Every finding on record at Hampton Ridge Healthcare and Rehabilitation

Based on observations, interviews, record review and other pertinent facility documents, it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection in accordance with the Center for Disease Control & Prevention (CDC) guidelines and standards of clinical practice by ensuring, a.) respiratory device tubing, masks, and mouthpiece were stored in protective coverings between uses identified for 6 of 7 residents (Resident #118, #68, #116, #5, #216, and #31) reviewed for respiratory care, b.) proper use of personal protective equipment (PPE) for 2 of 2 residents reviewed under enhanced barrier precautions (EBP) (Resident #144, #164), and c.) a urinary drainage bag attached to a urinary catheter device did not make contact with the floor to prevent possible contamination identified in 1 of 3 residents reviewed for urinary catheter (Resident #16). This deficient practice was identified in 4 out of 5 nursing units (Smart Rehab unit, North unit, South unit, and [NAME] unit) and was evidenced by the following:A.) Reference: Enhanced Barrier Precautions are indicated for residents known to be colonized or infected with an MDRO deemed novel or targeted by the CDC. When Contact Precautions do not otherwise apply, or when the resident has an indwelling medical device or wound. https://www.nj.gov/health/cd/documents/topics/hai/EBP_in_Nursing_Homes_Algorithm.pdf Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html Reference: Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html#:~:text=Routine%20instillation%20of%20antiseptic%20or,and%20maintenance%20(see%20Section%20III 1.) On 3/8/2026 at 9:18 AM, during the initial tour of the facility, Surveyor #1 observed Resident #118 in bed. The surveyor observed on the left side of the resident's bed, an unlabeled nasal cannula (NC) tubing (a tube with 2 prongs used to deliver oxygen directly into the nostrils) resting on the floor with the nasal prongs bent towards and touching the floor. The tubing was observed adjacent to a pair of black sneakers and open trash bin and was connected to an oxygen concentrator that was not on. An unbagged nebulizer (a machine used to administer medication in the form of mist inhaled into the lungs) mask was also observed on the resident's side table. The mask was lying on its side with the internal part exposed to air. A review of the electronic medical record (EMR) for Resident #118 revealed the following: A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included but not limited to respiratory failure and acquired COVID-19 infection while in the facility. A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool dated 2/14/2026, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated an intact cognition. The MDS further revealed that the resident was on intermittent oxygen therapy. A review of the Order Summary Report (OSR) active as of 3/8/2026, included the following Physician's Orders (PO): DuoNeb solution 0.5-2.5 (3) mg/3ml (Ipratropium Albuterol) 1 vial, inhale orally via nebulizer three times a day for asthma not to exceed 6 doses/ 24 hours. Mask care – shake out any residual medication and store mask in drawstring bag after each use; Oxygen via N/C @ 2 lpm (liters per minute) as needed for SOB (shortness of breath). A review of the individualized person-centered care plan revised on 2/9/2026, included a focus of potential for respiratory complications related to use of respiratory devices due to the diagnosis of respiratory failure. Interventions included administering medications as ordered and to monitor adverse effects. On 3/10/2026 at 10:28 AM, during an interview with the surveyor, Licensed Practical Nurse/ Unit Manager stated that respiratory tubing or masks get changed once a week and should be bagged when not being used in the resident's room. On 3/10/2026 at 11:06 AM, during an interview with the surveyor, Licensed Practical Nurse/ Infection Preventionist stated that nebulizer masks and nasal cannula/ oxygen tubing should be stored in Ziplock bags when not in use and are changed weekly. On 3/11/2026 at 9:42 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that oxygen tubing and nebulizer mask or mouthpiece should be stored in a bag at bedside to cover them from being exposed when they are not being used. A review of the facility policy date reviewed on 1/27/2026 titled Oxygen Tubing and Respiratory Products indicated under Procedure the following: Ensure if O2 (oxygen) tubing is not in use that it is in an oxygen bag labeled with the resident's name and room # as well as the date it was changed, both the tubing and the bag shall have a date. N.J.A.C. 8:39 – 19.4 (a) (k) 2.) On 3/8/2026 at 9:33 AM, Surveyor #1 observed Resident #68 in bed. The surveyor observed an unbagged nebulizer mask dated 3/5 lying sideways on top of an unlabeled plastic bag located on the side table. The internal part of the mask was exposed to air. A review of the electronic medical record (EMR) for Resident #68 revealed the following: A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included but not limited to acute upper respiratory infection, cerebral infarction (stroke), and other speech and language deficits following cerebral infarction. A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool dated 2/1/2026, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated a moderately impaired cognition. The MDS further revealed that the resident was on respiratory therapy. A review of the Order Summary Report (OSR) active as of 3/8/2026, included the following Physician's Orders (PO): Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3ml (Ipratropium-Albuterol) 3 ml inhale orally four times a day for SOB (shortness of breath). A review of the individualized person-centered care plan initiated on 1/24/2026, included a focus for risk of respiratory complications related to recent diagnosis and history of respiratory infection. Interventions included monitoring for general signs/symptoms of infection (fever, change in mental status, lethargy, irritability, change in appetite). The interventions also included monitoring for signs/symptoms of pneumonia and/ or respiratory infection (increased shortness of breath, cough, change in sputum/secretions, chest discomfort, decreased activity tolerance) and to notify the physician of any abnormalities. On 3/10/2026 at 10:28 AM, during an interview with the surveyor, Licensed Practical Nurse/ Unit Manager stated that respiratory tubing or masks get changed once a week and should be bagged when not being used in the resident's room. On 3/10/2026 at 11:06 AM, during an interview with the surveyor, Licensed Practical Nurse/ Infection Preventionist stated that nebulizer masks and nasal cannula/ oxygen tubing should be stored in Ziplock bags when not in use and are changed weekly. On 3/11/2026 at 9:42 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that oxygen tubing and nebulizer mask or mouthpiece should be stored in a bag at bedside to cover them from being exposed when they are not being used. A review of the facility policy date reviewed on 1/27/2026 titled Oxygen Tubing and Respiratory Products indicated under Procedure the following: Ensure if O2 (oxygen) tubing is not in use that it is in an oxygen bag labeled with the resident's name and room # as well as the date it was changed, both the tubing and the bag shall have a date. N.J.A.C. 8:39 – 19.4 (a) (k) 3.) On 3/8/2026 at 9:37 AM, Surveyor #1 observed Resident #116 in bed. The surveyor observed a nebulizer machine with an unbagged mask sitting upright on the holder. The internal part of the mask was exposed to air. A review of the electronic medical record (EMR) for Resident #116 revealed the following: A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included but not limited to acute respiratory infection and cerebral infarction (stroke). A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool dated 2/10/2026, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated a moderately impaired cognition. The MDS further revealed that the resident was on respiratory therapy. A review of the Order Summary Report (OSR) active as of 3/8/2026, included the following Physician's Orders (PO): Albuterol Sulfate Nebulization Solution 0.63 mg/3ml 1 vial inhale orally via nebulizer three times a day for SOB. Inhalation only. Mask care – shake out any residual medication and store mask in drawstring bag after each use; Oxygen via NC @ 2 LPM as needed for SOB. A review of the individualized person-centered care plan revised on 2/6/2026, included a focus of risk for respiratory complications related to diagnosis. There was no intervention addressing the use of respiratory medications or treatments. On 3/10/2026 at 10:28 AM, during an interview with the surveyor, Licensed Practical Nurse/ Unit Manager stated that respiratory tubing or masks get changed once a week and should be bagged when not being used in the resident's room. On 3/10/2026 at 11:06 AM, during an interview with the surveyor, Licensed Practical Nurse/ Infection Preventionist stated that nebulizer masks and nasal cannula/ oxygen tubing should be stored in Ziplock bags when not in use and are changed weekly. On 3/11/2026 at 9:42 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that oxygen tubing and nebulizer mask or mouthpiece should be stored in a bag at bedside to cover them from being exposed when they are not being used. A review of the facility policy date reviewed on 1/27/2026 titled Oxygen Tubing and Respiratory Products indicated under Procedure the following: Ensure if O2 (oxygen) tubing is not in use that it is in an oxygen bag labeled with the resident's name and room # as well as the date it was changed, both the tubing and the bag shall have a date. N.J.A.C. 8:39 – 19.4 (a) (k) 4.) On 3/8/2026 at 11:03 AM, Surveyor #1 observed Resident #5 in bed. The surveyor observed an unbagged and unlabeled nebulizer mouthpiece lying sideways on the bedside table. The mouthpiece was touching the surface of the table and was located adjacent to a used hairbrush, unused toothbrush, a box of toothpaste and a plastic knife with brownish substance. A review of the electronic medical record (EMR) for Resident #5 revealed the following: A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included but not limited to chronic obstructive pulmonary disease, pneumonia , and chronic respiratory failure with hypoxia (insufficient oxygen reaching the body tissues) A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool dated 2/3/2026, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated intact cognition. The MDS further revealed that the resident was on intermittent oxygen therapy. A review of the Order Summary Report (OSR) active as of 3/8/2026, included the following Physician's Orders (PO): DuoNeb Solution 0.5-2.5 (3) mg/3ml (Ipratropium Albuterol) 1 vial inhale orally via nebulizer every 4 hours as needed for wheezing not to exceed 6 doses/ 24 hours; Mask Care – shake out any residual medication and store mask in drawstring bag after each use. A review of the individualized person-centered care plan revised on 3/9/2026, included a focus of risk for respiratory complications related to recent diagnosis/ history of pneumonia. The interventions included administering nebulization treatment as ordered, assessing status pre- treatment and post-treatment. On 3/10/2026 at 10:28 AM, during an interview with the surveyor, Licensed Practical Nurse/ Unit Manager stated that respiratory tubing or masks get changed once a week and should be bagged when not being used in the resident's room. On 3/10/2026 at 11:06 AM, during an interview with the surveyor, Licensed Practical Nurse/ Infection Preventionist stated that nebulizer masks and nasal cannula/ oxygen tubing should be stored in Ziplock bags when not in use and are changed weekly. On 3/11/2026 at 9:42 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that oxygen tubing and nebulizer mask or mouthpiece should be stored in a bag at bedside to cover them from being exposed when they are not being used. A review of the facility policy date reviewed on 1/27/2026 titled Oxygen Tubing and Respiratory Products indicated under Procedure the following: Ensure if O2 (oxygen) tubing is not in use that it is in an oxygen bag labeled with the resident's name and room # as well as the date it was changed, both the tubing and the bag shall have a date. N.J.A.C. 8:39 – 19.4 (a) (k) During tour on 03/08/2026 at 9:34 AM, Surveyor #2 observed Resident #216 in bed. The nebulizer machine (a medical device that converts liquid medication into a fine, breathable mist, allowing patients to inhale drugs directly into their lungs via a face mask or mouthpiece) was observed on the dresser next to the bed. The nebulizer mask and reservoir were exposed to air and uncovered. According to the admission record Resident #216 had diagnosis which included but were not limited to asthma and respiratory failure. The 03/11/2026 admission Minimum Data Set (MDS, an assessment tool,) is in progress. A review of Resident #216's electronic health record reflected a physician's order for (Ipratropium-Albuterol 0.5-2.5 (3) milligrams/3 milliliters 1 vial inhale orally via nebulizer four times a day and budesonide suspension 0.5 milligrams/2 milliliters 1 vial inhale orally via nebulizer every 12 hours. A review of the facility provided policy, Infection Prevention and Control Program Oxygen Tubing and Respiratory Products, reviewed 1/27/26, which reflected all nebulizer tubing and equipment shall be dated and stored in a bag when not in use and replaced every 7 days. On 03/08/2026 at 09:31 AM, during initial tour, surveyor #3 observed Resident #31's nebulizer mask left on top of the night stand open to air. A review of Resident # 31's admissions record revealed that, Resident # 31 was admitted with but not limited to chronic obstructive pulmonary disorder (COPD; a progressive lung disease that makes it difficult to breathe). A review of Resident #31's admission Minimum Data Set (MDS) dated [DATE] revealed under section O that the resident received continous oxygen. A review of Resident #31's Electronical Medical Record revealed a physician's order for DuoNeb Solution, 1 vial inhale orally via nebulizer four times a day as needed for shortness of breath. A review of the Care Plan in the EMR revealed a focus for potential for respiratory complications related to use of respiratory devices due to diagnosis of COPD. During an interview on 03/08/2026 at 09:33 AM with surveyor #3, Licensed Practical Nurse (LPN) #1 said that nebulizer masks should be kept in a plastic bag when not in use and should not be left open to air. B.) On 03/11/2026 at 9:51 AM, surveyor #4 observed a sign on Resident #144's room door that read, Enhanced Barrier Precautions: Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Care Activities. The Resident Care Activities listed on the sign included, Transferring and Showering/Bathing. At the same date and time, Surveyor #4 observed outside of Resident 144's room to the side of the doorway was a plastic set of drawers that contained Personal Protective Equipment (PPE) including yellow gowns. On the same date and time, Surveyor #4 observed two Certified Nurses Aide (CNA) inside the room of Resident #144. The CNAs were preparing Resident #144 for transfer to a shower bed via mechanical lift. Prior to entering the room and while preparing for transfer, both CNA did not wear a gown. On the same date at 9:59 AM, Surveyor #4 observed the CNAs exit the room with Resident #144 on the shower bed and transport him/her to the shower room. Prior to entering the shower room with Resident #144 and as they were preparing the resident for the shower the CNAs did not wear a gown. A review of Resident #144's Physician's Orders located in the Electronic Medical Record (EMR) revealed an order for Maintain Enhanced Barrier Precautions scheduled for every shift. The order was initiated on 03/04/2026. A review of Resident #144's Care Plan Activity Report located in the EMR, revealed a care plan titled, Maintain Enhanced Barrier precautions with an initiated date 04/18/2024 and revision on 03/12/2026. In the care plan, there was an intervention that revealed staff will wear a gown and gloves during high-contact resident care activities including transferring from one position to another and bathing/showering. On the same date at 10:06 AM, during an interview with Surveyor #4, CNA #1 replied, Yes. when asked if he was supposed to wear a gown. A review of the policy titled, Enhanced Barrier Precautions reviewed 01/21/2026 revealed, Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier precautions include: Bathing/Showering and Transferring . Further, the policy revealed that, staff will don the appropriate personal protective equipment (PPE) prior to performing high-contact care activities. On 03/11/2026 at 10:29 AM while outside of Resident # 164's room, Surveyor # 5 observed an orange sign outside the room door that revealed a stop sign symbol and the words, Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Adjacent to the doorway was a plastic, clear bin containing yellow, wearable gowns. At that time, Surveyor # 5 observed a hospice company Certified Nurse Aide (CNA) in the room helping maneuver Resident # 164 in bed to begin hygienic care. The CNA did not have a disposable gown on while performing care on the residents. At 10:33 AM, the CNA exited the room. At that time, Surveyor # 5 asked him why he was not wearing a gown while performing care on the resident. The CNA replied, Sorry, sorry, okay, okay. A review of the policy titled, Enhanced Barrier Precautions reviewed 01/21/2026 revealed, staff will don the appropriate personal protective equipment (PPE) prior to performing high-contact care activities. N.J.A.C. 8:39-19.4(a) C.) On 3/8/26 at 11:07 AM, during the initial facility tour, the surveyor #6 observed Resident #16 lying in bed watching television (TV). The surveyor observed that the resident's urinary catheter device (UCD)drainage bag was lying on the floor and not placed in a dignity bag. Surveyor #5 reviewed the electronic medical record (EMR) for Resident #16. A review of the admission Record revealed that the resident had diagnoses including but not limited to pelvic inflammatory disease (infection of the pelvic organs) and obstructive and reflux uropathy (blockage that affects the flow of urine, causing it to back up into the kidneys). A review of the resident's admission Minimum Data Set (MDS), an assessment tool dated 1/30/26, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed that Resident #16 had an indwelling catheter. A review of the resident's Individual Comprehensive Care Plan (ICCP) included a focus area, initiated on 1/24/26 and revised on 1/27/26, identifying the resident as being at risk for urinary tract infection (UTI) related to (r/t) catheter use. Interventions included the use of a leg bag or privacy bag, as warranted, to maintain dignity and privacy, and to provide catheter care every shift as ordered and as needed. A review of the Order Summary Report of active orders as of 3/9/26 included a physician's order (PO), dated 1/23/26, to maintain Foley Catheter (F/C) privacy bag at all times, check placement every shift, and provide F/C care every shift. The Treatment Administration Record (TAR) for February and March 2026 indicated that the F/C privacy bag and placement tasks were documented as completed every shift. On 3/9/26 at 12:59 PM, surveyor #6 interviewed the certified nursing assistant (CNA) who stated that the UCD should not be placed on the floor in order to prevent infection. The CNA explained that the privacy bag should not be visible from the doorway and should be positioned on the opposite side of the bed to maintain the resident's dignity and privacy. On 3/10/26 at 11:56 AM, surveyor #6 interviewed the Licensed Practical Nurse (LPN), who confirmed that the UCD should not be placed on the floor for infection control purposes and should be kept in a dignity bag away from the doorway to protect the resident's privacy and dignity. On 3/11/26 at 10:29 AM, surveyor #6 interviewed Licensed Practical Nurse (LPN/UM), who confirmed that Resident #16 had active orders for UCD care. When asked about the UCD care tasks being signed off on the TAR, the LPN/UM stated that the tasks should not have been signed off on shifts when the ordered care was not provided. The LPN/UM further stated that the UCD should be placed in a dignity bag, positioned away from the doorway, hung to gravity, and never placed on the floor to promote infection control, privacy, and dignity. On 3/11/26 at 1:10 PM, surveyor #6 interviewed the Registered Nurse/Director of Nursing (RN/DON), who stated that she expected that the UCD to be placed in a dignity bag, kept off the floor, and positioned away from the doorway at all times. The RN/DON confirmed that positioning of the UCD away from the door, and placement in a dignity bag promotes privacy, while keeping the UCD off the floor supports infection prevention. A review of the facility policy titled Foley Catheter Management and Drainage Bag Placement, reviewed 3/11/26, indicated that it is the policy of this facility to ensure safe management of indwelling urinary (Foley) catheters in order to prevent infection, maintain resident dignity. All staff responsible for catheter care must follow infection prevention standards and maintain proper drainage bag placement, privacy bag use, and unobstructed urine flow. NJAC 8:39-33.2(c)5

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to a.) properly dispose of garbage and refuse in one of two (1 of 2) garbage disposal areas (Garbage Disposal Area #2), and b.) keep 2 of 2 garbage containers/dumpsters covered, creating the potential for odors and pest infestation. This deficient practice was evidenced by the following: On 3/9/26 at 9:38 AM, the surveyor accompanied by the Executive Chef/Food Service Director (EC/FSD), toured the trash disposal areas and observed that Garbage Disposal Area #2 had trash dumped in the ground and 2 dumpsters filled with trash and uncovered. The surveyor observed garbage on the ground was exposed to the environment and included boxes, a chair, a plastic bag containing soiled adult incontinence briefs and personal protective equipment, plastic cups, plastic lids, used gloves, masks, papers, plastic pipes, and wooden pallets. During the tour, the surveyor interviewed the EC/FSD regarding Garbage Disposal Area #2. The EC/FSD stated that maintenance of the facility's garbage disposal areas was a shared responsibility between the dietary and housekeeping departments. The EC/FSD further stated that garbage should be placed in the designated dumpsters and that the dumpsters should be kept covered at all times. The EC/FSD confirmed that garbage should never be discarded on the ground and that the garbage disposal areas should always be maintained in a safe and sanitary manner. The EC/FSD acknowledged that the improperly disposed garbage posed an odor and safety hazard, potentially harboring pests. On 3/5/26 at 9:21 AM, the surveyor interviewed the Housekeeping Director (HD) regarding the facility's trash disposal and removal practices. The HD stated that garbage was not collected due to approximately two (2) feet of snow in the area. The HD further stated that trash disposal areas should be maintained free of debris and trash to avoid contamination and attracting pests. On 3/9/26 at 9:46 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that facility staff had not cleaned the garbage area due to the presence of poison ivy and that a landscaping company was contracted to clean the area. The LNHA confirmed that garbage should be properly disposed of in the dumpsters and that the dumpsters should be kept closed to prevent rodents and contamination. A review of the facility's policy titled Cleaning the Dumpster Area/Loading Dock Area, revised 3/2026, indicated that the purpose of the policy was to effectively maintain the outdoor dumpster and loading dock areas free of refuse and waste food products. The policy also included that the DH would assign staff to clean the dumpster and/or loading dock area Monday through Friday each week and that the assigned staff shall pick up all debris and trash in the immediate area of the dumpster/loading dock and place it in the dumpster. NJAC 8:39-19.7(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the medication error rates are not 5 percent or greater. This deficient practice was identified for 1 of 7 residents (Resident #18), and 1of 2 nurses on the second-floor nursing unit during the Medication Administration task. The deficient practice was evidenced by the following:On 3/10/2026 at 9:24 AM on the North Wing, the surveyor observed Licensed Practical Nurse (LPN) #1 prepare Resident #18's medication for administration. At that time, LPN #1, removed one Metoprolol tablet (used to treat high blood pressure) and place it in the medication cup. At that time, the surveyor observed the Electronic Medical Administration Record (EMAR) on the medication cart computer with LPN #1. The EMAR revealed that the Metoprolol was scheduled to be given at 8:00 AM. On the same date and time, on the North Wing, the surveyor observed LPN #1 prepare Resident #18's medication for administration. At that time, LPN #1 determined she did not have Resident #18's folic acid tablet (a vitamin supplement). At that same time, LPN#1 asked the surveyor if she could use another residents prescribed folic acid tablet and stated, That is what we normally do. The surveyor instructed LPN #1 to follow the facility's policy. LPN #1 proceeded to remove one folic acid tablet from a medication card labeled for use on Resident #182 and place it in Resident #18's medication cup. On the same date at 11:14 AM during an interview with LPN # 1, the surveyor asked if a medication is ordered to be administered at 8:00 AM when should that medication be given by, LPN #1 refused to answer the question. LPN #1 further stated that 7:00 AM and 8:00 AM medications can sometimes take up to 10:00 AM to be administered. The surveyor then asked if it was okay to give 7:00 AM and 8:00 AM medications after an hour has passed, LPN #1 stated she was unsure and further stated that she tries to give as much as possible on time but it does not always happen. At that time when asked if she should have used a medication prescribed to another resident, LPN #1 stated, that normally rather than missing a resident's dose of medication, they will use another resident's medication if it is the same. The surveyor asked the LPN if that was part of the facility's policy and LPN #1 repeated, That's what we normally do.During an interview with the surveyor on 03/11/2026 at 12:59 PM, the Licensed Nursing Home Administrator (LNHA) stated that LPN #1 should have met with the pharmacy. The Director of Nursing (DON) further stated the physician could have been contacted to obtain an order for one of the over-the-counter doses of folic acid. A review of a facility policy titled, Administering Medications, reviewed on 03/12/2026, revealed under Policy Interpretation and Implementation number 3., Medications must be administered in accordance with the orders, including any required time frame . The policy further revealed under number 9., Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed time . The policy further revealed under number 16., Medications ordered for a particular resident may not be administered to another resident. N.J.A.C.8:39-29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to establish a system of records for controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications for 1of 5 medication carts inspected under the Medication Storage Task.This deficient practice was evidenced by the following:On 03/11/2026 at 10:40 AM in the presence of Licensed Practical Nurse (LPN) # 1, the surveyor inspected medication cart 1 on the North Wing unit. While observing the controlled medications, the surveyor observed 6 Oxycodone 5 milligrams tablets (mg) (a narcotic medication used to treat pain) in the blister pack within narcotic box for Resident #13. At that time, the surveyor reviewed the Oxycodone inventory sheet. The document revealed the administration of 2 oxycodone tablets that included a beginning balance of 8 and ending balance of 6 consistent with quantity remaining in the blister pack, with no documentation of the administration date or time. At that time during the interview with the surveyor, LPN #1 stated, That was me rushing, and confirmed that the date and time were missing from the documentation. A review of Resident #13's Medication Administration Record (MAR) indicated that the oxycodone was administered on 3/11/2026 at 8:28 AM. During an interview on 03/1/2026 at 12:59 PM with the surveyor, the Director of Nursing said that the expectation is for documentation to be completed at the time the nurse is administering the medication.Review of the facility's policy titled, Controlled Dangerous Substance (CDS) Procedure revised on 03/11/2026, revealed under Declining inventory sheets that All CDS medication declining inventory sheets must be signed by the nurse administering the medication at the time the medication is prepared for administration. NJAC 8:39-29.7(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to routinely post the Nursing Home Resident Care Staff Report (NHRCSR) since 03/04/2026 (4 days) in a place within the facility readily accessible to the residents and the visitors.This deficient practice was evidenced by the following:On 03/08/2026 at 9:02 AM, the surveyor observed the NHRCSR dated 03/04/2025 for the day, evening, and night shift. Each shift indicated a census of 195. The NHRCSR was observed posted on a ledge to the left of the reception desk in the front lobby. During an interview on 03/10/2026 at 12:59 PM with the surveyor, the staffing coordinator (SC) said that she sends the NHRCSR to the receptionist daily to post, and on Fridays the SC said she sends the whole weekend. She stated she was not here over the weekend and must have forgotten to send the schedule up to the receptionist. The SC then said it is important to post daily so the families can see the ratio of the staff to residents in the building. During an interview on 03/11/2026 at 12:59 PM with the survey team the Licensed Nursing Home Administrator (LNHA) said it is important to post the NHRCSR daily because the families are very interested in seeing the staff ratios, and it is also good to show prospective families that are looking for placement.At the time of survey, the facility did not have a policy for the daily posting of NHRCSR. NJAC 8:39-41.2 (a)(b)(c)(1)

Based on observation, interview, and record review it was determined that the facility failed to ensure that a midline dressing was changed and maintained in accordance with professional standards of practice and facility policy for 1 of 1 residents (Resident # 101) reviewed for parenteral fluids. The deficient practice was evidenced by the following: A review of the physician's orders located in Resident # 101's electronic medical record (EMR) revealed an order to change a midline/PICC (Peripherally Inserted Central Catheter) intravenous (IV) dressing, extension set & cap twenty-four hours post insertion then every week and PRN (as needed). The order was started on 03/11/2026 at 09:38 AM.A review of the physician's orders also revealed an order in the EMR to insert midline for IV fluids for acute kidney injury. The order was revised on 02/28/2026.A review of the care plan for Resident # 101 located in the EMR, revealed a focus for Potential for complications related to IV access site, IV therapy due to antibiotic treatment and hydration.A review of Resident # 101's Quarterly Minimum Data Set (an assessment tool) dated 12/27/2025 revealed under section C that Resident # 101 had a brief interview for mental status score of 15/15 indicating he/she had was cognitively intact.On 03/11/2026 at 10:38 AM, the surveyor observed Resident # 101 awake in bed. At that time, the surveyor observed a midline catheter inserted into the resident's right arm. A translucent, adhesive dressing was covering the area where the catheter was inserted into his/her arm. On the dressing was a handwritten date, 3/2.At that time, during an interview with the surveyor, Resident # 101 said that no one has changed the midline dressing since then.On 03/11/2026 at 12:02 PM during another visit by the surveyor, Resident # 101 was in bed. At that time, the surveyor observed that the previous dressing with the handwritten 3/2 was removed from Resident # 101 and a new dressing was applied to the PICC Line site dated 3/11/26 in blue ink.On 03/11/2026 at 12:59 PM during an interview with the surveyor, the Director of Nursing (DON) showed the surveyor a used dressing, partially wrapped in a disposable glove. The DON told the surveyor that she was showing the surveyor the previous dressing and that a new dressing was applied to Resident # 101 today. She said that the facility recovered the old dressing from a trash can to show the surveyor.A review of the facility-provided policy titled Catheter Insertion and Care revealed under General Guidelines that, Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days or if it is wet, dirty, not intact, or compromised in any way.N.J.A.C. 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding by failing to complete the formula label for a resident currently receiving a feeding. This deficient practice was identified for 1 of 3 (Resident # 8) reviewed for Tube Feeding.The deficient practice was evidenced by the following:A review of Resident # 8's 12/20/2025 Minimum Data Set (MDS; and assessment tool) revealed under section K that Resident # 8 was receiving a tube feeding while a resident in the facility.A review of Resident # 8's physician's orders located in the Electronic Medical Record (EMR) revealed that Resident # 8 was receiving nutritional formula via electronic pump from 7:00 PM at 65 milliliters an hour (ml/hr) for a total volume of 700 ml and to take down when the total volume has completed.A review of Resident # 8's care plan located in the EMR revealed a focus for at risk for alteration in nutrition related to therapeutic diet, also receiving enteral feedings to meet nutrition & hydration needs.On 03/11/2026 at 10:14 AM, the surveyor observed Resident # 8 asleep in their bed. At that time, the surveyor observed the feeding pump making an audible noise and the screen displaying Caution Cassette Error. The feeding pump tubing was connected to the resident. The surveyor observed the nutritional formula that was hanging off of a mobile pole. The nutritional formula label was not filled out whatsoever. The information missing from the label included the resident's name, room number, date, start time and rate per hour.On 03/11/2026 at 10:18 AM during an interview with the surveyor, the Licensed Practical Nurse Unit Manager (LPNUM) replied, Yes, it absolutely does. It goes up at four PM after the surveyor asked if the formula bottle has to be dated, labeled and filled out.A review of the facility policy titled, Infection Prevention and Control Program Gastric Tube Feeding Management revealed under Procedure that, 14. The nurse shall label the feeding bag/bottle with the date and time the feeding was started, the amount of the feeding and the nurse's initials. The nurse shall input the rate of the feeding, based on the physician order, and the total volume to be infused (dose) over 24 hours into the pump before the initial feeding is started.N.J.A.C. 8:39-27.1(a)

Complaint # 2723157Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as mandated for 1 of 1 resident (Resident #21) reviewed for abuse and was evidenced by the following:On [DATE] at 9:33 AM, the surveyor observed Resident #21, awake in bed. When the surveyor began speaking to the resident, the resident indicated to the surveyor that they were hard of hearing.On [DATE] at 11:22 AM, the surveyor together with another surveyor observed Resident #21, awake and alert in bed. The resident was calm with no sign of distress. The resident was asked by the surveyors through written questions that the resident was able to read and understand, whether they prefer a male or female aide (CNA) (Certified Nursing Assistant) to give them care. The resident stated that they only prefer female aides to give them care. The resident was asked if they previously had a problem with a male aide. The resident narrated that a few months ago, they had a male aide who gave them a shower with the name that sounded like [name redacted] who touched them inappropriately in the groin area. The resident stated that they told one of the people that changed them or the administrator on the day or the next day when the incident happened. A review of the electronic medical record (EMR) for Resident #21 revealed the following:A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to the following: Dementia, Depression, and Mixed Anxiety Disorder.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated [DATE], reflected that Resident #21 had severely impaired cognition. The MDS also revealed that the resident was dependent on staff for their activities of daily living that included toileting hygiene, shower, and lower body dressing.A review of the individualized person-centered care plan revised on [DATE], included a focus of impaired functional status related to impaired mobility due to fall at home resulting in fracture of the right shoulder. One of the interventions included no male CNAs created on [DATE].A review of the Point-of-Care (POC) documentation (care staff documentation of care activities in the EMR) in [DATE] revealed the resident was given shower on [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 10:10 AM, the Director of Nursing (DON) identified to the surveyor the male aide who gave the showers on the above dates as CNA #2.A review of the facility-initiated investigation file about Resident #21's allegation included the following: a summary of events with conclusion by the Licensed Nursing Home Administrator (LNHA) dated [DATE]; a list of female residents under the care of CNA #2 who were interviewed by LPN/ UM dated [DATE]; undated statement from CNA #2; statements from other CNAs and 2 nurses with varied dates from [DATE] to [DATE]; facility-wide re-education about Abuse, Neglect and Resident Rights from [DATE] to [DATE]; a completed background screening form of CNA #2; and Abuse and Neglect Policy and Procedure dated February 2025. The investigation concluded that there was no evidence to support the allegation of sexual abuse. CNA #2 was placed on administrative leave on [DATE] and was reinstated back to work on [DATE]. The investigation file did not include any documentation that the New Jersey Department of Health (NJDOH) was notified.On [DATE] at 9:42 AM, during an interview with the surveyor, the DON stated that when an allegation of abuse is reported, they interview the resident, check for pain and do skin assessment, do incident report, notify the family, physician, and police. The DON further stated that with the administrator already aware, investigation would be started and if the event is reportable, they report to the NJDOH. The DON stated that they report to the NJDOH within 2 hours if there's an injury and if not within 24 hours. On [DATE] at 12:58 PM, during an interview with the survey team, the Licensed Nursing Home Administrator (LNHA) stated that they should have reported the allegation to the NJDOH and that they were wrong in not doing so. The LNHA confirmed to the survey team that there was no evidence to support the allegation and that CNA #2 does not work in the facility anymore since their certification expired last [DATE].A review of the facility-provided policy revised in February 2025, titled Resident Abuse/ Neglect Policy and Procedure included under Investigative and Reporting Procedure: The Department of Health and Senior Services, and the Office of the Ombudsman if the resident is 60 or over, will be notified immediately (as soon as possible but not to exceed 2 hours) of the incident, followed by a written report within 5 days of the incident and if the alleged violation is verified, the facility shall take corrective action. N.J.A.C. 8:39-27.1(a)

Based on record review and staff interview, the facility failed to ensure that pre-employment screening procedures were completed for employees prior to hire, including obtaining reference checks and/or background screenings, in accordance with the facility's abuse prevention policies. This deficient practice was found for 23 out 108 employee files reviewed. This deficient practice was evidenced by the following:On 03/08/2026 during entrance conference, the surveyor requested that the Licensed Nursing Home Administrator (LNHA) provide personnel files for all employees hired since the last annual recertification survey in 10/2024, regardless of current employment status. The requested documentation included the department of hire, date of hire, license verification, reference checks, criminal background checks, and pre-employment medical documentation, including physical examinations and two-step Mantoux test results.On 03/09/2026 at 08:56 AM the surveyor began reviewing the files, and found the following:Employee #1, hired as a [NAME] on 10/09/2024, had no documented reference checks in the personnel file at the time of review.Employee #2, hired as a Housekeeper on 11/19/2025, had no documented reference checks in the personnel file at the time of review.Employee #3, hired as a Housekeeper on 03/12/2025, had no documented reference checks in the personnel file at the time of review.Employee #4, hired as a Licensed Practical Nurse (LPN) on 01/05/2025, had no documented reference checks in the personnel file at the time of review.Employee #5, hired as a Housekeeper on 05/21/2025, had no documented reference checks in the personnel file at the time of review.Employee #6, hired as a Nurse's Aide (NA) on 04/10/2025, had no documented reference checks in the personnel file at the time of review.Employee #7, hired as a NA on 12/18/2024, had no documented reference checks in the personnel file at the time of review.Employee #8, hired as a NA on 01/03/2025, had no documented reference checks in the personnel file at the time of review.Employee #9, hired as a NA on 12/18/2025, had no documented reference checks in the personnel file at the time of review.Employee #10, hired as a Certified Nurse Aide (CNA) on 04/09/2025, had no documented reference checks in the personnel file at the time of review.Employee #11, hired as a NA on 01/15/2025, had no documented reference checks in the personnel file at the time of review.Employee #12, hired as a NA on 10/08/2025, had no documented reference checks in the personnel file at the time of review.Employee #13, hired as a Housekeeper on 11/06/2024, had no documented reference checks in the personnel file at the time of review.Employee #14, hired as a NA on 11/24/2025, had no documented reference checks in the personnel file at the time of review.Employee #15, hired as a Housekeeper on 11/26/2024, had no documented reference checks in the personnel file at the time of review.Employee #16, hired as a CNA on 10/28/2024, had no documented reference checks in the personnel file at the time of review.Employee #17, hired as a Housekeeper on 11/20/2024, had no documented reference checks in the personnel file at the time of review.Employee #18, hired as a CNA on 10/08/2025, had no documented reference checks in the personnel file at the time of review.Employee #19, hired as a NA on 11/10/2025, had no documented reference checks in the personnel file at the time of review.Employee #20, hired as a CNA on 05/21/2025, had no documented reference checks, and no evidence of a completed criminal background screening prior to the start date in the personnel file at the time of review.Employee #21, hired as a CNA on 08/27/2025, had no documented reference checks in the personnel file at the time of review.Employee #22 hired as a CNA on 11/20/2024, had no documented reference checks in the personnel file at the time of review. Employee #23, hired as a CNA on 06/04/2025, had no evidence of a completed criminal background screening prior to the start date.During an interview on 03/09/2026 at 11:28 AM with the surveyor, the Human Resources (HR) staff member said if applicants don't have a work history they look at the background check for possible employment. When asked if they would check personal references, HR said, she never thought of that.On a follow up interview with HR on 03/10/2026 at 12:52 PM, she said that the department managers look over applications, conduct interviews and then send her the applications of the perspective applicant to run background checks and check references. HR said for some applicants, their friends were employees and did verbally vouch for them but there was nothing documented in writing. HR also said with the applicants that have already gone through some form of a nursing program, she assumed they were vetted somewhere. When asked about the missing background checks, HR said they somehow got missed, and she was running them at this time.During an interview on 03/11/2026 at 12:59 PM with the survey team, the (LNHA) said it is very important to have background checks and references to make sure applicants aren't a serial killer, have anger issues and to ensure they are a good fit to work in healthcare. The LNHA said we know we should have a least one personal reference, going forward there will be a check off list.A review of the facility provided policy titled. Resident Abuse/Neglect Policy and Procedure revealed under Screening that, We are dedicated to thoroughly investigating the past histories of any individual we are considering hiring as an employee or otherwise engaging. All prospective employees will be carefully screened using the following processes to identify potential risks of abuse/neglect of any resident: 1. Reference Check and, 2. License check and background checks: NJAC 8:39-9.3 (b)

Based on interview and record review, it was determined that the facility failed to develop and implement a care plan that meets the medical needs identified on the comprehensive assessment care for 1 on 35 residents reviewed for comprehensive care plans, Resident #5. This deficient practice was evidenced by the following: A review of Resident #5's admissions record revealed that, Resident #5 was admitted with but not limited to Benign Prostatic Hyperplasia (enlarged prostate), and Obstructive and Reflux Uropathy (a blockage in one or both tubes that carry urine from the kidneys to the bladder.) A review of the Resident #5's comprehensive Minimum Data Set (MDS), dated [DATE], revealed under section H that the resident had an indwelling catheter. A review of the current Care Plan (CP) for Resident #5 did not include documentation of a CP focus area or interventions for the care of indwelling catheters. During an interview on 10/21/2024 at 10:15 AM with the surveyor the Licensed Practical Nurse (LPN)# 1 was asked what should be on the CP for a resident with an in dwelling catheter. At this time LPN #1 responded, Indwelling catheter care and risk for infection. When asked if there should be a focus on the indwelling catheter on the resident's baseline CP, LPN #3 replied. Yes, there should be one that has to do with care. During an interview on 10/21/2024 at 01:22 PM with the surveyor asked the Director of Nursing (DON) if there should be a focus area on the indwelling catheter on the resident's CP. The DON responded, yes of course. A review of a facility provided policy with a review date of 3/2024 and titled Comprehensive Person-Centered Care Plan revealed under section Policy Statement that, 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. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) properly store medications, b.) maintain clean and sanitary medication storage areas, and c.) properly label opened multidose medications. This deficient practice was observed in 3 of 4 medication carts and was evidenced by the following: On [DATE] at 12:25 PM, in the presence of Licensed Practical Nurse 1 (LPN1), the surveyor observed the SMART nursing unit's medication cart #1. The surveyor and LPN1 observed a total of three (3) loose pills of varying colors and sizes in the bottom of the cart drawer, not in the pharmacy packaging (bingo cards). The LPN confirmed that pills should not be loose in the drawer. On [DATE] at 12:45 PM, in the presence of Licensed Practical Nurse 2 (LPN2), the surveyor observed the North Wing nursing unit's medication cart #1. The surveyor and LPN2 observed a total of ten (10) loose pills of varying colors and sizes in the bottom of the cart drawer, not in the pharmacy packaging. The surveyor further observed the locked controlled substance/narcotic medication box was missing all fasteners or bolts which kept the box secure to the drawer in which it was kept, which would allow the narcotic box to be able to be maneuvered out of the drawer. The surveyor observed one (1) multi-use bottle of prescribed lubricating eye drops, which was confirmed by LPN2 to have been opened and used. The bottle was not labeled or dated with the resident's name or date opened. At this time, LPN2 confirmed that the bottle should be labeled and dated. The LPN further confirmed that pills should not be loose in the drawer, and stated, I switched cards from one drawer to another and they smashed out. It happens. On [DATE] at 10:28 AM, in the presence of Licensed Practical Nurse 3 (LPN3), the surveyor observed the South Wing nursing unit's medication cart #2. The surveyor and LPN3 observed one (1) loose pill in the bottom of the cart drawer, not in the pharmacy packaging. On [DATE] at 12:00 PM, the surveyor interviewed the Director of Nursing (DON) who stated loose pills should be removed from the carts, and nurses, unit managers, and the pharmacy consultant are responsible for checking the carts for cleanliness and loose pills. The DON further stated that multi-use containers are usually labeled with a small label from the pharmacy with resident information. On [DATE] at 11:10 AM, the DON informed the surveyor that she spoke with LPN2 who informed her that she believed the label may have come off the eye drop bottle, and the DON's expectation is if the nurse noticed the bottle not labeled, she would throw it out and ask the pharmacy to have a new one delivered. A review of the facility's Medication Storage policy with a revised date ,d+[DATE] included C. medications will be stored in an orderly, organized manner in a clean area . E. medications will be stored in the original, labeled containers received from the pharmacy . F. expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy . A review of the facility's Schedule II Controlled Substance Medication policy with a revised date ,d+[DATE] under the section titled Storage of controlled dangerous substances (CDS) included 1. All CDS medications will be stored under double lock, separate from all other medications. 2. The keys to locked areas that store CDS medications must always be in the possession of a licensed nurse that meets the criteria for handling CDS medications as per facility policy and procedure. A review of the facility's Medication Labeling Policy and Procedure revised date of ,d+[DATE], included .external medications dispensed in a plastic bag (insulin pens, creams, ointments, etc.) will display a label on the plastic bag and a smaller flag label on the medication directly . If for some reason the label on a medication falls off and is lost the facility must notify the pharmacy of the occurrence immediately. The pharmacy will then resend the medication . N.J.A.C. 8:,d+[DATE].4

Based on observation, interview, and record review it was determined that the facility failed to a.) store respiratory equipment in a way to prevent contamination, and b.) assess a resident's pulse oximetry (a non-invasive way to monitor a persons oxygen level) as ordered by the physician. This deficient practice was for 1 of 2 residents reviewed for respiratory care (Resident #74) and was evidenced by the following: a.) On 07/17/23 at 10:52 AM, during the initial tour of the facility, the surveyor observed Resident #74 was in bed with eyes open. The surveyor observed an oxygen concentrator on the floor next to the resident's bed. At the time of the observation, the resident was not wearing the oxygen. The surveyor observed that the oxygen tubing was wrapped up around the handle of the concentrator and not in a bag. On 07/18/23 at 10:54 AM, the surveyor reviewed Resident #74 physician orders which showed an order for oxygen at two liters per minute continuous at bedtime, and another order to monitor the resident's pulse oximetry every shift and notify the physician if less than or equal to 90 percent. This was an active order dated 02/03/22. Review of the Admission Record Resident #74 was admitted to the facility on ,d+[DATE]. Medical diagnoses included, but not limited to congestive heart failure, covid-19, dementia, and depressive disorder. Resident #74 had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. On 07/18/23 at 12:11 PM, the resident was observed sitting on the side of the bed having lunch. The resident was not wearing oxygen and the oxygen concentrator was on the floor next to the bed turned off. The oxygen tubing was wrapped up in a circle and tucked in the handle of the concentrator, the tubing was not in a bag. On 07/19/23 at 12:15 PM, the surveyor observed the resident sitting on the side of the bed. The resident was not wearing oxygen during observation. Resident #74 told the surveyor that he/she wears oxygen at night. The oxygen tubing was connected to the concentrator and the tubing was wrapped up on top of the humidity bottle. The tubing was not in a bag. On 07/19/23 at 12:28 PM, the surveyor interviewed Licensed Practical Nurse/LPN (LPN #1) regarding storing of oxygen tubing when not being used by a resident. LPN#1 replied, It should be kept in a plastic bag. The surveyor asked why it should be in a plastic bag and LPN #1 said, Sanitary reasons. The surveyor showed LPN#1 Resident #74 oxygen tubing and LPN#1 said, It should be in a bag. On 07/19/23 at 12:50 PM, the surveyor interviewed LPN #2 regarding the storage of oxygen tubing. The surveyor asked LPN #2 how oxygen tubing was stored for a resident when not in use and LPN #2 responded, In a bag for sanitary reasons and to just keep it clean. b.) On 07/18/23 at 10:54 AM, the surveyor reviewed Resident #74 physician orders which showed an order for oxygen at two liters per minute continuous at bedtime, and another order to monitor the residents pulse oximetry every shift and notify the physician if less than or equal to 90 percent. This was an active order dated 02/03/22. On 07/18/23 at 11:00 AM, the surveyor reviewed Resident #74 care plan which had a focus of potential for Congestive heart failure related to cardiac status and a diagnosis of Congestive heart failure. The care plan was initiated on 03/22/20 with a revision date of 01/27/22. Included in the interventions was to provide oxygen as ordered and monitor pulse oximetry and lung sounds every shift. On 07/18/23 at 11:07 AM, the surveyor reviewed the pulse oximetry checks for May and June which showed the following: 7/2/2023 10:33 97.0 % Room Air 6/2/2023 12:38 95.0 % Room Air 6/1/2023 09:24 98.0 % Room Air 5/31/2023 10:48 96.0 % Room Air 5/30/2023 23:16 96.0 % Room Air 5/30/2023 12:52 95.0 % Room Air 5/30/2023 01:58 95.0 % Room Air 5/29/2023 13:26 95.0 % Room Air 5/29/2023 00:16 96.0 % Room Air 5/28/2023 13:57 98.0 % Room Air 5/26/2023 12:45 98.0 % Room Air 5/25/2023 20:08 97.0 % Room Air 5/25/2023 13:19 97.0 % Room Air 5/24/2023 22:26 98.0 % Room Air 5/24/2023 13:13 96.0 % Room Air 5/23/2023 01:09 97.0 % Oxygen via Nasal Cannula 5/22/2023 17:28 98.0 % Room Air On 07/20/23 at 11:50 AM, the surveyor interviewed the Director of Nursing (DON) regarding Resident #74 oxygen saturations and requested Resident #74 oxygen saturations for the months of June and July 2023. On 07/20/23 at 12:17 PM, the DON approached the surveyor and said, Let me tell you, pulse oximetry's were not done. They fell off when we stopped doing every shift vital signs for covid. The surveyor asked if they should have been done and the DON said, Yes. On 07/27/23 at 09:30 AM, the surveyor reviewed the facility's policy titled, Oxygen Tubing and Respiratory Products. The policy had a reviewed date of 01/01/23. The policy read that the facility was to ensure all oxygen tubing is single use for residents, clean, properly stored, and dated to prevent the transmission of infection. Under the procedure section, it stated the facility was to ensure if oxygen tubing is not in use, that it is in an oxygen bag labeled with the resident's name and room number as well as the date it was changed. NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to provide a device to address the contracture (a condition in which there is shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) for 1 of 2 residents (Resident #103) that were reviewed for Range of Motion (ROM). This deficient practice was evidenced by the following: The surveyor observed Resident #103 with a closed, left hand and without a palm grip on 7/18/23 at 12:40 PM, on 07/19/23 at 9:50 AM, on 07/20/23 at 10:32 AM, on 07/20/23 at 12:38 PM, and on 07/21/23 at 11:49 AM. When interviewed by the surveyor on 7/21/23 at 11:55 AM, the South Unit Manager stated that Resident # 103 should have been wearing a left palm grip but did not have one in his/her left hand as ordered. According to the medical record Resident # 103 was admitted with a diagnosis that included but was not limited to arthritis. The annual minimum dated set (MDS) (an assessment tool) dated 06/2/23 reflected that this resident was cognitively impaired. On 07/19/23 at 12:30 PM, the surveyor reviewed a copy of the resident's physician orders. A physician's order, dated 4/21/23, indicated that Resident # 103 should be wearing a left-hand Palm grip, wash cloth roll, or cling roll to L hand at all times as tolerated. On 07/19/23 at 12:30PM, the surveyor reviewed a copy of the resident's interdisciplinary plan of care. It indicated use of a palm grip to left hand/ if not available may use wash cloth or roll of kling. On 07/27/23 at 10:02 AM, the surveyor reviewed the facility provided policy for splint application which was reviewed on 7/2023. The policy reflects 6. apply splint, hand roll as per orders. NJAC 8:39-27.2(m)

Complaint #NJ153752 Based on interviews and review of the closed medical record, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan which included interventions to ensure that a resident's preference not be cared for by male aides was honored. This deficient practice was identified for 1 of 37 residents (Resident #211) reviewed for care plan development. This deficient practice was evidenced by: Review of Resident #211's Admission Record (an admission summary) revealed that the resident was admitted to the facility in March of 2022 with diagnosis which included but were not limited to: dementia, cognitive communication deficit, unilateral (one sided) primary osteoarthritis (degeneration of joint cartilage and the underlying bone), presence of right artificial knee joint, difficulty walking and retention of urine. Review of Resident #211's admission Minimum Data Set (MDS), an assessment tool dated 03/21/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out 15, which indicated that the resident was moderately cognitively impaired. Further review of the MDS indicated that the resident required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Section H of the MDS, Bladder and Bowel, revealed that the resident had an indwelling catheter (urinary catheter) and was always incontinent of bowel. Review of Resident #211's Care Plan revealed an entry that was initiated on 03/21/22, which specified that the resident had a diagnosis of anxiety disorder and exhibited paranoia, verbally/physically aggressive behavior, and had a history of delusions, and auditory (sense of hearing) and visual hallucinations. The entry noted that the resident was on Xanax (anti-anxiety medication) and Zoloft (antidepressant). The focus of the care plan entry concluded with, No male aides. Further review of the goals and interventions/tasks sections of the Care Plan failed to specify how the facility ensured that no male aides were assigned to the resident in accordance with the resident's Care Plan. Review of the Progress Notes within Resident #211's closed electronic health record, revealed a Nurse's Note dated 04/06/22 at 2:28 PM, that was signed by the Assistant Director of Nursing (ADON) and revealed the following: Unit Manager, Director of Social Services, and ADON reviewed careplan [sic]; updated as needed.Careplan [sic.] remains appropriate at this time. On 07/24/23 at 11:05 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that if a resident requested not to have a male aide provide care, then the Unit Clerk/Secretary was responsible to make sure that the request was placed on the CNA Assignment Sheet. The CNA explained that the assignment may then have to be adjusted to ensure that the resident's preference was honored. The CNA further stated that the request would also be passed on in report by nursing or the outgoing CNA. On 07/24/23 at 11:09 am, the surveyor interviewed the Secretary who stated that she worked at the facility for one year in June. She stated that nursing advised her of all resident special requests, and she was responsible to place the requests on the CNA Assignment Sheet. On 07/24/23 at 11:46 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that a resident request not to have a male aide was reported to the Secretary who was responsible for making the CNA Assignments and scheduling. On 07/24/23 at 11:51 AM, the Secretary provided the surveyor with 2022 CNA Assignment Sheets which failed to contain CNA Assignment Sheets that corresponded to the dates that Resident #211 resided at the facility. On 07/24/23 at 12:19 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that she had worked at the facility since 2012 and served in her current role as LPN/UM for one month. She stated that if a resident requested not to have a male aide provide care, then she would communicate with social services, update the resident's care plan and place the resident's preference on the CNA Assignment Sheet. On 07/24/23 at 12:27 PM, the surveyor interviewed the Social Worker who stated that she worked at the facility for four years. She stated that she had not had an instance where a female resident refused to be cared for by male CNAs. The SW stated that if she encountered this situation she would direct the resident's preference to the Unit Manager, Director of Nursing (DON), and Administrator and assist the resident to file a grievance if indicated. On 07/25/23 at 11:26 AM, the surveyor interviewed the ADON who stated that she assisted in Care Plan development. She stated that either the UM or Secretary informed the aides that males were not to be assigned to a particular resident or that assignments were switched to honor a resident preference that was Care Planned. The ADON stated that the preference could be placed on the CNA Assignment Sheet or on a sign behind the nurse's station at the desk. The ADON stated that if a male was accidentally assigned to the resident, then the resident would be interviewed and evaluated to ensure the resident was comfortable. The ADON was unable to state why she documented in the Nurse's Notes on 04/06/22, that she reviewed Resident #211's Care Plan and denied that the entry was in reference to no male aides being assigned to the resident. On 07/26/23 at 10:33 AM, in a later interview with the LPN/UM, she accessed Resident #211's electronic health record and demonstrated that the resident's Plan of Care (POC) Dashboard was updated with Special Instructions: No Male Aide. The LPN/UM also showed the surveyor that a male CNA was assigned to the resident on 04/02/22 and signed that he performed urinary incontinence care at 3:41 PM, personal hygiene at 3:41 PM, assistance with dressing at 3:41 PM, and assisted with nutrition at 5:23 PM. The LPN/UM stated that the male CNA did not document that any care was rendered thereafter. The LPN/UM stated that no male aide should have been placed on the resident's assignment. The LPN/UM stated that a caregiver should only sign for the tasks that they actually completed. On 07/26/23 at 11:27 AM, the surveyor attempted to interview the male CNA in question who was not available for interview. On 07/26/23 at 11:27 AM, the surveyor interviewed the DON and the Administrator in the presence of the survey team. The Administrator stated that chances were that the male CNA provided care to Resident #211 as evidenced by the tasks that he signed out in the POC on 04/02/22. The Administrator further stated that the male CNA might have also charted for another aide. The DON stated that if the resident's Care Plan specified No Male Aides on 03/14/22, then the request should have been placed on the CNA Assignment Sheets prior to 04/04/22, when the entry was first documented, according to CNA Assignment Sheets that the DON provided. On 07/27/23 at 9:10 AM, in a later interview with the DON, she provided the surveyor with printed copies of Resident #211's CNA Task History dated 04/02/22, and she explained that the male CNA documented that he provided personal care to the resident which included incontinence care, personal hygiene assistance with dressing and dining. The DON stated that the CNA's signature indicated that he rendered all services that he signed for. Review of an undated facility policy, Comprehensive Person-Centered Care Plan revealed the following: 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. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The IDT includes: The Attending Physician; A license [sic.] nurse who has responsibility for the resident; A nurse aide who has responsibility for the resident; .The resident and resident's legal representative . Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; .Reflect the resident's expressed wishes regarding care and treatment goals; Review of the facility's Resident Rights (May 2023) revealed the following: .To be treated with courtesy, consideration, and respect for your dignity and individuality . NJAC 8:39-11.2, 13/2(a)

Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool for 3 of 34 residents reviewed (Resident #74, #101, and #69). This deficient practice was evidenced by the following: On 07/17/23 at 10:53 AM, the surveyor observed Resident #74 sitting on the side of the bed in the room. There was an oxygen concentrator with oxygen tubing on the floor. Review of Resident #74 Admission Record, the resident was admitted to the facility on [DATE]. Medical diagnoses included, but not limited to congestive heart failure, covid-19, dementia, and depressive disorder. Review of the quarterly MDS, dated [DATE], revealed Resident #74 had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. Under Section O, Special Procedures and Treatments was blank, meaning the resident did not wear oxygen as a resident at the facility. Review of the physician orders showed an order for oxygen continuous at two liters per minute at bedtime, an active order dated 02/02/23. On 07/17/23 at 11:57 AM, the surveyor observed Resident #101 in the bed. There was an oxygen concentrator on the floor with oxygen tubing. The surveyor asked the resident if he/she wore the oxygen and the resident said, I wear it every night and sometimes during the day when I become short of breath. Review of the quarterly MDS dated [DATE], the resident was readmitted to the facility again in March 2023. The resident had a Brief Interview of Mental Status of 15, meaning Resident #101 was cognitively intact. Medical diagnoses included, but were not limited to heart failure, heart disease, and high blood pressure. Review of the quarterly MDS, dated [DATE] under section O, Procedures and Treatments the area for oxygen was left blank, meaning the resident did not wear oxygen as a resident at the facility. Review of the physician orders showed an order for oxygen at two liters per minute for shortness of breath, an active order dated 03/14/23. On 07/26/23 at 10:54 AM, a surveyor interviewed the Minimum Data Set Coordinator (MDSC). The surveyor asked who was responsible for filling out sections of the Minimum Data Set (MDS), and the MDSC said the Social Worker or Activities department filled out section F, nursing completed section J, the dietician completed section K, and therapy completed parts of section O. The departments will enter the data into the MDS themselves. The Director of Nursing oversees the completion of all of the MDS. The MDSC told the surveyor it was extremely important to be accurate for residents and for the state to see how we are doing. The MDSC also stated that they use the MDS to track how the residents are doing to see if there are significant changes or if therapy referrals are needed to work on for resident care and improvement. 44833 2. On 07/17/23 at 10:37 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) on the North nursing unit. The LPN/UM stated the facility is smoke free, however, there was one resident (Resident #69) who was grandfathered in and was able to remain the only smoking resident in the facility. On 07/17/23 at 11:34 AM, the surveyor observed Resident #69 in their room relaxing in bed. The resident informed the surveyor that he/she had smoked since the age of 14, and usually smokes one cigarette four times per day in the courtyard. The resident further informed that the facility holds on to the cigarettes and lighter, but the resident can smoke independently, safely. Review of Resident #69 Admission Record, the resident was admitted to the facility in March 2015. Medical diagnoses included, but not limited to chronic obstructive pulmonary disease (COPD, a disease affecting the lungs), and major depressive disorder (depression). Review of the annual MDS, dated [DATE], revealed Resident #69 had a Brief Interview of Mental Status of 15 out of 15, meaning the resident was cognitively intact. Under Section J, Current Tobacco Use, the assessment was answered No, indicating the resident did not use tobacco. Review the resident's medical record contained a Smoking Contract between Resident #69 and the facility signed by the resident and witnessed by the North unit's LPN/UM and dated 2/28/23. Review of nursing progress notes included a 7 day lookback note dated 2/13/2023 at 9:46 AM by the LPN/UM stating .resident goes outside to smoke .continues to be a safe smoker. A second 7 day lookback nursing note dated 2/8/2023 at 1:22 AM included Resident goes outside to smoke various times of the night . On 7/26/23 at 10:54 AM, the surveyor interviewed the MDSC who stated this resident had been smoking for quite a while, and the resident was still smoking at the time of the completion of this annual MDS. The MDSC stated they infrequently have agency staff assist with MDS completions, and that may have been the reason for the inaccurate smoking assessment for this resident, and after surveyor inquiry, this MDS was modified to reflect a yes for tobacco use. NJAC 8:39-11.2 (e)1

Based on observation, interview, and record review it was determined that the facility failed to follow proper infection control procedures by a.) not donning (put on) and doffing (remove) the proper personal protective equipment for residents on transmission based precautions, and b.) not performing hand hygiene between resident contact on 1 of 5 units (SMART Unit). This deficient practice was evidenced by the following: On 1/4/21 at 10:23 AM, the surveyor interviewed the Administrator, Director of Nursing (DON) and the Infections Preventionist (IP). The IP confirmed that the staff should be wearing masks and eye protection at all times. On the COVID-19 confirmed hallway the staff should wear full PPE (gown, gloves, mask and eye protection). On the Person Under Investigation (PUI) hallway the staff should wear full PPE. On the recovered and clean hallways, the staff should wear at minimum a surgical mask. The IP added that the staff had been fit tested for the N95 mask and if they choose to wear a surgical mask over it they could, but that it was not required. The Administrator stated that the residents ate meals in their rooms. The IP stated that a Food Service Worker (FSW) delivered the trays to the unit and the trays were distributed to the residents by the nursing staff. She added that the COVID-19 confirmed residents received their meals on disposable plates and utensils and reusable items were used on the other units. At 12:23 PM, the surveyor began tour on the SMART Unit that was comprised of a hallway dedicated to COVID-19 confirmed residents, a hallway dedicated to New Admissions Person Under Investigation (PUI) residents and a hallway dedicated to recovered residents. The surveyor observed multiple wall mounted ABHR dispensers throughout the SMART Unit hallways as well as wall mounted bins that contained PPE. At 12:29 PM, the surveyor observed a Certified Nursing Assistant (CNA #1) on the wing dedicated to confirmed COVID-19 residents dressed in full Person Protective Equipment (PPE-gown, gloves, mask, N95, and eye protection). CNA #1 delivered disposable meal trays to the residents in their rooms on that hallway. At 12:32 PM, upon completion of the lunch meal delivery, the surveyor observed CNA #1 discard her gown and gloves, exit the COVID-19 dedicated wing and wash her hands with soap and water appropriately. At 12:35 PM, the surveyor interviewed CNA #1 who confirmed that she was the dedicated CNA for the COVID-19 confirmed residents. On 1/4/21 at 12:47 PM, the surveyor observed CNA #2 and CNA #3 at a closed metal meal tray cart that they pushed on to the PUI hallway. The trays contained the lunch meal on reusable dishes and utensils. The surveyor observed that there were signs on the door frame that read: New Admission Precautions, and also a sign on the door itself that read: STOP Special Droplet/Contact Precautions, In addition to Standard Precautions. Only essential personnel should enter this room. Everyone Must: including visitors, doctors, and staff-Clean hands when entering and leaving room, Wear face mask, Wear eye protection (faceshield or goggles), Gown and glove at door . and Keep Door Closed. CNA #1 joined in the meal delivery on the PUI hallway. The doors of Rooms nine (9) to 15 were open to the hallway. The three (3) CNA's donned white disposable gowns that they retrieved from a bin on the wall outside of room [ROOM NUMBER]. They were already masked and wearing eye protection. CNA #2 entered room [ROOM NUMBER] where she set up the residents tray for consumption, and then exited the room wearing the white gown and went to the cart to remove another tray. CNA #1 removed a tray from the cart and went into room [ROOM NUMBER] where she set up the residents lunch tray while the resident sat in a chair next to the bed. CNA #1 then exited the room still wearing the white gown. CNA #1 then grabbed a second lunch tray and entered room [ROOM NUMBER] and set up that residents tray. CNA #1 then exited the room wearing the same white gown and preformed hand hygiene with Alcohol based gel. CNA #3 was observed in the hallway by room [ROOM NUMBER] putting on a new white disposable gown. At 1:05 PM, the surveyor interviewed CNA #2 who stated that the PUI hallway was for new patients on precautions and that it also spilled over to the middle hallway and that the remainder of the middle hallway for residents that were off quarantine. CNA #2 stated that the residents on the PUI hallway were potential COVID and We act like they have it. She added that the staff must wear gown, gloves, mask, surgical mask and eye covering. CNA #2 stated that they usually keep the same gown on when passing out trays, because we usually do not touch the residents and then added that there was still some confusion about it. CNA #2 confirmed that the staff was dedicated to specific hallways of the SMART Unit. The CNA's were then observed pushing the meal cart to the spill over PUI rooms and finally into the Recovered resident area of the middle hallway. The doors to the resident rooms were opened to the hallway. The first four rooms (18 - 21) on the middle hallway had the special precaution sign on the door to the resident rooms. The surveyor then interviewed CNA #3 who stated that gowns and gloves were changed after each resident. CNA #3 confirmed that she was dedicated to the New Admission PUI hallway. CNA #3 confirmed that the room [ROOM NUMBER] to 29 were residents that were off the 14 day quarantine. At 1:08 PM, the surveyor observed CNA #1 don a gown and gloves and bring a lunch tray to a resident in room [ROOM NUMBER]. CNA #3 then handed another lunch tray to CNA #1 who remained in room [ROOM NUMBER]. CNA #3 stated that that was how they usually passed out the trays. She added that they still treat them the as potentially infectious even though they were off precautions. CNA #1 then removed her gown and gloves and discarded them in a garbage can in the room, exited the room and preformed hand hygiene with an alcohol based hand rub (ABHR). CNA #3 then donned a gown and gloves and brought a lunch tray to room [ROOM NUMBER]. CNA #1 then handed a tray to CNA #3, who remained in room [ROOM NUMBER]. The surveyor then observed a resident in a motorized wheelchair propelled herself from the PUI hallway and onto the recovered section of the hallway. The resident stated that he/she resided in a room on the recovered hallway and stated that he/she was returning from physical therapy. The surveyor then observed CNA #3 had removed her gown and gloves and discarded them in room [ROOM NUMBER], exited the room and preformed hand hygiene with an ABHR. CNA #1 wearing full PPE entered room [ROOM NUMBER] (recovered resident room) and set the residents tray for the lunch meal. CNA #3, also wearing full PPE entered room [ROOM NUMBER] and assisted CNA #1 to reposition the resident in bed. The two CNA's then exited room [ROOM NUMBER] without their gown and gloves and perform hand hygiene with ABHR. The surveyor then observed a fourth CNA (CNA #4) provide a lunch meal to the resident in room [ROOM NUMBER] on the recovered hallway. CNA #4 then went to the meal tray cart and retrieved another meal. The surveyor did not observe CNA #4 conduct hand hygiene. At 1:16 PM, the surveyor observed CNA #1 and CNA #3 push the meal cart down the hallway and placed it in the hallway by room [ROOM NUMBER]. CNA #3 in full PPE entered room [ROOM NUMBER] with a lunch tray and then exited the room in full PPE and returned the tray to the meal cart and stated that they had a doubled lunch meal. CNA #3 then returned to room [ROOM NUMBER] and discarded her gown and gloves. CNA #1, dressed in full PPE, brought a lunch tray to a resident in room [ROOM NUMBER] where set up assistance was provided for the resident. CNA #2 was observed in room [ROOM NUMBER] without a gown and gloves and provided assistance to the resident that was seated in a chair by the door. CNA #2 moved the phone and bedside table and then exited the room and without conducting hand hygiene went to the meal cart and grabbed a tray and brought the tray to a resident in room [ROOM NUMBER] where she then set the tray up for the resident. The surveyor then observed CNA #1 and CNA #3 push the meal cart back up the hallway and placed it in the hallway by the nurses station. CNA #2 then exited room [ROOM NUMBER] and stood in the doorframe of room [ROOM NUMBER] talking to CNA #4. The surveyor did not observe hand hygiene. CNA #2 and CNA #4 stated that they make rounds on their resident's based on the residents therapy schedule. CNA #2 stated that they usually have the same assignment and that they have been dedicated to the hallway for residents that were recovered and no longer on quarantine. CNA #2 stated that they deliver the meal trays opposite of from well to ill residents rounds. She then added that the trays were delivered in the order that they come up to the floor from the kitchen. CNA #2 stated that they trays come up for the residents on the COVID hallway first and then a cart comes up for the residents on the other hallways. At 1:26 PM, the surveyor observed CNA #4 walk onto the COVID hallway, preformed hand hygiene with ABHR and then exited that area. At 1:30 PM, the surveyor observed CNA #3 return to the PUI hallway to make rounds. At 1:40 PM, CNA #3 pushed a small cart that contained three lunch meals and placed the cart in the hallway near the empty unit dining room. CNA #3 then pushed the small cart down the hallway through the PUI spill over rooms through the hallway to room [ROOM NUMBER]. At 1:46 PM, the surveyor observed CNA #4 bring the metal tray cart that was by the nurses station back down the hallway by room [ROOM NUMBER]. CNA #2 and CNA #4 began to remove completed meal trays from resident rooms on the recovered hallway. CNA #4 then entered room [ROOM NUMBER] and removed the completed meal tray from a resident and returned it to the cart. CNA #2 entered room [ROOM NUMBER] and removed the completed tray. Both CNA's returned the completed trays to the tray cart and without conducting hand hygiene CNA #4 re-entered room [ROOM NUMBER] and removed the completed tray and returned it to the meal cart. CNA #2, without conducting hand hygiene returned to room [ROOM NUMBER]. CNA #4 then removed the completed tray from a resident in room [ROOM NUMBER] and placed it on the meal cart. At 1:41 PM, the surveyor observed CNA #4 perform hand hygiene with ABHR, enter room [ROOM NUMBER], remove a completed tray to the meal cart and re-enter room [ROOM NUMBER] and remove the second completed tray and return it to the cart. Without conducting hand hygiene, CNA #4 pulled the tray cart up the hallway and parked it in the hallway by room [ROOM NUMBER]. CNA #4 then entered room [ROOM NUMBER] without wearing full PPE (no gown or gloves). The door of room [ROOM NUMBER] had the aforementioned Special droplet/contact precautions sign on the door. CNA #4 removed the completed meal tray from the room and placed it on the tray cart. CNA #2 was observed to enter room [ROOM NUMBER] without wearing full PPE (no gown or gloves) and removed the completed tray of Resident #6. Without conducting hand hygiene or donning full PPE (no gown or gloves), CNA #2 re-entered room [ROOM NUMBER] and went to the bedside of Resident #7. CNA #2 was observed standing at the bedside and assisted the resident by placing folded linen by the residents right leg. The surveyor observed the Special droplet/contact precautions sign on the door. At 2:00 PM, the surveyor observed CNA #2 wash her hands with soap and water appropriately. On the same day at 3:24 PM, the surveyor interviewed the Infection Preventionist (IP) and she was made aware of the surveyor's observations made during the lunch meal distribution on the SMART Unit. The IP confirmed that rounding for residents outside of an emergent situation, should begin with residents that were not exposed or have recovered from COVID-19, then to residents that were PUI and lastly to residents confirmed COVID-19. The IP added that PPE was used to protect the residents and staff. The IP stated that when the census on the COVID-19 confirmed unit was low, the dedicated staff would have to take an assignment on the PUI hallway and that they should conduct rounds beginning in the PUI hallway first, followed by the COVID-19 hallway. The IP stated that she had observed the tray delivery process on previous occasions and that the trays order of tray distribution depended on which trays were delivered to the unit first. The IP also stated that a gown and gloves were not required to be worn by staff when assisting residents on the recovered hallway. The IP confirmed that the staff should change their gloves and gowns between resident rooms on the PUI Hallway and that hand hygiene should also have been completed in between residents. She stated that the staff should not be coming out a resident room into the hallway with a gown on. She added that the staff did not technically have to wear full PPE because Resident #6 and Resident #7 were no longer on contact precautions. She added that the Special Precautions sign should have been removed from the door. She added that the staff should know who was no longer on precautions. The IP also confirmed that residents should not travel through the PUI hallway to go to or return from the therapy department. On the same day at 4:47 PM, the surveyor reviewed the schedule of food delivery that revealed the SMART Unit had two tray delivery times for each meal (breakfast, lunch, and dinner). On the same day at 5:04 PM, the surveyor reviewed an undated facility Policy and Procedure titled, Isolation Precautions. Under Types of Isolations it read: * Respiratory or Droplet - Masks are required if coming within three (3) feet of resident. Gloves are required if patient items in room are to be touched. Gowns are to be worn if rendering personal care. * Contact - Masks are optional. Gloves are to be worn if patient or items in room are to be touched. Gowns are to be worn if rendering personal care and contact with infected body fluids is expected. * [MEDICATION NAME] Precautions - Masks are optional. Gloves are to be worn if patient items in room are to be touched. Gowns are to be worn if soiling is likely. The policy definitions were as follows: Contact Precautions refers to measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. Droplet precautions refers to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Hand hygiene refers to washing hands with water and either plain soap or soap/detergent containing an antiseptic agent; or through applying an ABHR. Standard Precautions refers to infection prevention practices that apply to all residents, regardless or suspected or confirmed [DIAGNOSES REDACTED]. Standard Precautions is a combination and expansion of Universal Precautions and Body Substance Isolation (a practice of isolating all body surfaces such as blood, urine, and feces). PPE refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury. At 5:25 PM, the surveyor reviewed the facility policy with a revised date of 11/20/19 and titled, Personal Protective Equipment, read: Employees using PPE must observe the following precautions: * Wash hands immediately or as soon as feasible after removing gloves or any other form of PPE. If soap and water are unavailable, use an alcohol-based hand sanitizer that contains as least 60% alcohol to clean hands. * Remove PPE after it becomes contaminated and before leaving the work area. The surveyor then reviewed an undated Policy and Procedure titled, Hand Hygiene and read: Hand Hygiene Procedure based on CDC (Centers for Disease Control) guidelines: A. Use handwashing: 1. When hands are visibly dirty 2. After known or suspected exposure to [MEDICAL CONDITION] infection 3. After known or suspected exposure to Norovirus infection 4. If exposure to Bacillus Anthracis is suspected or proven 5. Before eating 6. After toileting B. Use alcohol based hand sanitizers for everything else. C. Routine hand washing technique: 1. Wet hands under running water. 2. Keeping hands lower than elbows, apply soap or antimicrobial skin cleanser and thoroughly distribute over hands. 3. Wash vigorously for at least 20 seconds, using friction to cover all surfaces of the hands, with particular attention to fingertips and nails. 4. Rinse under running water. 5. Use paper towel to dry hands. 6. Avoid recontamination of hands on sinks or sink components after washing (use separate paper towel as barrier to turn faucets off). D. When using alcohol-based hand sanitizers: 1. Put product on hands and rub hands together. 2. Cover all surfaces until hands feel dry. 3. Use based on manufacturers recommendations. The surveyor then reviewed the Admission Record of Resident #6 which revealed the resident was admitted to the facility in December of 2020. A review of Resident #6's Order Summary Report revealed a completed order dated 12/21/2020 for New-Re-admission transmission based (Droplet & Contact) Precautions x 14 days. The surveyor then reviewed the Admission Record for Resident #7 which revealed they were admitted to the facility in December of 2020. A review of the Order Summary Report revealed a completed order dated 12/28/2020 for New/Re-admission transmission based (Droplet & Contact) Precaution x 14 days. The surveyor then reviewed the successfully completed competencies for CNA #1, CNA #2, CNA #3 and CNA #4 related to: Personal Protective Equipment Application which read under: 10. Removed personal protective equipment inside the resident's room. 11. Placed in appropriate receptacle. 12. Performed hand hygiene. and, Gowning which read under: 10. Uses gowns only once and then removes and discards. 11. Performed hand hygiene. and, Hand Hygiene Competency read under: 1. The employee states the purpose of hand hygiene and gives examples of when handwashing/hand hygiene should be done: * Before and after resident contact. * After contact with blood, body fluids, or contaminated surfaces even if gloves are worn. * After removing gloves. * Before preparing food, water, or medication. * Before and after performing a treatment or procedure. * Before eating. *After toileting. * Between resident contact and if moving from a contaminated body site to a clean body site during resident care. 2. The employee states the equipment needed for handwashing and for hand hygiene with a waterless product. 3. The employee lists the steps for handwashing: * Wet hands under running water. * Apply about 5 ml of liquid (foam) soap. * Run vigorously for 20 seconds, cleaning under finger nails. * Rinse well under running water. * Dry hands with a clean paper towel. * Turn off faucet with a new paper towel. 4. The employee lists the proper use of an alcohol-based Hand Sanitizer: * Apply about 5 ml of product to the palm of one hand. * Rub hands together. * Rub the product over all surfaces of hands and fingers until hands are dry. The surveyor then reviewed the Course Completion History for the four CNA's identified above which revealed that they completed the CMS targeted COVID-19 training. N.J.A.C. 8:39 - 19.4

Based on observation, interview, document review, it was determined that the facility failed to ensure that kitchen staff wore beard restraints while preparing food in the kitchen, to maintain food sanitation. This deficient practice was observed during the initial tour of the kitchen and subsequent observations, for 5 of 5 food service workers, and was evidenced by the following: On 10/09/19 at 11:25 AM, the surveyor inspected the facility's kitchen in the presence of the Food Service Director (FSD). The surveyor observed five male Food Service Workers (FSW) (#1, #2, #3, #4, and #5) as they prepared food in the kitchen. All five FSW had beards and/or facial hair, none were wearing a beard restraint. When interviewed, the FSD stated that FSWs were to wear beard restraints while inside the kitchen and preparing food. The FSD also stated that it was the facility's policy for staff to wear hair/beard restraints while in the kitchen. During the food tray line observation on 10/18/19 at 11:20 AM, the surveyor observed FSW #1, enter the kitchen without wearing a beard restraint. FSW #1 went and stood near the steamtable where there was uncovered food items. The surveyor observed FSW #1 as he placed covered bowls of ready-to-eat peaches on a metal food cart. The FSW also removed containers of milk from the milk box and place them on to meal trays. When interviewed on 10/18/19 at 11:25 AM, FSW #1 stated that he had just returned from his lunch break and forgot to put on a beard restraint. FSW #1 stated that it was the facility's policy for staff to wear beard/hair restraints while in the kitchen. During another interview conducted by the surveyor on 10/18/19 at 12:20 PM, the FSD stated that FSWs were supposed to wear hair/beard restraints while in the kitchen. The FSD stated that he reminded his staff to wear hair/beard restraints while in the kitchen the other day. The FSD added FSW #1 knew better than to enter the kitchen without a beard restraint. During a dining room observation conducted by the surveyor on 10/21/19 at 12:30 PM. The surveyor, who was standing near the door of the kitchen inside the dining room, observed three FSWs standing near the steamtable preparing meal trays without wearing beard restraints. On 10/21/19 at 12:40 PM, in the presence of the FSD, FSW #2 was observed entering and exiting the kitchen without wearing a beard restraint. The surveyor also observed FSW #2 serve meals to residents in the dining room without a beard restraint. When interviewed, the FSD stated that he did not have any explanation as to why FSW #2 was not wearing a beard restraint. During an interview on 10/22/19 at 9:10 AM, the Infection Prevention Nurse (IPN) stated that all FSWs were required to wear beard/hair restraints while in the kitchen. The IPN stated that beard/hair restraints were worn to prevent contaminating the food. The IPN stated that she provided in-services education to the kitchen staff and added that the kitchen staff knew that hair/beard restraints should be worn in the kitchen. Review of the facility's undated policy titled, Employee Sanitary Practices, provided by the IPN, revealed the following: All kitchen employees will practice standard sanitary procedures. All employees shall: 1.) Wear hair restraints (hairnet, and/or beard restraint) to prevent hair from contacting exposed food. NJAC 8:39 17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to a.) follow appropriate infection control procedures while caring for a resident on contact isolation precautions, and b.) ensure the facility's Isolation Precautions policy and procedure was developed in accordance with the Center for Disease Control (CDC) guidelines on transmission based precautions. This deficient practice was identified for Resident #138, 1 of 3 residents reviewed for transmission based precautions and was evidenced by the following: On 10/10/19 at 10:40 AM, the surveyor observed Resident #138 from the resident's room doorway. The resident was laying in bed. The surveyor noted there was a red and white colored sign posted outside the resident's room door. The sign instructed visitors to report to the nurse prior to entering the room. There was also a red biohazard waste container inside the resident's room and in the hallway. The surveyor observed a beige colored cabinet affixed to the wall outside Resident #138's room, which contained Personal Protective Equipment (PPE). PPE are special coverings designed to protect individuals from exposure to or contact with infectious agents. These include gloves, face masks, protective eyewear, face shields, and protective gowns. On 10/18/19 at 11:51 AM, the surveyor observed from the doorway that Registered Nurse (RN) #1 was inside Resident #138's room. RN #1 was wearing gloves and was not wearing a gown. The surveyor observed as RN #1 handed Resident #138 a cup of drink. The surveyor also observed the resident who was swinging his/her hands in the air and towards RN#1. The RN#1 held and rubbed the resident's hands and adjusted the bed linens. When she finished, RN#1 removed her gloves, washed her hands and exited the room. The RN#1 then approach the surveyor and stated, I know my mistake, I was not wearing a gown. I should have been wearing a gown. During that interview, RN #1 stated she went inside the room to give the resident a drink. Review of the Admission Record revealed that Resident #138 was admitted to the facility with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set (MDS), an assessment tool dated 09/16/19, revealed that Resident #138 had long and short-term cognitive deficits. The MDS showed that the resident required extensive assistance from staff for all activities of daily living and was incontinent of bowel and bladder. Review of Resident #138's isolation care plan (CP), dated 10/10/19, reflected that the resident was on isolation precautions for [MEDICAL CONDITIONS]. [MEDICAL CONDITION], a contagious intestinal bacteria found in the stool (bowel movement), is transmitted through direct and indirect contact with an infected person and the person's environment. The CP interventions included to maintain isolation precautions according to the Medical Doctor's order and according to the facility's protocol. The CP also reflected to instruct family/visitors/caregivers to maintain isolation precautions and to discard in appropriate receptacle and wash hands before leaving the room. Review of an Order Summary Report, dated 10/10/19, reflected a physician's orders [REDACTED]. Review of a document titled; Lab Results Report, dated 10/10/19 at 9:26 AM, revealed that Resident #138 tested positive for [MEDICAL CONDITION] infection. During an interview on 10/22/19 at 9:02 AM, the Infection Prevention Nurse (IPN) stated that the minimum requirement for staff when caring for residents on contact isolation was to wear gloves. The IPN stated that [MEDICAL CONDITION] has spores that could live on surfaces for a long time and that it was recommended for staff to wear a gown and gloves. The IPN added, it was also the facility's policy for a gown and gloves to be worn when there was a possibility for staff to come in contact with bodily fluid or when providing direct patient care. When asked about the likelihood of coming in contact with bodily fluid in the environment of an incontinent resident, the IPN agreed that there was a likelihood that staff could come into contact with contaminated surface in the resident's environment. Review of the facility's undated policy titled, Isolation Precaution, reflected the purpose was to prevent the transmission of infection among the facility residents and that the policy was in accordance with state and federal guidelines. Under Types of Isolation, the policy indicated that gloves were to be worn if the resident or items in the room were to be touched, and that gowns were to be worn if rendering personal care and contact with infected body fluids was expected. The policy reflected under, Isolation Precautions Procedure, that standard precautions would be used for all resident care and that if excessive contact with body fluids was expected, gowns and/or masks should also be worn. The CDC guidelines for current recommendations on transmission based precautions indicated, under Part III: Precautions to Prevent Transmission of Infectious Agents, that healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., .C. difficile, noroviruses and other intestinal tract pathogens .). http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html The facility policy does not follow the above referenced CDC guidance on isolation practices, which requires individuals to don a gown and gloves when entering the room of a person on contact isolation. NJAC 8:39-19.4 (a)

Based on observation, interview and record review, it was determined that the facility failed to maintain 2 of 3 ice machines used for residents in a sanitary manner. This deficient practice was evidenced by the following: On 10/26/18 at 11:48 AM, in the presence of another survey team member, the surveyor checked the cleanliness of the ice machine on the North Wing. Using a clean paper towel, the surveyor wiped the interior area of the machine from which ice was dispensed into the storage bin. Upon examination, the surveyor observed several small, moist black particles/substance. At 12:18 PM, the surveyor again wiped with a paper towel the interior of the North Wing ice machine in the presence of the Registered Nurse/Unit Manager. There was black substance noted on the paper towel. On 10/26/18 at 12:07 PM, the surveyor checked the cleanliness of the West Wing ice machine. In the presence of another state surveyor, the surveyor wiped the interior of the ice machine with a clean, dry paper towel. The area which dispensed the ice into the bin produced a gray colored, opaque, gelatinous substance. At that time, a staff member entered to fill a cup of ice and water. The surveyor informed the employee of dirt and debris found on the ice machine. On 10/26/18 at 12:23 PM, the surveyor reported the condition of the ice machines to the administrator who stated that he had been made aware of the situation and that he had notified the maintenance department to clean the two machines. On 10/29/18 at 10:30 AM, the surveyor rechecked both ice machines and found them to be in a sanitary condition. On 10/30/18 at 10:00 AM, the Director of Nursing (DON) provided the surveyor with the policies and procedures which indicated that the maintenance department was in charge of cleaning the ice machines on a monthly basis in accordance with the manufacturer's recommendations. She stated that the administrative staff had met with the maintenance staff and the maintenance staff followed step-by-step instructions for cleaning the machines. The DON also presented a document to show that the machines were cleaned on 10/10/18. When asked how they ensured that the machine was kept clean between the monthly cleaning, the DON stated that they will revisit the process and did not provide further information. NJAC 8:39-17.2 (g)

Based on observation, interview and record review, it was determined that the facility failed to ensure that nursing staff a.) follow the physician ordered blood pressure (BP) parameter prior to the administration of a blood pressure medication (Resident #129), 1 of 35 residents reviewed; and b.) follow the physician ordered [MEDICAL TREATMENT] access cautionary to preserve and maintain proper functioning of the access (Resident #3), 1 of 5 residents reviewed for [MEDICAL TREATMENT]. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. During the initial tour of the facility on 10/22/18 at 12:22 PM, the surveyor observed Resident #129 who was seated in the day room wearing oxygen tubing. Upon interview, the resident denied having any discomfort. The resident was not able to provide specific information regarding his/her care or medication. On 10/24/18 11:31 AM, the surveyor reviewed the admission Minimum Data Set (MDS) an assessment tool dated 8/29/18. The MDS indicated that Resident #129 was cognitively intact, had no behaviors and needed assistance of two staff, members for bed mobility and transfer between surfaces. The MDS also reflected that the resident was admitted to the facility with medical [DIAGNOSES REDACTED]. depression. On 10/24/18 and 10/26/18 at 11:50 AM, the surveyor reviewed Resident #129's Medication Administration Record [REDACTED]. The [MEDICATION NAME] was scheduled on the MAR indicated [REDACTED]. The surveyor noted a blood pressure parameter for this medication which reflected to hold the [MEDICATION NAME] if the systolic blood pressure (SBP), the top number of blood pressure reading, was 130 and above. Further review of the MAR indicated [REDACTED] 10/2/18 at 1:00 PM, SBP was 138 10/3/18 at 9:00 AM, SBP was 132 10/4/18 at 5:00 PM, SBP was 132 10/6/18 at 5:00 PM, SBP was 158 10/7/18 at 5:00 PM, SBP was 154 10/12/18 at 5:00 PM, SBP was 135 10/14/18 at 5:00 PM, SBP was 130 On 10/29/18 at 11:00 AM, the surveyor interviewed the Registered Nurse (RN) who administered the medication to Resident #129 on 10/3/18. The nurse acknowledged that she administered the medication and was aware of the parameters. She stated she could not remember if the SBP was 132 or 123 and that she was not sure what happened on 10/3/18 and why she documented 132. The nurse did not provide further information as to why the [MEDICATION NAME] was administered on 10/3/18 when it was supposed to be held for a SBP greater than 130. The nurse stated she would check her worksheet and get back to the surveyor. The surveyor reviewed the resident's care plan dated 8/24/18 which reflected that the facility would monitor the blood pressure as ordered. On 10/29/18 at 2:00 PM, the surveyor informed the facility administration of the findings. On 10/30/18 at 1:00 PM, the surveyor met with the facility administration, whom did not provide further information regarding the [MEDICATION NAME]. 2. The surveyor reviewed the admission facesheet which reflected that Resident #3 was admitted to the facility with medical [DIAGNOSES REDACTED]. The surveyor reviewed the Minimum Data Set (MDS), an assessment tool dated 10/15/18. This reflected a Brief Interview for Mental Status of 11, which meant the resident had moderate cognitive impairment. The MDS also indicated the resident required one person physical assistance with activities of daily living. On 10/22/18 at 10:00 AM, during the initial tour of the facility, the surveyor observed Resident #3 who was resting in bed with eyes closed. The surveyor noted a gauze dressing with tape on the resident's right forearm which appeared to be a [MEDICAL TREATMENT]. The resident was not able to provide information regarding this dressing on his/her right forearm. The surveyor did not observe any signs in the resident's room as to the reason for the right arm dressing, no [MEDICAL TREATMENT] cautionary posted in the resident's room and no alert bracelet on the resident's arm. On 10/23/18 at 12:10 PM, the surveyor again observed Resident #3. The surveyor attempted to interview the resident but could not due to the resident's impaired cognitive status. The resident could not provide specific information regarding his/her care or the access site. On 10/23/18 at 12:30 PM, the surveyor reviewed the Electronic Medical Record (EMAR) which reflected the resident had a right forearm arteriovenous fistula (a surgically created vein used to remove and return blood during [MEDICAL TREATMENT]). Upon review of (MONTH) (YEAR) physician's orders [REDACTED]. On 10/24/18 at 11:33 AM, the surveyor reviewed the documentation on the electronic Vital Signs Sheet from 7/31/18 to 10/24/18 and noted that on the following dates, it was documented that the BP was taken on the resident's right arm, which was not in accordance with the physician's orders [REDACTED].>7/31/18, 8/3/18, 8/4/18, 8/5/18, 8/14/18, 8/20/18, 8/21/18, 8/25/18, 9/8/18, 9/9/18, 9/23/18, 9/24/18, 9/28/18, and 10/13/18. In addition, during the review of the vital signs form for this timeframe, the surveyor also noted that different 7AM-3PM staff documented four times and different 3PM-11PM staff documented 11 times that the resident's BP was taken from the right arm. On 10/24/18 at 12:10 PM, the surveyor interviewed a unit Licensed Practical Nurse (LPN) who cared for Resident #3. When asked about the care of the [MEDICAL TREATMENT] access and how they would know if a [MEDICAL TREATMENT] resident had arm precautions, the LPN stated, it is in the doctors orders, so the nurse should know. The nurse also stated she knew not to take blood pressure from the resident's right arm. The nurse did not have an explanation as to why staff documented that the BP was taken on the resident's right arm. On 10/29/18, the surveyor attempted to interview Resident #3 but was informed by staff that the resident was hospitalized . On 10/29/18 at 2:00 PM, the surveyor informed the facility administration of the findings. On 10/30/18 at 10:00 AM, during a meeting with the facility administration, the Director of Nursing (DON) stated that she spoke to the nurses and they informed her that they might have documented the BP on the wrong site. The DON also stated she felt the wrong site error was probably caused by the point click care system. The DON indicated that they did not utilize alert bracelet or post signs in the resident's room and that they go by the physician's orders [REDACTED]. The surveyor reviewed the Vital Sign Sheet again and this showed that the BP was documented as being taken on the left arm on most days, between 7/31/18 and 10/24/18, using the same point click system. The surveyor reviewed the facility policy titled, [MEDICAL TREATMENT] Policy and Procedure dated 5/15 which reflected, If a resident has an AV fistula, nursing will not obtain blood pressure or venipuncture from that extremity. Adherent to this policy was not reflected in the vital sign form completed by various nurses on two different shifts as provided by the facility The facility did not provide further evidence that staff consistently followed the precaution when obtaining blood pressure from Resident #3. NJAC 8:39-27.1 (a), (e)