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed that circuit changes were not documented in the electronic records, in section equipment change or additional comments, for 12 of 12 residents for RRC Ventilator Circuit change. (Residents #1, #2, #3, #4, #5, #6, #7, #8, #11, #17, #23, #25). A review of the facility policy, Ventilator; Standard of Care, revised on [DATE], revealed; 3) all ventilator monitoring is to be documented in the electronic record.this shall include but is not limited to, maintain the integrity of the circuit, changing the circuit when soiled and/or every 30 days.g) additional documentation will be performed as dictated by patient status and activities performed. A review of the facility policy, Ventilator; [NAME] C3 Ventilator, dated [DATE] and reviewed on [DATE], revealed; h) attach ventilator to patient.j) continue to monitor and document as per policy. NJAC 8:39-11.2 (b); 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the appropriate management of gastrostomy enteral feeding formula. This deficient practice was identified for 1 of 3 residents (Resident #11) reviewed for tube feeding and was evidenced by the following:On 7/6/26 at 11:50 AM, the surveyor observed Resident #11 in bed with a gastrostomy enteral feeding tube (FT; a tube surgically inserted into the stomach to provide food and nutrients) pump administering an unidentified formula at a rate of 70 milliliters (mL) per hour. The surveyor observed that the 1000 milliliter (mL) bag was unlabeled and did not include the Resident's name, formula type, date, or rate of infusion (mL per hour).On 7/6/26 at 12:00 PM, the surveyor reviewed the medical record for Resident #11.A review of the admission Record (AR) reflected that Resident #11 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; chronic respiratory failure (lungs cannot adequately pull oxygen into the blood or remove carbon dioxide), amyotrophic lateral sclerosis (a fatal neurological disorder that destroys motor neurons in the brain and spinal cord) and gastrostomy status.A review of the quarterly Minimum Data Set (MDS) assessment tool dated 4/11/26 reflected that Resident #11 had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated intact cognition. Further review assessed that the resident's weight was 164 pounds, he/she had a feeding tube and received 51% or more calories through parental or tube feeding and an average of 501cc/day or more of fluid intake via IV or tube feeding.A review of the resident's care plan reflected a focus area that included the resident required a tube feeding for nutrition related to (r/t) dysphagia (difficulty swallowing) with interventions that included but were not limited to; the resident needed the head of bed (HOB) elevated 45 degrees during and 30 minutes after the feed, and that the resident was dependent with tube feedings and water flushes .see MD orders for current feeding orders dated 7/13/23.A review of the current physician order summary included a physician's order (PO) for a standard formula 1.4 Oral Liquid (Nutritional Supplements); to give 70 mL/hr. via PEG-Tube (percutaneous endoscopic gastrostomy) every shift for nutrition for a total daily volume of 1120 mLs. Start infusion at 12 midnight and finish at 8 AM for a total volume of 560 mLs; start infusion again at 12 noon and finish at 8 PM for a total volume of 560 mLs.On 7/7/26 at 9:48 AM, the surveyor showed the above concern to the Registered Nurse (RN) assigned to Resident #11's care. The RN confirmed that the TF should be labeled with the resident's name, type of formula, infusion rate, date, time, and the nurse's initials. The RN acknowledged that it was her responsibility to ensure the feeding bag had been labeled according to facility policy.On 7/7/26 at 10:55 AM, during an interview with the surveyor, the Director of Nursing (DON) confirmed that all TF bags and bottles should be labeled with the resident's name, type of formula, infusion rate, date, time, and nurse's initials. At that time, the surveyor requested the facility's TF policy and procedure.On 7/9/26 at 12:08 PM, the survey team discussed the above observations and concerns with the DON, Licensed Home Administrator (LNHA), and the Director of Quality and Risk Management.A review of the facility's Feeding Tube Protocol, Care of the patient policy dated 1/30/24 reflected.It is the policy of this facility to outline the nursing management of patients with an indwelling feeding tube.If the product is in a ready-to-hang bottle, the nurse should label it with the patient's name, date, and time hung. The policy did not address the labeling of products that were not in ready to hang bags.NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide a resident with a pressure ulcer, the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcer development for 1 of 2 residents reviewed for pressure ulcers (Resident #7). According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents and immediately after glove removal. In addition, 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, and this should be done outside the water when rubbing your hands, then 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 approximately 20 seconds.Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.On 7/6/26 at 11:40 AM, the surveyor observed Resident #7 in bed with a ventilator (life-support machine that fully or partially takes over the breathing process when a person can't breathe adequately on their own) a tracheostomy (surgical opening (stoma) into the windpipe), a collar (mask that rests over the stoma to deliver supplemental oxygen to the airway) and a specialty mattress in place.On 7/7/26 at 9:15 AM, the surveyor reviewed the electronic medical record (E-mar) for Resident #7.A review of the admission Record reflected that the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to; chronic respiratory failure (lungs cannot adequately pull oxygen into the blood or remove carbon dioxide) ventilator and tracheostomy status.A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 6/14/26, reflected that resident #7 had a brief interview for mental status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS further assessed that Resident #7 had a stage 4 pressure ulcer (full-thickness wound over the sitting bone that exposes muscle, tendon or bone) and had skin and ulcer treatments that included but were not limited to; pressure reducing devices for bed and chair and application of ointments/medications and nonsurgical dressings. A review of the current Order Summary Report (OSR) reflected Resident #7 had a physician's order (PO) to cleanse the left ischial wound with wound cleanser, apply calcium alginate (highly absorbent wound pads used for moderate to heavily draining wounds), and cover with ABD (abdominal pad) pad daily and prn (when needed).A review of Resident #7's care plan reflected a focus area that indicated the resident had skin breakdown with interventions that included, but were not limited to; monitor the left ischial reopened wound weekly with recommendations to follow infectious disease guidelines and recommendations as ordered; administer treatments to left ischial wound, specialty mattress, assess effectiveness of treatments, and notify the physician if changes were needed.On 7/7/26 at 10:30 AM, the surveyor observed the Registered Nurse (RN) perform a wound treatment to Resident 7's stage 4 pressure wound. The RN disinfected the overbed table and washed her hands using appropriate technique. The RN gathered the supplies, which included 4x4 gauze pads, 2 ABD pads, a bottle of wound cleanser, and a calcium alginate dressing. The RN and RN/unit manager (who was assisting with positioning of the resident) donned gowns and gloves and entered the resident's room. The RN placed all supplies on top of the overbed table (OBT). The RN removed the soiled dressing, which had copious serous drainage. The RN, with the same gloves (now considered soiled) sprayed the wound cleanser directly into the wound. The RN cleansed the wound from the periwound (surrounding skin) to the wound bed (causing possible contamination from the skin into the open wound). The RN removed her gloves, applied alcohol-based hand rub (ABHR) and donned a new pair of gloves. The RN removed the sterile calcium alginate, tore it in half and handled the dressing by touching multiple surfaces rather than using the no touch technique (a method used during invasive procedures or wound care to prevent microbial contamination). The RN did not disinfect the OBT after the treatment was completed and she did not remove and discard the trash from the resident's room.On 7/7/26 at 10:45 AM, the surveyor discussed the infection control breaches with the RN. The RN acknowledged that she should have changed her gloves and performed hand hygiene after removing the soiled dressing, handled the sterile dressing using the no touch technique, and disinfected the OBT when the treatment was completed.On 7/7/26 at 10:55 AM, during an interview with the surveyor, the Director of Nursing (DON) confirmed the infection control breaches made by the RN during the treatment.On 7/9/26 at 12:08 PM, the survey team discussed the above observations and concerns with the DON, LNHA.On 7/9/26 at 12:51 PM, a review of the facility's Clean Dressing Change policy dated 4/7/25 reflected .It is the facility policy to provide wound care in a manner to decrease potential for infection and/or cross-contamination .Set up a clean field on the overbed table .Use no - touch techniques to remove ointments and creams .Liquid solutions should be poured directly onto gauze sponges .Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound .Cleanse the wound from the center of the wound outward .Discard disposable items and gloves into the appropriate trash receptacle .On 7/10/26 at 12:07 PM, the survey team met for the exit conference, no further information was provided. NJAC 8:39-19.4(a); 27.1 (a)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 4/6/25 at 9:36 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. In the Nourishment supply standing two door refrigerator, the surveyor observed a 46 ounce (oz) Thickened Orange Juice bottle and a 16 oz bottle water, both bottles had been opened and were missing open and use by labels. The FSD stated all items should have a open and use by label once opened, both items were discarded. 2. In the walk-in freezer, the surveyor observed fans with a greyish dust-like debris, one opened package of frozen pizza and one opened package of gluten free bread. The pizza and bread were both missing open and use by labels. The FSD stated they would alert the maintenance department to have the fans cleaned. 3. In the dairy walk-in refrigerator, the surveyor observed the fans with a greyish dust-like debris. 4. In the sandwich preparation area, the surveyor observed three open bags bread: one rye, one wheat, and one white bread; all observed without open and use-by labels. 5. In walk-in refrigerator next to the sandwich preparation area, was observed with fans that had a greyish dust-like debris. 6. In the CP-1 standing refrigerator, the surveyor observed an opened bag of Uni brand gluten free bread with a use by date of 2/14/25 and 2, 2oz cups with white grated cheese-like substance that was not labeled. The FSD stated all items should be discarded by the use by date. All items were discarded by the FSD. 7. In the Chef preparatory area, the surveyor observed a can opener with sticky purple debris and a sticky blackish substance on the can opener holder. The surveyor also observed an opened 1-gallon container of [NAME] cooking wine that had a use by date of 5/12/24. The FSD stated called equipment should be cleaned after each use. 8. In the spice shelf storage area, the surveyor observed a 28oz lemon pepper, 11oz dill weed, 11oz rosemary, 11oz thyme, and 11oz smoked paprika all opened and without open or use by labels. 9. In the cooking area, the surveyor observed a two-door standing oven, the top area of the oven was observed with a blackish sticky substance. On 4/7/25 at 9:30 AM, the Licensed Nursing Home Administrator (LHNA) provided the surveyor with two facility polices: Food Storage and Infection Control Guidelines/Hand hygiene for Food and Nutrition Services both with a revised date of 3/1/2022. Under the procedure section of the food storage policy it states, All unlabeled containers or cans will be removed .If there is any question about a product's storage or expiration, discard the product. Under the procedure section of the infection control guidelines it states, Storage areas will be inspected daily by the Food and Nutrition Services Manager .All equipment will be cleaned thoroughly after each use .Refrigeration, all units will be kept clean and in sanitary condition through regular cleaning. On 4/10/25 at 11:00 AM, the surveyor met with the LNHA for the exit conference. No further information provided by the facility staff. NJAC 8:39-17.2(g)

c). On 4/6/25 at 10:38 am, the surveyor observed Resident #17 in bed watching television. A review of the Resident Face Sheet, Resident #17 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, tracheostomy, pressure induced deep tissue damage of the sacral region and pressure ulcer of the right buttock. A review of Resident #17's Quarterly Minimum Data Set (MDS), an assessment tool dated 3/30/25, revealed that the resident's Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated that the resident was cognitively intact. Further review revealed the resident required total dependency for activities of daily living (ADL) and review of the skin portion of the MDS indicated that the resident had moisture associated skin damage. A review of the Physician's Order Summary Sheet revealed an order dated 1/22/25 to cleanse the sacral wound with wound cleanser, pat dry, apply a zinc oxide topical cream to the sacral wound and cover with a large foam dressing and to change daily and when needed. A further review revealed an order to cleanse upper right buttock with wound cleanser, apply silver alginate to wound bed, apply a zinc based hydrophilic wound paste to peri wound then cover with a foam dressing and to change daily. On 4/9/25 at 10:49 am, the surveyor observed the Registered Nurse (RN) perform a wound care treatment on Resident #17 and observed the following: The RN donned a plastic gown, and gloves then removed the old dressing form the right buttock area. Then without removing her gloves and performing hand hygiene, she used the cleansing spray and then cleansed the wound area with 4x4 gauze pads, then dried the area with more 4x4 gauze pads. The RN then removed the alginate packing from the package with the same gloves and then placed the packing back down then removed her gloves and used hand sanitizer. The RN then donned a pair of gloves and placed the packing on the wound, applied the zinc oxide cream with a tongue depressor, and then covered the wound with a foam dressing without changing her gloves. The nurse then performed wound care on the sacral area where she donned gloves and gown removed the open dressing, then used wound cleanser and 4x4 gauze pads to clean and dry the wound without changing her gloves and preforming hand hygiene. The RN applied the zinc oxide cream with a tongue depressor the applied the foam dressing with the same gloved hands. During an interview with the surveyor on 4/9/25 after the wound treatment was completed, the RN stated that she should have changed her gloves and used ABHR during the wound treatment after touching the old dressing and after touching the wound bed. On 4/9/25 at 1:39 pm, the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the wound observation. On 4/10/25 at 10:10, the surveyor met with the LNHA who stated that for infection control for the wound care is a standard of practice and would not rebuttal the observation. The surveyor reviewed the facility's policy and procedure titled, Clean Dressing Change, with an approval date of 4/7/25, which revealed after removing existing dressing gloves should be removed and hand hygiene should be performed. After cleansing the wound as ordered removed gloves and preform hand hygiene then put clean gloves on, then apply topical ointments or creams and dressing as ordered. NJAC 8:39 - 19.1 NJAC 8:39-19.4(a) Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate infection control practices for a.) storing linens observed in the laundry room, b.) tracheostomy (an opening to the neck into the trachea (windpipe) to facilitate breathing) care for 1 (one) of 12 residents (Resident #23), and c.) when performing a wound care treatment for 1 of 1 resident (Resident #17) performed by 1 nurse observed providing a wound care treatment. This deficient practice was evidenced by the following: a). On 4/8/25 at 10:45 AM, the surveyor and the Housekeeping Director (HD) observed the laundry room; the surveyor observed that there were 2 bins of clean linen in the hallway that were not covered. The HD stated that the housekeeping staff should be working on those clean linens, which is why they are not covered. The HD stated that the clean linen should be covered with plastic because it was exposed to the staff passing by the hallway area near the loading dock. b). On 4/6/25 at 10:15 AM, the surveyor observed Resident #23 lying in bed, alert and awake, with a tracheostomy tube attached to the ventilator machine (a device that supports breathing). On 4/6/25 at 12:42 PM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #23, which revealed the following: A review of the admission Record (an admission summary) (AR) reflected that Resident #23 was admitted with diagnoses that included but were not limited to, acute and chronic respiratory failure (impairment of oxygen between the lungs and the blood) with hypoxia (low level of oxygen). A review of the quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) dated 2/3/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident had a severe impairment cognition. Further review is reflected in Section O - Special Treatments, Procedures, and Programs - tracheostomy care while a resident. On 4/8/25 at 10:00 AM, the surveyor observed the Respiratory Therapist (RT) performing tracheostomy care. RT went inside the room wearing the apron, put on the gloves, took the heel protectors from the floor, removed the gloves, used hand sanitizer, and put on the gloves. RT #1 opened the sterile 4x4 size gauze and put it on top of the vent monitor table; the sterile 4x4 gauze touched the monitor screen. RT removed the soiled trach collar from the resident, took the sterile gauze from the top of the monitor, and wiped the neck stoma (surgical opening) using the gauze. The RT #1 removed the gloves, used hand sanitizer, took another sterile gauze, and then put it on the resident neck stoma. After putting in the gauze, RT #1 suctioned the resident, touched the vent monitor, then suctioned, touched the vent monitor again, turned off the lights, removed the gloves, and performed the handwashing. On 4/8/25 at 10:23 AM, the surveyor interviewed RT regarding the concern above. RT #1 stated that she should remove the gloves and other PPE (Personal Protective Equipment), before turning off the lights. She said she should not touch the screen wearing the same gloves between suctions. She stated that she could not recall when she had the competency test for trach care. On 4/9/25 at 9:51 AM, the surveyor interviewed the RT Manager (RT/M) and RT Supervisor (RT/S). The RT/M stated that when the RT was hired, they would provide an in-service regarding tracheostomy care, but there was no other competency after that. On 4/9/25 at 9:35 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the above concern but did not provide further information. On 4/10/25 at 12:05 PM, the surveyor met with the Licensed Nursing Home Administrator regarding the above concern but did not provide further information. A review of the policy titled Subject: Linen Collection and Distribution with a reviewed date of 5/7/24 under Procedure: Clean Linen Distribution: 2. Clean linen must be covered for transport to the units. A review of the policy titled Subject: Tracheostomy Care with a revised date of 12/14/24 under Procedure: To reduce the risk of infection, tracheostomy care is performed using sterile technique. 13. Discard supplies, remove PPE, and perform hand hygiene.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 5 (five) residents (Resident #19) observed during the medication observation pass. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/8/25 at 8:30 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN#1) in the room of Resident #19. The surveyor observed RN #1 checking the resident's identification bracelet and informed Resident #19 that she would be administering the resident's medications. On 04/08/25 at 8:35 AM, the surveyor observed RN #1 preparing to administer seven (7) medications to Resident #19 which included the following, Acidophilus capsule (supplement), Norvasc 5 mg tablet (blood pressure), Apixaban 5 mg (blood thinner), Lexapro 10 mg ( antidepressant), Pepcid 20 mg (medication for the stomach), Metoprolol 50 mg (blood pressure) and Riluzole 50 mg (medication to treat amyotrophic lateral sclerosis, Lou Gehrigsdisease). The surveyor observed RN#1 prepared all the medications for percutaneous endoscopic gastrostomy tube (PEG-tube) administration. At that time, RN#1 told the surveyor that Riluzole had to be administered on an empty stomach and that she stopped the resident's feeding at 7:30 AM. The surveyor then observed RN#1 administered all the medication via PEG-tube to Resident #19. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to amyotrophic lateral sclerosis (ALS) (nervous system disease that affects nerve cells in the brain and spinal cord), hypertension (a condition in which the force of the blood against the artery walls is too high), and chronic respiratory failure (a long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen levels and/or high carbon dioxide levels in the blood). A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 1/13/25, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident's cognition was cognitively intact. A review of the April 2025 Order Summary Report (OSR) revealed a Physician's Order (PO) dated 1/16/25, for Riluzole oral tablet 50 mg (Riluzole) give 1 tablet via PEG-tube two times a day for Lou Gehrigsdisease (ALS) administered on empty stomach. Hold feeding 2 hours before and resume feeding 1 hour after medication administration. A review of the April 2025 OSR revealed a PO dated 3/20/25 for Osmolite 1.2 Cal oral liquid (nutritional supplement) give 70 ml (milliliters)/hr (hour) via PEG-tube every shift for nutrition Osmolite 1.2 @ 70 ml/hr for a total daily volume of 1120 ml. Up at 11:00 PM and down at 7:00 AM until 560 ml has infused. Up at 11:00 AM and down at 7:00 PM until 560 ml has infused to meet total daily volume. A review of the April 2025 electronic Medication Administration Record (eMAR) revealed an order dated 01/16/25, for Riluzole oral tablet 50 mg give 1 tablet via PEG-tube two times a day for [NAME] disease (ALS) administered on empty stomach. Hold feeding 2 hours and resume feeding 1 hour after medication administration. On 4/8/25 at 11:45 AM, the surveyor in the presence of RN#1 reviewed Resident #19's physician's orders. RN#1 acknowledge that the resident had an order to administer Riluzole on an empty stomach and that the medication should be administered 2 hours after the feeding was stopped. RN#1 stated that she should have administered the medication 2 hours after the feeding was stopped. On 4/9/245 at 1:30 PM, the surveyor discussed the above concern with the Licensed Nursing Home Administrator (LNHA). There was no additional information provided. A review of the facility's policy Medication Management Manuel with a revised date of 5/30/24 revealed the following: 3. Ensure that the six rights of medication administration are followed: a. Right Resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation NJAC 8:39-11.2 (b), 29.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to monitor enteral tube feeding administration to assure the total volume administered was in accordance with physician's orders. This deficient practice was identified for 12 of 12 residents reviewed for enteral tube feeding, Resident #24, #2, #19, #5, #7, #13, #16, #1, #9, #12, #20 and #21. This deficient practice was evidenced by the following: 1. On 11/15/23 at 10:07 AM, the surveyor observed Resident #24 in bed watching television. The surveyor noted Resident #24 had an ongoing tube feeding (Enteral nutrition or tube feeding (TF), a way of delivering nutrition directly to your stomach or small intestine) in the process of receiving a water flush at 100 milliliter per hour (ml/hr.) set on the pump. The surveyor noted that there was a 1000 ml bottle of Glucerna 1.5 hanging on the IV pole, next to the resident but not currently running. On 11/20/23 at 10:39 AM, the surveyor interviewed the facility Registered Dietician (RD) who explained that she checks the resident's feed order frequently and checks that the pump is set at the correct rate. The RD explained that the total volume required for each resident is calculated by the hourly rate (ml/hr.) multiplied by the number of hours ordered for the feed. The RD further explained that if the physician's order is continuous, that would be calculated as a 24 hr. period. On 11/20/23 at 12:36 PM, the surveyor interviewed the Director of Nursing (DON) who stated that every nursing shift documents the total volume administered of feed for that shift. The nurse will zero out the reading on the pump at the end of their shift. The DON explained that in order to calculate the total volume administered to a resident for the day, you would have to add up the totals for each shift on that day. The surveyor reviewed the electronic medical record (e-MAR) for Resident #24 and found the following: A review of the resident's Admission Record (AR) (an admission summary, one-page summary of important information about a patient) reflected that Resident #24 was initially admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure, Type 2 Diabetes Mellitus without Complications, Tracheostomy and Muscle Weakness. A review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate care management dated 9/15/2023, revealed under Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) scored at 15, which indicated that the resident was cognitively intact. Review of Section K Swallowing/Nutrition of the Admission MDS, dated [DATE] documented the Resident #24 has a feeding tube. Review of the November 2023 ePO, revealed an order with a start date of 9/15/23 for Enteral Feed Order two time a day for monitoring Glucerna 1.5 @75ml/hr x 16 hours; up at 5PM and down 9AM. This would calculate to a total volume of 1200 ml for the day. Review of the documentation on the November electronic eMAR from 11/1/23 to 11/17/23, revealed that 9 out of 17 days, Resident #24 did not receive the total volume of nutrition ordered by the physician. The total calculations of the shifts for each day presented that Resident #24 received less than the total volume ordered. Review of Resident #24's weight history did not present any weight loss. 2. On 11/15/23 at 10:14 AM. the surveyor observed Resident #2 in bed with eyes closed. The surveyor noted Resident #2 was in the process of receiving their feed of Jevity 1.2 running at 70 ml/hr. (set on the pump). The surveyor reviewed the November 2023 eMAR for Resident #2 and found the following: Review of the AR for Resident #2 was admitted to the facility on [DATE] with diagnoses that included Chronic Respiratory Failure with Hypercapnia, Parkinson's Disease, Epilepsy and Tracheostomy Status. Review of Resident #2's Quarterly MDS dated [DATE] revealed that Section C-Cognitive Patterns could not be completed as Resident #2 could not respond to any of the questions. Resident #2 was documented as having a severely impaired cognition. Review of section K Swallowing/Nutrition of the Quarterly MDS, dated [DATE] documented that Resident #2 has a feeding tube. Review of the November 2023 ePO revealed an order for Jevity 1.2 @ 70 ml/hr. x 18 hrs. or until Total Volume infused = 1260 ml. with a start date of 7/15/23 and a revision date of 7/16/23. Total volume to be administered of 1260 ml for the day. Review of the November 2023 eMAR, documented from 11/1/23 to 11/19/23 revealed that 17 of 19 days, Resident #2 did not receive the total volume of nutrition ordered by the physician. The calculations of each day presented that each day Resident #2 received less than the total volume ordered. Review of Resident #2's weight history did not present any weight loss. 3. On 11/15/23 at 10:25 AM, the surveyor observed Resident #19 in bed with eyes closed. The surveyor noted that Resident #19 was in the process of receiving their feed of Vital 1.2 running at 65 ml/hr. (set on the pump). The surveyor reviewed the electronic medical record for Resident #19 and found the following: Review of the AR for Resident #19 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Chronic Respiratory Failure with hypoxia, Tracheostomy Status, Anemia, and Persistent Vegetative State. Review of Resident #19's Quarterly MDS, dated [DATE] revealed that Section C-Cognitive Patterns could not be completed as Resident #19 could not respond to any of the questions. Resident #19 was documented as having a severely impaired cognition. Review of section K Swallowing/Nutrition of the Quarterly MDS, dated [DATE] documented that Resident #19 has a feeding tube. Review of the November 2023 ePO revealed an order for Vital AF 1.2 infused at 65 ml/hr. with a start date of 7/15/23. This would compute a total volume to be administered of 1560 ml for the day. Review of the November 2023 eMAR, documented from 11/1/23 to 11/19/23 revealed that 19 of 19 days, Resident #19 did not receive the total volume of nutrition ordered by the physician. The calculations of each day presented that each day Resident #19 received less than the total volume ordered. Review of Resident #19's weight history did not present any weight loss. 31656 4. On 11/16/23 at 1:16 PM, the surveyor observed Resident #5 in bed with eyes closed. The surveyor noted that Resident #5 was in the process of receiving their feed of Jevity at a rate of 40 ml/hr. via feeding pump. On 11/20/23 at 10:22 AM, the surveyor observed Resident #5 in bed with eyes closed. The surveyor noted that Resident #5 was in the process of receiving their feed of Jevity running at 40 ml/hr. (set on the pump). The surveyor reviewed the electronic medical record for Resident #5 and found the following: Review of the AR, Resident #5 was admitted to the facility with diagnoses that included but were not limited to Chronic Respiratory Failure with Hypoxia, Unspecified Protein-Calorie Malnutrition, Tracheostomy, Essential Hypertension, Heart Failure, Anoxic Brain Damage, Chronic Kidney Disease, and Dementia. Review of Resident #5's Quarterly MDS, dated [DATE] revealed that Section C-Cognitive Patterns could not be completed as Resident #5 could not respond to any of the questions. Resident #5 was documented as having a severely impaired cognition. Review of section K Swallowing/Nutrition of the Quarterly MDS, dated [DATE] documented that Resident #5 has a feeding tube. Review of the November 2023 ePO revealed an order for Jevity 1.5 infused at 40 ml/hr. with a start date of 8/24/23 and a revision date of 11/7/23. This would compute a total volume to be administered of 960 ml for the day. Review of the November 2023 eMAR, documented from 11/1/23 to 11/19/23 revealed 19 of 19 days that Resident #5 did not receive the total volume of nutrition ordered by the physician. The calculations of each day presented that each day Resident #5 received less than the total volume ordered. Review of Resident #5's weight history did not present any weight loss. 5. On 11/16/23 at 1:41 PM, the surveyor observed Resident #7 in bed trying to communicate. The surveyor was able to have a conversation with Resident #7, with Resident #7 mouthing words. Resident #7 was in the process of receiving their feed of Vital AF at a rate of 60 ml/hr. via feeding pump. On 11/20/23 at 10:25 AM, the surveyor observed Resident #7 in bed with eyes closed. The surveyor noted that Resident #7 was in the process of receiving their feed of Vital AF running at 60 ml/hr. (set on the pump). The surveyor reviewed the electronic medical record for Resident #7 and found the following: Review of the AR for Resident #7 was admitted to the facility with diagnoses that included but were not limited to Chronic Respiratory Failure with Hypercapnia, Multiple Sclerosis, Unspecified Atrial Fibrillation, Tracheostomy, and Gastrostomy. Review of Resident #7's Quarterly MDS, dated [DATE] revealed that Section C-Cognitive Patterns BIMS was 14 out of 15. Resident #7 was documented as having intact cognition. Review of section K Swallowing/Nutrition of the Quarterly MDS, dated [DATE] documented that Resident #7 has a feeding tube. Review of the November 2023 ePO revealed an order for Vital AF infused at 60 ml/hr. with a start date of 7/15/23. This would compute a total volume to be administered of 1440 ml for the day. Review of the November 2023 eMAR, documented from 11/1/23 to 11/19/23 revealed that 15 of 19 days Resident #7 did not receive the total volume of nutrition ordered by the physician. The calculations of the 15 days presented that on each of those days Resident #7 received less than the total volume ordered. Review of Resident #7's weight history did not present any weight loss. 6. On 11/16/23 at 1:45 PM, the surveyor observed Resident #13 in bed with eyes closed and music playing in the room. The surveyor noted that Resident #13 was in the process of receiving their feed of Glucerna 1.2 at a rate of 60 ml/hr. via feeding pump. On 11/20/23 at 10:13 AM, the surveyor observed Resident #13 in bed with eyes closed. The surveyor noted that Resident #13 was in the process of receiving their feed of Glucerna 1.2 running at 60 ml/hr. (set on the pump). The surveyor reviewed the electronic medical record for Resident #5 and found the following: Review of the AR, Resident #13 was admitted to the facility with diagnoses that included but were not limited to Guillain-Barre Syndrome, Hypoxic Ischemic Encephalopathy, Type 2 Diabetes Mellitus, Cerebral Infarction, Tracheostomy, Gastrostomy, and History of Sudden Cardiac Arrest. Review of Resident #5's Quarterly MDS, dated [DATE] revealed that Section C-Cognitive Patterns could not be completed as Resident #13 could not respond to any of the questions. Resident #13 was documented as having a severely impaired cognition. Review of section K Swallowing/Nutrition of the Quarterly MDS, dated [DATE] documented that Resident #13 has a feeding tube. Review of the November 2023 electronic physician orders revealed an order for Glucerna 1.2 infused at 60 ml/hr. for a total of 18 hrs. with a start date of 9/11/23. This would compute a total volume to be administered of 1080 ml for the day. Review of the November 2023 eMAR, documented from 11/1/23 to 11/19/23 revealed that 15 of 19 days Resident #13 did not receive the total volume of nutrition ordered by the physician. The calculations of each day presented that each day Resident #13 received less than the total volume ordered. Review of Resident #13's weight history did not present any weight loss. 39399 7. On 11/15/23 at 10:32 AM, the surveyor observed Resident #16 in bed with eyes open wearing eyeglasses. The surveyor further observed that the resident had a tracheostomy tube (a medical device inserted into a surgically created opening in the trachea to facilitate breathing) in place. The surveyor also observed that Resident #16 was in the process of receiving their feed of Jevity 1.5 at a rate of 54 ml/hr. via feeding pump. On 11/16/23 at 10:20 AM, the surveyor observed Resident #16 in bed with eyes closed. The surveyor further noted that Resident #16 was in the process of receiving their feed of Jevity1.5 at a rate of 54 ml/hr. via a feeding pump. The surveyor reviewed the electronic medical record for Resident #16 which revealed the following: Review of the AR, Resident #16 was admitted to the facility with diagnoses that included but were not limited to Respiratory Failure, Anemia, Hypertension and Atrial Fibrillation. A review of the Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 9/11/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that the resident was cognitively intact. Further review of the Q/MDS under section K- Swallowing/Nutritional Status, dated 9/11/23, documented that Resident #16 has a feeding tube. Review of the November 2023 electronic physician orders (ePO) revealed an order for Jevity 1.5 to be infused at 54 ml/hr. with a start date of 7/15/2023. This would compute a total volume to be administered of 1080 ml for the day. Review of the November 2023 eMAR, documented from 11/1/23 to 11/20/23 revealed that 13 of 20 days Resident #16 did not receive the total volume of nutrition ordered by the physician. The calculations of each day presented that each day Resident #16 received less than the total volume ordered. Review of Resident #16's weight history did not present any weight loss. 8. On 11/15/23 at 10:40 AM, the surveyor observed Resident #1 in bed with eyes closed. The surveyor further observed that the resident had a tracheostomy tube (a medical device inserted into a surgically created opening in the trachea to facilitate breathing) in place. The surveyor also observed that Resident #1 was in the process of receiving their feed of Jevity 1.2 at a rate of 37 ml/hr. via feeding pump. The resident was non-verbal. On 11/16/23 at 10:45 AM, the surveyor observed Resident #1 in bed with eyes closed. The surveyor also observed that Resident #1 was in the process of receiving their feed of Jevity 1.2 at a rate of 37 ml/hr. via feeding pump. The surveyor reviewed the electronic medical record for Resident #1 and found the following: Review of the AR for Resident #1 was admitted to the facility with diagnoses that included but were not limited to Chronic respiratory failure, Quadriplegia, and Osteoporosis. Review of Resident #1's Q/MDS, dated [DATE] revealed that Section C-Cognitive Patterns BIMS not completed due to resident being in a vegetative state. Review of section K Swallowing/Nutrition of the Q/MDS, dated [DATE] documented that Resident #1 has a feeding tube. Review of the November 2023 ePO revealed an order for Jevity 1.2 to be infused at 37 ml/hr. with a start date of 7/15/23. This would compute a total volume to be administered of 888 ml for the day. Review of the November 2023 eMAR, documented from 11/1/23 to 11/19/23 revealed that 16 of 19 days Resident #1 did not receive the total volume of nutrition ordered by the physician. The calculations of the 19 days presented that on each of those days Resident #1 received less than the total volume ordered. Review of Resident #1's weight history did not present any weight loss. 9. On 11/15/23 at 10:45 AM, the surveyor observed Resident #9 in bed, awake and was watching TV. The surveyor further observed that the resident had a tracheostomy tube (a medical device inserted into a surgically created opening in the trachea to facilitate breathing) in place. The surveyor also observed that Resident #9 was in the process of receiving their feed of Glucerna 1.2 at a rate of 60 ml/hr. via feeding pump. The resident was alert and communicated to the surveyor via gestures. On 11/16/23 at 10:35 AM, the surveyor observed Resident #9 in bed alert and awake. The surveyor also observed that Resident #9 was in the process of receiving their feed of Glucerna 1.2 at a rate of 60 ml/hr. via feeding pump. The surveyor reviewed the electronic medical record for Resident #9 and found the following: Review of the AR for Resident #9 was admitted to the facility with diagnoses that included but were not limited to Respiratory Failure, Amyotropic Lateral Sclerosis and Polyneuropathy. A review of the Q/MDS, an assessment tool used to facilitate the management of care, dated 8/14/23 reflected that the resident had a BIMS score of 10 out of 15 indicating that the resident had moderately impaired cognition. Review of section K Swallowing/Nutrition of the Q/MDS, dated [DATE] documented that Resident #9 had a feeding tube. Review of the November 2023 ePO revealed an order for Glucerna 1.2 to be infused at 55 ml/hr. with a start date of 10/28/23 and had a discontinued date of 11/7/23. This would compute a total volume to be administered of 1320 ml for the day. There was another ePO for Glucerna 1.2 to be infused at 60 ml/hr. with a start date of 11/7/23. This would compute a total volume to be administered of 1440 ml for the day. Review of the November 2023 eMAR, documented from 11/1/23 to 11/19/23 revealed that 18 of 19 days Resident #9 did not receive the total volume of nutrition ordered by the physician. The calculations of the 19 days presented that on each of those days Resident #9 received less than the total volume ordered. Review of Resident #9's weight history did not present any weight loss. 46049 10. On 11/16/23 at 9:34 AM, the surveyor observed Resident #12 lying in bed with eyes closed and the head of bed elevated. The resident was receiving an enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) which was running at 40 ml/hr. on the feeding pump. A review of the electronic medical record of Resident #12 revealed the following: According to the AR, Resident #12 was admitted with diagnoses that included but were not limited to, Chronic Respiratory Failure with hypoxia [low levels of oxygen in your body tissue], Chronic Obstructive Pulmonary Disease (COPD), tracheostomy (a surgical opening in the windpipe to place a tube to allow air to enter the lungs), ventilator (machine to support breathing), and gastrostomy (a surgical opening into the stomach to insert a tube to provide nutrition). An Annual Minimum Data Set (MDS) assessment, a tool used to facilitate management of care, dated 10/4/23, indicated in Section B, Resident #12 was in a persistent vegetative state/no discernible consciousness. In Section K, Resident #12 was coded as receiving nutrition through a feeding tube while a resident. A physician's order dated 7/15/23 read: Enteral Feed Order two times a day for Monitoring CONTINOUS FEEDING: On Jevity 1.2 @ 40ml/hr. Record Intake q shift. Flush H2O = 120 ml q 6 hrs. According to the order the resident was to receive a total volume of 960 ml daily. A review of the November 2023 eMAR from 11/1/23 to 11/19/23 revealed for 16 out of 19 days Resident #12 did not receive the total volume of nutrition ordered by the physician. The calculations of each day presented that each day Resident #5 received less than the total volume ordered. A review of Resident #12's weight history did not present any significant weight loss. 11. On 11/15/23 at 10:41 AM, the surveyor observed Resident #20 lying in bed with the head of bed elevated. Resident #20 was alert, non-verbal, and able to communicate with gestures. The resident was receiving an enteral feeding which was running at 60 ml/hr. on the feeding pump. A review of the electronic medical record of Resident #20 revealed the following: According to the AR, Resident #20 was admitted with diagnoses that included but were not limited to, Acute Respiratory Failure with hypoxia, Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves), tracheostomy, ventilator, and gastrostomy. A QMDS assessment, dated 10/1/23, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #20 scored a 14 out of 15, which indicated the resident was cognitively intact. In Section K, Resident #20 was documented as receiving nutrition through a feeding tube while a resident. A physician's order dated 7/15/23 read: Enteral Feed Order two times a day for Monitoring Increase rate of Glucerna 1.2 to new goal of 60ml/hr. Water flush of 250ml q 6h. According to the order the resident was to receive a total volume of 1440 ml daily. A review of the November 2023 eMAR from 11/1/23 to 11/19/23 revealed that 18 out of 19 days Resident #20 did not receive the total volume of nutrition ordered by the physician. The calculations of each day presented that each day Resident #20 received less than the total volume ordered. A review of Resident #20's weight history did not present any significant weight loss. 12. On 11/15/23 at 10:15 AM, the surveyor observed Resident #21 lying in bed with the head of bed elevated. Resident #21 was alert, non-verbal, and able to communicate with gestures. The resident was receiving an enteral feeding which was running at 75 ml/hr. on the feeding pump. A review of the electronic medical record of Resident #21 revealed the following: According to the Admission Record (an admission summary), Resident #21 was admitted with diagnoses that included but were not limited to, Chronic Respiratory Failure, Amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical function), tracheostomy, ventilator, and gastrostomy. A QMDS assessment, dated 10/15/23, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #21 scored a 15 out of 15, which indicated the resident was cognitively intact. In Section K of the QMS, Resident #21 was coded as receiving nutrition through a feeding tube while a resident. Review of the resident's ePO dated 10/28/23 read: Enteral Feed . two times a day Osmolite1.5 x16 hours per day for a total of 1200cc. Feeding down at 7AM and up at 11AM; down at 7PM and up at 11PM. Continue 200 ml water flush q 4h. The feeding rate was not indicated in the order. This physician order was discontinued on 11/4/23. A physician's order dated 11/4/23 read: Enteral Feed Order two times a day for Monitoring Osmolite 1.5 x16 hours per day for a total of 1200cc. Feeding down at 7AM and up at 11AM; down at 7PM and up at 11PM. Continue 200ml water flush q 4h. The feeding rate was not indicated in the order. According to the physician's orders the resident was to receive a total volume of 1200 ml daily. A review of the November 2023 eMAR from 11/1/23 to 11/19/23 revealed that 15 out of 19 days, Resident #21 did not receive the total volume of nutrition ordered by the physician. The calculations of each day presented that each day Resident #21 received less than the total volume ordered. A review of Resident #21's weight history did not present any significant weight loss. On 11/20/23 at 11:07 AM, the surveyor interviewed Registered Nurse #2 (RN #2) about the documentation of a resident's enteral feeding intake. RN#2 stated the physician's order would be reviewed for the feeding rate and the total volume that would be administered to the resident. RN#2 further explained at the end of the shift the feeding machine was checked for the total volume the resident received during the shift and would be documented in the resident's MAR. The total volume the resident received would be cleared on the machine for the next shift. RN #2 acknowledged it would be expected for the total volume ordered by the physician to be administered to the resident. The surveyor reviewed the facility provided policy titled Feeding Tube Protocol, Care of the Patient, with a revised date of 11/2023. Under Protocol, B. Assessment/Monitoring it read: 1. Assess/monitor and document the following at least every 8 hrs. [hours] .b. Monitor intake and output, including flushes . Under Documentation, it read: 1. Documentation: Type, rate, and amount of feeding/medication .I & O [Intake and Output] . NJAC 8:39-25.2(c)2; 27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to follow a physician's order (PO) for the application of a device for 1 of 4 residents reviewed for the use of devices, Resident #24. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 11/15/23 at 10:07 AM, the surveyor interviewed Resident #24 in their room. The resident expressed themselves through nodding to yes/no questions and expressed that they had pain to both knees. A review of the resident's Face Sheet (FS) (A one-page summary of important information about a patient) reflected that Resident #24 was initially admitted to the facility on [DATE] with diagnoses that included but were not limited to Acute Respiratory Failure, Type 2 Diabetes Mellitus without Complications, Tracheostomy and Muscle Weakness. A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate care management dated 10/16/2023, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. A review of Resident #24's electronic medical record (e-MAR) revealed a PO with an order and start date of 10/18/23 for Arthritis off loader brace for right knee Dx: OA (Osteoarthritis) right knee. On 11/17/23 at 10:45 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1). CNA #1 stated that she routinely cares for Resident #24. CNA #1 stated that she has never seen or applied a knee brace to Resident #24. On 11/20/23 at 11:44 AM, the surveyor conducted a phone interview with Resident #24's Physiatry (MD #1). MD #1 stated that he ordered the right knee brace in the e-MAR following an assessment of Resident #24 on 10/18/23. MD #1 informed the surveyor that on 11/17/23 he became aware that the the knee brace had not been ordered by the facility staff. MD #1 further that at that point, he made sure to order the brace for Resident #24. MD #1 explained that the lapse in time for Resident #24 wearing the knee brace did not create any further issues for the resident. On 11/21/23 at 1:56 PM, the surveyor team met with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA). The DON explained that MD #1 entered the knee brace order incorrectly, so the order did not populate into the e-MAR, Treatment Administration Record (TAR) or the Medical Administration Record (MAR) and that is why the order was not carried out by the staff. No further information provided. NJAC 8:39-19.4 (a) (1)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) maintain medication carts in a clean and sanitary manner to prevent the spread of infection, and b.) don (put on) the appropriate personal protective equipment (PPE) prior to entering a resident room that required transmission based precautions (TBP) due to a contagious infectious disease. This deficient practice was identified for 2 of 3 medication carts inspected, and 1 of 1 resident, (Resident #16) reviewed for TBP. This deficient practice was evidenced by the following: 1. On 09/19/21 at 7:46 PM, the surveyor inspected a medication cart in the presence of the Licensed Practical Nurse (LPN), who identified the medication cart as Medication Cart #2. The surveyor observed that the interior drawers of Medication Cart #2, where medications were stored, were covered with a white substance and caked on gray debris. The surveyor interviewed the LPN at that time who stated that the white powdery substance was, possibly pill debris. The surveyor asked the LPN how frequently the medication carts were cleaned, and the LPN stated, I don't know. Sometimes I'll clean out the bottom of the carts where the liquids are because they spill. On 09/19/21 at 7:53 PM, the surveyor inspected a medication cart in the presence of the LPN who identified the medication cart as Medication Cart #3. The LPN and the surveyor observed a white and gray layer of a dust like substance and debris throughout the interior of the drawers of the medication cart. The LPN stated the purpose of a clean medication cart would be to prevent cross contamination. On 09/20/21 at 12:35 PM, the surveyor performed a second inspection of Medication Cart #2 and Medication Cart #3 in the presences of the Registered Nurse (RN). The surveyor, again, observed the white and gray caked on debris scattered throughout the interior drawers of both medication carts. The surveyor interviewed the RN at that time. The RN stated that the outside, not the inside, of the medication carts, were wiped down at the end of every shift. The RN further stated that the medication carts needed power washing in the inside of the drawers. On 09/20/21 at 1:10 PM, the surveyor interviewed the Director of Nursing (DON) who stated that cleaning the medication carts was on going, and was the responsibility of the nursing and housekeeping staff. The DON further added that the cleaning schedule for the medication carts consisted of the housekeeping department vacuuming the carts quarterly, and that in August the medication carts may have been cleaned with a vacuum cleaner, however, she was uncertain. The DON stated that if the nurses identified that the medication carts were dirty, they should have been cleaned as best as they could, and notified the DON. Upon surveyor inquiry, the DON was unable to speak to having a specific schedule for cleaning the medication carts, and unable to provide an accountability record for the cleaning of the medication carts. 2. On 09/19/21 at 6:52 PM, the surveyor observed a sign located inside of a yellow holder attached to Resident #16's door. The sign indicated, enhanced barrier precautions and contained PPE. The surveyors observed that the sign, enhanced barrier precautions had pictures of a gowns, gloves, and a mask on it. The surveyor donned the required PPE that was displayed on the sign prior to entering the resident's room, and observed Resident #16 lying in bed with his/her eyes closed and appeared sleeping. On 09/21/21 at 10:03 AM, the surveyor observed a yellow PPE holder hanging on the door outside of Resident #16's room. The holder contained disposable PPE gowns, three sizes of gloves, and disinfectant wipes. The yellow PPE holder had a sign attached to it which indicated, Contact Precautions. Report to Nurses' Station before you enter this room. The sign further indicated with pictures and in writing, to wear gloves, a gown, and wash hands prior to entering the resident's room. At that time, while in the hallway and having a clear unobstructed view, the surveyor observed that a maintenance staff member was inside Resident #16's room and was working on a television that was located in front of the resident's bed. The maintenance staff member was observed to be wearing an N95 mask and eye protection, and was not observed wearing a gown or gloves as the sign on the resident's door indicated was to be worn while inside the room. The surveyor conducted an interview with the maintenance staff member upon exiting Resident #16's room. The maintenance staff stated that he was just working on the television, so he did not have to wear the PPE (gown and gloves). The maintenance staff member further stated that he did not know the resident was on contact precautions, he did not speak to the nurse prior to entering the resident's room, and confirmed he was educated on what PPE to wear prior to entering a resident room who was on TBP. On 09/21/21 at 10:03 AM, the surveyor interviewed Resident #16's RN. The RN stated that Resident #16 was on contact precautions for c.diff ([CONDITION(S)] [CONDITION(S)]- an infectious organism that caused diarrhea) which indicated that staff would have to wear full PPE while in the resident's room. The RN stated full PPE included gloves and a gown. On 09/21/21 at 10:09 AM, the surveyor interviewed the DON who stated that Resident #16 was on contact precautions and that the maintenance staff member did not have to wear PPE while inside of the resident's room because he was not touching the resident. The surveyor observed that the maintenance staff was in direct contact with the resident's environment. On 09/21/21 at 10:54 AM, the surveyor interviewed the Registered Nurse/Infection Preventionist (RN/IP) who stated that the facility policy indicated that all staff were required to don PPE prior to entering a resident's room who was on contact precautions. The RN/IP further explained what contact precautions indicated. She stated that prior to crossing the threshold of a resident's room, who was on contact precautions, the required PPE must be worn. She stated the required PPE must be worn while touching the resident and while also having indirect contact with the resident's environment. The RN/IP further stated, all staff wear PPE regardless, no exceptions. The surveyor reviewed the medical record for Resident #16 which revealed the following: The Admission Record reflected that the resident was admitted to the facility in the and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 06/11/21, reflected that Resident #16 had a Brief Interview for Mental Status score of 14 out of 15 which indicated that the resident was cognitively intact. Review of a laboratory result, dated 09/15/21, at 10:09 AM, indicated that the resident had c.diff present in his/her stool. The September 2021 Active Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .diff. The Care Plan, updated 09/15/21, reflected a problem area that the resident was positive for c.diff. The goal of the resident's CP indicated that the infectious organism would resolve with antibiotic treatment. The interventions for the resident's CP included to start the resident on antibiotic treatment and contact precautions. Review of the facility's C.diff Infection Control Policy and Procedure revised 06/16/21 indicated, It has firmly established that person to person transmission can occur in the hospital setting and indeed major outbreaks have resulted. Staff hands are the most important mode of transmission, but studies have also demonstrated that c.difficile, as a spore forming organism, can survive for long periods of time in the environment and on contaminated equipment. The facility's C.diff Infection Control Policy and Procedure further indicated that gowns and gloves were required when entering a resident's room who was placed on contact precautions for c.diff. Review of the maintenance staff members education transcript dated 09/22/21 through 09/21/21 indicated that the maintenance staff member was educated on contact precautions and that barriers such as a gown and gloves were required to be worn when in direct contact with the resident and environmental surfaces. NJAC 8:39-27.1(a)

Based on observation, interview and record review it was determined the facility failed to change ventilator tubing according to facility policy in order to prevent infections for residents with tracheostomies and ventilators. This deficient practice was identified in Resident #16 and Resident #11, 2 of 4 residents reviewed for [MEDICAL CONDITION]/ventilator care and was evidenced by the following: 1. On 12/30/19 at 10:15 AM, the surveyor observed Resident #16 in bed with their eyes open. The resident had a [MEDICAL CONDITION] (an opening in the neck to place a tube that allows air to enter into the lungs) and it was connected to a ventilator (machine to support breathing). The blue tubing that went from the resident's [MEDICAL CONDITION] to the ventilator was dated 11/7/19. The surveyor observed a nightstand next to the residents bed. On top of the nightstand was a portable ventilator. The blue tubing on the portable ventilator was dated 11/3/19. Review of Resident #16 Admission Sheet indicated the resident was admitted to the facility on [DATE] with a medical [DIAGNOSES REDACTED]. The residents Brief Interview of Mental Status was 99, meaning it could not be completed related to severe cognitive impairment. Review of the residents Minimum Data Set (MDS), a quarterly assessment tool dated (MONTH) 7, (YEAR) indicated the residents functional status was a two person physical assistance for personal care and the resident had a [MEDICAL CONDITION] and mechanical ventilation. On 12/30/19 at 11:00 AM, the surveyor interviewed the residents nurse, a Registered Nurse (RN), regarding the facility process and policy for ventilator tubing changes. The RN stated she was not sure of the policy and it was the respiratory therapy department that responsible for changing the ventilator tubing. On 12/30/19 at 11:54 AM, the surveyor interviewed the respiratory therapist regarding the policy/procedure for changing tubing to the ventilators. The therapist told the surveyor that the tubings were changed monthly by the respiratory therapy department. On 01/02/2020 at 10:30 AM, the surveyor reviewed the facility policy titled Ventilator; Standard of Care. The policy was dated 03/19/2019. Under the procedure section of the policy it indicated that the circuit (tubing) would be changed when soiled or every thirty days. On 01/02/2020 at 11:00 AM the surveyor interviewed the Director of Nursing (DON) and the Administrator regarding the ventilator tubing (circuit) and both the DON and the Administrator stated they were changed when soiled or every thirty days. On 01/03/20 at 10:07 AM, the surveyor reviewed a physician order [REDACTED]. 2) On 12/30/19 at 10:15 AM during the initial tour of the third floor unit of the facility, this surveyor observed Resident #11 in bed awake and alert using his/her personal laptop computer. Resident #11 had a [MEDICAL CONDITION] connected to a ventilator ( machine used to support breathing). The surveyor observed that the blue tubing that is connected between the [MEDICAL CONDITION] and ventilator was dated 11/7/19. Resident #11 was admitted on [DATE] to the facility with a [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), the resident had a BIMS (Brief interview mental status) of 15. Resident #11's care plan indicated that the resident is at risk for developing an infection due to his/her Ventilator dependence. The resident's active physician orders [REDACTED]. On 12/30/19 at 10:40 AM, the surveyor interviewed a staff Registered Nurse on the unit regarding the policy for the care of the ventilator tubing, such as the changing and dating of the ventilator tubing. The Registered Nurse said, I think they are changed every month by the respiratory therapist. On 12/31/19 this surveyor asked the Director of Nursing (DON) for a policy regarding the Care of the Ventilator tubing. On 1/2/19 at 11:37 AM, the DON provided a copy of the policy titled Ventilator; Standard of Care, with subtitle Respiratory Care Services, dated 3/19/2019. According to the policy, Procedure number 1 All ventilators will be assembled, maintained, and processed by the Respiratory Care Department. In Procedure number 10, the policy indicated, to maintain the integrity of the circuit by changing circuit when visibly soiled and/or every 30 days. NJAC 8:39-19.4

Based on observation, interview, and record review, in the presence of facility management on 1/6/16, it was determined that the facility failed to ensure that the residents' physical environment was free of accident hazards. This deficient practice was evidenced by the following: During a tour of the Dwelling Place located on the 3rd floor within the hospital, the surveyor manually performed temperature testing with a calibrated thermometer of hot water within residents' rooms and kitchenette. The acceptable range is 95-110 degrees Fahrenheit (Fh). This is a Ventilator / Respiratory unit for residents who are totally dependent on staff for the care and supervision, so there were no observations of the 23 residents on the unit using sinks independently. The Residents' rooms (RR)and kitchenette that were tested for hot water temperatures between 12:38 p.m. and 1:15 p.m. that exceeded 110 degrees Fahrenheit (Fh) are as follows: 1. RR#382-128.0 degrees Fh 2. RR#370-129.9 degrees Fh 3. RR#369-129.9 degrees Fh 4. RR#366-130.9 degrees Fh 5. RR#386-129.6 degrees Fh 6. RR #383-129.1 degrees Fh 7. RR#378-129.1 degrees Fh 8. RR#374-129.2 degrees Fh 9. RR#377-129.2 degrees Fh 10.Kichenette -130-.2 degrees Fh The Facility Director ( FD) provided the surveyor a copy of the Domestic Hot Water Temperature Readings-Dover for 2015 for the unit. A review of the readings indicated that the hot water temperatures, through out the 52 week period the main staff documented hot water temperatures that exceeded 110-degrees Fh except for week # 41. At 1:15 p.m., the surveyor interviewed the Facility Administrator ( FA) who stated that he was not made aware of high hot water temperatures by maintenance staff however, FA was knowledgeable about the acceptable hot water ranges. At 4p.m., the FA stated to surveyor the unit had not developed a policy and procedure for the testing of hot water temperatures. 8:39-31.7(h)

Based on interview and review of documentation , it was determined that the facility failed to identify a quality deficiency related to monitoring hot water temperatures. This deficient practice was evidenced by the following: On 1/6/16, the facility hot water temperatures in resident rooms and kitchenette exceeded 110 degrees Fahrenheit. A review of the 2015 Domestic Hot Water Readings for this unit ( EAST) were elevated above 110 degrees Fahrenheit. on 1/6/16 at 4 p.m. The Facility Administrator stated to the surveyor that he was not aware of the high hot water temperatures being recorded by maintenance staff. (Refer to F323) NJAC 8:39-33.1(a)

br>C# NJ , NJ Based on interviews, record review, and a review of pertinent facility documents on 10/08/15, it was determined that the facility failed to allow unlimited visitation access past facility designated visiting timeframes for two (2) of four (4) family members/visitors interviewed. This deficient practice is evidenced by the following: According to a letter dated 9/23/15, sent to family members by the facility, indicated that .effective September 29, 2015, the Respiratory Rehabilitation Center (RRC) .will become a locked unit 24 hours a day. and that when visiting, you will be buzzed in to the unit. A review of the facility Rules and Regulations revision date 5/19/15, indicated that Visiting hours in the facility are from 8 a.m. to 8 p.m. During an interview on 10/8/15 at 11:10 a.m., the Administrator verified that the Visiting hours were from 8:00 a.m. until 8:00 p.m., and that this had started to be enforced in January 2015, prior to the unit becoming a locked unit. Interviews with family members/visitors, and residents occurred between 10:30 a.m. and 1:00 p.m. on 10/8/15. Of the 4 family members/visitors interviewed, 2 indicated that there were occasions that they would have liked to remain visiting past 8 p.m. In addition, 4 of 4 family members/visitors interviewed stated that they were aware of the facility designated visiting hours and that security made rounds at 8 p.m. to remind them to leave. However, none were aware that they could visit at any other time. During an interview with the Administrator and the Director of Nursing (DON) at 3:00 p.m., the Administrator stated that if after hours visitation was allowed for one, we would have to do for all. The DON stated at that time, if allowed, then everyone would want to stay later.

Based on observation, interview and medical record review it was determined that the facility failed to implement an established Comprehensive Care Plan (CCP) for resident transfers. This deficient practice was noted for 1 of 10 residents sampled for CCP, Resident #1, as evidenced by the following: On 4/13/14 at 10:15 a.m. during the initial tour of the unit, the Unit Manager told the surveyor that Resident #1 had a [DIAGNOSES REDACTED]. Resident # 1 was observed in the bed watching television. On 4/14/13 at 10 a.m. the surveyor reviewed Resident #1's medical record. The resident's Minimum Data Set (MDS), an assessment tool dated 3/16/14, indicated that the resident was cognitively intact and totally dependent with physical assist for transfers. The most recent fall assessment dated [DATE] revealed that Resident #1 was a high fall risk. The resident's " Nursing Assistant's Plan of Care" dated 12/18/13 and updated on 4/1/14, both indicated that the resident was a 2 person assist via a mechanical lift for all transfers. A Nurse's Note form timed 1315 (1:30 p.m.) on 3/13/14 revealed that Resident #1 " slid to the floor from the edge of the bed " during transfer. The surveyor reviewed the " Incident Reporting Information System " form dated 3/13/14 which indicated that the resident slipped from the edge of the bed to the floor when the nurse, with the aid of a Certified Nurse Assistant (CNA), was returning the resident to bed. On 4/14/14 at 1 p.m. the surveyor interviewed Resident #1 concerning the fall on 3/13/13. The resident stated, " I did not fall, they dropped me. They (2 staff members) brought the chair to the side of the bed and then they each got under my arms to lift me. I said ' I can ' t do this ' and then they dropped me to the floor." The surveyor questioned Resident #1 concerning the use of the mechanical lift during the transfer on 3/13/14 at 1:30 p.m.. The resident replied "They did not use it." On 4/15/13 at 9:45 a.m. the surveyor interviewed the Administrator and the Assistant Director of Nursing (ADON)/Supervisor who both agreed that the Nurse and the CNA did not follow Resident #1 ' s CCP when they transferred the resident without the use of the mechanical lift. NJAC:8:39 11.2(f)

Based on interview and review of the medical record, it was determined that the facility failed to obtain a complete physician's order related to tube feeding administration. This deficient practice was noted for 2 of 9 resident's sampled for tube feeding administration, Residents # 4 and #9. The facility also failed to obtain a physician's order for a prn (as needed) medication to indicate which medication should be administered in what order. This deficient practice was noted for 1 of 10 residents sampled for medication administration, Resident #9, as indicated by the following: 1. On 4/14/15 at 1:10 p.m. the surveyor observed Resident # 9 in bed performing upper body strengthening exercises. The resident had [MEDICAL CONDITION] in place to the [MEDICAL CONDITION], and was able to mouth answers to the surveyor. Review of the medical record revealed that Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During review of the April 2014 Physician's Order Sheet (POS), the surveyor noted that the physician's order for the tube feeding was Nepro 50 ml/hr via PEG (feeding tube). There was no indication in the physician's order to indicate to the licensed staff how long the feeding should run and there was no indication what the total volume of feeding that was needed to maintain the resident's weight. 2. The surveyor reviewed the medical record of Resident #9 that revealed there was a physician's order on the April 2014 POS which indicated that the resident was to receive MOM 30 ml by PEG Tube every day as needed for constipation. The resident also had an order for [REDACTED]. 3. During the initial tour of the unit on 4/13/14 at 9:15 a.m. the surveyor observed Resident #4 in bed with a tube feeding of [MEDICATION NAME] 1.2 infusing at 65 ml/hr. On 4/15/14 at 11 a.m. the surveyor reviewed the April 2014 POS which revealed the physician's order for [MEDICATION NAME] 1.2 at 65 ml/hr, but there was no evidence how many hours the physician wanted the tube feeding to run, nor did the order indicate the total amount of the feeding that the resident was to receive. The surveyor interviewed the Clinical Dietary Manager on 4/15/14 at 11a.m. who confirmed the surveyor findings of lack of documentation of the physician's order. Interview of the Assistant Director of Nursing (ADON)/Shift Supervisor at 11:20 a.m. also confirmed the lack of a full dietary order. NJAC 8:39-27.1(a)

Based on observations and review of facility documents the facility failed to failed to: 1) maintain proper proper hand washing techniques during medication administration and failed to execute infection control practices that would prevent and reduce the chances for spread of infection and cross contamination via medical equipment. These deficient practices were noted during medication administration as evidenced by the following: 1. On 5/16/13 between 8:13 a.m. and 9:55 a.m. during observation of the medication administration, the surveyor observed Nurse #'s 1, 2 and 3 administer medications to 5 residents of the facility. During that time, each nurse washed their hands with soap and water placing their hands under water after applying soap as follows: Nurse #1 did not rub soapy hands away from the water entering an isolation room. Nurse #2 did not rub soapy hands away from the water entering going from 1 isolation room to another. Nurse #3 rubbed soapy hands away from the water for 0 and 10 seconds going from 1 isolation room to non-isolation rooms. All 3 nurses were observed using very little to no friction after soap was applied to hands. On 5/16/12 at 1:30 p.m. the facility's current hand washing policy and procedure was requested. The hand washing procedure was submitted by facility administration and acknowledged as being the current procedure. Review of the facility's hand washing procedure revealed the following: Hand Hygiene Program, Hand Hygiene Technique (nonsurgical) with soap and water 1. " Wet hands with water using temperature that is comfortable. 2. Apply appropriate soap, and wash hands and wrists vigorously for at least 15 to 20 seconds, covering all surfaces of hands and fingers 3. Rinse hands under running water, allowing water to drip from fingertips. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for twenty (20) seconds." On 5/16/13 at 1:45 p.m. the surveyor reviewed the CDC guidelines for washing the hands with soap and water. The technique included to wet hands first with water and apply an amount of soap recommended by the manufacturer to the hands. Then rub hands together vigorously for at least 15 seconds covering all surfaces of the hands and fingers. Then rinse hands with water. 2. On 5/16/13 from 8:38 a.m. until 9:21 a.m., during the morning medication administration, the surveyor observed that Medication Nurse #2 did not cleanse the stethoscope before or after use with 2 residents and both residents lived in Isolation rooms. The surveyor observed the stethoscope draped on the outside of the medication cart over the sharps container for Nurse #3 at 9:24 a.m. Nurse #3 used the stethoscope for the first observed resident without disinfecting the head of the stethoscope. The Nurse then proceeded to cleanse the head of the stethoscope after use and draped the stethoscope over the sharps container on the medication cart while preparing the medication for the next resident. Once the medication was prepared, Nurse #3 reached for the stethoscope and the surveyor observed that the stethoscope fell on the floor. Nurse #3 lifted the stethoscope from the floor and proceeded to place the head of the stethoscope on the resident's abdomen to listen for bowel sounds prior to medication administration via a PEG tube. Upon completion of the medication administration the nurse then proceeded to cleanse the head of the stethoscope with an alcohol swab and drape the stethoscope over the sharps container on the medication cart. On 5/16/13 the surveyor reviewed the facility policy titled "Cleaning of Patient Equipment" which indicated "Nursing is responsible for cleaning of patient items that are kept on the nursing unit such as: Stethoscope" . The Procedure section of the policy section 1 states "Any item that touches a patient must be cleaned after patient use, using a hospital approved disinfectant including: Stethoscope". The policy also states "All patients on contact precautions are to have disposable/dedicated stethoscopes available for use. These can be found in the isolation carts/caddies." 3. During medication administration on 5/16/13 from 8:13 a.m. to 9:55 a.m. the surveyor observed 2 Nurses administer medications to 2 residents in isolation rooms. Nurse #2 who utilized a drawer tray unit, carried the drawer tray unit into the first resident's isolation room, placed the drawer tray unit on the resident's over bed table and proceeded to administer the medication to the resident. After medication administration the nurse then placed the drawer tray unit on top of the medication cart preparing a new set of medications for the next isolation room resident. The nurse then repeated the steps as previously stated with the next isolation room resident without ever disinfecting the drawer tray unit. During the medication administration on 5/16/13 the surveyor observed Nurse #1 who utilized the drawer tray unit and made sure to tell the surveyor that the drawer tray unit would be utilized to bring the medication into the resident ' s isolation room, remove the medication and then return the drawer unit to the medication cart prior to administering the medication to the resident. The nurse advised the surveyor that the drawer tray unit must stay outside of the resident's room for sterility issues. NJAC 8:39-19.4(a)

Based on observation, interview and record review, it was determined that the facility failed to adequately monitor and/or maintain relief of documented pain. This deficient practice was noted for 1 of 9 residents sampled, Resident #8, as evidenced by the following: On 5/16/13 at 8:23 a.m. during medication administration the surveyor observed Resident #8 grimacing and crying with pain. The resident's morning medication regime was administered via the stomach tube/PEG (Percutaneous Esophagogastrostomy) tube and included 5 different medications along with the flushing of the PEG tube before, after and between each medication with water. Interview of the medication nurse revealed that Resident #8 had a [DIAGNOSES REDACTED] irritation around the peg tube and that the irritation was associated with [MEDICAL CONDITION] treatment received after a historical left [PROCEDURE]. The resident's PEG tube was noted directly under her left breast bone at the irritation area. The nurse then explained that the resident exhibits discomfort and at times mild to severe pain when the resident's routine medication regime was administered via the resident's PEG tube. The nurse added that the tubing from the PEG tube was short and therefore had increased movement during medication administration. The resident was noted becoming increasingly agitated as the medication administration continued. The resident continued to grimace and cry. Resident #8's medication administration was completed at 8:32 a.m. and at the end of the medication administration, the surveyor noted the resident reaching her hands out and mouthing "help me, help me". On 5/16/13 at 10:30 a.m. the surveyor reviewed the resident's Nursing/physician progress notes [REDACTED].) which did not document that the resident had any pain issues. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The surveyor noted only an order for [REDACTED]. On 5/16/13 at 1:30 p.m. the surveyor reviewed the facility "Pain Assessment and Management" policy. The "Procedure" portion section C states "Assessment of pain control will be conducted at admission and throughout the continuum of care with appropriate documentation to facilitate communication between all health care team members" . The "Management" portion of the policy section B indicated" If pain control is not effective, a multidisciplinary team/quality assurance committee consisting of, but not limited to, a licensed practitioner and nurse, will assess, evaluate, and manage therapy as appropriate until the needs of the resident and/or family are met. Section C documented "Ongoing evaluation of the effectiveness and therapeutic level of pain control will be documented in the resident's medical record." NJAC 8:39-27.1(a)

Based on observations, interview and review of medical records and facility policy, it was determined that the facility failed to administer medications according to physician's orders [REDACTED]. This deficient practice was noted for 2 of 11 who where reviewed or observed during the medication pass, Residents #5 and 11 as evidenced by the following: 1. Resident #11 was readmitted to the facility on [DATE]. The surveyor observed the Medication Nurse on 5/16/13 at 9:18 a.m. administer medications to Resident #11. Resident #11 had a current physician order [REDACTED]. This order also included parameters to hold the [MEDICATION NAME] for a Systolic Blood Pressure (SBP) less than 100 and a Pulse less than 60. During the medication administration, Resident #11's SBP was 97 and the Carvedilol 6.25 mg was not administered in accordance with the order. This resident also had an order for [REDACTED]. During the observation of the medication administration the Registered Nurse (RN) withheld both the antihypertensives. The surveyor questioned the nurse regarding the holding of the [MEDICATION NAME] and the nurse replied that since the SBP was low the nurse used her "nursing judgement" to withhold both antihypertensives. The surveyor reviewed the current MAR that began with the readmission of Resident #11 on 5/11/13. During the 5 day period the surveyor noted 3 additional circled [MEDICATION NAME] 5 mg doses on 5/13/13, 5/14/13 and 5/15/13 which denoted withheld doses as per nursing standards of practice. Examination of the MAR, Nursing Progress Notes and physician progress notes [REDACTED]. As per the facility "Medication Administration Procedure", section named "Steps" item 6 states "Inform ordering practitioner if the following occurs: Any medication withheld". As per Nursing Professional Standards and the facility policy the Physician should have been informed about the withheld [MEDICATION NAME] and there should have been documentation from Nursing and the Physician. 2. On 5/16/13 the surveyor observed the nurse administer a dose of an antidepressant medication, [MEDICATION NAME] 50 mg in liquid form via the peg tube at 9:18 a.m. to Resident #11. When the surveyor reviewed the current medication orders it was noted that [MEDICATION NAME] 50 mg 1 "tablet" via PEG tube daily was ordered on the May 2013 POS and documented on the MAR. A review of the previous MAR documents indicated that [MEDICATION NAME] 50 mg in liquid form had been administered to Resident #11 prior to the May readmission. On 5/11/13 the current readmission ordered the [MEDICATION NAME] 50 mg in tablet form on the Physician order [REDACTED]. The nurse administered the correct medication in the correct dose but in a different forma than what had been ordered. As per the facility "Medication Administration Procedure", section named "Key Points" stating "Verify that the medication to be administered is appropriate for the patient and that the MAR matches the medication to be administered." The MAR documented Nurse #2 signing for [MEDICATION NAME] 50 mg tablet when liquid form was actually administered. 3. During tour of the unit with the RN on 5/15/13 at 10:40 a.m., the surveyor was informed that Resident #5 was alert and oriented, has been in the facility several months, had a [MEDICAL CONDITION] with [MEDICAL CONDITION] and used the ventilator at night only, received a regular diet with thin liquids, and was ambulatory in the room. During review of the medical record on 5/16/13 at 11:50 a.m., the surveyor noted that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the May 2013 physician's orders [REDACTED]. Indication on the MAR revealed the original order for the medication was 12/20/12. There also was an order for [REDACTED]. Indication on the MAR revealed the original order for this medication was 12/21/12. During the surveyor interview of the Assistant Director of Nursing (ADON) at 12:55 p.m. the surveyor was told that the Pharmacy Consultant also questioned the order of the pain medication. The ADON stated that the physician told them give the resident whichever 1 the resident wants. This information however does not appear on the physician's orders [REDACTED]. NJAC 8:39-27.1 (a) and 29.2 (d)

Based on documentation provided by the facility it was determined that the facility failed to inform residents and/or their families when there was a change from Medicare to another form of payment for the resident's stay at the facility. This deficient practice was noted for 4 of 5 Notice of Medicare Provider Non Coverage (cut letters)requested from the Administrator as follows: During entrance conference with the Administrator, Director of Nursing and Director of Operations and Education on 5/15/13 at 10:30 a.m. the surveyor requested to see documentation of 5 cut letters. The Administrator provided the surveyor with 5 cut letters with only the name of the resident and the date the Medicare services would be cut. There was no indication that the resident or their Power of Attorney (POA) were informed of the change from Medicare to any other form of payment. The Administrator came to the surveyor later in the day on 5/15/13 and stated that he found an e-mail indicating 1 resident's family was informed, but he was unable to find any other documentation for the other 4 residents which would have indicated the resident and/or their family were notified of the change in insurance. NJAC 8:39-5.1(a)

C# NJ & NJ Based on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to consistently initial/sign the treatment administration record (TAR) to indicate treatments were rendered and/or not rendered as ordered by the physician for 3 of 3 sampled residents (Resident #1, Resident #2 and Resident #3). This deficient practice is evidenced by the following: A review of Resident #1, Resident #2, and Resident #3's medical records by the surveyor on 4/19/12 revealed the following: 1. A review of Resident #1's physician's orders [REDACTED]. shampoo to scalp once a week on shower days 7-3 shift every Wednesday. A review of the April 2012 TAR for Resident #1 revealed the following: > GT site daily treatment order was not signed 17/18 opportunities. >[MEDICAL CONDITION] change order once a week was not signed 2/3 opportunities. > Body check weekly was not signed 2/3 opportunities. > [MEDICAL CONDITION] and change weekly was not signed 2/3 opportunities, and > Sebex shampoo to scalp once a week was not signed 2/3 opportunities. 2. A review of Resident #2's POS for April 2012, reflected an order to cleanse [DEVICE] site with NSS and leave open to air every day. A review of the April 2012 TAR for Resident #2 revealed: > GT site daily treatment order was not signed 9/18 opportunities. 3. A review of Resident #3's POS for April 2012, reflected an order for [REDACTED]. A review of the April 2012 TAR for Resident #3 revealed: > GT site daily treatment was not signed 19/19 opportunities. During an interview by the surveyor on 4/19/12 at 12:30 PM with the RN/charge nurse, regarding their practice and/or policy on TAR documentation, revealed that nurses need to sign the treatment orders after their treatments are provided. She further stated that it was unusual for treatment orders not to be signed. During an interview by the surveyor on 4/19/12 at 2:45 PM with the Director of Nursing (DON), revealed that nurses are suppose to document on the TAR according to standards of practice. The DON was unable to provide a written policy on TAR documentation, and stated that they follow the standards of practice. NJAC 8:39-35.2 (d) 6