Every finding on record at Hartwyck at Oak Tree

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss mattress (a specialized medical mattress that uses continuous airflow to prevent pressure ulcers, manage moisture, and enhance comfort for patients with limited mobility) was installed and checked for placement and function in accordance with a physician's order.This deficient practice was identified for 1 of 1 residents (Resident #52) reviewed for pressure ulcers and was evidenced by the following:On 5/19/26 at 10:02AM, the surveyor observed Resident #52 lying in bed with a dressing to the left lower leg. Resident #52 reported that the facility sets up transportation to wound care appointments and performed daily weights.On 5/20/26 at 11:06AM, the surveyor observed Resident #52 was not in the room, and the resident's bed did not have an air mattress or pump in place.The surveyor reviewed the Electronic Medical Record (EMR) for Resident #52. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; muscle weakness, difficulty walking, and non-pressure chronic ulcer (a long lasting open sore on the skin that does not result from sustained pressure on a bony prominence or under a medical device) of left lower leg with unspecified severity.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 5/18/26, included the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident had a risk of pressure ulcers and should have pressure reducing devices for the chair and bed. A review of the individual comprehensive care plan (ICCP) included a focus area dated 5/6/26 for skin integrity: at risk for breakdown. Interventions included provide pressure reducing and positioning devices.A review of the Order Summary Report included the following physician orders (PO):A PO dated 5/5/26 and discontinued on 5/20/26 for low air loss mattress, check function every shift.A PO dated 5/20/26 for dyno mattress (a type of pressure-relieving mattress system designed to help prevent and treat pressure ulcers in patients at high risk of skin breakdown), monitor placement and functioning every shift.A review of the May 2026 Treatment Administration Record (TAR) revealed a PO dated 5/5/26 for low air loss mattress, check function every shift that was initialed by a nurse every shift from 5/5/26 to 5/19/26, indicating the mattress was checked. On 5/20/26 at 12:31 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who confirmed there was a PO for the low air loss mattress. The RN/UM stated the air mattress was set to the resident's weight and the wound nurse would review the setting and calibrate the pump. The surveyor with the RN/UM went to Resident #52's room and observed there was no air mattress or pump on Resident #52's bed. On 5/21/26 at 12:44 PM, the surveyor interviewed Resident #52 who stated there was never an air mattress on the bed, and was told by staff that there will be an air mattress placed today while the resident was at therapy. On 5/21/26 at 12:58 PM, the surveyor interviewed the Director of Nursing (DON) who stated Resident #52 should have had a low air loss mattress. The DON further stated it was a communication error with maintenance to place the mattress, but it was ultimately nursing's responsibility to confirm placement and function every shift. On 5/22/26 at 12:25 PM, the survey team presented the above concerns to the Licensed Nursing Home Administrator, the DON, and the Post Acute Clinical Nurse. On 5/26/26 at 10:07AM, the LNHA acknowledged there was a concern with the mattress being ordered, not in place, and being signed off. A review of the facility provided HMNR Wound Prevention policy, last revised July 2020, revealed: All nursing team members will follow the Wound Prevention Protocol to assess/evaluate pressure injury risk, plan and implement the appropriate interventions, provide resident/patient care consistent with professional standards of practice, and evaluate the efficacy of the interventions to prevent avoidable pressure ulcers/injuries. Procedure .3. Nurses will implement the Wound Prevention Protocol. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order and implement interventions for a resident with edema (swelling) to the left arm and left hand. This deficient practice was identified for 1 of 1 residents (Resident #96), reviewed for positioning and mobility and was evidenced by the following:On 5/19/26 at 10:02 AM, during the initial tour, the surveyor observed Resident #96 sitting in a wheelchair in the hallway with a flesh-colored sleeve and glove to the left arm and left hand. The resident stated, it is to keep the swelling down.On 5/20/26 at 11:25 AM, the surveyor observed Resident #96 in a wheelchair in the room with the left arm sleeve and left hand glove in place. The resident stated, I don't want to take it off.The surveyor reviewed the electronic medical record (EMR) for Resident #96.A review of the admission Record (an admission summary), revealed the resident was admitted to the facility with diagnoses which included but were not limited to: muscle weakness; hemiplegia (paralysis or severe weakness affecting one side of the body) and hemiparesis (weakness on one side of the body, often caused by brain, spinal cord, or nerve damage) following cerebral infarction (a type of stroke caused by a blood clot in the brain) affecting left non-dominant side and pain.A review of the admission Minimum Data Set (MDS), an assessment tool dated 5/15/26, revealed the resident had a Brief Interview for Mental Status of 8 out of 15, indicating the resident had moderately impaired cognition. Further review of the MDS revealed impairment to one side of upper extremities. A review of the individual comprehensive care plan (ICCP) revealed a focus area for skin integrity: at risk for skin breakdown dated 5/18/26; and activities of daily living (ADL) function-impaired dated 5/16/26. There were no interventions related to the left arm sleeve or the left hand glove. A review of the Order Summary Report revealed a physician's order (PO) for:A PO dated 5/15/26 for Physical Therapy, Occupational Therapy, Speech evaluation on Admission. A PO dated 5/15/26 for ADL care provided every shift.A PO dated 5/15/26 for LIMB ALERT: Left arm precaution, No blood pressure, no intravenous access, no Blood draw due to mastectomy (surgery to remove all breast tissue from a breast).A PO dated 5/15/26 for Skin Assessment on Admission, 24-hours post-admission, and then twice weekly on shower days. No order for a left arm sleeve or a left hand glove were present. A review of the Physical Therapy Evaluation and Plan of Treatment dated 5/16/26 revealed under Initial Assessment/Current Level of Function and Underlying Impairments .Medical Factors .left upper extremity (LUE) limb alert, LUE compression sleeve. A review of the Occupational Therapy Evaluation and Plan of Treatment dated 5/18/26 revealed under Initial Assessment/Current Level of Function and Underlying Impairments .Medical Factors Precautions: LUE limb alert, LUE compression sleeve.On 5/20/26 at 12:16 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated the resident had a swollen left arm and that was the weak side. The RN/UM confirmed there was no order for the left arm sleeve or for the left hand glove. The RN/UM further stated, Every shift the nurse should be checking the skin and It should be part of the ADLs, we need to put it on.On 5/21/26 at 1:04PM, the surveyor interviewed the Director of Nursing (DON) who stated the compression sleeve was for edema from a mastectomy. The DON further stated nursing should have involved therapy and talked to the doctor to get an order if appropriate. The DON further stated, We have to have an order to have it (the sleeve/glove) and to check the skin.On 5/22/26 at 12:25 PM, the survey team presented the above concerns to the Licensed Nursing Home Administrator (LNHA), the DON, and the Post Acute Clinical Nurse.On 5/26/26 at 10:07AM, the LNHA acknowledged there was a left arm splint and left hand glove in place with no order. A review of the facility provided policy Splinting and Splint Precautions, last revised February 2018, revealed .Splinting shall be carried out in a standardized procedure. Process 1. All requests for splints .require a physician's order .4. After .ordering of an orthotic device, the therapist should provide the patient with written instructions on wearing schedules, precautions, and method for cleaning splints. NJAC 8:39-27.1 (a)(e)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to prevent the potential for cross contamination by not implementing Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms) for a resident with a tracheostomy (a surgical procedure that creates an opening in the neck allowing a patient to bypass their nose and mouth to breathe, receive mechanical ventilation, or clear mucus from their lungs) and an indwelling device (any tube/device left inside the body for an extended period) in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice and facility policy regarding the use of Personal Protective Equipment (PPE) (specialized gear worn to minimize exposure to hazards that cause serious workplace injuries, illnesses, or infections) for residents placed on EBP. This deficient practice was identified for 1 unsampled resident (Resident #26) observed for tracheostomy site care, and evidenced by the following: On 5/21/26 at 10:51 AM, the surveyor observed the Registered Nurse (RN) perform tracheostomy site care for Resident #26; EBP signage was displayed at the entrance to the resident's room, and the resident was previously noted to have a feeding tube (a medical device used to safely deliver liquid formula, fluids, and medications directly into the stomach or small intestine). The RN performed hand hygiene with alcohol rub upon entering the room, introduced herself, and verified the resident's identity before explaining the procedure to the resident. The RN performed hand hygiene with soap and water then donned (put on) non-sterile exam gloves before wiping the beside table down with alcohol-based cleanser and letting it air-dry. The RN performed hand hygiene and donned non-sterile exam gloves; she pushed a trash bin toward the bedside table using her leg then opened the tracheostomy care kit to set up the sterile work area. The RN disposed of the non-sterile gloves and donned a new pair then removed the soiled split-gauze (gauze with a cut in it to facilitate going around an object/tube) from around the resident's tracheostomy site. The RN disposed of the soiled gauze and gloves into the trash bin, performed hand hygiene, donned new non-sterile exam gloves then opened sterile saline (salt water) containers and emptied them into the sterile basin. She then soaked sterile 4x4 gauze in the sterile saline and proceeded to cleanse the tracheostomy site from the inside-out as indicated. After cleansing the site, the RN went to dispose of the gauze and non-sterile exam gloves and suddenly froze and looked down at her scrubs. At 10:57 AM, the RN asked the surveyor can I start over? I'm not wearing PPE and I should be; the surveyor advised the RN to do what they would have done if nobody were observing her, as surveyors could not be prescriptive. The RN proceeded to nod, dispose of the used supplies, clear the bedside table, wiped it down with an alcohol-based cleanser, and washed her hands with soap and water while waiting for the table to dry. The RN then donned a gown, mask, and non-sterile exam gloves before setting up the bedside table with the tracheostomy care kit. The RN performed hand hygiene with soap and water before donning the sterile gloves found inside of the tracheostomy care kit, then completed the rest of the tracheostomy care with no concerns noted. The RN disposed of the supplies, wiped the bedside table with alcohol-based cleanser, removed her PPE and washed her hands with soap and water for eight seconds before exiting the room. On 5/22/26 at 11:34 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that EBP should be used for any residents that had a higher risk for infection spread such as ventilated residents with tracheostomies, residents with open wounds, urinary catheters, indwelling devices, or central lines (blood stream). She further stated that PPE is required for direct care or prolonged exposure of over 15 minutes. When the surveyor asked what PPE should be worn during tracheostomy care the IP replied that a gown and gloves were necessary, as well as a shield if the resident is on the ventilator, and that a mask was optional. The IP then stated that the importance of wearing PPE when indicated was to avoid cross-contamination and to protect the staff member and the resident from spreading any infections. On 5/22/26 at 11:49 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that EBP was indicated for residents with indwelling devices such as urinary catheters, feeding tubes, and tracheostomy sites. She further stated that she would expect staff to be wearing a gown, gloves, and mask during tracheostomy care and that the importance of wearing PPE during direct care for a resident placed on EBP was to contain and control infections in the facility. On 5/22/26 at 12:33 PM, in the presence of the survey team, the surveyor presented the above concerns to the Licensed Nursing Home Administrator (LNHA), the DON, and the Post Acute Clinical leader. The LNHA confirmed the unsampled resident's room and stated, oh ok, enhanced barrier then, she (the RN) should have had a gown on. A review of the facilities HMNR Enhanced Barrier Precautions policy, last revised May of 2026, revealed: Purpose: To provide guidance for personal protective equipment (PPE) use to prevent transmission of novel viruses, epidemiologically significant organisms or CDC targets multi-drug resistant organisms (MDROs) and in response to a public health containment strategy. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high-contact care activities.examples of high-contact care activities include: dressing, bathing/showering, providing hygiene, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care.Procedure: Gown and or gloves will be used during high-contact care for residents with any of the following: wounds and/or indwelling medical devices (i.e., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Enhanced Barrier Precautions are intended to be used for the duration of a resident's stay in the facility. A review of the facility's HMNR Tracheostomy Care policy, revised October of 2022, revealed: Purpose: To ensure appropriate care is provided for the resident/patient with tracheostomy.Tracheostomy care is to be performed every shift and PRN (as needed) .Supplies in the room should include.gowns, gloves, masks with face shields. N.J.A.C. 8:39 - 19.4

Based on observations and interviews on 12/19/2024 in the presence of the Director of Maintenance (DOM), it was determined that the facility failed to ensure that the volume on the resident call bell system at the nurse's station on floor 3 was set to a level to be heard. This deficient practice had the potential to affect all residents and was evidenced by the following: An observation on at 11:50 AM revealed when the call bell was tested from resident room [ROOM NUMBER], there was no audible notification of the call bell activation. An observation at 11:55 AM revealed when the call bell was tested from resident room [ROOM NUMBER], there was no audible notification of the call bell activation. In an interview at 12:05 PM, nursing staff informed the surveyor that they discovered that the volume on the call bell system had been turned all the way down and it had been corrected. An observation at 12:07 PM revealed when the call bell was tested from room [ROOM NUMBER], there was now audible notification of the call bell activation as the facility turned on the volume to the system. In interviews at the time, the DOM confirmed the observations. The facility's Administrator was informed of the deficient practice at the Life Safety Code exit conference on at 12:30 PM. NJAC 8:39-31.2(e). 31.8(c)9

Based on observation, interview, and record review, it was determined that the facility failed to document the code status (medical instructions regarding resuscitation and other lifesaving measures in the event of a medical emergency) for 2 of 4 residents reviewed (Resident #31 and # 49) for code status. This deficient practice was evidenced by the following: 1. On 12/13/24 at 11:40 AM, during the initial tour, the surveyor observed Resident #31 in bed. The resident was observed with a tracheostomy and was dependent on a ventilator. The resident was not able to be interviewed. The surveyor reviewed Resident #31's electronic medical record (EMR). A review of the resident's Face Sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; acute respiratory failure, unspecified whether hypoxia hypercapnia (a medical condition that occurs when there is a problem with gas exchange between the lungs and blood) and multiple sclerosis (a chronic disease that affects the central nervous system, which includes the brain, spinal cord, and optic nerves.) A review of the resident's EMR and hard paper chart, revealed there was no physician's order (PO) for the resident's code status. On 12/17/24 at 12:26 PM, the surveyor interviewed Registered Nurse (RN) #1, who stated Resident #31 was a full code. RN#1 reviewed the EMR in the presence of the surveyor and was unable to locate a code status PO. She then reviewed the hard paper chart in the presence of the surveyor. She reviewed the POLST (Physician Orders for Life-sustaining Treatment) and verified that it was blank. She continued to look through the chart and stated that I know the resident is a full code. After further review of the paper chart, she was able to show the surveyor the admission sheet that listed the resident as a full code. She confirmed that was not a PO. 40042 2. On 12/13/24 at 11:22 AM and on 12/16/24 at 10:13 AM, the surveyor observed Resident #49 in bed with his/her eyes closed and did not respond to surveyor. A review of the resident's Face Sheet revealed the resident was admitted to the facility with diagnoses that included but were not limited to; traumatic brain injury (an injury to the brain caused by a violent blow to the head), generalized epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures), and ventilator dependent (cannot breathe on his/her own required mechanical ventilation). A review of the resident's EMR and hard paper chart, revealed there was no PO for the resident's code status. On 12/17/24 at 11:45 AM, the surveyor interviewed the Admissions Director. She stated that she had access to the hospital EMR's and before a resident was admitted she would check for code status. If she was able to obtain a resident's code status, she would include that information on the Hartwyck at Oak Tree Wing Note under Advanced Directives. In addition, she stated that this informative sheet was provided to department heads prior to the resident's admission. On 12/17/24 at 11:55 AM, the surveyor interviewed RN #1 and Licensed Practical Nurse (LPN) #1. Both stated that Resident #49 was a full code status, however they were unable to provide documented evidence of a PO. RN #1 reviewed the resident's hard paper chart in the presence of the surveyor and LPN #1 and was able to provide a Wing Note which indicated the resident was a full code status. Both nurses acknowledged that this was not equivalent to a signed PO. On 12/17/24 at 11:10 AM, the surveyor interviewed the Social Work Director in presence of the survey team. She stated that she was unaware that Resident #49 did not have a PO for code status. She further stated that as far as she knew, the nurses were aware of the wishes to sustain life. On 12/17/24 at 1:15 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the residents code status should have been in the EMR and there needed to be a PO. The DON further stated that a code status order should be obtained at the time of admission, when the nurse calls the doctor for admission orders. She reviewed the EMR in the presence of the surveyor and acknowledged there was no PO for code status for Resident #31 or Resident #49. At that time, the DON was able to show the surveyor Resident #31's completed POLST that was in the facility's previous EMR chart. The DON stated the purpose of the code status was to know the wishes of the resident and the goals of care. The facility was unable to provide a policy related to code status. NJAC 8:39-4.1(a)2

Based on observation, interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times. This deficient practice was identified for 1 of 1 residents (Resident #56)reviewed for dialysis. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: On 12/13/24 at 10:51 AM, the surveyor observed Resident #56 in bed with eyes open but was not responding verbally. The surveyor interviewed the resident representative (RR) that had walked into the room to visit Resident #56. The RR stated that the resident had a recent stroke and had been on dialysis prior to coming to the facility and had remained on dialysis while in the facility. The surveyor reviewed the medical record for Resident #56. A review of the resident's Face Sheet revealed diagnoses which included but not limited to; chronic kidney disease, end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood), dependence on renal dialysis (a mechanical process used to filter waste from the blood) and essential (primary) hypertension (high blood pressure). A review of a significant change Minimum Data Set, an assessment tool used to facilitate the management of care dated 10/30/24, reflected the resident had a brief interview for mental status score of three (3) out of 15, indicating that the resident had a severely impaired cognition. A review of the resident's Care Plan Activity Report, (an interdisciplinary care plan) revealed an active focus area, with an effective date of 9/10/24 and review date of 11/23/24, that the resident was currently on dialysis related to end stage renal disease. An intervention/task included but was not limited to, Ensure medications administration times are adjusted to the dialysis schedule. The goal reflected The risk for dialysis-related complications will be minimized. A review of the resident's electronic physician's order (PO) reflected a PO for Hemodialysis on Tuesday-Thursday-Saturday @ (at) 9:45 AM Pick up time 9AM at{name of dialysis facility, and phone number and transportation phone number redacted] with a start date of 11/16/24. Further review of the PO reflected the following: -a PO dated 11/30/24 for Sevelamer Carbonate (a medication used to lower the amount of phosphorous in the blood when receiving dialysis) 0.8 grams (GM) oral powder packet, give 1 packet by g-tube (gastrostomy tube- a tube placed in the stomach when food or medication cannot be taken by mouth) route 3 times per day for ESRD. -a PO dated 11/30/24 for Hydralazine ( a medication used to treat high blood pressure) 100 milligrams (MG). give 1 tablet by g-tube route 3 times per day with food Dx: HTN. -a PO dated 11/23/24 for Polyvinyl alcohol 1.4% ( artificial tears) eye drops, instill 1 drop by eye route in each eye every 6 hours for dry eyes. A review of the resident's dialysis book, that was kept on the unit, reflected that dialysis was scheduled for a 9 AM PM pick up time and a chair time of 9:45 AM. In addition, the dialysis book contained a Dialysis & Facility Communication Sheet for the dates of 12/10/24, 12/12/24 and 12/14/24 that were completed indicating that the resident had received dialysis on those days. A review of the December 2024 electronic medication administration record (EMAR) indicated medication administration times that occurred during the time that the resident was out of the facility at dialysis. The EMAR revealed the following: -on 12/10/24, 12/12 and 12/14 the doses for Sevelamer Carbonate 0.8 GM at 2:30 PM indicated that the medication was not administered. There was a corresponding reason for 12/12/24 that indicated out at dialysis and on 12/14/24 the reason indicated LOA (leave of absence). There was no documented reason for 12/10/24. -on 12/10/24, 12/12 and 12/14 the doses for Hydralazine 100 MG at 2 PM indicated that the medication was not administered. There was a corresponding reason for 12/12/24 that indicated out at dialysis and on 12/14/24 the reason indicated LOA (leave of absence). There was no documented reason for 12/10/24. -on 12/10/24 and 12/12 the doses for Polyvinyl Alcohol 1.4% eye drops at 12 noon indicated that the medication was not administered. There was a corresponding reason for 12/12/24 that indicated out at dialysis. There was no reason documented for 12/10/24. A review of the resident's corresponding electronic progress notes (EPN) revealed that there was no documentation of the reason for the above medications to not be administered. On 12/17/24 at 9:44 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who verified that Resident #56 went out to dialysis on Tuesday, Thursday and Saturday. The surveyor with LPN#1 reviewed the EMAR for Resident #56. LPN#1 explained that the EMAR indicated a marking for the dates of 12/10, 12/12 and 12/14 that indicated medications were not administered. LPN#1 then verified that on 12/12/24 she had not administered the resident's Sevelamer Carbonate 0.8 GM and Hydralazine 100 MG because the resident was out to dialysis. LPN#1 then stated that the resident had been returning by 2 PM and that the medications were able to be administered but that lately the resident was returning later from dialysis. LPN#1 also stated that on 12/14/24 the Hydralazine 100 MG dose had an administration time changed to 3 PM. The LPN#1 could not speak to why the administration time for the Hydralazine was not changed prior to 12/14 and that the Sevelamer Carbonate administration time remained at 2 PM. LPN#1 added that the procedure was that if a medication was not able to be administered when the resident was out to dialysis then the administration time should be changed. On 12/18/24 at 10:27 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated that during her review she would make the recommendation that medication times need to be adjusted to accommodate dialysis times. The CP added that she was unsure if the nurses were required to obtain a PO for a time change but that a PO was required if the physician wanted specific medications held on dialysis days and only administered on non-dialysis days. On 12/18/24 at 12:26 PM, the survey team met with the facility administrative team. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) acknowledged that Resident #56's medications should be adjusted to accommodate when the resident was out to dialysis. On 12/18/24 at 1:00 PM, the surveyor interviewed the Unit Manager/Registered Nurse (UM/RN) who stated that for dialysis residents adjusting the administration time of medications was important in order for the resident to be able to receive their medications. The UM/RN stated that the procedure was for the medication nurse to adjust medication times to allow for the resident being out of the facility. The UM/RN also stated that if the resident was not receiving their medications or there was a delay in receiving their medications because they were out to dialysis then the physician should be notified, and the physician may make a change in the PO. The UM/RN added that if the EMAR reflected medications were not administered because the resident was out to dialysis then he should have been notified. The UM/RN stated that he thought Resident #56 returned to the facility in time to receive 2 PM medications. On 12/19/24 at 9:24 AM, the survey team met with the administrative team. The LNHA stated that he thought in November the medications were recognized as needing to be adjusted but was not aware that in December the medications continued to indicate out to dialysis. The LNHA also stated that there was no mention of medication timing regarding dialysis in either of the facility policies for Medication Administration and/or Dialysis Services that had been provided to the surveyor. A review of the facility policy dated as last approved 4/2024 for Medication Administration provided by the DON, reflected that Medications must be administered in accordance with written orders of the attending physician. In addition, The nurse administering the medication must record the administering, refusal, or holding of medication on the resident's MAR. A review of the facility policy dated as last approved 8/2024 for Dialysis Services provided by the DON, reflected that The facility will ensure that residents/patients who require hemodialysis services receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's/patient's goals and preferences. NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

C #: NJ 868 Based on interviews, record review and review of other pertinent facility documents on 10/22/21, it was determined that the facility failed to follow their policy by ensuring services offered were within the scope of the organization to meet the needs of Residents for 1 of 8 Residents (Resident #6), reviewed for medication. This deficient practice is evidenced by the following: 1. According to the Face Sheet, Resident #6 was admitted to the facility on [DATE] and was discharged on [DATE] with primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Nursing Progress Notes (NPN) dated 9/11/21 through 9/15/21, showed that Resident #6 was alert oriented x 2 (person and place). According to Resident #6 Baseline Care Plans (BCP) dated 9/11/21 showed Potential for Pain. Intervention included but was not limited to: Administer prescribed pain medication. The Progress Notes (PN) from the Acute Hospital (AH, included in Resident #6 medical record) dated 9/8/21 to 9/9/21 under February 22, 2021 discussion showed that the Pain Management team switched the Resident over to Barbiturate narcotics to [MEDICATION(S)] which the Resident takes every 8 hours. This appears to control Resident #6 pain issues. The New Admission Order Set dated 9/11/21 showed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Routine Medications form dated 9/11/21, showed the aforementioned order with the administration time at 6:00 am, 2:00 pm and 10:00 pm. However, the [MEDICATION(S)] medication was not administered as ordered from 9/11/21 until it was discontinued on 9/14/21. The NPN showed the following: On 9/13/21 at 7:00 am-3:00 pm shift showed the medication [MEDICATION(S)] could not be administered to Resident #6 because it needed physician authorization and the Director of Nursing (DON) was aware. Resident #6's Representative (RR) was aware. The RR offered to bring in their own medication supply from home, however, the medication would require physician's authorization to release the [MEDICATION(S)] medication. On 9/13/21 at 3:00 pm-11:00 pm shift showed that the RR requesting the [MEDICATION(S)] for Resident #6. At 9:00 pm, the Physician called the facility and informed a registered nurse (RN) that he could not prescribed the pain medication ([MEDICATION(S)]) and to monitor the Resident for signs and symptoms of withdrawal. The PN documented by the Physician dated 9/14/21 showed the RR was considering taking the Resident home due to issue with [MEDICATION(S)] medication. The Resident was started on Narco 5/325 mg twice a day for pain control. During an interview with the Director of Nursing (DON) on 10/22/21 at 8:40 am, she stated the facility received a referral from the AH. The facility's Clinical Screening Coordinator (CSC) has to review the resident's medical record including medications and determine whether they should be admitted according to the services the facility could provide. In the case of Resident #6, the CSC missed the [MEDICATION(S)] during the medication profile review. The facility could not admit a resident on [MEDICATION(S)] medication because the facility does not have a licensed Physician to prescribe the [MEDICATION(S)] medication. She stated that the CSC was aware of the facility's scope of services. During an interview with the Assistant Director of Admission (ADA) on 10/22/21 at 9:48 am (who works with CSC) she stated that CSC knew that the facility does not accept resident on [MEDICATION(S)] medication and they never did in the past. CSC would review the medical records including the medication profile, then would let her know if the Resident was cleared for admission. The ADA could not explain how the [MEDICATION(S)] was missed during the medication profile review. She further stated nurses would received nurse to nurse report prior to admission. During an interview with the Resident #6's RR on 10/22/21 at 1:27 pm, the RR stated that Resident #6 was on [MEDICATION(S)] medication for almost 1 year now for chronic pain due to Peripheral [CONDITION(S)]. Prior to being admitted into the facility on [DATE], the RR was informed by the AH that the facility would be able to provide Resident #6's [MEDICATION(S)] medication. The RR would never agree for the Resident to be admitted into the facility if they could not provide the [MEDICATION(S)] because the Resident could experience withdrawal symptoms if not taken as scheduled. She stated that she was not made aware until 2 or 3 days later ( 9/13/21) and it was too late because the Resident was already in the facility. During the telephone interview with the CSC on 10/22/21 at 2:06 pm, she stated that she was aware that the facility could not accommodate or could not accept a resident on [MEDICATION(S)] because the facility did not have physician/s to prescribe the medication. She explained that when she reviewed the medication profile for Resident #6 she missed it. She stated she was later re-educated by the DON because the RR for Resident #6 was upset for admitting the Resident into the facility for not able to provide the aforementioned medication. During the telephone interview with the Primary Physician (PP) on 10/25/21 at 1:30 pm, he stated that the facility could not admit a resident on [MEDICATION(S)] at present because there was no licensed physician to prescribe the [MEDICATION(S)]. The covering physician on 9/12/21, reached out to the facility and informed the nurse the reason for not able to authorize the release of the [MEDICATION(S)] from the pharmacy. The PP explained that the facility reached out to the pain management physician who originally prescribed the [MEDICATION(S)] to the Resident to suggest alternative pain medication. The PP explained that the Resident experienced a one time episode of agitation the day of admission (9/11/21). However, he could not explain if that was from withdrawal symptoms (such as anxiety, restlessness, pains) or could be the Resident was adjusting to the new environment. The Job Description titled Clinical Screening Coordinator revised 9/1/21, showed .responsible for evaluation for transfer of patients .for the post acute care .including reviewing patients records .conferring with the case management staff in the acute care setting . The facility policy titled Scope of Services Policy originally created on 09/1999, last reviewed 10/2021 showed under Purpose: To identify the general scope of services offered within the organization .under the Procedure showed services offered within the organization but were not limited to: services nursing services, medical services. The policy did not reflect service for [MEDICATION(S)] management. NJAC 8:39-27.1 (a) NJAC 8:39-27.1 (b)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide appropraite hygiene and fingernail care for resident's dependent on staff for activities of daily living. This deficient practice was identified for 2 of 21 residents, (Resident #11 & #31) reviewed for care. This deficient practice was evidenced by the following: 1. Resident #11 was admitted to the facility in 2011 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Quarterly Minimum Data Set (MDS - an assessment tool) with an assessment Reference date (ARD) of 05/28/2021 coded Resident #11 of being severely impaired for decision making. On the Section G of the MDS which referred to Activity of Daily Living, Resident #11 coded 4 and 2 which indicated total dependence of staff for all activities of daily living. The Section G 0400 which referred to Functional limitation in Range of Motion Resident #11 coded 2 and 2 which indicated impairment on both upper and lower extremities. A review of Resident #11's care plan dated 09/05/2019 revealed a care plan for activities of daily living (ADL). The goal set by the facility for Resident #11 was for his/her ADL will be meet satisfactorily as evidenced by being kept clean, dry, and odor free daily. The approaches were to: a) Provide education and management training of Resident #11 current condition and needs to the direct care giver, and b) provide Resident #11 with total care for his/her ADLs. On 05/24/2021 at 10:06 AM, the surveyor observed Resident #11 in bed, his/her arms were flexed to the chest and both hands were contracted. On 05/25/2021 at 11:30 AM, the surveyor observed Resident #11 in bed, the Certified Nursing Assistant (CNA) was at the bedside providing care. An interview on 05/26/2021 at 11:21 AM, with the CNA who cared for Resident #11 revealed Resident #11 was totally dependent on staff for all activities of daily living. According to the CNA, Resident #11 was unable to make his/her needs known. The CNA stated that Resident #11 could not do anything for himself/herself. On 05/26/21 at 11:25 AM, the surveyor observed Resident #11 in bed, The CNA was in the room. The surveyor asked the CNA if she could observe Resident #11's hands. When the CNA opened Resident #11's hands, the fingernails were observed to be long and a black like substance was observed underneath the fingernails, no open areas were observed on the resident's hands. Upon further inquiry regarding nail care, the CNA stated that a man was responsible to provide nail care. On 05/26/2021 at 11:30 AM, an interview with the Unit Manager Nurse (UMN ) revealed that the CNA was referring to the Podiatrist. The surveyor escorted the UMN to the room where we both observed the black coated substances underneath the fingernails nails and the elongated fingernails. On 05/26/21 at 11:35 AM, a second interview with UMN revealed that the nurses were responsible to trim the resident's nails. The UMN further stated that the CNAs were to communicate if a resident's nails needed to be trimmed/cleaned. The UMN indicated that she was not informed that Resident #11's nails needed to be trimmed and cleaned. The UMN told the surveyor that she would trim and clean Resident #11's nails. On 05/26/21 at 12:46 PM, the Director of Nursing (DON) was made aware of the above issue. The DON told the survey team that the CNAs were responsible to provide nails care to the residents and not the nurses. The facility was asked to provide the policy for hygienic care which would include nail care, none was provided. On 05/28/21 at 10:06 AM, the surveyor interviewed the UMN regarding the CNA's assignment sheet. UMN stated that in the morning the assignment was made according to the census and that a verbal report was given in the morning to the direct care staff. The nurses would follow up to ensure that the assignment was carried out. The UMN provided the assignment sheet, nail care was not noted on the assignment sheet The UMN stated that all shifts should be responsible for nail care not only the 7:00 AM to 3:00 PM shift. An observation on 05/28/2021 at 10:00 AM of Resident #11's hands revealed Resident #11's fingernails had been trimmed and cleaned. Also, Resident #11 was provided with a splinter to prevent the nails from injuring his/her skin. 2. Review of the Face Sheet revealed that Resident #31 had been originally admitted in 2017. Resident #31 was noted to have cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS, dated [DATE], revealed that Resident #31 was unable to be assessed for a Brief Interview for Mental Status (BIMS), was severely impaired to make decisions regarding tasks of daily life, and functional status was total dependence for personal hygiene. The Quarterly MDS further revealed that the resident was absent of spoken words, sometimes made themselves understood and sometimes was able to understand others. Review of the on-going Care Plan revealed Resident #31 was totally dependent with assistance/supervision for all functional mobility and ADLs with approaches that included but were not limited to provide total care of ADLs, and was at risk for skin breakdown for conditions that included but were not limited to contractures, decreased mobility, and a history of breakdown with approaches that included but were not limited to providing preventive skin care and performing weekly skin/wound assessments. Review of Resident #31's Admission Order Set dated 05/06/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #31's Treatment Administration Record (TAR) for 05/01/21 through 05/31/21, revealed a skin assessment was completed on 05/25/21 on the 7 AM to 3 PM shift and the 11 PM to 7 AM shift with no concerns noted. On 05/24/21 at 09:59 AM, the surveyor observed Resident #31 lying in bed, both hands were bent in at the wrist and fingers curled in. The surveyor observed there were no splints, devices, or objects in either hand or applied to either wrist. The surveyor observed on both hands, the fingernails were long and in contact with the resident's skin by the palm and wrist area. On 05/25/21 at 09:50 AM, the surveyor observed Resident #31 lying in bed, both hands were bent in at the wrist and fingers curled in. The resident had a soft doll under the right elbow. The surveyor observed there were no splints, devices, or objects in either hand or applied to either wrist. The surveyor observed on both hands, the fingernails were long and were in contact with the resident's skin by the palm and wrist area. On 05/26/21 at 08:44 AM, the surveyor observed Resident #31 lying in bed, both hands were bent in at the wrist and fingers curled in. The surveyor observed Resident #31's fingernails were long and were in contact with the resident's skin by the palm and wrist area. On 05/26/21 at 09:15 AM, the Registered Nurse (RN) stated Resident #31 was able to move and open his/her hands and would do this by following simple commands. In the presence of the surveyor, the RN requested Resident #31 to open their right hand, but the resident did not answer or acknowledge the surveyor or RN. The RN opened Resident #31's right hand in the presence of the surveyor. Both the RN and surveyor observed a red, indentation by the end of the palm and top of the wrist where the nail met the skin but no open area. The surveyor and RN also observed a tan color crusted substance between the right-hand thumb and first finger. The surveyor and RN observed Resident #31's left hand, the resident was unable to straighten or open his/her hand. The RN opened the left hand and the surveyor and RN observed a red indentation on the skin at the top of the wrist where the fingernail met the skin but no open area. The RN stated Resident #31's fingernails needed to be cut and cleaned and both hands needed to be cleaned. The RN stated the resident's nails were too long and need to be cut by the CNA. On 05/26/21 at 09:42 AM, the RN Unit Manager on the 3rd floor ventilator unit, stated resident skin checks were done twice a week and that Resident #31 had a skin check completed on 05/25/21. The RN Unit Manager stated the nurses would be responsible to cut the resident nails but that she and the other RN have not had time to do anyone's nail care. On 05/26/21 at 11:07 AM, the DON stated no skin assessment sheet would be completed unless there was a wound. The DON stated the CNAs were overseen by the nurses and were responsible for fingernail care which would be assessed during morning and evening daily care. The DON stated there would not be any documentation that nail care was done. The DON stated the CNA should have noticed the fingernails and it was important to keep the fingernails cut to prevent skin damage and for cleanliness and dignity. On 05/26/21 at 12:24 PM, the CNA stated that resident care consisted of things like washing the skin and applying moisturizer, making sure the hands were clean, and checking the skin. The CNA stated the nurses would do nail care and that she was not allowed to cut nails. The CNA stated she had seen Resident #31's long nails today (05/26/21) and made the RN aware verbally. On 05/26/21 at 12:48 PM, the DON stated the facility did not have any policy or procedure on nail care or ADL care. Review of the Nursing Progress Notes dated 05/26/21 revealed the following: 11 PM to 7 AM shift, revealed Resident #31 was oriented to person only and that the skin was intact, warm, and dry. An entry timed 10 AM, that a skin assessment on the resident's hands was done and the fingernails were trimmed and cleaned. An untimed entry that recapped the assessment by the RN with the surveyor present, included the RN seeing a small red line but no skin break and that the RN would have the resident's nails clipped. The facility provided the CNA Orientation Critical Elements which included but were not limited to Patient care - ADL's Grooming - hair, nails, foot care, shaving. NJAC 8:39-27.1(a), 27.2(g)

Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to send a Urinalysis Culture and Sensitivity (UAC&S) specimen to the laboratory for analysis within an appropriate time frame which led to a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/24/21 at 11:10 AM, the surveyor observed Resident #88 lying in bed. The resident was calm and pleasant. The surveyor observed that the resident had a urinary catheter drainage bag in a privacy bag attached to the bed frame, hanging below the level of the resident's bladder. The foley catheter tubing was observed to be clear and empty of urine. The surveyor asked the resident how long he/she had resided at the facility and the resident stated, thirty minutes. On 05/25/21 at 12:30 PM, the surveyor observed the resident in his/her room seated in a wheelchair. The surveyor observed that the resident's urinary catheter bag was stored in a privacy bag, below the level of the resident's bladder, and attached to the seat of the resident's wheelchair. The surveyor observed clear, yellow urine in the catheter tubing. The surveyor reviewed the medical record for Resident #88. Review of the resident's admission Minimum Data Set, MDS (an assessment tool used to facilitate the management of care) dated 06/1/2021 reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 5 out of 15 which indicated the resident had impaired cognition and was confused. Section H, Bladder and Bowel of the resident's MDS reflected that the resident had a catheter (including suprapubic and nephrostomy tubing) to drain his/her urine. Section I, Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/26/2021 at 9:36 AM, the surveyor reviewed the resident's May 2021 hand-written Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Urine Culture dated 05/20/2021reflected that the resident's urine was slightly cloudy, a trace amount of bacteria was present in the urine, and the White Blood Cells (cells that indicate infection) in the residents urine were high. The resident's medical record did not reflect that the Culture and Sensitivity for the urine (a test that specifically indicates what type and amount of bacteria in the urine is present and offers appropriate antibiotic treatment options) was present in the medical record. On 05/26/21 at 9:44 AM, the surveyor interviewed the Change Nurse (CN) who stated that the lab did not run the culture and sensitivity report for the resident until yesterday (05/25/2021). The CN stated that she was unaware of why there was a delay in the laboratory specimen report and was looking into it. The CN stated that a culture and sensitivity for a urinalysis would usually take 72 hours to be completed by the lab. The CN further stated that the staff should have followed up with the resident's UAC&S results and notified the physician of the delayed pending results. On 05/26/21 at 12:19 PM, the surveyor interviewed the Registered Nurse/Unit Manager who stated that the lab specimen for the UAC&S was not collected by the laboratory because the nurse did not make the laboratory aware that the urine specimen was in the refrigerator. The RN/UM further stated that due to the urine specimen not being collected in an appropriate time frame, the resident's UAC&S was delayed, and the resident did not receive treatment right away for a positive urine culture. On 05/26/2021 at 1:46 PM, the surveyor reviewed the laboratory urine culture dated 05/26/2021 which revealed that the resident was positive for a Urinary Tract Infection (UTI) and had greater that 100,000 colony counts of bacteria in his/her urine. On 05/26/21 at 1:56 PM, the surveyor conducted a follow up interview with the RN/UM who stated that she had received a laboratory report that the resident was positive for a UTI, the resident's physician was notified, and the resident was started on antibiotic therapy related to the resident's history of UTI's. The RN/UM further stated that the sensitivity for the urinalysis was still pending, but the Dr. started the resident on antibiotic treated related to a history of UTI's. The surveyor inquired if the resident was currently symptomatic of a UTI and the RN/UM stated that the resident's physician was very involved in care and ordered labs on the resident because the resident was presenting with a decreased appetite. The RN/UM stated that she didn't know what happened and why the lab was not done and would investigate the reason why the lab was missed. Review of the May 2021 POS reflected a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's UAC&S dated 05/31/2021 reflected that the antibiotic treatment the physician prescribed for the resident was effective at treating the resident's UTI. Review of the resident's Care Plan dated 06/23/21 reflected a focus area for Urinary Catheter Use. The Care Plan reflected that the resident was at risk for having UTI's due to having a suprapubic catheter (a flexible tube that is inserted into the bladder to drain urine). The goal of the resident's Care Plan was that the resident would not develop UTI and my current UTI would be properly managed and treated. The approaches in the resident's Care Plan included to monitor labs and report any abnormal findings to my primary care physician. On 06/02/21 at 9:28 AM, The surveyor interviewed the Director of Nursing who stated that the UAC&S was something that fell through the cracks. Review of the facility's, Significant Change in Condition or status Policy and Procedure revised 05/2020 indicated That the responsible RN would notify the resident's attending physician of the resident's condition if it was necessary and appropriate and in the best interest of the resident. The, Significant Change in Condition or Status Policy and Procedure further indicated that the nurse would document in the resident's medical record at least daily until there was a condition, resolution, or improvement. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to: a.) assess a resident with contractures (a permanent tightening of the muscles, tendons, and skin that limits mobility) for the use of splints (a ridged device used to protect, immobilize, or restrict motion), b.) apply splints as ordered by a physician, and c.) develop a comprehensive care plan for use of the splint. This deficient practice was identified for two out of five residents reviewed, (Resident #21 and Resident #50) for position and mobility related to limited range of motion and was evidenced by the following. 1. According to the Cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) and assessment tool dated 03/03/2021, indicated that Resident # 21 had severe cognitive impairment and required complete care with all aspects of activities of daily living (ADL's). The MDS reflected that the resident did not utilize braces or splints on any aspect of the body. The MDS also indicated that the resident had functional limitations in range of motion on both sides of body in the upper extremities to include the shoulder, elbow, wrist, and hand. On 05/24/21 at 10:40 AM, the surveyor observed Resident #21 during tour lying in bed with both hands exposed and laying on top of the blanket. The resident was not able to be interviewed due to severe cognitive impairment and was non-verbal. Both hands were observed to be visibly deformed with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The surveyor did not observe the resident wearing any positioning devises on his/her hands. The May 2021 Treatment Administration Record (TAR) reflected a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a nurse's signature on the TAR on 05/24/21 on the 7AM-3PM shift that indicated that the comfy hand splints were intact and on the resident. The surveyor did not observe hand splints on the resident or in the resident's room on 05/24/21. On 05/25/21 at 07:40 AM, the surveyor had a second observation of Resident # 21 lying in bed with both hands laying on top of the blanket. There were no hand splints observed on the resident at this time. A review of the May 2021 TAR reflected a nurse signed on 05/25/21 on the 11:00 PM-7:00 AM shift indicating that the bilateral comfy hand splints were in place. On 05/25/21 at 10:14 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who was caring for Resident # 21, who stated that the resident required complete care with all aspects of ADLs. She also stated that the resident had severe cognitive impairment and was not able to communicate needs or wants and was not able to move independently. The CNA added that the staff had to reposition the residents every two hours. The CNA further stated that the resident did not wear any special devices or splints on his/her contracted hands or wrists. The CNA opened up the residents contracted hands to show the surveyor that the residents nails were trimmed and that there were no skin impairments on the inside of the resident's hands. The CNA added that the only opening on the resident's skin was at the sacral area. The surveyor did note that there was a dressing on the sacrum and that both lower extremities were offloaded with a pillow. On 05/25/21 at 10:17 AM, the surveyor interviewed the Restorative CNA who stated that she performed passive range of motion (ROM) on residents and the resident had decreased mobility. She stated that she did not perform ROM on Resident # 21 and that the resident was not on her caseload. She added that she did not apply splints to Resident #21's hands. On 05/25/21 at 10:37 AM, the surveyor interviewed the Occupational Therapist (OT) who stated that all resident on the vent unit were screened quarterly for changes in functional status and any new contractures or positioning issues. She stated that comfy splint is a palm protector for a resident with contracture to prevent nails from digging into the skin, prevent skin breakdown, and to also aid in prevention of further contractures. The OT further stated that it would be important to apply these splints as ordered by the physician to prevent breakdown and further contractures in residents with existing contractures. On 05/25/21 at 11:05 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) for the Vent Unit who stated that Resident # 21 did not wear any splints or devices on the contracted bilateral (B/L) hands. The RN/UM admitted that it was her signature on the May 2021 TAR dated 5/24/21 on the 7:00 AM - 7:00 PM shift that comfy splints were in place on the resident's B/L hands. She then stated that the resident has not had these splints available for some time. The RN/UM stated, I have to be honest; I don't remember the last time the resident had these splints. These residents change rooms so much and are in and out of the hospital so much I'm not sure where the splints are. The RN/UM stated that she should have notified the therapy department that the splints were missing and that she should have circled her signature on the May 2021 TAR and wrote on the back of the May 2021 TAR detailing that the splints were missing. On 05/25/21 at 11:42 AM, the DON stated that the nurse should have signed the TAR and circled her signature that the splints were not available and then signed the back of the TAR on the rational as to why the splints were not applied. The DON further stated that if the nurse knew that the splints were missing, then she should have contacted the therapy department to get new splints or assured that the resident was reevaluated. On 05/26/21 at 08:30 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who worked on the ventilator unit and took care of Resident # 21 on the 11:00 PM - 7:00 AM shift. The LPN stated that Resident # 21 was unresponsive and required complete care with all aspects of ADLs. The LPN admitted that she signed the May 2021 TAR on 05/24/21 on the 11:00 PM - 7:00 AM shift that the splints were on Resident #21's B/L hands but did not apply them and could not locate then in the resident's room. She stated that she could not recall the last time she saw the splints on the resident. I should have checked that the splints were in place before I signed the TAR and I take full responsibility. When the surveyor asked the LPN what she should have done when she could not find the splints, she did not have a response. The surveyor reviewed Resident #21's medical record which revealed the following information: The Vent Admission Order Set dated 04/08/21, reflected physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Interdisciplinary Plan of Care (IPOC) with a readmitted [DATE], indicated that the resident may have pain related to contractures and to have the resident evaluated and treated by rehab (Physical therapy, Occupational Therapy and Speech Therapy). There was no mention of comfy hand splints written on the IPOC. On 05/26/21 at 10:59 AM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #21 was readmitted to the facility with comfy splint orders. She added that when a resident was admitted with splints or any adaptive equipment then the admitting nurses should have notified therapy department and then a therapy screen or evaluation would have been performed by the therapy team. The DON further stated that she does not know why this process was not implemented or why the resident was not screened by therapy for these hand splints after admission to the facility on [DATE]. On 05/26/21 at 11:30 AM, the surveyor interviewed the acting Director of Rehabilitation (DOR) who was also a physical therapist who stated that the therapy department evaluated Resident #21 on 05/25/21 and provided the evaluation to the surveyor. The Occupational Therapy Plan of care (evaluation only) dated 05/25/21, indicated that the resident was non-verbal with cognitive impairments and had mild flexion contractures on all digits. The palm protector/comfy hand splint was donned (applied) and recommended to be worn and to take off during care and skin checks each change of shift to prevent further contractures and to prevent skin breakdown. The DOR also provided a manufacturers description and use of a comfy hand/wrist/finger Orthosis from www.pattersonmedical.com for contracture management, which indicated that the comfy hand splint supports and positions weakened hands. Reduces pain by immobilizing hand and prevents and treats the development of contractures, arthritic and neuromuscular deformities and ulnar deviation and wrist drop. 2. According to the Resident #50's May 2021 POS, the residednt had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Significant Change MDS dated [DATE], indicated that Resident #50 had Brief Interview of Mental Status (BIMS) score of 11 out of 15 which indicated the resident was cognitively intact with confusion. The MDS further indicated that the resident had functional limitations in range of motion on one side of his/her body in the upper extremities to include the shoulder, elbow, wrist, and hand. On 05/24/21 at 12:10 PM, the surveyor observed Resident #50's in his/her room. The surveyor further observed that the resident's right hand was contracted, and the resident was not wearing a splinting device. The surveyor attempted to interview the resident and the resident stated, No, no, no, or Yes, yes, yes. While giving the thumbs down sign when stating, no and the thumbs up sign when stating, yes. On 05/25/21 at 9:57 AM, the surveyor observed the resident seated in his/her wheelchair in front of the nurse's station manually touching a computer tablet with his/her left hand. The surveyor observed that the resident's right hand was contracted, and the resident was not wearing a splinting device. The surveyor further observed that the resident's fingernails on his/her hands were trim and clean. On 05/25/21 at 12:32 PM, the surveyor observed the resident seated in front of the nurse's station in his/her wheelchair. The resident's right arm was positioned in front of him/her and resting on the right cushioned side bar of the wheelchair. The surveyor did not observe a splinting device to Resident #50's right hand. On 05/28/21 at 10:07 AM, the surveyor observed the resident seated in front of the nurse's station in his/her wheelchair. The surveyor observed a hand splint attached to the resident's right hand. On 05/28/21 at 11:09 AM, the surveyor interviewed the resident's CNA who stated that the resident was somewhat alert and able to express himself/herself by pointing to things. The CNA stated that she took care of the resident regularly and stated that the resident was on hospice services and would sometimes refuse to eat. The CNA stated that one of the resident's hands was contracted, but she forgot which side. The CNA further stated that for the longest time she had not seen the resident wear a splinting device to his/her hands. On 05/28/21 at 11:22 AM, the surveyor interviewed the resident's LPN who stated that the resident was alert and oriented, had [CONDITION(S)] (partial loss or the inability to express language, although comprehension remains intact), and she took care of the resident frequently. The LPN told the surveyor that the resident went on hospice services because he/she was refusing medications. The LPN further stated that the resident's right hand was contracted and the resident wore a splinting device to his/her right hand during the day and that usually someone working in the therapy department would apply it to the resident's right hand. The LPN stated that the nurses were responsible for signing the treatment book as accountability that the resident was wearing the hand splint. The LPN further stated that the resident never refused to wear the hand splint. On 05/28/21 at 11:32 AM, the surveyor interviewed the Charge Nurse (CN) who stated that she was familiar with the resident and that sometimes the resident would refuse morning care depending on his/her mood. The CN stated that she thought the resident's right side was weak and she could not recall if the resident wore a splinting device. The CN stated that if the resident refused a treatment, the nurses would circle that the resident refused and write an explanation on the back of the TAR. The CN stated that the purpose for wearing a splinting device was to prevent further contractures and wounds from developing. The CN further stated that if the resident refused to wear the splinting device, that would be documented in the resident's Care Plan. On 05/28/21 at 11:37 AM, the surveyor observed the resident's right hand in the presence of the CN. The surveyor observed that the resident's nails were trimmed short, clean, and that there were no marks or indentations on the resident's hands. On 05/28/21 at 11:51 AM, the surveyor interviewed the resident's OT who stated that she was familiar with the resident and the resident had [CONDITION(S)] (weakness or the inability to move) on the right side and his/her right hand was contracted. The OT further stated that the resident did wear a right-hand splint and the nurses or CNA's were the staff members responsible for the application of the splint and would sign daily in the TAR when it was applied. The OT stated that therapy was involved in the screening and assessment process for the use of the splint related to contractures and the therapy department would provide the nurses with education on the application of the splinting device. The OT further stated that the splints purpose was to prevent contractures from worsening. On 06/02/21 at 9:20 AM, the surveyor interviewed the DON who stated that the resident had a long history of refusing care and medications. The DON further stated that she interviewed the residents regular LPN who stated that she would be documenting all the time because the resident refused his/her hand splints all the time so that was the reason why she didn't document in the resident's medical record that the resident refused to wear his/her right hand splint. The DON provided the surveyor with a statement written by the resident's LPN which indicated, I was the nurse for [resident's name redacted] on 5/24 - 5/25. The brace was put on those days. I basically place the brace once [gender redacted] is out of bed, but some days [gender redacted] would refuse. It all depends on [gender redacted] mood. In those particular days I would go back during the day to put it on. The LPN's statement provided to the surveyor by the DON contradicted the surveyor's interview with her conducted on 05/28/21 at 11:22 AM. The surveyor reviewed the medical record for Resident #50. The May 2021 POS reflected a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Remove for hygiene and skin check every shift. The May 2021 TAR reflected that the 7:00 AM - 3:00 PM nurse signed on 05/24/21 and on 05/25/21 that the resident's right hand splint was always on the resident. The resident's IPOC updated 01/16/21 indicated a focus area for mood and behavior that the resident refused care and medications. The IPOC further reflected that the resident had contractures. There was no mention in the resident's IPOC that the resident had a right-hand splint, refused the right-hand splint, or interventions to promote the resident's use of the right-hand splint. The resident's Occupational Therapy Plan of Care (Evaluation Only) dated 05/29/21 indicated that the resident had a contracture to his right upper extremity and hypertonic (resistance to passive movement) muscle tone. The reason for the referral indicated that the resident was referred to OT services to establish splint wearing services. There was no indication on the resident's OT evaluation that the resident's range of motion had deteriorated. The facility policy with effective date of 10/2021 and titled, Splinting and Splint Precautions indicated that all request for splints for physical and occupational therapy require a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy also indicated that therapist will provide an in-service to a nursing staff, patient or family. A further review of the, Splinting and Split Precautions Policy indicated that splints were fabricated for resident's that required intervention and splinting would be carried out in a standardized practice. NJAC 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: a.) dispose of a needle with a syringe (sharps) in it's appropriate receptacle and b.) maintain a safe environment during medication administration. This deficient practice was identified for two of four resident's reviewed, (Resident #67 and Resident #75) for medication administration. The deficient practice was evidenced by the following: 1. On 05/25/2021 at 7:40 AM, the surveyor observed the Registered Nurse (RN) on the 300 Unit administer the medication, [MEDICATION(S)] (a blood thinning medication) to Resident #67. The RN administered the medication, pulled up the top of the plastic safety syringe attached to the needle so the needle was not exposed, removed her gloves, washed her hands, exited the room with the used syringe, and discarded the used syringe in the waste receptacle bin attached to the medication cart. The surveyor observed that the receptacle bin was directly underneath the sharps container (container used to dispose of used syringes). The used syringe was visible and within reach. The RN went to the next room to check on another resident. The surveyor stayed by the medication cart and summoned another staff member who was in the hallway. The staff member identified herself as the facility's Infection Control Preventionist (IP). At 8:25 AM, immediately upon the staff member identifying herself as the IP, the surveyor inquired about the policy for sharps disposal. The IP told the surveyor that all syringes should be disposed in the sharps container. The surveyor then showed the IP the used syringe that was visible and within reach placed in the waste receptacle. The IP guarded the medication cart until the nurse returned to the hallway. At 8:30 AM, the IP instructed the RN to remove the used syringe from the receptacle bin. The RN discarded the used syringe in the sharps container attached to the medication cart. At 8:30 AM, the RN stated that she should have disposed of the used syringe in the sharps container and stated, I am sorry. At 11:38 AM, the surveyor notified the Administor and Director of Nursing (DON) that the RN placed the used syringe in the waste recepticle and not the sharps container on the medication cart. The surveyor asked the facility's administration to provide the policy for sharps disposal, none was provided for review. On 06/02/21 at 9:08 AM, the DON stated the RN told her that she thought she had thrown the used syringe into the sharps container and not the waste receptacle.The DON stated that she thought the RN was a good nurse and it was done by accident. 2. Resident #75 was admitted to the facility with diagnoses which included, unspecified Dementia without behavioral disturbances, polyneuropathy (malfunction of peripheral nerves throughout the body), hypertension (elevated blood pressure), and pure [CONDITION(S)]. The Annual Minimum Data Set (MDS - an assessment tool) dated 04/23/2021 revealed a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS)assessment, which indicated a moderate cognitive impairment. Surveyor interviews with staff reflected that Resident #75 was able to make his/her needs known and was forgetful at times. On 06/01/21 at 9:30 AM, the surveyor observed on Resident #75's bedside table, eight tablets inside a medication cup. Resident #75 stated that the nurse left his/her medications that morning. The surveyor observed no residents in the area who were ambulatory or who had access to the medications on the bedside table. On 06/01/21 at 09:40 AM, the surveyor interviwed Resident #75's Licensed Practical Nurse (LPN) who stated that Resident #75 received the medications that morning at 8:40 AM. The LPN showed the surveyor the June 2021 Medication Administration Record (MAR) where the she had signed for the administration of the medications. The LPN further stated she observed Resident #75 swallow the medications. Again, in the presence of the Charge Nurse, the LPN confirmed that she observed Resident #75 swallow the medications that morning. On 06/01/2021 at 9:45 AM, a review of the June 2021 MAR revealed that the following medications were administered and signed for on 06/01/2021 at 8:00 AM. [MEDICATION(S)] (medication to relieve nerve pain) 300 milligram ( mg), [MEDICATION(S)] sulfate (iron supplement) 325 mg, Isosorb (medication to increase blood flow so the heart pumps easier) 30 mg, [MEDICATION(S)] (mineral supplement) 10 Milliequivalents (MEQ), Vitamin B 12 (vitamin supplement) 1,000 micrograms, Vitamin D (vitamin supplement) International Units (IU), [MEDICATION(S)] (an anti-depressant) 2.5 mg, and [MEDICATION(S)] (medication to lower blood pressure) 12.5 mg. On 06/01/21 at 9:46 AM, the Charge Nurse observed the medication cup with the medications and stated the process was not safe and was unacceptable. The Charge Nurse stated the LPN should not have left the medications unattended at the resident's bedside and should not have signed for the medications if they were not administered. The Charge Nurse further stated that this process violated the facility's protocol and five rights of passing medications (right resident, right dose, right time, right route, and right medication). The Charge Nurse indicated that Resident #75 was alert and able to follow directions. Upon further inquiry, the Charge Nurse stated that Resident #75 did not have an order to self administer medications. The surveyor requested the facility's Medication Administration Policy along with the medication pass competency for the nurse. On 06/01/21 at 9:56 AM, the surveyor conducted a second interview with the LPN who stated that the medications in the cup belonged to Resident #75. The LPN stated that Resident #75 was eating breakfast so she left the medications at the bedside at 8:40 AM. The LPN recanted her story and stated that she did not observe Resident #75 swallow the medications that morning. The LPN further stated she had expected Resident #75 to take the medications while eating breakfast. According to the LPN, the protocol was to observe residents swallow their medications and then sign the MAR that the medications were administered. On 06/01/21 at 10:41 AM, the DON stated that her expectations would be for the nurse to have stayed in the room to ensure the resident swallowed their medications before signing the MAR. The DON stated the facility's process of medication administration competency was different with every nurse because medication pass orientation was based on the nurses level of experience and the severity of the facility's needs. The nurses would meet with the educator and review the orientation materials which covered medication pass. The DON further stated that the Consultant Pharmacy or the Unit Manager would be responsible to follow the nurse to ensure they were administering medications correctly and safely. The DON further stated, if medications were not administered, the protocol would be to inform the physician and assess the patient for an adverse effect. The DON stated that on the 300 unit, the residents were appropriately social distanced on the unit, continuously monitored, or remained their rooms. The DON further stated that Resident #75's roommate was unable to the get out of bed on his/her own. On 06/01/2021 at 11:06 AM, during a follow up interview with the Nurse Educator (NE), regarding the medication competency for the nurse, the Charge Nurse was present and stated, I did not have any documentation that it (LPN's medication competency) was done. The NE stated that based on the agreement with the staffing agency, the facility would expect that the agency staff would be competent in administering medications. The NE told the surveyor that the only competencies that the LPN completed were the hand hygiene observation and Personnel Protective Equipment (PPE). There was no documentation that the LPN had completed the medication pass competency with the facility. The NE indicated that he did not have an employee file for the LPN. On 06/01/21 at 11:27 AM, the NE showed the surveyor the orientation list that needed to be completed for agency staff, but there had not been one completed for LPN. The LPN had been provided with the, Corporate Health Nursing and Rehab Nursing Orientation for agency Nurses, but did not complete the Medication Pass Competency located in the orientation book. A review of the facility's policy titled, Standards of Nursing Practice: RN, LPN, CNA, APN, initiated 02/2020 last revised 07/2021 indicated the following under Medication Administration: A) To administer medications, all nurses must pass a medication exam and Medication Pass competency observation. B) Each facility's Pharmacy and Therapeutics Committee approves a medication reference book or database which serves as a guideline for drug dosages and precautions. C ) Provider Pharmacy procedure manuals are available at each facility as a further reference. Another Corporate Policy titled, Medication Administration, last revised 02/2020, indicated, The nurse shall remain in the resident's room until the resident has taken the medications. On 06/02/2021 at 10:15 AM, during an exit conference with the administrative staff, the DON indicated that she could not explain what had happened or why Nurse #1 had not completed the orientation required by the facility. NJAC: 8: 39-27.1(a)

Complaint: NJ 612 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) serve hot and cold foods at an acceptable temperature for the residents and b.) have a facility policy and procedure for maintaining appropriate food temperatures. This deficient practice was identified on the second floor during a food test tray observation and by two out of seven residents during the February 2021 Resident Council Meeting Minutes. The deficient practice was evidenced by the following: On 05/28/21 at 11:30 AM, the surveyor observed the food trucks containing the resident's lunch meal leave the kitchen. At 11:31 AM, the surveyor observed the food trucks arrive on the second floor to be passed out to residents who resided on the unit. The surveyor observed that the food was stored and served to the residents on a plate which was covered by a dome container. The surveyor further observed that the soup was served in plastic container with a plastic lid over it. The cold drinks were placed on top of the resident's meal tray. At 11:35 AM, the surveyor conducted an interview with the Food Service Director (FSD) who stated that the goal was for hot foods temperatures to be between 150 to 160 degrees Fahrenheit (F) and cold food temperatures should be below 41 degrees F. At 11:50 AM, the surveyor took the temperatures of the food of the last tray remaining on the food truck. The surveyor had calibrated the thermometer prior to taking the temperatures of the food on the tray. The surveyor's thermometer registered the temperature of the baked cod at 113.3 degrees F. The FSD utilized her thermometer to take the temperature of the food on the tray after the surveyor. The FSD's temperature of the baked cod was 109 degrees F. The surveyor's temperature of the potato wedges was 117.8 degrees F. The FSD temperature of the potato wedges was 100 degrees F. The surveyor's temperature of the soup was 139.1 degrees F. The FSD temperature of the soup was 140 degrees F. The surveyor's temperature of the 4 ounces (oz) of whole milk on the resident's lunch tray was 53.4 degrees F. The FSD temperature of the 4 oz of whole milk was 53 degrees F. The surveyor's temperature of the 4 oz of apple juice was 56.6 degrees F. The FSD temperature of the 4 oz of apple juice was 56 degrees F. The FSD stated that the temperature of the food was not in an acceptable range. At 11:58 AM, the FSD stated that she wasn't sure if the facility had a food temperature policy and procedure. At 12:07 PM, FSD confirmed that the facility had no specific policy for the temperature of food when it was to be served to the resident. Review of the February 2021 Resident Council Meeting minutes revealed two out of seven residents interviewed stated that the food was served cold. One resident stated, The coffee is like water and the food is usually cold. Another resident stated, The food is cold. Review of the Resident Council Response Form dated February 2021 indicated that the FSD followed up with the resident's concerns and told them that because the facility was using paper products during the Pandemic, it was resulting in the food not being served as hot as it used to be. The Resident Council Response Form further indicated that the residents could ask the staff for another tray or have the food heated up if it needed to be. NJAC 8:39-4.1

Based on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to: a.) ensure staff followed current standards of practice at point of care testing regarding transport and disposal of used lancets safely, b.) performed appropriate hand hygiene during a wound treatment observation according to facility policy and the Center of Disease Control (CDC) guidelines, and c.) wore the facility required Personal Protective Equipment (PPE) on the ventilator unit. This deficient practice was identified for one of five medication carts reviewed for infection control, one of one resident's reviewed, (Resident #1) during during a wound care observation, and on one of two nursing units in the facility. The deficient practice was evidenced by the following: 1. On 05/25/2021 at 09:30 AM, the surveyor went to the 300 Unit to check the medication carts as part of the survey process. At 09:45 AM, the surveyor checked the medication cart on the 300 B side with Nurse #1. Nurse #1 opened the medication cart drawer and there was a little basket that contained two used lancets stored with alcohol pads, seven clean, and unused lancets along with the facility glucometer. The surveyor inquired about the used and unused lancets comingled together with the glucometer. The nurse stated that the open lancets were used that morning to monitor the resident's blood sugars and could not be used again. On 05/25/2021 at 10:10 AM, the surveyor asked Nurse #1 for the protocol for the disposal of used lancets. The nurse told the surveyor that the protocol was to disinfect the glucometer after each resident and to dispose of used lancets after use in the sharp's container. The Infection Control Preventionist (IP) was nearby and heard the conversation. The IP intervened and asked the nurse to discard all the lancets, the alcohol pads and to disinfect the tray along with the glucometer. Nurse #1 discarded all the lancets in the sharp container attached to the medication cart in the presence of the surveyor. The glucometer was removed and disinfected. On 05/25/21 at 10:21 AM, the IP stated Nurse #1 had been employed by the facility for many years. According to the facility's policy the nurse should have discarded the lancets in the sharp's container after use. The used lancets should never have been stored with the clean, unused lancets for infection control prevention. The IP indicated that she counseled the nurse, assisted the nurse to disinfect the medication cart and the glucometer. The IP indicated that Nurse #1 always followed the facility's policy and procedure but could not explain what was going on with Nurse #1 today. On 05/25/21 at 10:31 AM, during a second interview with Nurse #1, she stated that she monitored the blood sugar at 9:00 AM for a resident and at 9:10 AM for another resident. She told the surveyor that she disinfected the glucometer after each resident. The surveyor verified that neither resident was on Transmission Based Precautions. On 05/25/2021 at 11:15 AM, a follow up interview with Nurse #1 revealed that there were no sharp's containers in the resident rooms to dispose of the used lancets so she placed the used lancets in the tray along with the clean, unused lancets and the glucometer. Nurse #1 stated that she should have disposed of the used lancets after use in the sharp's container attached to the medication cart. On 05/25/2021 at 11:40 AM, the survey team discussed with the Administrator and the Director of Nursing (DON) the observed practice of the used lancets stored in the medication cart along with clean, unused lancets and the clean glucometer. On 05/25/2021 at 11:43 AM, the DON stated that her expectations would be for staff to dispose of the used lancets in the sharp's container to prevent the spread of infection. The team requested the facility's policy for Infection Control and sharps disposal. On 05/25/2021 at 12:30 PM, the surveyor requested the Infection Control Policy from the IP. The IP stated that Nurse #1 had been working at the facility for [AGE] years and she could not explain what happened. The IP told the surveyor that the nurse had been educated on Infection Control Prevention. On 05/27/21 at 1:23 PM, the DON provided a policy and procedure titled: HMNR Medical Device Safety and Point of Care Testing revised 01/2021 which indicated the following under Purpose: Prevention and control of transmission of Infection. Policy: Medical devices may be used for administration of medications, point of service testing and other medical uses. Procedure: Point of care testing may be accomplished through use of portable handheld instrument which may include blood glucose monitoring, prothrombin time, I-stat device (e.g. chemistry) , and COVID-19 testing. 1. Blood specimen by finger stick: Single use auto-disabling device only may be used. These are devices that are disposable and prevent reuse through an auto-disabling feature. Must never be used for more than one resident/ patient. Dispose of used needle stick device in a sharp container. Never put devices or supplies in pocket. 2. Blood Glucose meters may be shared in the rehabilitation facility but must be disinfected after each use per manufacturer's instruction, meeting the criteria specified by the FDA. Nurse #1 although aware of the facility's policy for Infection Control did not follow the policy. 2. On 05/26/21 from 10:02 AM to 10:32 AM, the surveyor observed the Resident Nurse (RN) perform the wound care treatment to Resident #1's right buttocks with assistance from the Charge Nurse (CN). At 10:02 AM, prior to performing the wound care treatment, the surveyor observed the RN turn on the faucet to the sink in the resident's bathroom with her hands, apply soap without rinsing her hands under the running water and rub both her hands together under the running water for 15 seconds. The surveyor did not observe the RN rub her hands outside of the running water to produce a lather from the soap. The surveyor then observed the RN gather supplies at the treatment cart outside of the resident's room and bring them into the resident's room to perform the treatment to the resident's right buttocks. The surveyor then observed the RN clean fecal matter from the resident's buttocks. At 10:12 AM, the surveyor observed the RN perform hand hygiene again in the resident's bathroom. The surveyor observed the RN turn on the faucet to the sink in the resident's bathroom with her hands, apply soap without rinsing her hands under the running water and rub both her hands together under the running water. The surveyor further observed the RN add more soap from the soap dispenser three times. Each time the RN added soap to her hands, the surveyor observed that she never produced a lather with the soap and had her hands were positioned under the running water in the sink while she rubbed them together. The RN then went over to the resident to perform the wound care treatment. At 10:34 AM, the surveyor interviewed the RN who stated that appropriate hand hygiene required her to turn on the faucet, wet hands with water, apply soap, and run hands together for 20 seconds in the sink under the water in a downward position. The RN then stated that she would dry her hands with a paper towel, and then turn off the faucet with a new paper towel. At 12:30 PM, the surveyor interviewed the CN who stated that the correct procedure to wash hands was to turn on the faucet, wet hands, apply soap, rub hands with friction outside running water to produce a lather for 20 seconds. Then rinse the soap from the hands under the running water. The CN further stated that hands would be dried with a clean paper towel and another paper towel would be utilized to turn off the faucet. The CN stated that the purpose of hand hygiene was to prevent the spread of germs. On 06/01/21 at 9:50 AM, the surveyor interviewed the IP who stated that the correct hand washing procedure was the staff member should turn on the water, wet hands, get soap on hand and lather both hands together with friction outside of the running water for 20 seconds. The IP further stated the staff member would then rinse off hands under the running water, use paper towel to dry hands, and use new paper towel to turn off the faucet. Review of the Handwashing Observation Checklist conducted for the RN dated 1/12/21 reflected that the RN, 1. Hands washed properly with clear running water 2. Disinfectant or soap used 3. Front and back of hands properly scrubbed 4. Hands rinsed appropriately 5. Faucet turned off with paper towel 6. Hands dried correctly 7. Towels properly discarded and Handwashing was done in 20 seconds. The Handwashing Observation Checklist reflected that the RN appropriately washed her hands. Review of the updated Handwashing Observation Checklist conducted for the RN dated 6/1/21 reflected that the RN, 1. Remove hand and wrist jewelry/watches and push sleeves up above the wrist prior to handwashing 2. Stand well away from the sink in order to prevent [NAME] splashed 3. Turn on the water gently and adjust water temperature to a comfortable level 4. Wet hands and wrist thoroughly 5. Dispense the correct amount of soap 6. Scrub each hand with the other, creating as much friction as possible by interlacing the fingers and moving the hands back and forth 7. Scrub the hands for 20 seconds outside of the running water 8. Rinse the hands thoroughly under running water, keeping the hands down below the level of the elbows 9. Does not touch the surface of the sink 10. Dry the hands and wrists gently with a paper towel and discard into the wastebasket 11. Turn the faucet off with a new, dry paper towel 12. Discard the paper towel into the wastebasket Review of the facility's, Handwashing and Hand Hygiene Policy and Procedure revised 08/2020 indicated that the purpose of performing hand washing was to prevent the spread of infection. The, Handwashing and Hand Hygiene Policy and Procedure further indicated to perform hand hygiene before and after touching wounds. Review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. 3) During the survey teams' entrance on 05/24/21, the facility informed the surveyors that there were no COVID-19 positive residents in the facility but there were residents on TBP or observations as new or readmissions. The facility informed the surveyors that on the 2nd and 3rd floors, the staff and surveyors were required to wear an N95 mask with a surgical mask over it and eye protection. The facility had supplied a facility floor plan which indicated rooms highlighted in yellow to be TBP rooms which required PPE. The 3rd floor had four rooms highlighted. During a tour of the facility, the surveyor approached the elevators in the lobby and observed a sign that indicated, NO ONE IS ALLOWED ON THE 2ND OR 3RD FLOOR WITHOUT PROPER P.P.E. IE, GOGGLES OR SHIELD AND N95. The surveyor toured the 3rd floor on 05/24/21 and observed four rooms to have STOP see nurse signs and bins with PPE supplies outside the room. On 05/25/21 at 12:13 PM, the surveyor observed the Registered Nurse Unit Manager (RN/UM) on the 3rd floor wearing two surgical masks and a face shield. During an interview at that time, the RN/UM stated her allergies were bothering her, so she was not wearing the facility required N95 mask. She stated the N95 mask was for the protection of the staff and the residents on the floor. The RN/UM further stated she had an assignment and was caring for residents on the ventilator unit, she had been fit tested for the N95 mask, and had the N95 mask available to her. On 05/25/21 at 12:25 PM, the Director of Nursing (DON) stated the purpose of staff on the 2nd and 3rd floors wearing full PPE was because there were quarantined residents. The DON stated the staff were to wear the N95 mask to prevent spread of infection. The DON further stated the RN/UM on the 3rd floor, especially with an assignment that included ventilator and TBP residents, would be required to wear the N95 mask, surgical mask over it and eye protection. Review of the facility provided assignment sheet for May 25, 2021, revealed the RN/UM was responsible for the care of 10 residents on the ventilator unit and three of those residents were on TBP. Review of the facility PPE Donning and Doffing Competency Tool included but was not limited to, PPE was worn to minimize exposure to hazards and prevent the spread of germs, PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas, and that the appropriate PPE should be worn according to the TBP in effect. The RN/UM was noted to be competent in all the steps and signed her competency on 03/25/21. Review of the Fit Test Record dated 11/05/20, revealed the RN/UM had been fit tested for the respirator mask. Review of the facility Universal Pandemic Precautions policy and procedure, dated 11/23/20, revealed but was not limited to, the N95 masks were recommended for use with residents who are COVID-19 suspects, Persons Under Investigation (PUI), and Quarantined; eye protection was required for residents who were PUI or on quarantine; universal eye protection must be worn when providing direct care or having close (within six feet) contact with residents and at all times on the units where suspect, PUI or quarantine residents were located. NJAC 8:39-19.4(a)(1,2); 19.4(l,n); 27.1(a)

Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to ensure that appropriate infection control practices were followed by staff to prevent the spread of COVID-19. This deficient practice was identified for 1 of 7 staff members observed on 2 of 2 nursing units, and was evidenced by the following: On 12/7/2020 at 9:00 AM, the survey team conducted an entrance conference with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON stated that the facility currently had two COVID-19 positive residents who resided on a designated section on the third floor. She added that those residents had a designated nurse and a designated Certified Nursing Aide (CNA) who only cared for the two residents. The DON stated that the remaining 94 residents in the building were on a fourteen-day quarantine for possible exposure to COVID-19 from staff members who tested positive for COVID-19. The DON stated that they placed all residents on a transmission-based precautions (TBP) to be cautious. She added that all staff members were required to don full Personal Protective Equipment (PPE; items worn to protect the wearer from contracting infectious agents) which included an N95 (respirator) mask with a surgical mask covering, eye protection, disposable gown, and gloves prior to entering any resident's room. Staff were expected to doff (remove) the gown and gloves prior to exiting the room and perform hand hygiene with soap and water or an alcohol-based hand rub (ABHR). The DON stated that all staff on the two nursing units were supposed to wear N95 mask throughout the units. The DON stated that all residents were tested for COVID-19 on a weekly basis and that staff were currently getting the COVID-19 rapid [MEDICATION NAME] testing trial every other day since 11/30/2020. She added that previous to 11/30/20, staff were routinely tested weekly. At 11:00 AM, the surveyor entered the third-floor nursing unit and observed in all four wings, that TBP signs and PPE bins were located outside each resident room door. The surveyor observed that outside each resident room was an ABHR dispenser mounted to the wall. At 11:05 AM, the surveyor interviewed CNA #1 who stated that the cautionary signs on the residents' room doors were there to notify staff of residents' TBP status and to show the type of PPE staff should don when providing care to residents. The surveyor observed that CNA#1 wore only a surgical mask and goggles and not the N95 mask and gown. When questioned, CNA#1 stated that she wore N95 mask earlier, and that she removed it because she needed a break because N95 mask was uncomfortable. At that time, CNA #1 proceeded into resident room [ROOM NUMBER] with no observed hand hygiene, and wearing only surgical mask and goggles. CNA#1 did not don gloves or gown. The surveyor noticed outside the door to room [ROOM NUMBER], a quarantine TBP sign which indicated that prior to entering the room, staff should wash or sanitize their hands and don gown, gloves, eye protection, and a N95 mask covered with a surgical mask. There was a PPE bin located directly outside the door to room [ROOM NUMBER] which contained gowns, gloves, surgical masks, and germicidal bleach wipes. The surveyor also observed an ABHR dispenser that was mounted on the wall outside the room. There were two residents in room [ROOM NUMBER]. The surveyor stood outside room [ROOM NUMBER] and observed CNA#1 as she exited the residents' bathroom, carrying a blue plastic garbage bag that contained unidentifiable materials. CNA #1 placed the garbage bag into a covered linen bin and rolled the bin down the hallway to outside of room [ROOM NUMBER]. The surveyor did not observe CNA#1 perform hand hygiene after handling the plastic bag and the linen bin. CNA #1 then proceeded into room [ROOM NUMBER], while still wearing the same surgical mask and goggles, no gown, no gloves. The surveyor observed outside the door to room [ROOM NUMBER], a quarantine TBP sign, a PPE bin, and ABHR mounted on the wall. CNA #1 went into the residents' bathroom, and exited the bathroom wiping her hands with a disposable towel. She proceeded to the resident's dresser and moved around the resident's belongings which was on the dresser. CNA#1 then went over to Resident #1 and picked their water cup, went to the bathroom with the water cup and then brought the cup back to the resident. CNA#1 then went back into the bathroom and came out with a water basin and placed the basin on the resident's tray table. She then closed the resident's privacy curtains blocking the surveyor's view of the resident. CNA#1 then went to Resident#1's closet, removed some clothing and placed the clothing on the bed and then walked out of the room with no observed hand hygiene. From room [ROOM NUMBER], CNA #1 walked into room [ROOM NUMBER] with no observed hand hygiene or donning of new PPE. The surveyor observed quarantine TBP sign, PPE bin, and ABHR dispenser mounted to the wall outside the door of room [ROOM NUMBER]. The surveyor observed CNA#1 as she moved resident's belongings on the dresser. She then picked a pair of gloves from a box on the resident's dresser and left the room with the gloves. The surveyor did not observe CNA#1 perform hand hygiene. At 11:21 AM, CNA #1 walked back into room [ROOM NUMBER] and donned the gloves she picked from room [ROOM NUMBER]. She did not perform hand hygiene. The surveyor observed the CNA#1 move sheets around the Resident#1's bed. At this time, the surveyor interviewed a unit Registered Nurse (RN) who was outside of room [ROOM NUMBER] preparing medications. The RN confirmed that CNA #1 was performing direct care on Resident #1. The surveyor asked the RN if CNA #1 should be wearing full PPE to perform care on Resident #1. The RN stated that CNA #1 should be wearing full PPE, and confirmed that CNA#1 was not wearing a gown. The RN did not stop CNA#1 but rather continued to prepare medications for residents. The surveyor then asked the RN if she should stop CNA#1 from performing care and have her don full PPE. The RN agreed and then went to CNA#1 and informed her to don full PPE. In the presence of the surveyor, CNA #1 stated to the RN that she was unaware that she needed to wear a gown to perform care for Resident #1. CNA #1 then exited room [ROOM NUMBER] wearing a pair of gloves and proceeded to a PPE bin across the hall from room [ROOM NUMBER]. With the same gloves she wore when she exited room [ROOM NUMBER], CNA#1 pulled out a gown from the PPE drawer, and donned the gown. When interviewed regarding CNA#1's reaching into the bin for a gown while wearing the same glove she wore in room [ROOM NUMBER], both the RN and CNA #1 did not respond. CNA#1 then removed the gloves, performed hand hygiene and proceeded back into the room [ROOM NUMBER] and donned new gloves. At 11:33 AM, the surveyor interviewed CNA #1 again. She stated that nurses were supposed to inform CNAs as to what PPE to wear in residents' rooms and that she was supposed to don PPE prior to entering the room and doffed the PPE prior to exiting the room and to perform hand hygiene. At 11:40 AM, the surveyor interviewed the third-floor Licensed Practical Nurse/Charge Nurse (LPN/CN) who stated that staff were aware of what PPE to don prior to entering a room based on the sign outside the resident's door. She added that the sign indicated what type of TBP the resident was on, and what type of PPE that staff are to don. The LPN/CN stated that staff were informed of this when the signs first went up and were also informed of any changes every morning. The LPN/CN stated that staff received their N95 mask each morning when they entered the unit and that staff knew to report to the supervisor if they did not have a N95 mask. At 11:45 AM, the surveyor interviewed the RN again. She stated that staff were aware of what PPE to don prior to entering a room based on the sign outside the door. The RN stated that staff donned full PPE - gown, gloves, eye protection, N95 mask, and a surgical mask prior to entering a resident's room. The RN stated that she should have stopped CNA#1 immediately and have her don full PPE including N95 mask before continuing with performing care. At 12:20 PM, the surveyor interviewed the in-service Educator/Infection Preventionist (IE/IP) who stated that staff were educated on TBP and donning/doffing of PPE at the start of the current outbreak which started on 11/16/2020. The IE/IP stated that CNA #1 was out of the facility on vacation for two weeks in November and returned to work on 11/23/2020. At 12:21 PM, the DON stated that facility's protocol when a staff member was out of the facility on vacation, was to first test the staff member for COVID-19 prior to returning to work. Then educate the staff on any changes that have occurred in the facility since the last time they worked. The DON stated that the IE/IP and the nursing supervisors oversaw all education and made sure that all staff were updated with education. Review of in-service education for CNA #1 reflected that she was last educated on infection control practices on 10/22/2020. The IE/IP stated that CNA #1 would have been verbally educated on anything she missed upon returning to work. The IE/IP stated that the CNA was a fulltime staff member who worked on the long-term care nursing unit and not with COVID-19 positive residents. Review of assignment sheet showed that CNA#1 did not work with covid-19 positive residents. At this time, the LNHA confirmed that CNA #1 should have been verbally informed of any facility changes upon return to the facility from vacation. The LNHA stated that both the Nursing Supervisor and the Charge Nurse should be educating staff daily and performing rounds to ensure that staff were adhering to TBP. At 1:10 PM, the surveyor interviewed CNA #1 again who confirmed that she was out of the facility for a few weeks in November. CNA#1 stated that she was educated by the LPN/CN and was told to wear PPE according to any TBP signs on residents' doors. CNA#1 could not provide a reason as to why she had not donned full PPE prior to entering the TBP rooms earlier. At 1:22 PM, the surveyor interviewed the RN/NS who stated that he educated staff on infection control every morning during morning meetings. The RN/NS stated that he reminded staff on a daily basis that they needed to don full PPE which included a N95 mask. The RN/NS stated that the facility had a large supply of PPE and so there should have been no reason why staff were not donning full PPE. A review of the Face Sheet (an admission record) reflected that the Resident #1 was readmitted to the facility in March 2020 with the primary [DIAGNOSES REDACTED]. A review of the December 2020 Physician's Order Sheet (POS) indicated that the resident had a physician's order (PO) dated 11/26/2020 for quarantine TBP for fourteen days. A review of the most recent quarterly Minimum Data Set (MDS), a tool used to facilitate the management of care, dated 11/23/2020, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated a fully intact cognition. A review of the resident's COVID-19 test results reflected that the resident tested negative for COVID-19 on 12/4/2020, 11/29/2020, 11/27/2020, 11/25/2020, and 11/18/2020. The surveyor reviewed CNA #1's COVID-19 tests, which indicated that CNA#1 tested negative for COVID-19 on 12/4/2020 and 11/24/2020. At 2:22 PM, the surveyor interviewed Resident #1 who stated that staff donned eye protection, mask, gown, and gloves when entering his/her room. The resident was unsure the exact date that staff started donning the full PPE but stated that staff wore PPE because of the germs in the building. At 2:35 PM, the DON informed the survey team that the CNA#1 should have been aware of the PPE to don from the morning meeting. The DON acknowledged that CNA#1 should have worn a N95 mask on that floor, donned full PPE prior to entering rooms of residents on TBP, and performed hand hygiene prior to entering and exiting the rooms. The DON stated that the RN should have stopped CNA #1 immediately from performing care on Resident #1 without donning full PPE. At 3:00 PM, the DON stated that all the residents on the third-floor long-term care nursing units were placed on TBP for possible exposure to a staff member that tested positive for COVID-19 on 11/23/2020. The DON stated that the second staff member on the third floor who tested positive for covid-19 on 11/30/2020 from rapid response [MEDICATION NAME] test was retested with follow-up PCR test (a diagnostic test that detects the [MEDICAL CONDITION]) and that the staff member tested negative. At 3:45 PM, the survey team addressed their concerns with the LNHA, DON, IE/IP, and the IP who all acknowledged their concerns. A review of the facility's policy labeled: Hackensack Meridian Nursing and Rehabilitation Managing Outbreaks policy dated revised date 3/2020 included to provide in-service education to all staff on all shifts. The policy also included that signs will be posted at the entrance to the facility and outside of resident's room that will include precaution and reinforce hand hygiene. A review of the facility policy labeled: Hackensack Meridian Nursing and Rehabilitation COVID-19 Strict Isolation Precautions and Discontinuance of Isolation policy dated updated 5/23/2020 included that the use of N95 respirator masks will be used upon entering the room of a COVID-19 suspect cases or persons under investigation for COVID-19. A review of the Linen Services Related to Infection Control policy dated retrieved 3/5/2020 included that staff perform hand hygiene each time after handling solid linen. N.J.A.C 8:39-19.4

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 07/02/19 at 09:39 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. There was a bucket identified by the FSD as a sanitizing bucket. FSW#1 used a sanitizer test strip to measure the level of sanitizer potency in the bucket. The sanitizer did not register on the strip. When interviewed at the time, FSW#1 revealed the sanitizer should register at over 200 parts per million (ppm). The FSD indicated the contents of the bucket may be bleach and not sanitizer, and that's why it didn't register. The surveyor interviewed FSW#2 who indicated he'd filled the bucket and used sanitizer and not bleach. FSW #2 demonstrated how the bucket was filled by emptying the contents and refilling the bucket straight from the sanitizer hose. FSW#2 used a sanitizer test strip on the newly filled bucket which registered over 200 ppm. FSW#2 was unable to explain why the original bucket did not register on the test strip. 2. In the cooking area on a cart under the spice shelf, there was a five-pound (lb) container of Italian breadcrumbs which was open and undated. When interviewed at the time, the chef indicated any food should be labeled and wrapped after opening. 3. There were a total of 19 opened and undated spices stored on a shelf in the cooking area. Six of these spice containers had open lids including paprika, steak seasoning, ground ginger, ground cumin, Cajun seasoning and ground black pepper. The chef revealed lids should be closed when not in use. The chef further indicated some of the spice containers were sticky to touch and confirmed seeing particles on the shelf where the spices were stored. The chef revealed that spices should be wiped down after each use. The FSD confirmed, lids should be closed when not in use and all opened spices should be dated and stored clean. 4. There was a 20-pound jasmine rice bag stored on a cart under the spice shelf in the cooking area. The bag was opened and loosely tied with a piece of plastic. The FSD was not able to locate an open date. The FSD indicated the rice should be dated and stored in a sealed container after opening. 5. In the cook's area on a shelf under the countertop, the surveyor observed five- 1/3 size steam pans, seven- 1/3 medium pans, and 29 sheet pans wet nested. The FSD indicated pans should be air dried in the dish washing area prior to storing. 6. In walk-in refrigerator #1, there was a one-pound vegetable stock base and a bag of mixed-dried fruit and nuts, both open and undated. There were 11 crates of eggs stored above a case of bacon and hot dogs. Both the bacon and the hot dogs were open and exposed to air. The FSD immediately discarded the vegetable stock base, fruit and nut mix, hot dogs and bacon. On 07/03/19 at 09:53 AM, the surveyor, who was accompanied by the Food Service Director (FSD), returned to the kitchen and observed the following: 7. The surveyor observed a 46 ounce can of tomato juice dented at the top seam and a 50 ounce can of cream of chicken soup dented at the base corner on a storage rack with undented cans in storage room two. When interviewed at the time, the FSD indicated that there was a separate area to store dented cans and dented cans should not be stored on the storage rack with other cans. 8. There was a 10-pound bag of egg noodles, a 25-pound bag of brown rice, a bag of sliced almonds and a bag of cookie crumbs for baking, all open and undated. The FSD revealed the staff went through the pantry's yesterday and must have missed these. The FSD further indicated the items should be wrapped or in a container after opening and should be dated. On 07/09/19 at 1:33 PM, the Administrator confirmed food should be labeled and stored in a container after opening. The Administrator also indicated pans should be completely dry prior to storage. During a subsequent interview with the Administrator on 07/10/19 at 10:40 AM, the Administrator revealed eggs and meat should be stored separately from each other to prevent cross contamination and dented cans should be stored in a separate area until they are returned to the vendor. The Surveyor reviewed the facility's undated policy entitled Dented Cans, provided by the FSD, with a review date of 01/05/11. Under Procedure: (3. Any cans with visible dents will . be segregated and returned to vendor.) NJAC 8:39-17.2(g)

Based on observation, interview and review of the medical records and other facility documentation, it was determined that the facility failed to a.) provide a rationale for the use of an antidepressant medication in the absence of targeted behaviors and b.) provide a process to monitor effectiveness of an antidepressant medication for an unresponsive resident. This deficient practice was identified for Resident #54, 1 of 6 residents reviewed for unnecessary [MEDICAL CONDITION] medications and was evidenced by the following: According to the Admission record Resident # 54 was readmitted to the facility on [DATE]. The resident's original admitted was 10/22/18. The facility form titled Cumulative [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment tool dated 5/31/19, reflected that the resident had severe cognitive deficits and required total care with all aspects of activities of daily living. On 07/02/19 at 12:22 PM, on initial tour, Resident #54 was in bed receiving care and was non-verbal with both eyes closed. The Certified Nursing Assistant (CNA) was present in the resident's room providing care to the resident and stated that the resident was non-verbal and had some kind of [MEDICAL CONDITION] and was unresponsive. The facility Admission/Readmission Assessment (ARA) guide dated 11/29/18 and 5/30/19, indicated that Resident #54 was comatose (of or in a state of deep unconsciousness for a prolonged or indefinite period, especially as a result of severe injury or illness). On 07/02/19 at 12:23 PM, the surveyor interviewed the primary care Registered Nurse (RN) who stated that the resident was non-verbal and severely demented. The RN added that the resident has not responded since he/she was admitted to the facility and had the [DIAGNOSES REDACTED]. The Physician order [REDACTED]. The Pharmacy Consultant Sheet dated 10/31/18, 2/25/19, 3/27/19, 5/30/19 and 6/28/19 respectively, did not address the use of the medication [MEDICATION NAME] for Resident #54. On 07/03/19 at 12:45 PM, the surveyor interviewed the Advanced Nurse Practitioner (ANP) who provided medical care to the resident who stated that the resident had [MEDICAL CONDITIONS] secondary to a [MEDICAL CONDITION] and was in a persistent vegetative state. The ANP added that the resident had Dementia and did not communicate or interact with staff. On 07/08/19 at 10:37 AM, the surveyor reviewed the Care Plan (CP) dated 6/9/19, which indicated the resident was on [MEDICAL CONDITION] medication [MEDICATION NAME] secondary to the [DIAGNOSES REDACTED]. The resident remained unresponsive. The Interdisciplinary Care Plan Note (IDT) dated 12/13/18, 3/7/19 and 6/4/19 reflected that the resident was on the [MEDICAL CONDITION] medication [MEDICATION NAME] but did not indicate how the medication was being monitored. The resident remained unresponsive and without behaviors. The facility Monthly Psychoactive Summary's dated 12/2018, 1/2019, 2/2019, 3/2019, 4/2019, 5/2019 and 6/2019 did not indicate a description of the resident's targeted behaviors or how the resident was affected/benefited from the use of the antidepressant drug [MEDICATION NAME]. On 07/08/19 at 11:28 PM, the surveyor interviewed the primary care RN who stated that Resident #54 was readmitted from the acute care hospital on [DATE] on the medication [MEDICATION NAME]. The RN added that a Psychiatric Consult was ordered to clarify the need for the medication. The nurse also added that the resident did not exhibit behaviors and remained unresponsive since admitted to the facility. According to the Psychiatric Consult dated 1/3/19, the psychiatrist indicated that Resident # 54 was non-verbal, had no evidence of thought process, no evidence of behaviors, but had the diagnose of Depression and Dementia. He also indicated that the resident was on [MEDICATION NAME] for Depression. On 07/09/19 at 10:29 AM, the surveyor interviewed the facility psychiatrist by phone in the presence of two additional surveyors. The psychiatrist stated that the medication [MEDICATION NAME] was ordered for off label use to manage motor sensory recovery for the muscles of the diaphragm and if the medication was to be discontinued or if a gradual dose reduction (GDR) was attempted, then this could cause a medical decompensation. He added that the diaphragm muscles could weaken and therefore the resident could have a change in the ventilator settings. In addition, he did not want any abrupt changes in the resident's medications due to his medical history. He further stated the resident had a history of [REDACTED]. On 07/09/19 at 12:35 PM, the surveyor interviewed the primary care physician (MD) in the presence of four additional surveyors who stated the resident is non-responsive and has not opened his/her eyes since admitted to the facility. The MD added that the resident had [MEDICAL CONDITIONS] and was in a coma or persistent vegetative state. The MD revealed that the resident had a [DIAGNOSES REDACTED]. The MD also added that the resident did not exhibit behaviors, however was admitted from the hospital on these medications, so she continued them just in case the resident woke up. The MD admitted the medications [MEDICATION NAME] could not be monitored for effectiveness because the resident was non-responsive. The MD further revealed that the medication was not being utilized for off-label use as previously indicated by the psychiatrist but was being administered for the [DIAGNOSES REDACTED]. On 07/10/19 at 10:41 AM, the surveyor interviewed the Director of Nursing (DON) and Regional Registered Nurse (RRN) who both stated that the resident did not exhibited signs or symptoms of Depression, however the resident had a history of [REDACTED]. The DON and RRN did not provide information to the surveyor on how the nursing staff was to monitor the effectiveness of the medication [MEDICATION NAME] when the resident was unresponsive and did not exhibit behaviors. The Administration team did not provide supportive information related to the medication [MEDICATION NAME] being used for motor sensory recovery for the muscles as stated by the psychiatrist. The DON added that the psychiatrist came to the facility on [DATE] and documented that the medication was being used for motor sensory muscle recovery, however, this documentation copy was not provided to the surveyor. On 07/10/19 at 12:15 PM, the surveyor interviewed the ANP who stated that the resident was put on [MEDICATION NAME] for the [DIAGNOSES REDACTED]. At that time, he discussed with her the study that was done about the medication [MEDICATION NAME] being helpful with motor sensory recovery, and that this has now been taken into consideration. The facility policy tilted Unnecessary Drugs-[MEDICAL CONDITION] with effective date of 10/2018, indicated that each resident's entire drug/medication is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being. The policy also indicated that the medication would be monitored for efficacy and adverse consequences and residents using [MEDICAL CONDITION] medications will be monitored for efficacy and adverse consequences. There is no indication this policy was consistently followed. 8:39-33.2 (c) 4

Based on observation, interview and review of facility documentation, it was determined that the facility failed to remove expired biologicals and medication from the storage drawers in the medication room. This deficient practice was identified in 1 of 2 medication rooms inspected and was evidenced by the following: On [DATE] at 9:40 AM, the surveyor inspected the second-floor medication room (med room), and noted the following expired items: 1. One [MEDICAL CONDITION] (trache) tube with cuffed inner disposable cannula that expired on ,[DATE] 2. One trache cap that expired in ,[DATE] 3. One deluxe biohazard spill kit which expired ,[DATE] 4. One medium universal securement (a type of Band-Aid) which expired on ,[DATE] 5. 72 [MEDICATION NAME] of antiseptic swab pad (used for disinfecting intravenous sites) which expired in ,[DATE] 6. One [MEDICATION NAME] iodine prep pad that expired on ,[DATE] 7. One IV connecting tubing that expired in ,[DATE] 8. One tube of nitro bid ointment (blood pressure medication) that expired on ,[DATE] 9. One safety needle set (this is a type of hollow needle used to access an inplanted venous access line - Porth-A-Cath) which expired on ,[DATE]. 10. One safety needle set that expired on ,[DATE] 11. One safety needle set that expired on ,[DATE] 12. One safety needle set that expired on ,[DATE]. The surveyor completed the inspection at 10:05 AM. On [DATE] at 10:10 AM, the surveyor interviewed the unit charge nurse, a Registered Nurse and showed her all the above expired biologicals. The nurse stated she was the acting charge nurse for the day because the actual charge nurse was off and that she was the medication nurse. When asked about the expired medical supplies in the med room, the Nurse stated that the charge nurse usually checked and cleaned the med room weekly, and that the Consultant Pharmacist (CP) also checked the med room routinely. She did not know how often the CP checked the med room. When asked about the expired needles , the nurse stated they get residents with Port-A-Cath occasionally and that they would obtain supplies from the med room to access the line. She also stated that staff would normally obtain supplies from the med room when needed. On [DATE] at 11:15 AM, the facility Director of Nursing (DON) provided the surveyor with an employee statement form dated [DATE] from the 11:00 PM to 11:00 AM Nursing Supervisor. The statement indicated that the expired items were put in the bottom cabinet awaiting central supply to discard. The Nursing Supervisor added that the expired supplies were not used. During an interview at the above date and time, the facility could not provide a policy or procedure for expired medical supplies and equipment. NJAC: 8:39 29.4 (g)

Based on observation, interview and record review, it was determined that the facility failed to follow infection control protocol in regards to administration of oral, enteral and intravenous medications. This deficient practice was identified for 3 of 6 residents observed during the medication administration, Resident #7, Resident #97 and #398. The deficient practice was evidenced by the following: 1. On 7/3/19 at 9:50 AM, the surveyor observed Nurse #1 administered the following medications to Resident #203. [MEDICATION NAME] 5 mg 1 tab Acidophilus 2 tabs Eliquis 5 mg 1 tab [MEDICATION NAME] 20 mg PO [MEDICATION NAME] 20 mg PO Osartan 100 mg PO [MEDICATION NAME] 20 mg 1 tab Metropolol 25 mg 1 tab [MEDICATION NAME] 25 mg 3 tabs. [MEDICATION NAME] 17 gm [MEDICATION NAME] 25 mg 1 tab [MEDICATION NAME] 100 mg 1 caps. During the process, the nurse dropped two [MEDICATION NAME] tablets and the [MEDICATION NAME] tablet on top of the medication cart. The nurse picked up the three tablets with her bare hands, put them in the cup and administered them all to Resident #7. The surveyor interviewed the nurse at 10:00 AM that same day regarding the observed practice, the nurse stated, I should have discarded the pills for infection control purposes. 2. On 7/6/19 at 11:00 AM the surveyor observed Nurse #2 administered [MEDICATION NAME] (a broad spectrum antibiotic) to Resident #97. Resident # 97 had a Peripherally Inserted Central Catheter ( PICC ) line into the right upper arm. Nurse #2 entered the room and informed the resident of the procedure. Nurse #2 used the gel sanitizer to cleanse her hands. She then went to the medication cart and gathered supplies needed for the intravenous medication to be administered. The nurse placed the supplies consisting of alcohol pads, saline syringes, connection tubing and the intravenous bag of [MEDICATION NAME] on the resident's bed. The nurse used an alcohol pad to cleanse the hub of the PICC Line then flushed the line with the saline syringe. The nurse then picked the [MEDICATION NAME] bag from the bed, broke the seal to allow the solution to mix with the powder, inserted the connection tubing to the medication, hung the bag on the pole and attempted to connect the tubing to Resident #97's PICC Line. Nurse #2 kept pulling on the cap and was able to remove the cap on the 3rd attempt, then connected the [MEDICATION NAME] to the PICC line with her bare hands. An interview with the nurse on 7/10/19 at 10:00 regarding the technique observed, the nurse told the surveyor that she was unsure of the protocol to follow for the administration of intravenous medication. A review of the facility's policy titled, HMNR IV Therapy Guidelines dated 3/2013 last approved 12/2017, indicated the following under Procedure: Gather your supplies Wash your hands with soap and water or antiseptic gel. Establish a clean field (do not place supplies directly on bed covers or a non-sterile surface ) #6: Clean hands then put on non-sterile gloves. 3. Resident #398 had a [DIAGNOSES REDACTED]. Resident #398 had a Gastrostomy Tube [DEVICE] in place (Tube inserted into the abdomen to provide nutrients and medications). On 7/9/19 at 11:30 AM the surveyor observed Nurse #3 administer [MEDICATION NAME] and [MEDICATION NAME] to the [DEVICE]. The nurse cleansed the bedside table and gathered the supplies. The nurse then used an alcohol pad to disinfect the bell of the stethoscope before checking the [DEVICE] for placement. After disinfecting the bell of the stethoscope, the nurse blew air on the bell before applying the bell on the resident's abdomen. Upon inquiry Nurse #3 told the surveyor that the bell of the stethoscope was cold. The facility was made aware of the above observations and requested the in -serviced for infection control and on disposal of medication. The in-services were completed in (MONTH) 2019 and (MONTH) 2019. The facility did not have a comment regarding the above observations. NJAC 8:39: 19.4 (a) 5,

Based on observation, interview and record review, it was determined that the facility failed to accurately assess a resident's cognitive and behavioral status. This deficient practice was identified for Resident #74. The facility also failed to complete a Fall Risk Assessment (a tool to determine if a resident was prone to accidents and injury) and Braden Scale Assessment (a tool to determine if a resident was at risk of developing pressure sores), in accordance with scheduled assessment guidelines. This deficient practice was identified for 4 of 22 residents reviewed Resident #9, #35, #74 and #85 and was evidenced by the following: 1. On 5/9/18 at 10:30 a.m. a surveyor toured the 300's Unit and reported that Resident #74 was in bed, very restless, with eyes closed. The resident was noted with his/her feet over the siderails. Later that same day at 11:00 a.m., the surveyor observed the resident in bed, the siderails were elevated and padded, the resident was still restless and attempted to climb out of bed. On 5/10/18 at 10:30 a.m., the surveyor observed the resident in bed, very restless. The resident was unable to follow commands. The same observations were made on the following days, 5/11 10:27, 5/14 11:15 a.m., 5/15 10:10 a.m., and 5/16/18 at 9:45 a.m. On 5/11/18 at 11:15 a.m., the surveyor reviewed the resident's clinical record. According to the Admission Face Sheet the resident was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ( MDS ), a resident assessment tool dated 3/5/18, revealed the resident was awake, alert and oriented. The resident received a score of 15 on the Brief Mental Status exam. The Admission nursing assessment revealed that the resident was alert, confused and agitated since admission. All the nurse's notes from the admission date of [DATE] to 3/31/18 reflected that the resident was very confused, agitated and restless. An interview on 5/14/18 at 11:00 a.m., with the Nurse who had been in charge of the unit revealed that Resident #74 had been alert, confused and agitated since admission. The nurse further stated that she could not recall the resident being awake, alert and oriented. The Nurse's Notes on admission indicated that Resident #74 was restless, agitated, disruptive and pulled the tracheotomy tube out on admission. An interview on 5/14/18 at 11:30 a.m., with the Certified Nursing Assistant who cared for the resident revealed that the resident was combative with care and had been difficult to manage since admission. An interview with the MDS Coordinator on 5/16/18 at 11:05 a.m., revealed that the resident was alert. She stated she used a picture board to complete the assessment and Resident #74 was able to proceed with the interview. The MDS Coordinator also revealed that the Section E of the MDS which coded the behavior was completed by the Social worker. The surveyor reviewed the nurses progress notes with the MDS Coordinator where we both noted the MDS coding did not reflect the resident status according to numerous documentation included in the Nurses Notes. There was also no significant change assessment done to indicate the decline in the resident's status if any. An interview with the Social Worker on 5/16/18 at 11:45 a.m., revealed that she did not get any input from the staff nor did she review the Nurse's Notes prior to completing Section E which referred to the residents behavior. On 5/16/18 at 1:10 p.m., the Social Worker provided an assessment dated [DATE] which revealed the following: Unable to assess, does not seem to comprehend. On 5/17/18 at 10:30 a.m., the MDS Coordinator agreed that both Section C and E of the MDS which referred to cognition and behavior that exhibited a look back of 7 days were coded in error. 2. On 5/16/18 the surveyor reviewed the Fall Risk Assessment (a tool used to determine risk for injury) and the Braden Scale Assessment (a tool to predict the risks of developing pressure sores) for the following sampled residents: Resident #9, #35, #74 and #85. Resident # 9 had a Fall Risk assessment dated [DATE]. According to the Center for Medicare and State guidelines, the Admission assessment should be completed within 14 days, the Quarterly assessment should be completed every 3 months and the Annual assessment every year. A Significant Change assessment should be completed if the resident presented a change in condition in any of the three areas of coding. Consecutively, a Fall and a Braden Scale Assessment would be completed with every assessment. On 5/16/18 at 11:15 a.m., the surveyor reviewed Resident #9's clinical record and noted that both Fall and Pressure ulcer Risk were completed on 5/16/18. According to the scheduled assessments, a Quarterly Assessment should be completed on 8/16/18. Further review of the clinical record revealed that the 8/16/18's assessment for both Fall and Pressure Ulcer were already completed. Resident #35 had a Fall Risk assessment dated [DATE]. A review of the clinical record revealed that the next Fall and Braden Scale Assessments scheduled for 8/19/18 were already completed. Resident # 74 had a scheduled Assessment due on 8/26/18. A review of the Fall and Braden Scale Assessments revealed that both assessments were already completed for 8/26/28. Resident #85 Fall and Braden Scale Assessments were completed on 3/27/18. On 5/16/18 at 12:30 p.m., the surveyor reviewed Resident #85's clinical record and noted that the next assessment scheduled for 6/27/18 had been completed. An interview with the nurse on 5/16/18 at 10:30 a.m., revealed that she completed the Fall and Pressure sore risk Assessment. She could not provide the rationale for completing the assessment in advance. The facility was made aware of the concerns on 5/17/18 at 1:15 p.m. On 5/18/18 at 10:00 a.m., the facility indicated that the Assessment should not have been done in advance. NJAC 8:39 -11.2 (1)

Complaint # NJ 3 CROSS REFERENCE F 226 Based on interviews, review of medical records (MR), and other facility documentation, it was determined that the facility staff failed to provide care for 1 of 3 sampled residents (Resident #1) who asked Certified Nursing Assistant (CNA) #1 for assistance to transfer from the bed to the chair, and to the bathroom. The CNA responded no. Additionally, the CNA was eating crackers and watching television in Resident #1's room. The actions of CNA #1 caused Resident #1 to become upset, yell and cry. This deficient practice is evidenced by the following; 1. CROSS REFERENCE F 226, See Example #1 8:39-4.1(a)(5)

A. Based on observation and interview with the administrative staff it was determined that the facility failed to protect residents from the potential exposure to excessive hot water temperatures. This deficient practice was identified on 2 of 2 Long Term Care Units and involved 4 of 5 resident bathrooms checked by the surveyors for excessive hot water temperatures. This resulted in an Immediate Jeopardy situation which was identified on 2/18/22 at 2 p.m. and corrected the same day, 2/18/11 at 3:30 p.m., based on an acceptable plan of correction, which has been implemented by the facility. This deficient practice was evidenced by the following: On 2/18/11 at 2 p.m. Surveyor #1 took the temperature of the hot water in the bathroom of resident room 328 and found it to be 120 degrees Fahrenheit (F). The surveyor immediately went to the Administrator's office to notify her of the discovery of the unacceptable temperatures. The Director of Maintenance (DOM) was present and stated that the water temperature was set at the upper limits of the allowable range due to general staff complaints of showers being too cold. After the surveyor reviewed the regulation with the Administrator, the Administrator and the DOM went to the resident floors to check temperatures at approximately 2:30 p.m. They confirmed that the unacceptable temperatures ranged from 110 to 122 degrees F. Surveyor #2 on the 2nd floor continued to take temperatures in resident bathrooms on this floor with the following results: 2:30 p.m. room 227 = 118 degrees F 2:35 p.m. room 222 = 120 degrees F 2:37 p.m. room 201 = 122 degrees F 2:45 p.m. room 231 = 110 degrees F Immediately after Surveyor #2 obtained the above temperatures, the facility's Infection Control nurse observed that the surveyor's thermometer and confirmed it was calibrated correctly at 32 degrees F. upon testing according to manufacturer's recommendation. At 3:15 p.m., the Administrator informed Surveyor #1 that the DOM had immediately turned the hot water heater down upon notification of unacceptable hot water temperatures. Surveyor #1 requested a Plan of Correction which included the above and in addition: 1. The hot water circulating pump was re-adjusted to 110 degrees F to achieve compliance. 2. Water temperatures in resident rooms to be monitored every 4 hours for 7 days. 3. Temperature of the water at the hot water heater will be checked every 4 hours for 7 days. 4. Temperature monitor will be reported to the DHSS for 3 days 5. After 7 days temperatures will be taken once per shift during no-shower times. At 3:30 p.m. Surveyor #1, in the presence of the Administrator and the Director of Maintenance, observed the temperature at the hot water heater to be 109 degrees F. Temperatures were then taken at 3:35 p.m. by Surveyors #1 and #2 on the 2nd and 3rd floor Long Term Care units. The temperatures were as follows: Rooms 232 and 218 were measured at 109 degrees F. Room 332 was measured at 107 degrees F. The Immediate Jeopardy was corrected at 3:30 p.m. on 2/18/11 Daily Maintenance logs were obtained from the DOM for the month of February 2011 on 2/18/11 at 3:35 p.m. The DOM stated that temperatures were taken in resident rooms on each floor during times that showers were normally given. The log dated 2/18/11 for " Shift #1 " indicated that the temperatures were 110 degrees F when taken on each floor, however review of the logs failed to indicate the times that temperatures were taken. The log dated 2/17/11 for " Shift #1 " indicated that the temperature in the shower room on the 2nd floor was 113 degrees F. The surveyor reviewed the remaining logs which revealed temperatures were recorded at 110 degrees F or below. This deficiency continues at a scope and severity of D based on the evidence in Part B. B. Based on interview and review of the daily maintenance logs submitted to the DHSS for review it was determined that the facility failed to ensure that water temperatures in resident areas did not exceed the set regulatory temperatures at the domestic Hot Water Delivery system. Review of the daily Maintenance Temperature logs submitted by the facility to the NJDSS for the period of 2/18 to 2/23/11 indicated that the water in resident areas was being delivered at a higher temperature than the setting at the Domestic Hot Water Delivery System. This was noted for 8 of 67 temperatures taken in resident rooms. These inconsistencies were documented as follows: On 2/22/11 the delivery system gauge showed the hot water temperature in that portion of the system ranged from 100 to 112 degrees F. when checked throughout the day (specific times were not always noted). A corresponding check of resident rooms showed higher temperatures than the delivery system indicated. A temperature range of 106 degrees F. was noted in room 216. A temperature of 118 degrees F. was documented in rooms 203 at 12:10 p.m. and in rooms 219 and 300 at 4:15 a.m. On 2/23/11 the delivery system gauge showed the hot water temperature at 108 degrees F. at 12:30 p.m. A corresponding check of resident rooms showed higher temperatures that the delivery system indicated. A temperature of 111 degrees F. was recorded in room 225 and 109 degrees F. was recorded in room 304. On 2/23/11 at 4:30 a.m. the delivery system gauge showed the hot water temperature at 104 degrees F. while at the same time the hot water temperature in room 203 was measured at 112 degrees and in room 325 was measured at 111 degrees F. During a phone interview on 2/28/11 at approximately 11:30 a.m., the Administrator confirmed the discrepancy between the temperature setting at the Domestic Hot Water Delivery System and the temperatures actually being delivered to the resident units. The Administrator indicated that further evaluation of the water heating system is warranted. The Administrator also acknowledged that times of testing had not been consistently recorded on the logs and should have been. NJAC 8:39-31.7 (h)