Every finding on record at Emerson Health Care Center

Based on observation, interview, and record review, it was determined that the facility failed to a.) ensure that the respiratory equipment was dated properly and b.) develop a comprehensive, person-centered care plan for a resident who was receiving continuous oxygen (O2). This deficient practice was observed for 1 of 4 residents (Resident #71) reviewed for respiratory care. This deficient practice was evidenced by the following: On 2/1/23 at 11:59 AM, during the initial tour, the surveyor observed Resident #71 in bed with O2 in use via a face mask set at 4 liters per minute (LPM) attached to a humidified O2 concentrator (a medical device used for delivering O2). The O2 tubing was dated 1/26/23. On 2/7/23 at 12:04 PM, the surveyor observed Resident #71 in bed with O2 in use via face mask set at 4 LPM attached to a humidified O2 concentrator. There was no date indicated on the O2 tubing when it was last changed. On 2/8/23 at 12:30 PM, the surveyor observed Resident #71 in bed with O2 in use via a face mask set at 4 LPM attached to a humidified O2 concentrator. There was no date indicated on the O2 tubing when it was last changed. A review of Resident 71's medical record revealed the following: The Face Sheet (an admission summary) revealed that Resident #71 was admitted to the facility with diagnoses that included but not limited to (primary) Corticobasal basal degeneration (a rare condition that can cause gradually worsening problems with movement, speech, memory, and swallowing), Unspecified Dementia without Behavioral disturbance, and Unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date of 1/7/23, reflected that Resident #71's Brief Interview of Mental Status was not completed due to cognitive impairment. A further review of qMDS under Section O. Treatment and Procedures, indicated that the resident received oxygen treatments in the facility. The February 2023 Physician's Order Form revealed that there was an order dated 4/1/22 for O2 at 4LPM via face mask continuous; clean O2 equipment and change tubing weekly on Thursdays on 11:00 PM to 7:00 AM shift. The surveyor reviewed the resident's comprehensive care plans which did not reflect a care plan for Resident #71's continuous oxygen use. On 2/8/23 at 12:33 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) was brought inside Resident #71's room. During the interview, the LPN/UM stated that Resident #71 was on continuous oxygen and that the O2 tubings are changed weekly every Thursdays by the night shift nurse. The LPN/UM acknowledged that the O2 tubing was not dated. She stated, it should be dated to ensure that it was changed. At around the same date and time, the LPN/UM stated that she was responsible for initiating and revising the residents' care plans in her assigned unit. The surveyor and the LPN/UM reviewed the resident's care plans. She acknowledged that there should have been a care plan for Resident #71 who was on continuous oxygen. A review of the facility policy titled Departmental (Respiratory Therapy)- Prevention of Infection with a review date of 1/2023 under General Guidelines: 3. Change respiratory tubing and date, humidification bottle, nebulizer kits on a weekly basis when opened. A review of the facility policy titled, Care Plans, Comprehensive Person-Centered with a review date of 1/2023 under Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It further indicated under Policy Interpretation and Implementation, 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; k. Reflect treatment goals, timetables, and objectives in measurable outcomes; 12. The comprehensive, person-centered care plan is developed within (7) days of the completion of the required comprehensive assessments (MDS). On 2/9/23 at 11:08 AM, the team met with the Licensed Nursing Home Administrator (LNHA), Assistant LNHA, Director of Nursing (DON), and Infection Preventionist (IP). The surveyor discussed the above concern. On 2/13/23 at 11:38 AM, the team met with the LNHA, Assistant LNHA, IP, DON, and ADON. No additional information was provided. NJAC 8:39-11.2(b)(e); 27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan (CP) for a resident in the facility. This deficient practice was identified for 1 of 1 resident reviewed for comprehensive care plans (Resident #99) who had a diagnosis of Type 2 Diabetes Mellitus. This deficient practice was evidenced by the following: On 2/01/23 at 11:15 AM, the surveyor observed Resident # 99 in bed. The resident stated he/she was a diabetic and was on insulin medication. A review of Resident #99's medical record revealed the following: The Face Sheet (an admission summary) revealed that Resident #99 was admitted to the facility with diagnoses that included but not limited to Type 2 Diabetes Mellitus with specified complications (DM), Covid-19, and Multiple Myeloma. The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date of 1/18/23 revealed a Brief Interview for Mental Status score of 15 out of 15, which indicated that the resident was cognitively intact. The admission MDS further revealed that the resident had an active diagnosis of DM and was on Insulin injections. A review of Resident #99's CP did not include that the resident was a diabetic and was on insulin injections. A review of the facility policy titled, Diabetes - Clinical Protocol revealed under Monitoring and Follow-Up, 4. The Physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the Medication Administration record and care plan. A review of the facility policy titled Care Plans, Comprehensive Person-Centered under Policy Interpretation and Implementation, 8. The comprehensive, person-centered care will: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; o. Reflect the recognized standards of practice for problem areas and conditions. 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. A review of the facility policy titled Comprehensive Assessment and Care Delivery Process revealed under Policy Interpretation and Implementation, 3 Information analysis, b. Define conditions and problems that are causing, or could cause, other problems. (1) Identify potential causes or contributing factors of problems and symptoms, including: (a) Medical. C. Define current treatment and services; link with problems/diagnoses. On 2/07/23 at 11:38 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) assigned to the First Floor-North Unit. The RN/UM stated that the admission CP are completed by the admitting nurse within 48 hours and that the unit manager will review and add any additional CP if needed. The RN/UM further revealed that residents who had a diagnosis of DM should have a CP. The RN/UM could not explain why Resident #99 did not have a CP addressing his/her diagnosis of DM and insulin medication. On 2/09/23 at 11:06 AM, the team met with the Licensed Nursing Home Administrator (LNHA), Assistant LNHA, Director of Nursing (DON), and Infection Preventionist. The surveyor discussed the above concern. The surveyor asked if a resident who had a diagnosis of DM should have a care plan. The DON stated, Yes, there should be a care plan. Sometimes diabetes and blood sugar may be under the wound care plan but it should be care planned. On 2/13/23 at 11:00 AM, the team met with the LHNA, Assistant LNHA, and DON. No additional information was provided. NJAC 8:39-11.2 (e)(2)

Based on observation, interview, record review, and a review of pertinent facility documents, it was determined that the facility failed to ensure personal protective equipment (PPE) was removed in accordance with nationally accepted guidelines for infection prevention and control. This deficient practice was identified for 1 of 4 staff members observed donning and doffing. The evidence was as follows: According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 2/23/21 included, HCP (Healthcare Personnel) must receive training on and demonstrate an understanding of: when to use PPE, what PPE is necessary, how to properly don (put on), use and doff (remove) PPE in a manner to prevent self-contamination, how to properly dispose of or disinfect and maintain PPE, limitations of PPE. It further included that HCP should perform hand hygiene before putting on and removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process .Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene .Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Reusable (i.e., washable or cloth) gowns should be laundered after each use .Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location. On 3/11/21 at 11:55 AM, the surveyor observed a housekeeper on 1 South which was a dedicated unit for Persons Under Investigation for COVID-19 (PUI), exit room [ROOM NUMBER] wearing a blue disposable gown and gloves. The housekeeper removed the gloves and gown right outside of room [ROOM NUMBER]. The housekeeper then placed the gloves and gown into the housekeeping trash bin. The housekeeper then opened the housekeeping cart without performing hand hygiene to look for alcohol-based hand sanitizer to perform hand hygiene. The surveyor observed only two alcohol-based hand sanitizers mounted to the wall on the PUI unit. On 3/11/21 at approximately 12:00 PM, the surveyor interviewed the housekeeper, who stated that the trash can for the gloves and gown are inside the bathroom of room [ROOM NUMBER]; I put it inside my housekeeping cart trash. The surveyor inquired if she had any training on how to put on, remove, and discard PPE. The housekeeper stated, yes. The housekeeper could not speak to why she didn't remove the gown and gloves before leaving the room. On 3/12/21 at 1:10 PM, the survey team met with the Administrator, Assistant Administrator, Director of Nursing, and the Infection Control Preventionist and discussed the above observation and concern. On 3/15/21 at 1:35 PM, the DON stated that the housekeeper was re-educated regarding donning and doffing and that the housekeeper didn't think she was in the hallway since she was right outside the room when she took off her gown. The DON and the Administrator acknowledged that the housekeeper should not have placed the blue disposable gown inside the housekeeping cart trash bin. A review of the facility's undated Policy for Personal Protective Equipment-Donning and Doffing included that the policy's purpose was to prevent the spread of infections .remove gloves and discard them into a waste receptacle in the room .if the gown is disposable, discard it into the waste receptacle inside the room and wash the hands. NJAC 8:39-5.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to set the appropriate weight in an air mattress used to promote wound healing for 1 of 3 residents reviewed for pressure ulcer according to professional standards of practice. This deficient practice was evidenced for Resident #19 and 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 3/9/21 at 11:12 AM, the surveyor toured with the Licensed Practical Nurse/Unit Manager (LPN/UM), who informed the surveyor that Resident #9 was cognitively impaired, required total assistance with activities of daily living (ADL), and had a community acquired pressure ulcer from the recent re-hospitalization . She indicated that the wounds were the same, and that the resident is on a specialized mattress to promote wound healing. On that same date and time, both the surveyor and the LPN/UM observed that the resident was lying on an air mattress. The air mattress was set at 180 pounds (lbs) and 25 cycles. The LPN/UM stated that the resident was not 180 lbs; The mattress was not set according to manufacturer's specific instructions. She further stated I don't know why it was set at 180 lbs. I'm not sure what was the 25 cycles means. The LPN/UM stated that it was the nurse's responsibility to make sure that the air mattress weight was correct. A review of the resident's Face Sheet (an admission summary), indicated that the resident had [DIAGNOSES REDACTED].), and Unspecified protein-calorie malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands). A review of the 11/27/20 Significant Change/ Minimum Data Set (SC/MDS), an assessment tool used to facilitate the management of care, indicated the resident had severely impaired cognition. A review of the March 2021 physician's orders [REDACTED]. A review of the March 2021 Treatment Administration Record (TAR) showed that the above order was signed by the nurses routinely. On 3/12/21 at 10:51 AM, the surveyor and the LPN/UM went to the resident's room and checked the air mattress. The surveyor and the LPN/UM observed the resident's air mattress was set at 80 lbs and 20 cycles. The LPN/UM informed the surveyor and stated, I immediately corrected it and changed the weight to 80 lbs on that same date after the surveyor's inquiry. She further stated, honestly, I don't know when asked by the surveyor how did she know that the cycle of air mattress should be at 20. At that same time, the LPN/UM informed the surveyor that no one knew who changed the weight to 180 lbs and 25 cycles at the time the surveyor and LPN/UM observed it. She further stated that she will get back to the surveyor regarding who changed the cycle from 25 to 20. On 3/12/21 at 1:00 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), Director of Nursing (DON), Infection Preventionist Nurse (IPN), and discussed the above observations and concerns. The surveyor asked for additional information about the air mattress, and the DON stated that they will get back to the surveyor on Monday, 3/15/21. Both the LNHA and DON acknowledged that the staff should have been educated about the air mattress. On 3/15/21 at 9:24 AM, the Licensed Practical Nurse (LPN) informed the surveyor that he was the regular nurse of Resident #9. The LPN stated that it was the nurse's responsibility to change the weight in the air mattress of the resident and sign the TAR that he checked the air mattress every shift. He further stated that I don't know what happened when asked by the surveyor why the right weight was not set on 3/9/21. On 3/15/21 at 9:30 AM, the LPN/UM informed the surveyor that it was the wound doctor who changed the cycle from 25 to 20. The LPN/UM stated that according to the wound doctor, 20 to 25 cycles were appropriate for the resident. She further stated that she did not have an education about the air mattress manufacturer's specifications with respect to the correct settings. She indicated that now I know that the cycles are meant for minutes of alternating pressure. On 3/15/21 at 12:58 PM, the surveyor called the wound doctor and spoke to the office staff. The office staff from the wound doctor stated that she will relay the message to the doctor to call back the surveyor. The wound doctor did not return the surveyors call. On 3/16/21 at 12:25 PM, the surveyors met with the LNHA, AA, DON, IPN, Assistant Director of Nursing (ADON). The DON stated that there was no negative effect on the resident. A review of the undated facility Prevention of Pressure Ulcer/Injuries Policy, provided by the LNHA, included Support Surfaces and Pressure Redistribution: use of an alternating air pressure or low air loss mattress assist in the prevention and care of pressure injuries. The inflation and deflation of inflatable air tubes imitate the patient's movements by relieving under-body pressure must be set according to manufacturer's recommendation. Monitoring: 1. Daily checks of alternating air pressure or low air mattress placement and functions every shift. 2. Ensure that low air mattress inflation pressure is set according to the patient weight. NJAC 8:39-11.2 (b)

Based on observation, interview, and record review, it was determined that the facility failed to maintain complete, accurate, and readily accessible medical records. This deficient practice was identified for 1 of 24 residents reviewed, Resident#24, and was evidenced by the following: This deficient practice was evidenced by the following: On 3/9/21 at 11:10 AM, during the tour, the Licensed Practical Nurse/Unit Manager (LPN/UM) informed the surveyor that Resident #24 was on hospice care. The resident was lying on an air mattress. At that same date and time, the LPN/UM stated that the hospice nurse does the virtual visit once a week. She further noted that the facility's protocol was to have hospice nurses do virtual visits due to COVID positive in the facility and promote the resident's safety. A review of the resident's Face sheet (an admission summary) disclosed that the resident had [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate care management dated 12/14/20, indicated a Brief Interview for Mental Status (BIMS) scored at 99, indicating that Resident#24 was unable to be interviewed. The QMDS further indicated that the resident was on Hospice. A review of the March 2021 physician's orders [REDACTED]. A review of the Hospice Nurse (HN) Plan of Care Information (HN) provided by the LPN/UM in the binder showed no notes for January 2021. The only notes in the binder for 2021 were notes dated 2/26/21 and 3/2/21 that included a fax cover sheet from hospice dated 3/10/21. Further review of the HN notes dated 3/2/21 showed that the Opioid Care plan was documented as PRN. There was no care plan for the standing order of opioids. On 3/12/21 at 11:23 AM, the LPN/UM informed the surveyor that the hospice notes were filed in the hospice binder. She stated that it was her responsibility to make sure that the virtual notes and all other documents about the resident's care regarding hospice will be filed in the binder as part of the resident's medical records. At that same date and time, the surveyor and the LPN/UM checked the hospice binder and did not find the hospice nurse's weekly virtual visit notes for January February 2021 except for dates 2/26/21 and 3/2/21. The LPN/UM stated, I don't know what happened, why there were missing notes. Furthermore, the LPN/UM informed the surveyor that the resident was on a standing and PRN orders for [MEDICATION NAME]. She stated that she should have checked the accuracy and availability of hospice notes. She further stated that she should have clarified with the HN about the care plan for opioids that it should be both a routine order and PRN. On 3/12/21 at 1:10 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Administrator (AA), Infection Preventionist Nurse (IPN) and discussed the above concerns. On 3/15/21 at 9:33 AM, the LPN/UM informed the surveyor that she received all missing notes from the HN's virtual visits. The LPN/UM indicated that there were no new recommendations. The HN faxed the corrected care plan for opioids that included the routine and PRN order [MEDICATION NAME] for pain management. At that same time, the LPN/UM stated that moving forward, she would make sure that the hospice notes will be check to make sure that it was submitted and filed in the resident's medical records binder on time. On 3/15/21 at 3:20 PM, the HN informed the surveyor via a phone conversation that Resident#24 was doing better and would eventually be discharged from hospice. She stated that she usually sends the virtual visit notes bi-weekly via fax. She further said, I don't know what happened, why the virtual notes for January, February were not filed and not available in the facility. Furthermore, the HN informed the surveyor that she had fax all virtual notes on 3/12/21 that were missing as requested by the facility after the surveyor's inquiry. She further stated that she also sent the corrected care plan via fax to include the routine standing order for [MEDICATION NAME]. A review of the facility Hospice Program Policy provided by the LNHA with a revised date of July 2017 included Hospice services are available to residents at the end of life. Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record-keeping requirements, to hospice staff furnishing care to the residents. On 3/16/21 at 12:25 PM, the surveyors met with the LNHA, DON, AA, IPN, Assistant Director of Nursing (ADON). The facility provided no additional information. NJAC 8:39-35.2 (d)(5)

Based on observation, interview, and review of records, it was determined that the facility failed to a.) to sanitize and use properly the disinfecting wipes for cleaning the table used for testing visitors and staff for COVID-19, b.) practice appropriate hand hygiene for 2 of 8 staff, and c.) follow environmental infection control in the laundry for 1 of 2 staff, observed in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: A review of the U.S. CDC's Cleaning and Disinfecting Your Facility updated on 7/28/2020, included, Practice routine cleaning of frequently touched surfaces. High touch surfaces include tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, sinks, etc. Disinfect with a List N: disinfectants for use against [DIAGNOSES REDACTED]-CoV, [MEDICAL CONDITION] that causes COVID 19. For electronics, such as tablets, touch screens, keyboards, remote controls, and ATMs, consider putting a wipeable cover on electronics. Follow the manufacturer's instructions for cleaning and disinfecting. If no guidance, use alcohol-based wipes or sprays containing at least 70% alcohol. Dry surface thoroughly and wear appropriate PPE when cleaning or disinfecting frequently touched surfaces and electronics. The U.S. CDC's Preparing for COVID-19 in Nursing Homes updated on 11/20/2020, indicated, Environmental Cleaning and Disinfection: develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. Ensure HCP are appropriately trained on its use. According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/2020 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. According to the U.S. CDC guidelines Appendix D-Linen and Laundry Management, Best Practices for Environmental Cleaning in Healthcare Facilities last reviewed 3/27/2020 included, Best practices for management of clean linen: Sort, package, transport, and store clean laundry in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. According to the U.S. CDC guidelines for Environmental Infection Control in Health-Care Facilities (2003), last reviewed 11/5/15 included, Hygienically clean laundry carries negligible risk to health-care workers and patients, provided that the clean textiles, fabric, and clothing are not inadvertently contaminated before use. After washing, cleaned and dried textiles, fabrics, and clothing are pressed, folded, and packaged for transport, distribution, and storage by methods that ensure their cleanliness until use. On 1/11/21 at 8:35 AM, the surveyors observed the Infection Preventionist Nurse (IPN) performed the rapid COVID testing of three visitors in the facility lobby. The IPN did not sanitize the tables used for testing before and after COVID testing. There were no disinfecting wipes available on top of the table that was also used as a common area for answering screening COVID questions. After testing the visitors for COVID-19, the IPN did not properly dispose of the used testing kits and specimens in a covered medical waste garbage can. At 9:03 AM, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) informed the surveyors that there were two positive COVID-19 staff, one from Dietary and one Housekeeping Director that were both at home self-isolating according to CDC guidelines. At 9:43 AM, the IPN stated that she was responsible for testing visitors and staff for COVID-19. She further stated that the Housekeeper had cleaned the table in the reception area in the morning which was why she did not sanitize the tables anymore before and after COVID testing of the visitors. Furthermore, the IPN stated that it was the practice already when she started in the facility to dispose of the used testing kits and specimen in the regular garbage that had no cover. At 10:11 AM, the surveyor in the presence of the Supervisor of Laundry (SL) observed the Laundry Aide (LA) folding clean clothes of the residents in a separate room. There were two books and a cup of a cold drink on top of the table where LA folding clothes. The LA had no answer why there were books and a drink on top of the table used for folding clothes. At the same time, the surveyor and the SL observed the LA perform handwashing for 13 seconds. The SL stated that the LA should have washed her hands for at least 20 seconds. The SL further stated that there should be no food, drinks, books, and other things on top of the table where the LA folding clean clothes to mitigate the spread of infection. At 10:32 AM, the surveyor observed the IPN perform staff COVID-19 testing. The IPN did not perform hand hygiene in between changing gloves The IPN did not wait for the table to air dry after sanitizing the table with disinfecting wipes. At 10:47 AM during the interview, the IPN and the DON both stated that the IPN should have waited for 5 minutes to let the table air dry. Both the IPN and the DON acknowledged that the IPN should have performed hand hygiene in between gloves use. At 12:00 PM, the surveyors informed the LNHA and the DON of the above concerns. A review of the facility's Handwashing/Hand Hygiene Policy provided by the LNHA with a revised date of 8/2015 included, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: before donning sterile gloves, after removing gloves, and Handwashing Process Monitoring: thirty seconds hands total scrubbing time. A review of the facility's COVID-19 Outbreak Response and Testing Policy provided by the LNHA with a revision date of 5/13/2020 included, Frequent testing for COVID-19. Frequent monitoring of proper hand hygiene and the use of PPE. At 12:46 PM, the surveyors met with the LNHA, DON, IPN, Assistant Administrator and there was no additional information provided by the facility. NJAC 8:39-19.4 (a) (1) (n)

Based on observation, interview, record review and policy review, it was determined that the facility failed to follow professional standards of nursing practice when a nurse signed for a medication indicating that it had been given to Resident #270 but had not been. This deficient practice was identified for 1 of 27 residents reviewed and 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. Record review of the facility's policy, Medication Administration Guidelines, revised 11/17, showed that the nurse will sign for each medication administered on the Medication Administration Record [REDACTED]. On 05/11/18 at 8:25 AM the surveyor reviewed the record of Resident #270 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed as severely cognitively impaired on the Admission Minimum Data Set, an assessment tool, dated 05/14/18. The surveyor reviewed the (MONTH) (YEAR) MAR indicated [REDACTED]. The medication had not been initialed as being given that morning at 7:30 AM. The surveyor spoke to the Licensed Practical Nurse (LPN) who was administering medications that morning. The surveyor asked the LPN if she had dispensed the [MEDICATION NAME] ER that day at 7:30 AM. She immediately stated she had and initialed the MAR. The surveyor counted the resident's current supply of [MEDICATION NAME] ER. The resident was newly admitted to the facility. Thirty tablets of the medication were delivered to the facility on [DATE] and there were twenty-three tablets remaining. Seven doses had been dispensed. If the medication had been administered as ordered from 05/04/18 through 05/11/18, there would have been 8 doses dispensed and twenty-two tablets remaining. On 05/11/18 at 9:00 AM the surveyor spoke to the DON regarding these findings. She agreed that there were twenty-three tablets currently on hand. The DON stated she would check the backup supply of medication and speak with the LPN. On 05/11/18 at 9:17 AM the DON told the surveyor that the LPN admitted that she had not dispensed the medication as ordered that morning and should not have signed the MAR indicated [REDACTED]. On 05/15/18 at 11:35 AM the surveyor brought these findings to the attention of the Administrator. No additional information was provided. NJAC 8:39-27.1 (a)

Based on interview and review of the medical record, it was determined that the facility failed to ensure that residents were visited and examined by a medical physician with alternating visits provided by a Nurse Practitioner (NP). This deficient practice was noted for 1 of 8 attending physicians and 3 of 24 residents, Residents #2, #20, #21, as evidenced by the following: 1. The surveyor reviewed the medical record of Resident #2 on 1/4/12 at 12:40 p.m. . The resident was admitted to the facility on [DATE] and the medical record revealed that the only documentation by the Attending Physician was on the Physician's Progress Notes done on 12/2/11. Documentation from 1/4/11 to 11/9/11 was done by the NP only. 2. The surveyor reviewed the medical record of Resident #21 on 1/9/12 at 2:15 p.m. which revealed the resident was admitted to the facility 2/20/09. The Physician's Progress Notes from 1/4/11 to 1/6/12 were signed by the NP and the only documentation by an attending physician was 12/2/11. The physician's orders [REDACTED]. December 2011 was signed by a physician. 3. The surveyor reviewed the medical record for Resident #20 on 1/9/12 at 12:00 p.m. which indicated the resident was admitted to the facility initially on 2/20/09. The resident was then readmitted to the facility on [DATE] after a hospital stay with [DIAGNOSES REDACTED]. Further review of the medical record by the surveyor revealed that there was no documented evidence that the resident was seen and examined by the Physician since January 2011. The record revealed the resident was only seen and examined by the Advanced Practice Nurse (APN) since admission to the facility. Interview with the Administrator, and the Director of Nursing (DON) 1/9/12 at 2:45 p.m. confirmed that there was no documented evidence that Resident #20 was seen and examined by the Physician since January 2011. NJAC 8:39-23.2(d)

Based on review of documentation provided by the facility, it was determined that the facility failed to maintain a surety bond in the amount of, or in excess of, the amount of money being held for the residents. This deficient practice was noted for 13 security deposit accounts and 155 Personal Needs Accounts (PNA) held by the facility as evidenced by the following: On 1/3/12 at 1:30 p.m., the surveyor reviewed the Surety Bond (Patient Trust Funds Bond) and the total amount of money being held for the residents by the facility. The Administrator provided the surveyor with the aggregate amount of money held in the PNA and the total monies held as security deposits for the residents. The surveyor reviewed the total amount of the PNA and security money which was far in excess of the amount the Surety Bond covered. NJAC 8:39-9.5(c)3

Based on observation, interview and review of the previous plan of correction provided by the facility, it was determined that the facility failed to maintain accessibility for 15 months of Minimum Data Set (MDS) assessments. This deficient practice was noted on 4 of 4 units in the facility as evidenced by the following: 1. During review of the medical records on 2 South unit on 1/4/12 at 12:05 p.m., the surveyor noted the medical record only contained 2 MDS assessments. Interview of the Licensed Practical Nurse (LPN) in charge at 12:20 p.m. confirmed the medical record only contained the last 2 MDS assessments. She confirmed the other 15 months of the MDS were kept in a locked room next to the nursing station and the LPN indicated the room was a supply room. On 1/10/12 at 11:15 a.m. the Administrator provided the surveyor with a copy of the Plan of Correction from the last standard survey from the Department of Health and Senior Services on 12/14/10. The correction by the facility at that time was "only the most recent MDS assessments will be placed in the chart binder. All other MDS assessments over the past fifteen months will be placed in a file cabinet centrally located in each nurse's station." 2. During review of the medical records on the 2 North unit on 1/4/12 at 11:45 a.m., the surveyor noted that the medical record contained only 2 MDS assessments. At 11:55 a.m., the Unit Manager for 2 North confirmed the medical record contained only the last 2 MDS assessments and the remainder of the MDS assessments for the past 15 months were kept in a locked room on the unit near the nursing station. 3. During review of the medical records on unit 1 North on 1/4/12 at 11:00 a.m., the surveyor interviewed the LPN on the unit and asked if the MDS assessments were kept on the chart. The LPN stated that the most recent MDS assessment was on the chart and the other MDS assessments were kept in a file cabinet in the medication room. The surveyor observed the medication room to be locked, with a key pad lock system. During interview of the nurse, she confirmed that the other 15 months of the MDS assessments were kept in the locked medication room. 4. During review of the medical records on unit 1 South on 1/4/12 at 12:15 p.m., the surveyor noted that only the most recent Quarterly MDS assessment was on the medical record. The surveyor interviewed the Registered Nurse (RN) unit manager on the unit and asked if the MDS assessments were kept on the chart. The RN stated that the most recent MDS assessment was on the chart, the other 15 months of MDS assessments were kept in a file cabinet in the medication room. The surveyor observed the medication room to be locked, with a key pad lock system. During interview of the nurse, she confirmed that the other 15 months of the MDS were kept in the locked medication room. NJAC 8:39-35.2 (a)

Based on interview and review of records provided by the facility it was determined that the facility failed to have the Medical Director or physician designee attend the quarterly Quality Assurance Committee meetings. This deficient practice was noted for 2 of 4 Quality Assurance Meetings as evidenced by the following: During interview with the Director of Nursing (DON) on 1/10/11 at 11:00 a.m., the surveyor reviewed the attendance sign in records for the last 4 quarterly meetings of the Quality Assurance Committee. There was no signature indicating attendance by the Medical Director or any designated physician for the meeting held on 1/18/11 and 4/27/11. Interview of the DON confirmed the Medical Director did not attend and sign the attendance sheet. NJAC 8:39-33.1(b)

C# NJ Based on interviews, review of medical records, and other facility documentation, it was determined that the the facility failed to consistently ensure that the appropriate dose of a significant medication/[MEDICATION NAME] was obtained and /or administered in accordance with the acceptable standards of clinical nursing practice for 1 of 4 residents (Resident #1). This deficient practice is evidenced by the following: A review of the resident's medical record on 4/19 and 4/29/11 by the surveyor revealed the following: 1. According to her face sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated 6/8/10 reflected that the resident had poor short term and good long term. She was assessed as needing supervision to extensive assistance with his activities of daily living. An 8/10 physician's orders [REDACTED].o.) daily., and repeat PT and INR on 8/20/10. Further review of the POS dated 8/20/10 had an order for [REDACTED]. daily, and to recheck PT and INR on 8/27/10. A specimen inquiry report (SIR) dated 8/20/10, documented that the resident's PT and INR were both high PT was 25.2, reference range is between 11.7 to 14.5 sec. The INR was 2.1, and reference range was between 0.9-1.1. Further review of the SIR dated 8/27/10, documented elevated ..."critical results.." for PT 75.4 and INR 7.9. An interdisciplinary progress notes (IPN) dated 8/20/10 at 1:00 pm, documented the resident on [MEDICATION NAME] 6 mg 1 tab, p.o. and recheck PT and INR on 8/27/10. Further review of the IPN, documented that on 8/27/10, a phone call was received from the laboratory notifying them of the resident's critical and/or elevated PT and INR results. The physician was notified and held the [MEDICATION NAME] for 8/28/10. On 8/28/10, the resident's [MEDICATION NAME] and ASA were held until further orders. There was no documentation on the 8/20/10 IPN, that the nurse who obtained the [MEDICATION NAME] order for 6 mg had any concerns with the dose ordered by the physician. An interdisciplinary resident care plan dated 5/6/10 to 4/11, reflected that the resident was at risk for skin breakdown due to his medications including [MEDICATION NAME], and one of the goals was ..."will not develop complications...". Interventions included; to monitor medication profile and labs as necessary (PRN). On 8/27/10, an intervention to monitor PT and INR as ordered by MD, monitor for signs and symptoms of bleeding, hold [MEDICATION NAME] until further orders, and monitor vital signs was added. On 9/1/10, it was further documented that [MEDICATION NAME] 2.5 mg was restarted. A review of the medication administration record sheets (MARS) from 8/10 and 9/10, reflected that the [MEDICATION NAME] 6 mg was administered to the resident daily at 6:00pm from 8/20/10 x 7 days, and the [MEDICATION NAME] was held the rest of 8/10. Further review of the MARS, revealed that the [MEDICATION NAME] 2.5 mg was resumed on 9/1/10, and the ASA 81 mg on 8/2/10. the PT and INR were monitored regularly. On 9/24/10, it was documented on the MARS that the resident's PT was 27.2 and INR was 2.3. A medication incident/error report (MERR) dated 8/30/10, faxed to the Department of Health and Senior Services (DHSS) by the facility on 10/14/10 as requested by DHSS due to a complaint call, reflected that on 8/20/10 at 1:00pm, the nurse called the physician to report the resident's PT and INR results, and obtained an order for [REDACTED]. daily. The resident was receiving 2.5 mg of [MEDICATION NAME]. Repeat PT and INR was reordered and the resident was monitored for signs and symptoms of bleeding. Further review of the MERR under comments/recommendations, documented that the nurse who obtained the order stated that the physician ordered [MEDICATION NAME] 6 mg. ..."This nurse should have verified that [MEDICATION NAME] was previously [MEDICATION NAME] 2.5 mg and INR elevated, and if in doubt report to nursing supervisor." A continuation of the investigation conducted by the Director of Nursing (DON) dated 8/27/10, revealed that when the ordering physician was interviewed about the [MEDICATION NAME] 6 mg, he stated that it was a wrong order, he would not have given it, and there was ...."no medical reason to give that order..." An inservice regarding [MEDICATION NAME] therapy and medication error dated 9/3/10 was provided to the nurse/LPN who obtained and transcribed the [MEDICATION NAME] 6 mg order. During an interview by the surveyor on 4/19/11 at 10:28 am with Resident #1, revealed that she was not aware of any medication error, and claimed that she never had any adverse reactions to any of her medications. During an interview by the surveyor on 4/29/11 at 12:00pm with the LPN who obtained the order from the physician (MD) on 8/20/10, revealed that she called the MD to report the laboratory results as a routine. According to the LPN, the MD verified getting the results and ordered the [MEDICATION NAME] 6 mg. According to the LPN, she questioned the MD if he was sure that that was what he wanted, and the MD responded.."yes..". She proceeded to write the order. When questioned by the surveyor if she had concerns about the physician's orders [REDACTED]. When questioned by the surveyor if she brought up any concerns about the physician's orders [REDACTED]. The LPN said that she did not, but when it was brought up to her attention by the facility she felt horrible. She verified being counseled by the facility about the medication error/[MEDICATION NAME]. During an interview by the surveyor on 5/10/11 at 10:32 am with the resident's primary physician and supposedly gave the [MEDICATION NAME] 6 mg order, corroborated what was documented on the MERR. He further stated that he relied on the results relayed to her by the nurse from the facility, and if he was told that the resident had an INR of 2.1 and the resident was regularly on 2.5 mg, he would have kept the resident on the same dose and repeat the lab in 1 month. He further stated that it "makes no sense.." to triple the dose and the nurse should have questioned it. When questioned by the surveyor if he looked at the laboratory result prior to giving his order, he stated that from his recollection he did not have the actual report, and if he did he would not have ordered [MEDICATION NAME] 6.0 mg. When questioned by the surveyor about the significance of the medication error to the resident, he revealed that the error was caught timely, the resident had no bleeding nor bruising. The [MEDICATION NAME] was stopped, checked over time, and the resident was safe and had no negative outcome. He further stated that there must have been some communication gap, but the nurse should have questioned ..."why triple dose". During an interview by the surveyor on 4/19/11 at 12:20 pm with the RN/unit manager about their practice with reporting and obtaining [MEDICATION NAME] orders, she revealed that whether the result is normal or abnormal they notify the physician of the results by calling them in order to get an order for [REDACTED]. Further interview with the RN, revealed that she was the one who discovered the medication error. The LPN, according to the RN, should have checked the previous order and questioned the MD since the order could cause the INR to elevate and could make the "...blood thinner." She further stated that she addressed the critical lab results immediately on 8/27/10. NJAC 8:39-27.1 (a)