Every finding on record at Heath Village

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 2 of the 21 residents (Resident #9 and Resident #14) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following:1. On 3/18/26 at 10:11 AM, the surveyor observed Resident #14 in bed. The resident's call device hung down to the floor, out of reach of the resident.On 3/18/26 at 10:13 AM, the surveyor interviewed Resident #14 and asked where their call bell was located. The resident replied that they did not see where it was. The resident stated further, What am I going to do if I need to call someone? On 3/18/26 at 1:22 PM, the surveyor made a second observation of Resident #14 lying in bed. The call device was in the same position as the previous observation, hanging down to the floor, out of reach of the resident.On 3/19/26 at 9:46 AM, the surveyor made a third observation of Resident #14 in bed. The call device was in the same position as the previous observations, hanging down to the floor, out of reach of the resident.On 3/19/26 at 9:51 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who acknowledged that the call bell should be accessible to the resident. Moreover, the CNA stated that the clip on Resident #14's call device was broken.A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 1/5/26, revealed that Resident #14 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderately impaired cognition.A review of the care plan report initiated on 12/31/25 revealed that Resident #14 is risk for falls related to (r/t) impaired mobility after hospitalization for fall, use of psychoactive medications, and impaired cognition. Interventions included but were not limited to, Place call bell within reach and encourage to call for assistance.2. On 3/19/26 at 9:56 AM, the surveyor observed Resident #9 lying in bed. The resident's call device hung down to the floor, out of reach of the resident.On 3/19/26 at 12:27 AM, the surveyor made a second observation of Resident #9 lying in bed. The call device was in the same position as the previous observation, hanging down to the floor, out of reach of the resident.A review of the care plan report initiated on 1/16/26 revealed that Resident #9 is risk for falls r/t balance problems, confusion, poor safety awareness, and unsteady gait. Interventions included but were not limited to, Place call bell within reach and encourage to call for assistance.On 3/20/26 at 1:28 PM, the surveyor discussed the concern with the Licensed Nursing Home Administrator and the Director of Nursing (DON). The surveyor interviewed the DON who stated that the call bell must be placed within reach of the resident.The facility's Nurse Call System Policy and Procedures did not address the positioning of the call bell.NJAC 8:39-31.8(c)9

Based on observation, interview, and record review, it was determined that the facility failed to revise the care plan (CP) report for 1 (one) of 21 residents (Resident #49) reviewed for a comprehensive CP.This deficient practice was evidenced by the following:On 3/18/26 at 10:13 AM, the surveyor observed Resident #49 in bed, awake, watching TV, and was able to answer the surveyor's inquiry. Resident #49 stated that they do not have any concerns with the facility.On 3/19/26 at 12:48 PM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #49, which revealed the following:A review of the admission Record (AR, an admission summary) reflected that Resident #49 was admitted with diagnoses that included but were not limited to depression, anxiety, mood disorder, and dementia (loss of memory).A review of the quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) of 2/27/26, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident had intact cognition. Further review of Q/MDS, reflected in Section N, revealed that the resident is taking antipsychotic medications.A review of the Order Summary Report (OSR) with the start date of 11/21/25, Seroquel 25 mg by mouth at bedtime for depression related to other specified mood disorders. A review of the Care Plan (CP) report with an initiated date on 11/22/25, with a focus on Resident #49, is on antidepressant Zoloft related to depression. On 3/20/26 at 11:13 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the Psychotropic medication, including Seroquel and Trazodone, should be included in the CP because it is part of the care for the resident and the LPN stated that the CP is also used to monitor the side effects of medications.On 3/20/26 at 11:20 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM), who stated that all the nurses are responsible for documenting the CP. The LPN/UM did not provide further information on why the Seroquel and the Trazodone were not in the CP. The LPN/UM updated the CP after the surveyor's inquiry.O 3/20/26 at 1:40 PM, the team of surveyors met with the Administrator, Director of Nursing, and Nursing Supervisor, but did not provide further information.A review of the facility policy titled Care Plan revealed under 8. Documentation Requirements - Care Plans must be accurate, current, and individualized.

Based on observation, interview, record review, and review of facility policies, it was determined that the physician's progress notes (PPN) are not legible. This deficient practice was identified for 1 of 22 residents (Resident #35). This deficient practice was evidenced by the following:On 3/18/26 at 10:20 AM, the surveyor observed Resident#35 sitting in the activity room.On 3/18/26 at 1:23 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #35, which revealed the following:A review of the admission Record (AR, an admission summary) reflected that Resident #35 was admitted with diagnoses that included, but were not limited to, an unspecified dementia (loss of memory) and mood disturbance.A review of the quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) dated 12/19/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident had severe cognitive impairment. On 3/20/26 at 10:49 AM, the surveyor observed that the physician had handwritten notes located in the chart. The surveyor noted that the handwritten notes were not legible.On 3/20/26 at 11:13 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), regarding the above concern, and the surveyor showed the LPN the handwritten progress notes written by the physician, dated 12/29/25, 1/27/26, and 2/27/26. The LPN stated that she was having difficulty reading the doctor's handwritten notes, and she will ask the LPN Unit Manager (UM) or another nurse to read them for her, but if they cannot, she would call the physician to clarify the notes.On 3/20/26 at 11:20 AM, the surveyor interviewed the LPN/UM, regarding the concern. The LPN/UM was trying to read the physician's notes and stated that she could read some of the notes, but not all of them. If it happens, she would call the physician to clarify the notes.On 3/20/26 at 1:30 PM, the team of surveyors met with the Administrator, the Director of Nursing (DON), and the Nursing Supervisor. The DON agreed that it was difficult to read the notes. No further information was provided.A review of the facility policy with the title Physician (MD/DO) Required Visits, updated in January 2025, did not address the legibility of doctors' notes.NJAC 8:39-35.2 (d)(5)

Based on observation and interview on 3/24/26 in the presence of the Life Safety Director (LSD) Assistant Plant Operations Director (APOD) and Plant Operations Director (POD), it was determined that the facility failed to ensure that wooden handrails were installed, maintained, secured and splinter free in all required locations. This deficient practice was identified for 1 of 8 areas observed, had the potential to affect all residents, and was evidenced by the following by the following: An observation at 11:40 PM revealed that the Juniper Way wing handrails by the exit/egress doors to the public way were blocked from access due to a long 2-shelf furniture unit approximately 5' wide. In an interview during the above findings, the LSD, APOD and POD all confirmed the observation.The Plant Operations Staff was informed of the deficient practice at the Life Safety Code exit conference on 3/25/26 at 12:45 PM.NJAC 8:39-31.2(e) NFPA 10

Based on observations, interviews, review of the medical records, as well as review of other pertinent facility documentation, it was determined that the facility failed to a.) report and immediately investigate a fall which occurred for 1 of 4 sampled Residents, (Resident #15), who were investigated for falls and, b.)consistently implement identified safety interventions as per the residents physician's orders and care plan to prevent falls for 1 of 4 sampled Residents, (Resident #16), who were investigated for falls. This deficient practice was evidenced by the following: 1. On 3/18/26 at 11:45 AM, the surveyor interviewed Resident # 15, who was in their room, and the resident stated that the resident did fall in the facility two different times, with no injuries and that the staff educated the resident to call for assistance. A review of the resident medical records revealed the following: Resident # 15 was admitted with diagnoses which included, but were not limited to low back pian, age related osteoporosis, and chronic pain syndrome. The admission Minimum data Set (MDS) (an assessment tool), dated 1/3/26, revealed that Resident # 15 had a Brief Interview for Mental Status (BIMS) score of 15/15, that indicated that Resident # 15 was cognitively intact. A review of the facility fall investigation (FI) revealed that on 1/29/26 at 9:30 AM, during morning medication pass, Resident # 15 told the Licensed Practical Nurse (LPN #1), that the resident fell last night after using the bathroom and that the resident was assisted the resident back into the chair. The FI revealed that their investigation found that a staff member, a Certified Nursing Assistant (CNA #1), found Resident # 15, when doing rounds at 5:00 AM, and resident was in front of the recliner chair, stated that they slid down to the floor and stated was fine. The FI revealed that the CNA # 1 did not report the fall to anyone, educated the resident to call for help and then placed the resident back into the chair. The FI concluded that the resident had no injury. The facility provided the surveyor with an Employee Counseling Form (ECF) dated 2/6/26, which revealed that the CNA # 1did not report the incident to the nurse and nurse was unable to assess the resident as nurse was not aware of the incident, and the CNA should not move the resident that was found on the floor, and will report it to the nurse immediately so the nurse can assess the resident. The ECF was signed by the CNA and the Supervisor who provided counseling to the CNA # 1. Upon review of the resident's electronic health record (EHR), specifically the progress notes (PN), there was no PN which revealed that the resident had fallen on 1/29/26 at 5:00 AM. Upon further review, a PN written on 1/29/26 at 18:02 by LPN # 1, revealed During morning med pass, resident reported to this nurse that she fallen last night while transferring into her recliner after using toilet. Resident reported that she was assisted back into her chair by a staff member. At this time she has no c/o pain or signs of distress. MD and POA was made aware. no new orders. vs were taken . staff to educate resident that she is not to transfer herself into recliner, wheelchair or onto toilet. endorsed to next shift and resident. A review of the fall care plan (CP) revealed that the resident had a fall and it was updated with a date of 1/29/26. At 1:20 PM, the surveyor interviewed with the Director of Nursing (DON), who stated that the CNA # 1 did not report the fall and did assist the resident back to the chair, and she was not supposed to. The DON stated that the facility did counsel the CNA # 1 about the correct steps to take with a fall. 2.) On 03/18/26 at 11:31 AM, the surveyor was conducting an initial tour of the facility and observed Residnet#16 in bed in their room. The surveyor introduced themselves to the resident and the resident agreed to talk to the surveyor. The surveyor observed a floor mat in place to the resident's left side of bed, and a second mat standing against the wall not in place at right side of the bed. The resident verbalized she knew no details of the intention of the floor mats or how they were to be used A review of the EHR revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including but not limited to difficulty walking, muscle weakness and the need of care following surgery of the digestive system. A review of Resident# 16's MDS dated [DATE] reflected the resident needs assistance with transfers, ambulation and activities of daily living. The MDS reflected the resident had a BIMS score of 13 of 15 indicating the resident had little to no cognitive impairment A review of Resident #16's EHR revealed a Morse Fall Scale (an assessment tool used to determine a resident's risk level of falling), dated 12/23/25. The score documented on the assessment was 80 and a score of 45 or greater indicates a high risk of falls. The EHR further revealed a physician's order dated 9/17/25 that required floor mats on both sides of the resident's bed and placement to be checked every shift. A review of Resident #16's plan of care reflects a focus on the resident's risk for falls, initiated on 9/17/2025 with interventions including but not limited to mats on the floor when resident is in bed, initiated on 9/17/2025. On 03/18/26 at 1:25 PM, the surveyor made a second observation in the residents' room and observed the fall mat in place on resident left side of bed, no mat on right side of the bed, a was leaning against the bedroom wall. On 03/18/26 1:30 PM, the surveyor interviewed CNA #2, the CNA assigned to Resident# 16 care. The surveyor asked about Resident #16's mat placement. CNA#2 stated she was aware that mat from the resident's right side of the bed was against the wall, she stated the resident requested the tray table be next to the bed and the CNA did not put down the mat in order to accommodate the table position request. CNA #2 stated she did not report the issues with positioning the right mat to the nurse. On 03/18/26 at 1:40 PM, the surveyor interviewed LPN #2, the nurse overseeing care provided by CNA #2. The nurse confirmed the resident had an active physician's order for floor mats to be in place on both sides of the bed and stated the mats should have been in place. The LPN #2 further confirmed she did not receive a report of concern from CNA #2 about not placing the mat or difficulty using the mat and table on same side of the bed. LPN #2 confirmed that overbed tables can be positioned safely on top of the floor mats. LPN #2 accompanied the surveyor to the room and confirmed that mat from right side of bed was leaning up against the wall. She stated she would correct the situation immediately. On 3/20/26 at 1:29 PM, the Survey team met with Administrator, DON and Nursing supervisor to discuss findings to date. The DON agreed the mats should have been in place as ordered by the physician whenever the resident is in bed. A review of the undated Fall Prevention and Post-Fall Management policy, revealed that the purpose is to ensure that prompt and appropriate post-fall response occurs, and immediate post-fall procedure included safety first, initial assessment, neuro checks, notifications, and transfer decision. NJAC 8:39-33.1(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide ordered respiratory care consistent with professional standards of practice for 1 of 2 residents (Resident #9) reviewed for respiratory care.This deficient practice was evidenced by the following:On 3/18/26 at 10:27 AM, the surveyor observed Resident #9 lying in bed, receiving oxygen via a nasal cannula (NC, a plastic prong attached to a tube, inserted into the nostrils through which oxygen flows). The surveyor observed that the oxygen flow meter was set at 1.5 liters per minute (L/min). On 3/18/26 at 1:26 PM, the surveyor made a second observation of Resident #9 lying in bed, receiving oxygen via NC. The surveyor observed that the oxygen flow meter was set at 1.5 L/min. On 3/19/26 at 9:56 AM, the surveyor made a third observation of Resident #9 lying in bed, receiving oxygen via NC. The surveyor observed that the oxygen flow meter was set at 1.5 L/min. A review of the Order Summary Report for Resident #9 revealed an order with a start date of 1/23/26 for oxygen via nasal cannula at 2 L/min continuously every shift for shortness of breath (SOB).A review of the March 2026 Medication Administration Record for Resident #9 revealed that the nurses recorded oxygen use every shift on 3/18/26, as well as the day and evening shifts on 3/19/26.A review of the care plan report initiated on 1/16/26 revealed that Resident #9 has ineffective gas exchange and is on oxygen therapy due to SOB related to Myocardial Infarction (MI). An MI is the medical term for a heart attack. Interventions included but were not limited to, Administer oxygen as ordered.On 3/19/26 at 10:01 AM, the surveyor interviewed the Registered Nurse (RN) Supervisor in Resident #9's room. The surveyor asked the RN Supervisor what the oxygen flow rate was, in L/min, currently set on the oxygen flow meter. The RN Supervisor stated that the oxygen flow meter was set at 1.5 L/min. The RN Supervisor acknowledged that it was set incorrectly and adjusted the oxygen flow rate to 2 L/min per the physician's order. They stated that oxygen should be administered as ordered by the physician, and the nurses are expected to check the setting every shift.A review of the facility's Oxygen Use and Management Policy revealed, Oxygen shall be administered, monitored, and maintained in accordance with physician orders, manufacturer guidelines, CMS regulations, and applicable New Jersey Department of Health (NJDOH) standards.A review of the facility's Oxygen Use and Management Procedure, under Initiation of Oxygen Therapy, revealed, Set prescribed flow rate.A review of the facility's Oxygen Use and Management Procedure, under Nurse/CNA Responsibilities, revealed, Ensure that oxygen flow rate is at right setting as order by physician.On 3/19/26 at 1:47 PM, the surveyor discussed the concern with the Licensed Nursing Home Administrator and the Director of Nursing. They did not provide further information.NJ 8:39-25.2(c)3

Based on observation, interview, and record review, it was determined that the facility failed to ensure the proper administration of Fluticasone (Flonase; nasal spray used to relieve allergies and nasal congestion) in accordance with manufacturer's specifications and professional standards of practice during the medication pass observation on 12/13/24. The deficient practice was identified for 1 of 4 nurses who administered medications to 1 of 4 residents (Resident #11) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The nurse practice act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, 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 casefinding; 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. A review of the manufacturer's specification for Fluticasone under instructions for use included the following: Step 1: Blow nose to clear the nostrils; Step 2: Close 1 nostril. Tilt head forward slightly and keeping the bottle upright, carefully insert the nasal applicator into the nostril; Step 3: Breathe in through nose, while breathing in press firmly and quickly 1 time on the applicator to release the spray . On 12/13/24 at 9:04 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #11. The medications included a physician's order for Flonase Allergy Relief nasal suspension 50 microgram /actuation, 1 spray in both nostrils one time a day for allergies with an order start date of 9/24/24. At 9:06 AM, the surveyor observed the LPN pull one piece of tissue and folded it into her hand. At 9:07 AM, the LPN confirmed with the surveyor that she was ready to administer Resident #11's medication and walked into the resident's room with the medication and one tissue. At 9:08 AM, the surveyor observed the LPN explain to the resident that she would be administering their nasal spray. The LPN sprayed 1 spray into each of the resident's nostril and handed a tissue to the resident. The resident used the tissue to dab at the dripping from the nose. At 9:10 AM, outside the resident's room, in front of the medication cart, the surveyor and the LPN reviewed the medication package for the Fluticasone nasal spray that was stored in the LPN's medication cart. The manufacturer's specification for the Fluticasone was not in the box. The surveyor and the LPN reviewed the electronic Medication Administration Record for Resident #11's Fluticasone. The medication instructions did not include ancillary instruction as per manufacturer's specification for the resident to blow their nose to clear their nostril prior to administration. At that time, the LPN stated that she could always look up the information on her phone if there was information that she did not know. The LPN also stated that she would look for the proper administration of Fluticasone at the nurse's station. On 12/16/24 at 11:40 AM, during an interview with the surveyor, Registered Nurse/Unit Manager (RN/UM) for [NAME], Chestnut, and Juniper, stated that the manufacturer's package insert for the Fluticasone should have been with the medication package. At that time the RN/UM also stated that the LPN who administered the medication to Resident #11 should have instructed Resident #11 to blow their nose prior to administration of the Fluticasone nasal spray to ensure full effectiveness of the medication. The RN/UM stated that she would educate the staff on proper administration of Fluticasone nasal spray and ensure that the manufacturer's package insert would be left in the medication package for reference. The RN/UM informed the surveyor that she would communicate the concern with the Director of Nursing (DON) and believed that upper management was aware of the concern. On 12/16/24 at 1:37 PM, during a meeting with the survey team, the DON, the Infection Preventionist (IP), the Assistant Director of Nursing (ADON) and the Licensed Nursing Home Administrator (LNHA), the surveyor discussed the concern regarding the improper administration of the Fluticasone nasal spray to Resident #11, that was not in accordance with manufacturer's specifications and professional standards of practice. On 12/18/24 at 11:11 AM, the DON acknowledged the medication pass concern. The ADON provided in-services that was started with the nursing staff. A review of the provided facility policy, Medication Management dated October 2024, included the following: It is the policy to maintain safe and competent medication management system that is based on best practice and care process of the resident . NJAC 8:39-11.2(b), 29.2(d)

Based on observation, interview, and record review it was determined that the facility failed to maintain infection control standards and procedures during wound care treatment for 1 of 2 residents (Resident #89), reviewed for care and services for pressure ulcers. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 12/12/24 at 12:20 PM, the surveyor observed Resident #89 in bed on a specialty mattress. The surveyor reviewed the medical record for Resident # 89. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses that included but were not limited to diabetes mellitus, neoplasm of the rectum, gastrostomy status (a tube inserted through the wall of the abdomen into the stomach to provide nutrition) and stage 3 pressure ulcer of the sacrum (a wound that involves the full thickness of the skin). A review of the Admission Minimum Data Set assessment tool (MDS) dated [DATE] indicated the resident had a moderate cognitive impairment as referenced by a score of 11 on the Brief Interview for Mental Status (BIMS) in Section C. Section M indicated the resident was admitted with two stage 3 pressure ulcers. The 12/9/24 Weekly Wound Assessment Report included documentation regarding the stage 3 sacral pressure ulcer which was currently unchanged. A review of the Physician Order (PO) dated 12/16/24 included: soak sacral wound with 1/4 strength Dakin's Solution (a topical antiseptic) for 15 minutes, remove the soaked dressing after 15 minutes, pat dry, apply Santyl (ointment used to remove dead tissue from wounds to promote healing), pack with Calcium Alginate (used to absorb wound fluid) and cover with Mepilex (absorbent foam dressing). On 12/17/24 at 11:05 AM, the surveyor observed the pressure ulcer treatment. The Licensed Practical Nurse (LPN), assisted by the Registered Nurse (RN) performed the treatment. After reviewing the physician's treatment order, the LPN gathered all of the supplies and placed them on top of the treatment cart. The LPN and RN then donned (put on) surgical masks, disposable gowns and gloves, and entered Resident #89's room. The LPN placed the supplies on top of the uncleaned dresser, disinfected the resident's overbed table, picked up the trash can and moved it next to the bed. The LPN, with the same gloves (now considered soiled), applied a clean barrier to the overbed table and put the supplies on top of the clean barrier. The LPN removed her gloves and performed hand hygiene. The LPN removed the soiled dressing and packing from the resident's sacral area, removed her gloves, and proceeded to the bathroom to perform hand washing. On 12/17/24 at 11:20 AM, the LPN applied clean gloves and packed the wound with Dakin's Solution-saturated gauze. The LPN and RN repositioned the resident, doffed (took off) their Personal Protective Equipment (PPE) washed their hands and left the room, allowing the wound to soak for 15 minutes according to the physician's order. On 12/17/24 at 11:35 AM, the LPN gathered the needed supplies and placed them on top of the treatment cart. The supplies included a tube of Santyl ointment, Calcium Alginate dressing, scissors, sterile Q-Tips, a foam dressing and a marker. The LPN put a small amount of Santyl ointment into a plastic cup and put the tube back into the treatment cart. The LPN and RN donned PPE and entered Resident #89's room. The LPN set the supplies onto the dresser, disinfected the overbed table and with the same gloves (now considered soiled) applied the clean barrier, and then placed all the supplies on the clean barrier. The LPN performed hand hygiene, donned gloves, and removed the packing from the sacral wound. The LPN removed her gloves, performed hand hygiene, and applied the Santyl to the wound with a sterile Q-Tip. The LPN without cleaning the scissors, cut the Calcium Alginate package, packed the wound with the Calcium Alginate, and applied the dated initialed foam dressing. The surveyor interviewed the LPN and RN after the LPN had completed the treatment. The LPN confirmed that she should not have placed all of the treatment supplies on an unclean surface. The LPN acknowledged that she should have removed her soiled gloves and washed her hands after she disinfected the overbed table and touched the garbage can. The LPN stated that the facility policy was to clean the scissors before and after each use. On 12/17/24 at 12:29 PM, the surveyor discussed the treatment observation with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). On 12/19/24 at 12:45 PM, the surveyor interviewed the DON who confirmed the LPN should not have put the supplies on an unclean surface, should have changed her gloves after disinfecting the overbed table and handling the trash can, and should have disinfected the scissors before and after each use. A review of the facility's undated Wound Care Competency included performing hand hygiene before setting up a clean field. No further information was provided by the facility. NJAC 8:39 19.4 (a)

Based on observation, interview and record review, it was determined that the facility failed to maintain proper care of indwelling urinary catheters to prevent Urinary Tract Infections (UTIs) for 4 of 4 residents (Resident #41, #23, #20 and #14) reviewed for urinary catheter care use. This deficient practice was evidenced by the following: 1. On 9/27/23 at 10:33 AM, Resident #41 was observed lying in bed with both eyes closed. The surveyor reviewed the medical record for Resident #41. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in October 2020 with diagnoses that included urinary retention (difficulty urinating), a history of malignant neoplasm of the bladder (bladder cancer), and Alzheimer's disease(a brain disease that causes memory loss). A review of the 9/13/23 Quarterly Minimum Data Set (MDS), an assessment tool, revealed the resident had a Brief Interview for Mental Status (BIMS), which indicated that the resident had a score of 9 out of 15 indicating the resident had moderate cognitive impairment. A review of the order summary revealed a physician order dated 3/14/23, to change the foley catheter on the 8th of each month on 7-3 shift. Further review revealed that the urinary leg bag combination pack was to be changed weekly every Thursday on the 11 to 7 shift. A review of the Individualized Comprehensive Care Plan (ICCP) included a focus area created on 5/26/21, which revealed the resident had an indwelling catheter related to urinary retention and bladder cancer. Interventions included securing the catheter tubing to the leg or abdomen to avoid tension on the urinary meatus and to keep the drainage bag below the bladder. On 9/27/23 at 11:55 AM, the surveyor interviewed the Certified Nursing Assistant (CNA), who stated the resident used a leg bag and the leg bag stayed in the bed with the resident. On 9/27/23 at 12:00 PM, the surveyor interviewed the Registered Nurse (RN), who stated that the urinary catheter bags were changed weekly and she monitored the resident's output. The nurse exposed the urinary bag that was lying in the bed next to the resident. The urinary bag had blood-tinged urine in the bag. The RN further stated that that was the type of bag that the facility used and the staff did not change to a leg bag. On 9/28/23 at 9:41 AM, the surveyor observed the Infection Preventionist/Registered Nurse (IP/RN) and the Director of Nursing (DON) at the resident's bedside with the urinary catheter leg bag lying next to the resident. The IP/RN stated that urinary bags lay in the bed with residents and the urinary bags do not hang on the side of the bed. On 9/28/23 at 9:51 AM, the surveyor interviewed the IP/RN who stated the facility used a combination urinary pack at the facility for 6 years. She further stated that it was the system that the facility used, and the collection bag did not hang off the side of the bed. The policy for urinary catheter care dated 9/28/23 stated that the catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. 45209 2. On 09/26/23 at 10:52 AM, a surveyor observed Resident #23 in bed with a leg catheter bag next to their right knee. The surveyor reviewed the medical record for Resident #23. A review of the Admission Record face sheet reflected the resident was readmitted to the facility in June of 2023 with diagnosis which included Urinary Tract Infection, Urinary Retention, and Congestive Heart Failure. A review of the Admission MDS dated [DATE], the resident had a BIMS score of 15 out of 15, which indicated a fully intact cognition. Further review of the MDS indicated the resident as dependent on staff for all activities of daily living (ADLs) and required the use of an indwelling urinary catheter. A review of the ICCP included a focus area created on 06/28/2023, that the [Resident] has indwelling catheter [related to] retention [ .] at risk for complications associated with indwelling [foley catheter]. Interventions included: Secure catheter tubing to leg or abdomen to avoid tension on urinary meatus and keep drainage bag below the bladder. On 09/28/2023 at 10:00 AM, the surveyor entered the resident room and did not observe a foley bag hanging from Resident #23's bed. On 09/28/2023 at 10:01 AM, the surveyor interviewed CNA #1 who confirmed that the resident had a foley bag and prefered to stay in bed. CNA confirmed that the foley bag could also be used as a leg bag, but the resident did not like to wear it. On 09/28/2023 at 11:01 AM, the surveyor, in the presence of RN #1, entered the room of Resident #23 and requested permission to look at their foley catheter. RN #1 removed the blanket and revealed the foley catheter bag on the bed by the resident's right knee. On 09/28/2023 at 11:45 AM, the surveyor interviewed RN #1 who confirmed that Resident #23 had history of urinary retention and Extended Spectrum Beta-Lactamase (ESBL- a drug resistant bacterial infection) in the urine. Upon viewing the foley bag on the bed, RN #1 acknowledged that the foley bag ideally should be positioned below the level of the bladder. When asked why is it was important for the foley bag to be below the level of the bladder RN #1 reported, to get all the urine out [of the bladder], [they have] ESBL in the urine so [it should be below the bladder] for infection control and to get the 40 milliliters of drainage that they [the physicians] want to see per hour. When asked if there was a way to hang the foley bag on the bed, RN #1 stated no. The policy for urinary catheter care dated 9/28/23 stated that the catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. 46889 3. On 9/26/23 at 11:14 AM, the surveyors observed Resident #20 lying in bed with urinary catheter leg bag attached to the right upper leg laying on top of the bed. The surveyor reviewed the medical record for Resident #20, which reflected the following: A review of the Admission Record face sheet reflected the resident was admitted to the facility on [DATE] with diagnosis which included but not limited to Benign Prostatic Hypeplasia (BPH) is a condition in men in which the prostate gland is enlarged with lower Urinary symptoms, and presence of urogenital implants (indwelling catheter). The Admission MDS, an assessment tool, dated 7/03/23 reflected that the resident was admitted to the facility on [DATE] and had a BIMS score of 14 out of 15, reflecting an intact cognition. The assessment reflected that the resident's urinary incontinence is not rated, and always incontinent of bowel elimination. The Admission MDS also revealed that the resident functional status reflected that the resident walk in room and walk in corridor, revealed that the activity did not occur. The Care Plan created on 7/01/23 reflected that Resident #20 has an indwelling catheter related to a history of retention, and BPH. The care plan intervention includes secure catheter tubing to leg or abdomen to avoid tension on urinary meatus and keep drainage bag below the bladder. On 9/28/23 at 9:58 AM, the surveyor interviewed the nurse's aide and stated that the leg bag was not meant to be hung and an anti-backflow tube was attached. On 9/28/23 at 01:24 PM, the surveyor verified the resident's ambulatory status with the MDS Coordinator. The MDS Coordinator verified with the surveyor that the resident has non ambulatory since admission. The policy titled Heath Village Urinary Catheter Care dated 9/28/23 revealed under procedures, 9. Leg bags are not routinely used, unless resident is ambulatory. 11. The catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. 48781 4. On 09/26/23 at 11:30 AM, the surveyor observed resident #41 in the room laying on a low air mattress bed. The resident was not interviewable, and their eyes were closed. Two Hospice aides were in the room and one Hospice aide stated the resident does not respond now. The resident used to get out of bed using a mechanical lift to transfer to a wheelchair but is now declining and stays in bed. The resident has been in Hospice Care for about four months. On 09/26/23 at 11:37 AM, the surveyor observed the urinary leg bag laying on the bed at the same level as the resident's bladder. The catheter contained blood-tinged urine in the tube and in the drainage bag. The surveyor observed the Hospice aide wearing gloves and emptying urine from the leg bag into the urinal. The aide then disconnected the tube from the leg bag and drained the blood-tinged urine from the tube into the urinal and then re-attached the tube into the leg bag. The surveyor observed the aide empty the urine in the toilet, washed the urinal in the sink and then came out of the bathroom with the same gloves on. No changing of gloves or handwashing was observed. The aide proceeded to touch the overhead bed table, bed sheets, bed rails and the resident with the same gloves on. On 09/26/23 at 12:05 PM, the surveyors interviewed the Hospice Registered Nurse, who stated the resident has a Diagnoses of Urinary Retention, Parkinson's, Dementia, Alzheimer's, and history of Bladder Cancer and has been using a leg bag for years. On 09/28/23 at 10:25 AM, the DON submitted the facility Policy and Procedure for Urinary Catheter Care dated 12/8/2021 and updated 9/28/23. The Policy and Procedure for Catheter Care stated, Maintain a sterile, continuously closed drainage system; leg bags are not routinely used, unless resident is ambulatory; The only place, in the closed system, intended to be open is the empty spout at the bottom of the drainage bag; The catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. On 09/28/23 at 12:15 PM, the surveyor discussed the above concerns with Administration, DON, Infection Preventionist and Assistant Director of Nursing. 34033 5. On 9/26/23 at 10:55 AM, the surveyor observed Resident #14's room door with a STOP sign indicating Contact Precautions. The surveyor donned the proper personal protective equipment (PPE) and entered the resident's room. The surveyor observed Resident #14 sitting in a wheelchair. The resident stated that he/she was very happy with the care living here in the facility and had no issues. On 9/27/23 at 11:17 AM, the surveyor interviewed the IP who stated that Resident #14 recently was placed on Contact Precautions because he/she had a multi-drug-resistant organism (MDRO) in the urine and had a foley catheter. The surveyor reviewed the medical record for Resident #14. A review of the quarterly MDS, an assessment tool used to facilitate the management of care, dated 8/20/23, reflected that the resident had a BIMS score of 15 out of 15, indicating that the resident had an intact cognition. A review of the Order Summary Report reflected a physician's order dated 4/23/22 for Foley Catheter care every shift for hygiene. A review of the individualized plan of care (IDCP) created on 4/2/22 with a revision date of 9/26/23 reflected a focus area that the resident has indwelling catheter r/t (related to) retention, hx (history) of bladder cancer-chronic infections in the urine-at risk for reoccurrence. The IDCP also reflected an intervention initiated on 5/20/22 to Secure catheter tubing to leg or abdomen to avoid tension on urinary meatus (the opening of the urethra) and keep drainage bag below the bladder. On 9/28/23 at 10:30 AM, the surveyor donned the proper PPE and entered the room of Resident #14. The surveyor observed the resident sitting in a wheelchair. The resident stated that he/she had a catheter and showed the surveyor his/her left leg which had a bulge by the resident's ankle that was covered by the resident's sweatpants. The resident stated that the catheter was strapped to his/her leg. The resident stated that the nurses took care of the catheter. The resident then stated that at night when he/she went to bed the catheter remained strapped to his/her leg while he/she was lying in bed. On 9/28/23 at 10:44 AM, the surveyor interviewed the CNA #2 who stated that Resident #14 had a leg bag catheter. The CNA #2 added that the catheter bag was strapped to the resident's leg by applying two straps, one strap was placed higher up on the leg and the second strap was placed lower above the ankle. The CNA #2 also stated that the leg bag was always used, and no other catheter bag was used. The CNA #2 added that she had worked at the facility for [AGE] years and a while back they had used a different kind of catheter bag which hung on the side of the bed but that was no longer used. The CNA #2 added that only leg bag catheters were used even when residents were lying in bed. On 9/28/23 at 12:24 PM, the survey team met with the LNHA, DON, IP, and Assistant Director of Nursing (ADON). The DON stated that after surveyor inquiry they were reviewing the continued use of only the leg bag catheters and updating the facility Catheter Care policy. A review of the facility policy dated 9/28/23 for Urinary Catheter Care provided by the DON revealed that the procedures included Leg bags are not routinely used, unless resident is ambulatory. In addition, The catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. NJAC-8:39-19.4 (a)5, 27.1(a)

Based on observation, interviews, and record review it was determined that the facility failed to ensure a fall intervention, specifically a bathroom door alarm, was in place and functioning for a resident with a history of falls. This deficient practice was identified for 1 of 2 residents reviewed for falls, Resident #49, and was evidenced by the following: According to the Admission Record, Resident #49 had diagnoses that included but were not limited to Alzheimer's disease and fracture of the left radius (forearm). A review of the Quarterly Minimum Data Set (MDS), an assessment tool, dated 9/10/2023, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 3 which indicated that the resident's cognition was severely impaired. An additional review of the MDS revealed the resident had falls with injuries. A review of the Resident's care plan revised on 9/7/23 included that the resident was at risk for falls related to confusion, limited mobility, and poor safety awareness with a goal that the resident would be free of major fall related injuries. Interventions included but were not limited to; bathroom door alarm added for safety which was initiated on 8/29/23. A review of progress notes, dated 8/27/23 at 3:10 am, reflected that the staff responded to an alarm and found the resident lying on the bathroom floor holding onto their wheelchair. A review of the resident's Incident Report (IR), dated 8/27/23, revealed that the resident was found on the floor in the bathroom and sustained a skin tear to their left leg. The fall investigation review indicated that a bathroom door alarm was added for safety on 8/28/23. On 09/27/23 at 10:45 AM the surveyor observed Resident #49 seated in a wheelchair in their room. The surveyor observed the bathroom door was open with no audible alarm sounding. On 09/27/23 at 10:58 AM, the assigned certified nurses aide (CNA) entered the resident's room. The surveyor asked the CNA how they knew how to take care of residents who had falls. The CNA stated they used a paper cheat sheet, that let the staff know about resident care and alarms the resident should have. At that time, the surveyor asked the CNA to check the bathroom door. The CNA stated she didn't know about that alarm, looked at the bathroom door alarm and stated that the alarm wasn't working. On 09/27/23 at 10:59 AM the assigned Licensed Practical Nurse (LPN) was outside of the resident's room and stated she hadn't seen the resident yet, but the alarm was working the day prior. She added that the bathroom door should be closed. On 09/27/23 at 11:10 AM, the surveyor reviewed the CNA cheat sheet (titled daily report) with the CNA which indicated that the resident had a bathroom alarm. During an interview with the surveyor on 09/27/23 at 11:22 AM, the LPN stated that she and the Unit Manager (UM) informed the staff of interventions for the residents verbally and that their assignment (daily report) sheet would be updated. She stated that Resident #49's bathroom door should have been closed so if it was opened, the alarm would go off. During an interview with the surveyor on 09/27/23 at 12:12 PM, the Director of Nursing (DON) stated after a fall, the resident's care plan was updated by the nurse or the Unit Manager, and the transfer sheet (daily sheet) with interventions would be updated for the CNAs. The DON added that the CNAs also access the resident's care plan. She stated the CNAs completed safety checks at the start and the end of the shift to ensure alarms were in place and functioning. She explained that the door to Resident #49's bathroom should have been closed and the alarm should have been checked for placement and functioning. During an additional interview with the surveyor on 09/28/23 at 10:01 AM, the DON stated that the door alarm was part of the resident's care plan and the CNA should have ensured Resident #49's alarm was in place for safety. A review of a facility policy titled, Comprehensive Resident Centered Care Plans dated 6/1/2023, included but was not limited to; It is the policy of the facility to promote seamless Interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. NJAC 8:39- 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the administration of controlled medication for 1 sampled resident (Resident #7) identified upon inspection of 1 of 4 medication carts (Willow unit). The evidence was as follows: On 9/28/23 at 10:44 AM, the surveyor in the presence of the Registered Nurse (RN) inspected the [NAME] unit medication cart. The surveyor and the RN reviewed the controlled medications located in a secured and locked controlled medications box. When the controlled medication inventory was compared to the corresponding declining inventory sheet, the surveyor identified the following concerns. Resident #7's morphine sulfate oral solution 100 milligram (mg)/ 5 milliliter (ml) oral solution container, a medication used for pain, did not match the declining inventory sheet quantity. The bottle of morphine had the tamper evident seal removed indicting the bottle had been opened and the corresponding declining inventory sheet indicated there had been no doses removed from that morphine bottle. At that time, the RN stated she had not administered morphine to the resident that day and acknowledged the tamper evident seal had been removed from the bottle of morphine and the declining inventory sheet reflected there had been no doses removed from the bottle. The RN further stated when administering a controlled substance, the nurse was to remove the dose from inventory and complete the declining inventory sheet indicating the medication had been removed from stock, administer the medication, and then sign the medication administration record (MAR) which indicated the medication had been administered. On 9/28/23 at 11:22 AM, the surveyor interviewed the Assistant Director of Nursing (ADON). Together the surveyor and the ADON reviewed the declining inventory sheet for morphine for the resident, and the corresponding MAR. The ADON acknowledged according to the September 2023 MAR a dose of morphine had been given on 9/22/23 at 8 AM, however the corresponding declining inventory sheet did not indicate a dose of morphine had been given on that date. The ADON further acknowledged the tamper evident seal had been removed from the resident's morphine bottle. The ADON stated the process was the nurse removed the medication, signed the declining inventory sheet, administered the medication, and then signed the MAR that the medication was given. The ADON acknowledged the nurse did not follow that process on 9/22/23. On 9/29/23 at 10:09 AM, the surveyor attempted to interview via telephone the nurse who had signed the MAR on 9/22/23 at 8:00 AM, the nurse did not pick up the call. On 9/29/23 at 10:20 AM, the surveyor interviewed the facility consultant pharmacist (CP) who stated the declining inventory sheet was for inventory control, to ensure the medication counts were accurate. The CP acknowledged the nurse should have documented on the declining inventory sheet that the medication had been removed from stock, administered the medication, and then documented the dose on the MAR. A review of the Admission Record face sheet reflected the resident was admitted to the facility in August of 2023 with diagnoses which included chronic kidney disease, depression, and ventricular premature depolarization (irregular heartbeat). A review of the Order Summary Report (OSR) included physician's orders (PO) dated 9/20/23, for morphine sulfate oral solution 20mg/5 ml; give 0.25 ml by mouth every 2 hours as needed for moderate to severe pain and morphine sulfate oral solution 20mg/5 ml; give 0.25 ml by mouth every 2 hours as needed for dyspnea (air hunger) 0.25 ml =5 mg. A review of the corresponding September 2023 Medication Administration Record (MAR) revealed the resident received a dose of morphine on 9/22/23 at 8:00 AM. A review of the facility's undated Controlled Substances policy dated 6/1/23 .when a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the declining inventory sheet and the medication administration record (MAR): 1. date and time of administrations (MAR and declining sheet) 2. amount administered (declining sheet) 3. remaining quality (declining sheet) 4. initials of the nurse administering the dose, completed after the medication is actually administered (MAR and declining sheet). NJAC 8:39- 29.2(d), 29.7(c)

Based on observations, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to a.) ensure that the facility's policy for the appropriate personal protective equipment (PPE) for staff to wear for a resident who was newly admitted to the facility, to address the risk for infection transmission, and was in accordance with acceptable standards of infection control practice, and b.) wear all required PPE in the room of a newly admitted resident who was on droplet precautions and was unvaccinated for COVID-19 for 2 of 3 staff, according to the facility policy and New Jersey Department of Health guidance. This deficient practice was identified for one of two unvaccinated new admission residents reviewed, Resident #172, and was evidenced by the following: a) During an interview with the survey team on 06/06/22 at 09:39 AM, the Assistant Director of Nursing (ADON) stated that unvaccinated residents that were new admissions were placed on droplet and contact precautions requiring PPE: face shield, gown, gloves, and a surgical mask, when entering the room. The ADON stated that exposed residents were placed on Droplet precautions with an N95 mask (an N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particle), requiring full precautions: gown, gloves, face shield and N95. During a tour of the Laurel Unit on 06/06/22 at 11:19 AM, Surveyor #1 observed a sign outside the room of Resident #172 that read Contact/&Droplet Precautions. The door did not have a Stop sign: must wear an N95 mask. There was a PPE isolation cart outside the door. On 06/06/22 at 11:29 AM, Surveyor #1 observed Physical Therapist (PT) #1 knock on the door of Resident #172's room. She was wearing a surgical mask and a face shield. She donned (put on) a gown and gloves. She entered the room and closed the door. The surveyor reviewed Resident #172's medical records. According to the Admission Record (AR), Resident #172 was admitted from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The on-going personalized Care Plan revealed a focus area that Resident #172 was not vaccinated for COVID-19, dated 06/05/22. The Interventions included but were not limited to encourage to wear mask during visitations and during close contact activities due to increased risk. According to the social services note dated 6/6/22 at 11:30 AM, indicated that Resident #172 declined the flu shot, PNA (pneumonia), and Covid-19 vaccines. Resident #172 is not vaccinated for COVID-19 . Resident #172 and family were educated on the need for PPE during visitation until he/she is off isolation due to not being vaccinated. They are aware the PPE is located outside the room and that surgical masks can be provided should they only have cloth masks. During an interview with Surveyor #1 on 06/07/22 at 11:48 AM, the Director of Nursing (DON) stated that unvaccinated new admissions had signs for droplet/contact precautions requiring gown, gloves, a face shield, and a surgical mask to be worn in the room. She stated that exposed residents had signs for droplet/contact precautions with a Stop Sign: A N95 must be worn, requiring a gown, gloves, face shield, and a N95 be worn in the room. During an interview with Surveyor #1 on 06/08/22 at 10:31 AM, the Infection Preventionist Registered Nurse (IP/RN) stated that new admissions that were not vaccinated were placed on contact /droplet isolation for 10 day, requiring a surgical mask, gloves, gown, and face shield to enter the room. She stated that Resident #172 was not vaccinated and was on droplet/contact precautions, requiring PPE: gown, surgical mask, gloves, and face shield to be worn in the room. She stated that the facility followed guidelines from the Center of Disease Control (CDC) and New Jersey Department of Health (NJ DOH) and discussed the guidelines with team, which included the Infectious Disease (ID) doctor. In the presence of the survey team and the Licensed Nursing Home Administrator (LNHA) on 06/08/22 at 11:38 AM, the IP/RN stated that they were following the guidance from NJ DOH dated 2/25/22. The IP/RN read #5 of the guidance: New or readmitted asymptomatic patients/residents who are not up to date . the patients/residents should be placed in quarantine and cared for using full PPE (gown, gloves, eye protection that covers the front and sides of face, and a NIOSH-approved N95 or equivalent or higher-level respirator). The LNHA stated that the purpose of special precautions was to minimize the risk of exposure. She stated that the guidance was for the facility to follow. She further stated that guidance is open for interpretation per their ID doctor and that the guidance refers to consideration for cohorting for covid 19. During an interview with Surveyor #1 on 06/09/22 at 09:42 AM, Certified Nursing Assistant (CNA) #1, stated that the signage outside the room of Resident #172 was for droplet/contact precautions which meant that a surgical mask, face shield, gown and gloves must be worn when entering the resident's room because the resident was not vaccinated. In the presence of the survey team, the Executive Director, and the LNHA on 06/10/22 at 11:06 AM, the DON confirmed that they are standing by their policy for unvaccinated new admissions isolation protocol as advised by their ID doctor that a surgical mask, face shield, gown and gloves was required in the room. During an interview with Surveyor #1 on 06/13/22 at 11:06 AM, PT#1 stated that unvaccinated precaution included a surgical mask, goggles/shields, gloves and gown. She stated that Resident #172 was unvaccinated and that a N95mask was not required in the resident's room. b) On 06/08/22 at 10:02 AM, two surveyors observed a staff member inside of Resident #172's room. The surveyors observed that the staff member was wearing eye goggles, a surgical mask, and was standing within arm's length of the resident. The surveyors observed the outside of the room with signage that included contact and droplet precaution, stop see nurse, instructions to use hand hygiene, [PPE] gown and gloves required to enter the room, mask with eye shield for potential body fluids splashes or sprays, and hand hygiene when exiting. There was a plastic bin which contained PPE gowns, gloves, surgical masks, and disinfectant wipes, right outside the door. At that time, a Licensed Practical Nurse (LPN) came to Resident #172's room to inform the staff member inside the room, that she was required to wear PPE while in Resident #172's room. The staff member was identified as a contracted x-ray technician. The x-ray technician stepped out of the room into the hallway, donned a PPE gown and gloves, and re-entered the room. The LPN informed the x-ray technician and surveyors that Resident #172 was on transmission-based precautions because he/she was a new admission and was not vaccinated for COVID-19. On 06/08/22 at 10:07 AM, the two surveyors observed the door open, the x-ray technician move the resident's tray table and she proceeded to write information on paperwork. The x-ray technician was observed to be in close proximity to the resident's face, and Resident #172 was unmasked. The x-ray technician discarded her PPE. The x-ray technician was still wearing the same surgical mask and eye goggles. On 06/08/22 at 10:09 AM, during an interview with the two surveyors, the x-ray technician stated she did not know if she saw the precautionary signs on Resident #172's door. The x-ray technician stated, they are doing this because he/she is unvaccinated, that is silly. Surveyor #2 asked about the required PPE and the x-ray technician showed the surveyor her eye goggles and stated that her company said, eyewear is eyewear. She acknowledged that according to the signage on Resident #172's door, that going into the room she should wear all PPE such as eye wear, mask, gown, and gloves. The x-ray technician further stated the facility never told her what PPE she should wear. On 06/08/22 at 10:15 AM, during an interview with the two surveyors, the LPN stated all staff would need to wear a surgical mask, face shield, PPE gown and gloves to enter Resident #172's room because he/she was not vaccinated for COVID-19. The LPN further stated that PPE was used to protect staff if a resident were to spit while talking. The LPN stated that if the x-ray technician had followed the signage to see nurse, she would have instructed the x-ray technician what PPE she was required to wear. In the presence of the survey team on 06/08/22 at 11:47 AM, the IP/RN stated the hospital would have to do contact tracing on residents being admitted to the facility. The IP/RN stated she could not say that all residents were in the hospital 10-14 days prior to admission and could not say if they were possibly exposed at the hospital or even by the transport company. On 06/08/22 at 12:02 PM, during an interview with Surveyor #2, the IP/RN stated the x-ray technician should have entered Resident #172's room wearing a surgical mask, PPE gown, gloves, and should have followed the signs on the resident doors regarding transmission-based precautions (TBP). The IP/RN stated if there were no nurse around, the x-ray technician should have reported to the nurse's station. The IP/RN stated if the proper PPE was not worn, it would increase the risk of the spread of infection. The IP/RN further stated that contract staff would be told by the nurse on duty, to always see well residents first and the ill or TBP residents last. In the presence of the survey team on 06/10/22 at 11:10 AM, the DON stated when the facility used contract workers they are expected to abide by standards of practice. On 6/13/22 at 12:53 PM, during a telephone interview with Surveyor #3, the Local Health Officer (LHO) who oversees the public health department, stated several weeks ago her department was asked to speak with Communicable Disease Service (CDS) and the facility on a phone call. The LHO stated that CDS informed the facility that they must follow the guidance (Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated 2/25/22) including wearing the full PPE which included an N95 mask. The LHO stated the guidance as written should be followed. A review of the Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities guidance dated 2/25/22, included but was not limited to: 5) New or readmitted asymptomatic patients/residents who are not up to date with all recommended COVID-19 vaccine doses and have a [CONDITION(S)] test negative upon admission or readmission, should be placed in quarantine and cared for using full PPE (gowns, gloves, eye protection that covers the front and sides of face, and NIOSH [National Institute for Occupation Safety and Health] approved N95 or equivalent or higher-level respirator), even if they have a negative test upon admission. A review of the facility provided Completed Development Opportunities in-services from the x-ray contracted company, dated 12/02/21, revealed that the x-ray technician had completed the Infection Control Practices course including infection prevention and control, standard and transmission-based precautions, barriers and use of personal protective equipment, and strategies for preventing the spread of infectious disease to healthcare workers and patients. A review of the facility provided Field Personnel COVID-19 Procedures/Use of PPE guidance from the x-ray contracted company, undated, included but was not limited to 3. PPE required for patient encounters with suspected or known positive COVID-19. a. mask; b. gloves; c. eye protection/shield; d. gown/approved covering; e. wash hands with soap and water or hand sanitizer; and f. for patient, covering for patient's nose and mouth if the patient is symptomatic. These procedures are based on current CDC guidance/guidelines . All field personnel should routinely review the CDC's website for updates A review of the facility's policy, [name redacted] COVID19-Resident Admission/Re admission Protocols revised 5/10/2022, revealed For unvaccinated COVID19 residents they will be on contact and droplet precautions isolation for 10 days. When on isolation, full PPE will continue to be used. If no know exposure to COVID 19, an approved NIOSH N-95 will not be required. A review of the facility's policy, Application of Transmission-Based Precautions revised 6/8/22, revealed Purpose: transmission-Based precautions are used for residents who are known or suspected to be infected or colonized with infectious agents, which require additional control measures to effectively prevent transmission. Cohorting: Readmissions/new admissions that are unvaccinated for COVID19 vaccine should be on droplet precautions and contact precautions for 10 days. NJAC 8:39-19.4(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to follow professional standards of clinical practice concerning 1.) administration of medications for 1 of 4 residents(Resident #15) and 2.) following a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. This deficient practice was evidenced by the following: 1. On 06/07/22 at 10:02 AM, the surveyor observed Resident #15 in his/her room sitting in a wheelchair. The surveyor observed two small plastic cups, one containing pills and the second containing applesauce sitting on the overbed table. Resident #15 stated that he/she takes medications by themselves but never signed papers to be able to do so and nobody ever educated him/her on what to do. Resident #15 stated that he/she didn't know what each pill was for but knew some of them and would take the medications when he/she wanted to. Resident #15 tilted the small plastic cup and the surveyor observed seven pills. Resident #15 was unable to identify the pills. The surveyor reviewed Resident #15's medical records. The Admission Record (an admission summary) revealed that Resident #15 had been admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Annual Minimum Data Set (MDS) dated [DATE], a tool used to facilitate the management of care, revealed that Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The Nursing Admission Assessment, dated 5/10/22, revealed that Resident #15 had both short- and long-term memory problems, poor balance, and behaviors of being anxious, and could be resistive. The facility provided; Order Summary Report for June 2022, did not reflect documented evidence to indicate Resident #15 was able to self-administer his/her medications. According to the Care Plan with an initiated date of 3/15/22, revealed a focus area that Resident #15 displayed signs/symptoms of impaired cognition/impaired thought process as evidenced by forgetfulness and/or confusion related to dementia. On 6/07/22 at 10:11 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that she was an agency nurse who had been working at the facility for four weeks. The LPN stated that Resident #15's medications were scheduled for 9 AM and she was aware it was after the hour time range to administer the medications. The LPN stated, I ran out for a bell. I usually let Resident #15 take them [medications] but I have to watch him/her. That was on me. I should not leave them.[medications] Anyone could walk in and take them [medications] and the resident might not take them [medications]. The LPN further stated that she knew at least one of the medications was a vitamin but would have to look up the other medications to see what they were and that she would go get the pills from the resident room. On 6/07/22 at 10:17 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) for Resident #15. She stated that the process for medication pass would be to follow the five rights, knock on the resident's door, and administer medications with precautionary measures. The LPN/UM stated that no residents on the unit were able to self-administer medications. The LPN/UM further stated that pills should never be left in a resident's room because the pills might not be taken by the resident or someone else could take them. On 6/07/22 at 10:46 AM, the surveyor interviewed the Director of Nursing (DON) who stated that medication administration consisted of the five rights, nurses should introduce themselves to the resident, know the medications they are administering, check the medications against the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that others could take the medications and/or the resident may not remember to take the medications. If a resident refused to take the medications at that time, the nurse must take the medications away and destroy them. The DON stated that nurses all have medication competencies including the agency nurses. On 6/09/22 at 10:10 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she was told by the LPN that she went to administer Resident #15's pills, heard an alarm, went to answer the alarm, and forgot to go back to Resident #15. The ADON stated that the LPN should have taken the medications with her and not have left them in the resident's room. The ADON further stated that since it was after 10 am and the medications were not in her sight, the LPN should have removed the medications and gave new pills because the LPN would not have known what medications were in that cup or missing from the cup. The ADON stated that the LPN should have called the physician about the late administration of medications and should have documented the conversation, but it did not get done. 2. On 6/8/2022 at 9:35 AM, the surveyor observed Resident #38 at the bedside sitting in their chair and able to respond to the surveyor's question appropriately. The resident had no shortness of breath and denied discomfort at that time. The resident stated he/she had weight fluctuations since admission but had no concerns. The surveyor reviewed Resident #38's medical records. The Admission Record reflected that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15, which reflected the resident had an intact cognition. It also reflected that the resident had no shortness of breath (SOB). According to the Order Summary Report for June 2022, revealed an order dated 4/20/22 for daily weights everyday shift and to call the medical doctor (MD) if there is a weight gain of 2 Lbs. (pounds) or more/day. The electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .) or more/day weight gain: 6/3/22 130 Lbs. (4 Lbs. weight gain) 5/30/22 126.6 Lbs. (2.6 Lbs. weight gain) 5/21/22 126 Lbs. (2 Lbs. weight gain) A review of the resident's hybrid (paper and electronic/computer-generated) medical records did not reflect documented evidence that the physician was notified of the resident's 2 Lbs. or more/day weight gain on 5/21/22, 5/30/22, and 6/3/22. On 6/8/22 at 10:08 AM, the surveyor interviewed the Registered Nurse (RN). She acknowledged that the resident had an MD order for daily weights and that the nurse should have called the MD for 2 Lbs. or more/day weight gain. She further stated that the resident was weighed daily during the morning shift by the Certified Nursing Aide (CNA). The CNA was then expected to record the weight in the resident's electronic medical record (EMR) and report it to the RN. The RN reviewed the resident's 6/2022 EMAR in the presence of the surveyor and she acknowledged to surveyor that the resident had more than 2 Lbs. weight gain on 6/3/22. She further explained that the nurse should've called [name redacted] to notify him of the weight gain, and should've documented in the nurse's notes that the MD was notified of the weight gain. The RN could not provide any information to reflect that the MD was notified of the weight gain on 6/3/22. On 6/8/22 at 10:34 AM, the surveyor interviewed the LPN/UM who stated that the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She could not speak to why the MD was not contacted about the resident's weight gain of at least 2 Lbs./day on 5/21/22, 5/30/22, and 6/3/22 and why there was documented evidence in the EMR to reflect that the MD was alerted of the weight gain. Furthermore, she stated that the nurses should have called and notified the MD of the resident's weight gain and should've documented in the nurse's notes that the MD was notified. The LPN/UM also stated that it was important for the nurses to follow the MD's order for daily weight and to notify the MD if the resident had a weight gain of 2 or more Lbs. as this could be an indication of resident's change in condition. At 11:08 AM, the LPN/UM informed the surveyor that the resident's MD visited the resident on 4/21/22, 5/2/22, and 5/28/22. She acknowledged to the surveyor that there was no documented evidence in the Office/Outpatient Visit physician's notes dated 5/28/22, that the MD was notified and aware of a 2 Lbs. weight gain on 5/21/22. 3. On 6/3/22 at 11:45 AM, the surveyor observed Resident #45 sitting in their high back chair, awake, alert, and he/she was able to respond to the surveyor's question appropriately. The resident had no shortness of breath and denied discomfort at that time. The resident stated he/she had weight fluctuations since admission but was not worried about it. The surveyor reviewed Resident #45's medical records. According to the resident's Admission Record reflected that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 14 out of 15, which indicated that the resident had an intact cognition. It also reflected that the resident had no SOB. The Order Summary Report dated June 2022, revealed an order dated 1/29/2022 for daily weight one time a day and to call the MD if there was a weight gain of 2 Lbs. or more/day. The eMAR reflected the following dates with 2 lbs. or more/day weight gain: 6/6/22 198.8 Lbs. (3.8 Lbs. weight gain) 6/2/22 198.4 Lbs. (2.7 Lbs. weight gain) 5/27/22 194.6 Lbs. (3.4 Lbs. weight gain) 5/20/22 193 Lbs. (4.6 Lbs. weight gain) 5/17/22 190.8 Lbs. (4.4 Lbs. weight gain) 5/7/22 196.4 Lbs. (3.4 Lbs. weight gain) 5/3/22 197.6 Lbs. (6 Lbs. weight gain) 4/26/22 195.8 Lbs. (3.8 Lbs. weight gain) 4/23/22 190.8 Lbs. (2.3 Lbs. weight gain) 4/10/22 193.5 Lbs. (4.9 Lbs. weight gain) 4/7/22 183.5 Lbs. (2.5 Lbs. weight gain) 4/5/22 184.6 Lbs. (3.6 Lbs. weight gain) 4/1/22/ 190 Lbs. (2.8 Lbs. weight gain) 3/31/22 187.2 Lbs. (5.5 Lbs. weight gain) 3/15/22 184.8 Lbs. (3 Lbs. weight gain) 3/3/22 182.6 Lbs. (3.8 Lbs. weight gain) 2/22/22 178.4 Lbs. (3 Lbs. weight gain) 2/17/22 179 Lbs. (3 Lbs. weight gain) 2/4/22 177.2 Lbs. (2.9 Lbs. weight gain) 1/31/22 170 Lbs. (2.2 Lbs. weight gain) 1/30/22 167.8 Lbs. (2.4 Lbs. weight gain) According to the resident's hybrid medical records did not reflect documented evidence that the physician was notified of the resident's 2 Lbs. or more/day weight gain on the dates indicated above. Furthermore, there was no evidence for a daily weight on 5/11/22, 3/27/22, 2/6/22 and 2/5/22. On 6/9/22 at 10:09 AM, the LPN/UM stated that she could not speak to nor provide documented evidence that the MD was notified of the resident's at least 2 Lbs. weight gain but did acknowledge there should have been documentation. She stated that the MD should have been notified at that moment when the nurses discovered a 2 Lbs. or more weight gain for that resident. Furthermore, she acknowledged to the surveyor that there was no weight documented on 5/11/22, 3/27/22, 2/6/22, and 2/5/22 and could not speak to why the weights were not documented. At 10:15 AM, the LPN/UM acknowledged to the surveyor that the resident's MD visited the resident on 2/13/22, 3/25/22, and 4/23/22 and that there was no documented evidence in the MD Office/Outpatient Visit notes that the MD was notified and made aware of 2 Lbs. or more weight gain on the dates indicated above from the eMAR. At 10:23 AM, the surveyor conducted a phone interview with the RN in the presence of the LPN/UM. The RN acknowledged to the surveyor that she was the day shift nurse assigned to the resident on 6/2/22. She also acknowledged that the resident had a 2.7 Lbs. weight gain on that day. She stated that she did not call the MD to notify the resident's weight gain because she was not comfortable with the resident's weight given by the CNA and stated that the resident may be wearing too much clothing. She stated that she asked the CNA to reweigh the resident for weight verification, but she did not follow up with the CNA and stated, I should have followed up and documented it in the nurse's progress notes and acknowledged that she did not do so. The RN stated that she did record and sign for the resident's weight in the eMAR on 6/2/22. She also stated that she should have called and notified the MD of the resident's weight gain and potential weight discrepancy and documented it in the nurses notes but she did not do so. The LPN/UM was present all throughout the surveyor's interview with the RN. At that time, the LPN/UM acknowledged that the RN should have followed up with the CNA for the resident to reweigh for verification, notified the MD of the resident's weight gain and potential weight discrepancy, and documented this in the nurse's notes, and stated absolutely. On 6/10/22 at 11:16 AM, the team met with the Administrator (LNHA), DON, and Executive Director to discuss the above concerns. The DON stated that the nurses should have notified the MD and assessed the residents for signs and symptoms of CHF, and it should have been documented in the nurses' notes in the EMR. Furthermore, she stated that a weight change beyond the prescribed parameters would be considered a change in condition which is why the nurses should perform physical assessments to ensure the weight gain was not related to CHF. On 6/14/22 at 11:55 AM, the team met with the DON, ADON, Infection Preventionist Nurse (IPN), and the Executive Director. No further information was provided prior to the survey team's exit. A review of the facility's policy on Weight Policy and Procedure updated on 10/15/22 reflected that a charge nurse was to report a weight increase as ordered by the physician. It was also indicated that for daily weights, the nurse must document the weight of greater than or equal to 2 Lbs. and what was addressed to the MD. A review of the facility's Procedure for Notification of Changes for Resident reflected that the nurse would notify the resident, resident's physician and the resident representative(s) for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician. It also indicated to document the notification and record any new orders in the resident's medical record. A review of the facility provided, Medication Pass Observation, dated 05/02/22, included but was not limited to 9.c. resident observed to ensure swallowed meds [medications], and revealed LPN was deemed competent to follow all steps to administer medications safely. A review of the facility provided, Position Description, Performance and Competency Review for position title LPN, undated, included but was not limited to duties and responsibilities to perform medication and treatment duties. A review of the facility provided, Self-Administration of Medications policy and procedure, dated 10/30/17, included but was not limited to a resident may only self-administer medications after the [Interdisciplinary Team] IDT has determined which medications may be safely self-administered. The facility was unable to provide any documentation or determination that Resident #15 was deemed competent to self-administer his/her own medication. A review of the facility provided, Administration of Medications, undated, included but was not limited to 4. Administer oral medication and remain with the resident while he/she takes the medication. Never leave a drug in resident's room. 10. If a resident refused to take a medication, indicate by a circle on administration record and on back of record. NJAC 8:39-11.2(b), 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 2 of 6 medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 10:30 AM, the surveyor inspected the [NAME] unit medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened bottle of [MEDICATION(S)] Ophthalmic drops (medication used for [CONDITION(S)]. [CONDITION(S)] is a group of eye diseases that can cause vision loss and [CONDITION(S)] by damaging a nerve in the back of your eye) and an opened bottle of [MEDICATION(S)] Ophthalmic drops (medication used for [CONDITION(S)]) that were both opened on [DATE] and were expired. The surveyor interviewed LPN #1 who stated that both the [MEDICATION(S)] and [MEDICATION(S)] Ophthalmic drops were expired and should have been removed from the medication cart. On [DATE] at 10:55 AM, the surveyor inspected the Juniper unit medication cart in the presence of LPN#2. The surveyor observed an opened [MEDICATION(S)] Insulin Pen (medication used for Diabetes) with an opened date of [DATE] that contained no resident's name on the pen. The surveyor interviewed LPN #2 who stated that all insulins including pens and vials should contained the name of the resident. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. [MEDICATION(S)] Ophthalmic drops once opened have an expiration date of 28-days 2. [MEDICATION(S)] Ophthalmic drops once opened have an expiration date of 28-days. On [DATE] at 11:20 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and no further information was provided by the facility. A review of the facility's policy for Disposal of Medications and Medication-Related Supplies that was dated ,d+[DATE] and was provided by the DON indicated the following: When medications are discontinued by the prescriber or the resident is discharged and medications are not sent with the resident, the medications are marked as discontinued and stored in a secure and separate area from the active supply, marked discontinued and securely stored until destroyed. C. Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue (to avoid inadvertent administration). Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy. A review of the facility's policy for Specific Medications Administration Procedures that was dated ,d+[DATE] and was provided by the DON indicated the following: D. Check expiration date on package/container before administering any medications. When opening a multidose container, place the date on the container. NJAC: 8:,d+[DATE].4 (a) (h) (d)

Based on interview, review of the medical record and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy prior to transfer to the hospital for 2 of 2 resident's (Resident #15 and #46) reviewed for hospitalization s. This deficient practice was evidenced by the following: 1. On 06/06/22 at 10:54 AM, the surveyor observed Resident #15 in their room sitting in a wheelchair self propelling around. On 06/07/22 at 9:45 AM, the surveyor observed Resident #15 in their room sitting in a wheelchair. The surveyor interviewed Resident #15 who stated he/she was recently in the hospital for fluid in the heart. A review of the facility provided Admission Record revealed that Resident #15 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility provided Universal Transfer Form, dated 05/04/22, revealed that Resident #15 was transported to the hospital ED [emergency department] to Hosp [hospital] Admission. A review of a nurse's Progress Note, dated 05/04/22 at 22:45 [10:45 PM], revealed Resident #15 informed staff that he/she was having an attack and became lethargic. The physician was contacted and ordered the resident to be sent to the hospital emergency room for evaluation. A review of a nurse's Progress Note, dated 05/05/22 at 2:20 AM, indicated that Resident #15 was being admitted to the hospital. The surveyor reviewed Resident #15's Electronic Medical Record and medical chart at the facility and was unable to locate any written notice of bed hold that would have been provided to the resident or resident representative. On 06/13/22 at 11:19 AM, the surveyor interviewed the Director of Social Services (DSS) who would have been responsible for the bed hold notifications, she stated that she did not have any letters that were sent out for Resident #15 when he/she went to hospital regarding bed hold. On 06/13/22 at 11:35 AM, the surveyors informed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) of no documented evidence that written notification about bed hold were sent to families of residents admitted to the hospital. 2. On 6/7/22 at 9:40 AM, the surveyor reviewed Resident #46's medical record, which revealed that the resident was transferred to the hospital on 3/8/22. The surveyor did not observe evidence of written notification of the facility's bed hold policy prior to the transfer to the hospital to the resident or the resident's representative. On 6/7/22 at 11:27 AM, the surveyor interviewed the DSS who stated that the facility automatically holds a long-term care (LTC) resident's bed, and that the bed hold policy is provided on admission. The DSS then stated that when a resident on the subacute unit was transferred to the hospital, the facility called the resident's family and notified them of the fee amount to hold the bed. The DSS added that the facility used to send a written letter in the past but that the facility no longer sent them. The surveyor requested the DSS provide any documented evidence that Resident #46 or the resident's representative received written notification of the bed hold policy when the resident was transferred to the hospital. On 6/13/22 at 9:08 AM, the DSS provided the surveyor with a letter that notified Resident #46's representative that the resident was transferred to the hospital and the reason. The letter did not include written notification of the bed hold policy, or the fee charged. The DSS provided a copy of the admission agreement with the following highlighted: Bed hold-private pay billing-beds will be held for LTC resident when discharge to a hospital unless otherwise notified by the resident or responsible party. On 6/13/22 at 10:37 AM, the surveyor interviewed the DSS who stated that for Resident #46, who resided on the LTC unit, there was an automatic bed hold and the facility charged the resident the rate minus a 10% discount. The surveyor asked the DSS if the resident or resident's representative was notified of the bed hold charge and policy at the time of transfer to the hospital. The DSS stated that the resident and resident's representative were notified on admission that there would be a bed hold charge. She further stated that the facility does not notify the resident or the resident's representative of the bed hold charge or policy when they are transferred. On 6/14/22 at 10:41 AM, during surveyor interview in the presence of the survey team, the LNHA stated that the information the DSS provided was what the facility had been doing in regard to the bed hold charge and policy. A review of the facility provided undated policy titled, Bed Hold Policy, included the following: Policy: It is the policy of Heath Village to hold offer to hold the bed if the resident, patient or responsible party is accepting of this at a private pay rate. Procedure: 1. Long-term care (Private Pay): Beds will be held for long-term care residents of The [name redacted] when discharged /transferred to a hospital or other facility unless otherwise notified by the resident or responsible party. If upon discharge, the resident or responsible party request the bed not to be held, they must notify staff at The Meadows, than all personal belongings must be removed at the time of discharge and the bed reassigned. The daily rate will continue to be charged to the resident until the day all of the resident's belongings have been removed from the room. 2. Long-term care (Medicaid): The [name redacted], in compliance with the Medicaid Program, will hold a bed for 10 days when a person is discharged to a hospital unless otherwise notified by the The [name redacted] patient or responsible party. A resident whose hospitalization or therapeutic leave exceeds the 10 day bed hold period under the Medicaid bed hold policy will be readmitted to the facility immediately upon the first availability of a bed in a semi-private. The resident has the option of using personal funds to ensure return to the same occupancy at the regular daily rate upon the expiration of the mandated 10 day bed hold. If upon discharge to a hospital, and upon resident's or responsible party's request that the bed is not to be held for 10 days, then all personal belongings must be removed by the responsible party at the time of discharge to the hospital, and the bed may be reassigned. 3. Subacute rehab/respite: The [name redacted] will not hold a bed for a rehab/respite patient when discharged /transferred to a hospital or other facility unless specifically requested by the patient or responsible party. All bed hold days will be discounted 10% off the stated per diem rate while absent from the facility. If not holding the bed, all personal belongings must be removed by the responsible party at the time of discharge or the private pay daily rate charge will apply. The policy did not contain information regarding written notification of the facility's bed hold policy upon transfer to the hospital. N.J.A.C. 8:39-5.1 (a)

Based on observation, interview, and record review it was determined that, the facility failed to post the nurse staffing information on 0 of 3 areas of the facility in a prominent place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 6/3/22 at 9:00 AM, upon entry into the facility the surveyors did not observe that there was a Nursing Home Resident Care Staffing Report (NHRCSR), or a similar form with the required data, displayed in the facility lobby for residents or visitors to view. On 6/8/22 at 9:48 AM, the surveyor did not observe a NHRCSR displayed in the facility lobby. The surveyor interviewed the Receptionist who stated that she had a copy of the Daily Schedule (DS) at her desk. The surveyor observed the DS which included the names of the staff that were scheduled to work on each unit for that day. The DS did not include the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care by shift: Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. The DS also did not include the census of the facility. The Receptionist stated that she would highlight the names of the staff listed as they came into the facility. On 6/8/22 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) on the Juniper Unit. The LPN stated that there was a DS and assignment sheet and that it was kept in the office behind the closed doors. The surveyor asked the LPN if there was any NHRCSR displayed for residents or visitors to view. The LPN stated that she had not seen anything posted for resident or visitors to view. On 6/8/22 at 10:17 AM, the surveyor interviewed the Registered Nurse on the Juniper Unit. The RN stated that the DS was kept in the Nursing Station. She added that the DS was at the main desk but that she was not sure if it was visible for resident or visitors to see. On 6/8/22 at 10:29 AM, the surveyor asked the Receptionist if a resident or a visitor would be able to view the DS. The Receptionist stated that no one had asked her to view it and that if someone did, that she would have to ask someone if they were allowed to view it. The Receptionist confirmed that the DS did not have the hours, the staff worked, or the facility census listed on it. On 6/9/22 at 11:56 AM, the surveyor interviewed the Staffing Coordinator (SC) who stated that she usually posts a DS at the entrance on the Laurel unit. The surveyor asked the SC if that was the main entrance. The SC stated that the entrance on the Laurel unit was used during the evening hours and weekends when the main entrance was closed. The SC confirmed that she did not post a NHRCSR which included the hours worked at either entrance. The surveyor asked the SC the reason she had not posted the NHRCSR. The SC stated that she submitted the NHRCSR to the appropriate agency and kept a copy of it but that she was not aware that she was supposed to post it. On 6/10/22 at 9:08 AM, the surveyor interviewed the Unit Secretary (US) of the Laurel and Juniper units who stated that she received a DS from the SC and that it was posted at the Nurses Station and that it was not out in the public area visible to residents or visitors. The surveyor asked the US if a DS or NHRCSR was posted in a public area, and she stated that she was not aware that it was posted anywhere for residents or visitors to view. The US added that in the past it was posted but was not sure why it had been stopped being posted. On 6/10/22 at 11:09 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who confirmed that the NHRCSR was not posted for residents or visitors to view. A review of the facility provided policy titled, Staffing Protocol, with a revised date of 10/26/2020, included the following: Policy: [name redacted] will provide nursing services and licensed nursing and ancillary personnel at all times. Objective: To fully staff each unit as required by standards, acuity levels, and by skill level of staff to properly meet the needs of all residents. 1. To determine minimum staffing, multiply the total number of residents by 2.5 hours a day. 2. In addition, the acuity levels will be calculated and added to that total . 4. Staffing coordinator/designee will log in to nj.gov to report staffing totals as per regulation. Staffing is reported for each shift for each day. 5. Nursing staffing is posted daily. NJAC 8:39-41.2 (a)

Based on observation, interview, and review of records, it was determined that the facility failed to: a.) practice appropriate hand hygiene for 3 of 10 staff observed; and, b.) ensure that workers are knowledgeable of the cleaning chemical used in the workplace for 3 of 3 staff in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/2020 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene, which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. A review of the U.S. CDC's Cleaning and Disinfecting Your Facility, updated on 7/28/2020, included, Practice routine cleaning of frequently touched surfaces. High touch surfaces include tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, sinks, etc. Disinfect with a List N: disinfectants for use against [DIAGNOSES REDACTED]-CoV, [MEDICAL CONDITION] that causes COVID 19. For electronics, such as tablets, touch screens, keyboards, remote controls, and ATMs, consider putting a wipeable cover on electronics. Follow the manufacturer's instructions for cleaning and disinfecting. If no guidance, use alcohol-based wipes or sprays containing at least 70% alcohol. Dry surface thoroughly and wear appropriate PPE when cleaning or disinfecting frequently touched surfaces and electronics. Additional considerations for employers: Educate workers performing cleaning, laundry, and trash pick-up to recognize the symptoms of COVID-19. Develop policies for worker protection and provide training to all cleaning staff on-site prior to providing cleaning tasks. Ensure workers are trained on the hazards of the cleaning chemicals used in the workplace in accordance with OSHA's Hazard Communication Standard. 1.On 1/26/21 at 8:55 AM, the Assistant Director of Nursing (ADON) informed the surveyors that there was no positive COVID-19 resident in the facility. The ADON further stated that two staff were tested positive for COVID-19 that were out self-isolating. At 10:16 AM, the surveyor observed the Registered Nurse/Unit Manager (RN/UM) performed handwashing for 39 seconds. The RN/UM did not wet her hands before applying soap. The RN/UM stated, I was nervous, when asked by the surveyor why she did not wet her hands before applying the soap. At 10:29 AM, the surveyor observed the Houskeeper#1 (HK#1) in a non-COVID unit did not perform hand hygiene in between the use of gloves. HK#1 did not respond when asked by the surveyor why she did not perform hand hygiene in between the use of gloves. At 10:37 AM, the surveyor observed HK#1 performed handwashing for 13 seconds. HK#1 did not wet hands before applying soap. At that same time, during the interview, HK#1 stated that she should wash her hands for 10 seconds. HK#1 had no answer why she did not wet her hands before applying soap. At 10:57 AM, the surveyor observed the Licensed Practical Nurse (LPN) in a non-COVID unit performed handwashing for 24 seconds under the stream of running water. The LPN stated, nobody corrected me before, when she was asked by the surveyor why she laddered her hands under the stream of running water. She further stated that she was not aware that she should not ladder her hands under the stream of running water. At 11:36 AM, the ADON, in the presence of the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), informed the surveyors that staff should wet their hands before applying soap, ladder hands for at least 20 seconds, and should not ladder hands under the stream of running water according to facility policy. A review of the facility Handwashing Procedure that was provided by the ADON with an updated date of 10/1/19 included Handwashing using soap and water: turn on the water and adjust temperature; wet hands with water; soap hands well; rub hands briskly for at least 20 seconds; rinse with hands lowered to allow soiled water to drain directly into the sink. Do not splash water on clothing. Do not allow hands to touch the sink. Dry hands well with disposable hand towel/tissue, especially between fingers. Use disposable hand towel/tissue to turn off the faucet. 2. On 1/26/21 at 11:03 AM, the Rehab Director/Physical Therapist (RD/PT) informed the surveyor that the Rehab Department use the disinfecting spray for cleaning the frequently touched surfaces and equipment in the gym after each use of the resident. The RD/PT was unable to state the contact time (which is the time that the disinfectant needs to stay wet on a surface in order to ensure efficacy) of the disinfecting spray. At that same time, the RD/PT stated that he was educated about the disinfecting chemicals but not about the contact time. 3. On 1/26/21 at 10:26 AM, the surveyor interviewed a housekeeper assigned at the observation unit. The housekeeper showed the surveyor the disinfectant spray being used to sanitize the residents' rooms. The housekeeper was unable to state the contact time (which is the time that the disinfectant needs to stay wet on a surface in order to ensure efficacy) of the disinfecting spray. On 1/26/21 at 10:58 AM, the surveyor interviewed a housekeeper who was cleaning the hallway. The housekeeper stated to the surveyor that she was assigned to clean the hallway and the rehab/gym twice a day. The housekeeper showed the surveyor the disinfectant spray being used to sanitize the residents' rooms. The housekeeper was unable to state the contact time (which is the time that the disinfectant needs to stay wet on a surface in order to ensure efficacy) of the disinfecting spray. On 1/26/21 at 12:08 AM, the surveyor interviewed the Housekeeping Director (HD). The HD stated to the surveyor that the contact time of the disinfectant spray used to sanitize the facility was 1-2 minutes. Upon reviewing the product specification document of the disinfectant chemical, the document showed that the actual contact time of the disinfectant spray was 3 minutes. At 11:36 AM, the surveyors met with the LNHA, DON, and ADON and were aware of the above concerns. NJAC 8:39-19.4 (a) (1) (2) (n)

Based on observation, interview and record review, it was determined that the facility failed to ensure: a.) transmission-based precautions were being implemented in accordance with national standards for infection control, and b.) appropriately cohort residents with infections. This deficient practice was identified for 2 of 7 residents reviewed for infections (Resident #76 and #82), and was evidenced by the following: 1. On 12/17/18 at 9:54 AM, the surveyor observed the room designated for Resident #82. The resident was not in the room at the time. The surveyor observed a stop sign on the door frame of the resident's room which indicated to stop and report to the nurse before entering the room. There was no personal protective equipment (PPE) of gowns, gloves, or masks directly outside of the resident's room. The surveyor observed a cart containing, an assortment of PPE, three rooms down and located at the end of the hallway. On 12/17/18 at 11:37 AM, the surveyor observed Resident #82 walking out of his/her bathroom using a rolling walker. A Certified Nursing Aide (CNA1) was assisting the resident out of the bathroom. The CNA1 was not wearing PPE. The surveyor attempted to converse with the resident, but the resident did not acknowledge the surveyor. The resident continued to walk down the hallway with the CNA1. The surveyor reviewed the medical record for Resident #82. A review of the resident's (MONTH) (YEAR) Order Summary Report (OSR) reflected that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the resident's most recent admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/3/18 reflected that the resident had a brief interview for mental status (BIMS) score of 5 out of 15 which indicated the resident had a moderate to severe cognitive impairment. A further review of the resident's (MONTH) (YEAR) OSR reflected that the resident had a physician's orders [REDACTED]. The OSR further reflected that the resident had a PO dated 12/13/18 for the antibiotic medication [MEDICATION NAME] 250mg/5ml. The order specified to give 2.5 ml by mouth four times a day for CDI for 14 days. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The (MONTH) (YEAR) MAR further reflected that the resident was receiving the antibiotic medication [MEDICATION NAME] 2.5 ml by mouth four times a day at 0000 (12:00 AM), 0600 (6:00 AM), 1200 (12:00 PM), and 1800 (6:00 PM). A review of the resident's individualized Care Plan (CP) revised on 12/13/18 indicated that the resident had a CDI. The goal of the CP was that the resident would have no complications related to the CDI through the next review date. The interventions included to wear gowns and masks when changing contaminated linens, to disinfect all equipment before leaving the room, and to use as much disposable equipment as possible or use dedicated equipment such as thermometer and blood pressure cuff. On 12/18/18 at 12:30 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN). The LPN stated that the resident was on the antibiotic medication [MEDICATION NAME] for CDI and required contact isolation. The LPN stated that since the resident had been on the medication he/she had not been having as many loose stools. The LPN further stated that the resident was occasionally incontinent of bladder and bowel and used the toilet in his/her bathroom during the day. The LPN stated that if a resident was on contact isolation for a CDI, that PPE was only required to be worn when the staff provided direct care to the resident. On 12/19/18 at 12:06 PM, the surveyor interviewed the resident's CNA1. The CNA1 stated that the stop signs outside of the resident's room indicated that the resident required contact precautions because the resident had a CDI. The CNA1 further stated that only when providing direct care to the resident, the staff were required to apply a gown, gloves, and mask to prevent the spread of infection prior to entering the resident's room. 2. On 12/18/19 at 10:31 AM, the surveyor stood in the hallway outside the room assigned to Resident #82 and his/her roommate, Resident #76. The surveyor observed that Resident #76 was using the shared bathroom and was being assisted by the CNA2. The surveyor was standing outside of the resident's room and overheard CNA2 explain to Resident #76 in the bathroom to pull the call bell when he/she was done. The surveyor then observed the CNA2 stand outside of the resident's bathroom and wait for the resident. When the resident was finished using the bathroom, the surveyor observed the CNA2 enter the resident's bathroom and assist Resident #76. The CNA2 was no wearing PPE when caring for Resident #76 while in the shared bathroom for the resident with a CDI. On 12/18/18 at 12:24 PM, the surveyor observed a portable bedside commode next to the bed of Resident #76. The bedside commode consisted of just the toilet seat and a lid. There was no collection pan attached to the commode. On 12/19/18 at 10:00 AM, the surveyor observed Resident #76 seated in his/her wheelchair in the main activity room on the unit watching television. The surveyor attempted to interview the resident, but the resident did not respond. The surveyor reviewed the medical record for Resident #76, who was the roommate for Resident #82 who had a CDI. A review of the (MONTH) (YEAR) OSR reflected that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the resident's most recent quarterly MDS dated [DATE] reflected that the resident had a short and long-term memory problem with a moderately impaired decision-making capacity. A further review of the (MONTH) (YEAR) OSR reflected that the resident had a PO dated 12/14/18 for the antibiotic medication, [MEDICATION NAME] 500 mg by mouth two times a day for 10 days for a UTI. A review of the (MONTH) (YEAR) MAR indicated [REDACTED]. A review of the residents CP initiated on 12/16/18 reflected that the resident had a UTI and was at risk for the reoccurrence of UTI. The goal of the CP was for the UTI to be resolved without complications through the next review period. The interventions of the CP reflected to administer the antibiotic as ordered and to aid with toileting and other ADLs as needed. On 12/18/18 at 11:29 AM the surveyor interviewed CNA2. The CNA2 stated that Resident #76's roommate had a CDI. The CNA2 stated that because the roommate had a CDI, Resident #76 would use the commode in the bathroom, as a raised toilet seat. The CNA2 stated that Resident #76 preferred to use the toilet instead of a commode, so they use the commode as a raised toilet seat in the shared bathroom. The CNA2 confirmed that both residents shared the same bathroom, but Resident #76 utilized the raised toilet seat. On 12/18/18 at 12:30 PM, the surveyor interviewed the LPN assigned to Resident #76. The LPN stated that the resident was on an antibiotic for a UTI. The LPN stated that when the resident went to the bathroom, the resident would use the bedside commode. The LPN further explained that the CNA would assist the resident in the bathroom by placing the commode next to the toilet in the resident's bathroom. The LPN stated that the commode was not to be placed over the toilet in the bathroom because the resident's roommate (Resident #82) had a CDI. On 12/18/18 at 12:55 PM, the surveyor interviewed the Administrator, Director of Nursing (DON), and the Infection Prevention (IP) Nurse in the presence of the survey team. The IP stated that the facility used standards consistent with current Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC) guidelines when creating the facility's Infection Control Program. The IP stated that when a resident had a CDI, the resident would be placed on contact isolation precautions and required the use of PPE which meant the staff had to apply a gown, gloves, and mask prior to entering the resident's room. The IP further stated that staff were required to apply the PPE only when rendering direct care to the resident. The IP further stated that when a resident with a CDI was cohorted with another resident who did not have a CDI, the non-affected resident would be required to use the bedside commode. The IP stated that the bedside commode was not to be placed over the toilet and should be placed separately in the resident's bathroom to prevent the spread of infection. On 12/18/18 at 01:08 PM, the DON stated that a history of antibiotic usage or current usage of an antibiotic would make a resident more susceptible to acquiring CDI. The DON confirmed that since Resident #76 was on an antibiotic for a UTI, he/she would be at a higher risk for developing a CDI. The DON acknowledged that the Resident #76 was sharing a room/bathroom with a resident with an active CDI. On 12/20/18 at 12:28 PM, the Administrator and DON were unable to provide documented evidence that Resident #82 and #76 were reviewed for appropriateness of cohorting while sharing a bathroom, prior to surveyor inquiry. A review of the facility's Infection Control Policy revised on 06/01/18 reflected that standard and transmission-based precautions were to be followed to prevent the spread of infection. The Infection Control Policy further reflected, d. When and how isolation should be used for a resident; including but not limited to; c. selection of room (private/semi-private/cohorted on a case-by-case basis as appropriate and available-facility to identify risk factors that could lead to the likelihood of transmission. According to the APIC Implementation Guide, Guide to Preventing [MEDICAL CONDITION] Infections dated 2013, page 86 includes, When considering potential roommates, select someone who is not taking antibiotics and is not compromised to the point of being susceptible to infections in general . Alternatives include cohorting residents with CDI in the same room; assigning the CDI resident with a roommate that does not use the bathroom; assigning the CDI resident in a room closest to the bathroom; and having the non-CDI roommate use a bedside commode. If the CDI resident must use a bedside commode, line the commode with a plastic bag and absorbent material to reduce healthcare worker exposure to fecal matter. NJAC 8:39-19.4(a)

Based on observation, interview and record review, it was determined that the facility failed to ensure a vitamin was administered under the tongue in accordance with manufacturer instructions and accurate pharmacy procedures. This deficient practice was identified for 1 of 9 resident ' s observed during the medication pass observation (Resident #14), and was evidenced by the following: On 9/25/17 at 9:26 a.m. during the medication pass observation, the surveyor observed Resident #14 sitting in a wheelchair in his/her room. At that time, the Licensed Practical Nurse (LPN) prepared a vitamin B-12 tablet at the medication cart to administer to Resident #14. A review of the September 2017 electronic Medication Administration Record [REDACTED]. The order specified to administer 1000 micrograms (mcg) of the Vitamin B-12 tablet sublingually one time a day for supplementation. The vitamin was plotted to be administered at 9:00 a.m. daily. As the LPN was preparing the resident ' s Vitamin B-12 tablet, she popped out a single 1000 mcg tablet into a medicine cup from the medication bingo card. A sticker on the Vitamin B-12 bingo card specified instructions to not chew or swallow whole. At 9:31 a.m., the surveyor observed the LPN identify Resident #14, and she provided a medicine cup to the resident which had the Vitamin B-12 tablet in it. The LPN did not provide instruction to the resident as to how to take the Vitamin B-12 tablet. At that time, the surveyor observed Resident #14 take the single Vitamin B-12 tablet out of the medicine cup, put it in his/her mouth and swallowed the vitamin whole with four ounces of a liquid. The LPN then confirmed the resident swallowed the medication whole at the completion of the administration observation. At 9:33 a.m., the LPN returned to the medication cart, and signed for the administration of the vitamin B-12 tablet in accordance with physician orders. On the same day 9/25/17 at 10:00 a.m., the surveyor interviewed the LPN who administered the Vitamin B-12 tablet to the resident. The LPN acknowledged that Resident #14 swallowed all the medications whole, including the vitamin. At that time, the surveyor and LPN reviewed the physician order [REDACTED]. In addition, the surveyor and LPN reviewed the medication bingo card which specified to not swallow whole. The LPN acknowledged she did not instruct the resident to leave the tablet under the tongue in accordance with manufacturer specifications, she could not speak to why she did not follow the pharmacy cautionary. On 9/25/17 at 12:00 p.m., the surveyor reviewed the medical record for Resident #14 which indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the manufacturer specfications for Vitamin B-12 sublingual tablet, Place under tongue and let melt all the way. Do not chew, suck or swallow tablet. On 9/25/17 at 12:25 p.m., the surveyor interviewed the Director of Nursing (DON) who acknowledged that the Vitamin B-12 tablet should have been dissolved under the tongue and not swallowed whole in accordance with the manufacturer specifications. A review of the facility's undated Administration of Medications policy included to explain medication procedure to resident and bring medication to the bedside; read label three times before administering medication. NJAC 8:39-29.1 (e)

Based on observation, interview, and record review, it was determined that the facility failed to accurately monitor the amount of nutritional formula administered to Resident #4 over 24 hours, as prescribed by the physician. This deficient practice was identified for 1 of 2 residents reviewed for the care of tube-fed (TF) residents, and was evidenced by the following: During the initial tour on 8/28/16 at approximately 10 a.m., the surveyor observed Resident #4 to be thin in appearance, and lying in bed. The unit nurse told the surveyor that the resident had been recently admitted from the hospital, and received all nourishment through a gastrostomy tube (GT). The surveyor observed an open-bag system labeled as set up on 8/26/16, containing [MEDICATION NAME] 1.2 calorie (cal)formula, and the pump was running at 60ml per hour. The digital display indicated that 1955 ml had been administered at this time. At 12:20p.m., the surveyor observed the TF disconnected from Resident #4, as the resident was in the bathroom. The digital display indicated that 2062 ml had been administered. At 1p.m., the surveyor again observed the TF being administered to Resident #4. On 8/29/16 at 12:50 p.m., the surveyor observed Resident #4 in bed with a [MEDICATION NAME] 1.2 cal (calorie) feeding infusing at 60ml/hr. The open-bag system was labeled as hung on 8/28 at 2:35 p.m., and the amount infused at this time read 3436 ml. The surveyor reviewed the medical record on 8/29/16. A Physician order [REDACTED]. According to the PO, Resident #4 should receive 1440ml of nutritional formula in 24 hours. Review of the August Medication Administration Record [REDACTED]. Review of a Dietary Alert Sheet dated 8/28/16 indicated that the current formula of [MEDICATION NAME] 1.2 cal was not meeting nutritional needs, and a recommendation was made to change the formula to the higher caloric [MEDICATION NAME] 1.5 cal. The resident's only weight since recent admission was 131lbs. During an interview on 8/29/16 at 1:40 p.m., the Registered Nurse (RN) verified that there was no system in place to account for the amount of formula administered to Resident #4 in 24 hours. The RN further stated we're going to get a new system in place. During an interview on 8/31/16 at approximately 10:40 a.m., the Assistant Director of Nursing (ADON) stated that open-bag feeding administration sets should be changed every day. NJAC 8:39-27.1(a)

Based on observation, interview and review of the medical record, it was determined the facility failed to provide adequate supervision to prevent falls; failed to have a system in place for monitoring resident activities when leaving the unit; and failed to complete a thorough and accurate investigation of a fall incident for 1 of 9 residents, Resident #14, who fell and sustained a fractured wrist. This deficient practice was evidenced by the following: Resident #14 was admitted to the facility in January, 2012 with [DIAGNOSES REDACTED]. During the tour of the facility on 11/26/13 at 10:50 a.m., the Registered Nurse (RN) told the surveyor that Resident #14 fell in the bathroom and fractured his/her wrist. The RN stated that the resident used a splint on her arm. On 12/2/13 at 9:15 a.m., the surveyor observed the resident at breakfast seated at the table in a wheelchair (w/c) with a pad alarm on the seat. The resident wore a sling on his/her left arm. The surveyor asked the resident what happened to his/her left arm. The resident stated s/he recently fell on the floor in the bathroom. Resident #14 stated s/he was on the floor for 3 hours before someone found him/her. The resident told the surveyor s/he did not ring the call bell after s/he fell because s/he knew the aide had gone home. The resident also stated, in response to the surveyor's question, that s/he had falls prior to this fall. Resident #14 stated s/he fell out of bed and in the bathroom but couldn't remember the details. The surveyor asked the resident if s/he was currently able to walk. The resident replied that s/he walked in the past but was no longer able to walk. The surveyor reviewed the resident's medical record on 12/2/13. The IDC team assessed the resident's risk for falls using the Morse Fall Scale (MFS). The MFS described the fall risk scores as follows: Low Risk equaled a score of 0-24; Moderate Risk was 25-44; and High Risk was 45 and greater. On 9/20/13 the RN assessed the resident's risk for falls using the MFS. The resident scored 85, at high risk for falling. The Interdisciplinary (IDC) team assessed the resident utilizing the quarterly Minimum Data Set, an assessment tool. The IDC team documented that the resident scored a 10 on the Brief Interview for Mental Status (BIMS) examination, which indicated that the resident had moderate cognitive impairment. The IDC team further documented in the MDS that the resident did not walk, needed extensive assistance with moving about on and off the unit, needed extensive assistance with transferring from surface to surface, and extensive assistance with hygiene and bathing. The surveyor interviewed the Director of Physical Therapy (DPT) on 12/3/13 at 11:20 a.m. The DPT stated that the resident declined in the ability to ambulate over time and became wheelchair bound. The DPT also stated that the resident fatigued easily when self-propelling the wheelchair and needed assistance in getting from place to place on the unit. The DPT stated that the resident was discharged from occupational therapy on 3/23/13 and from physical therapy on 4/8/13. At this time the resident needed moderate assistance from 2 people and could stand for only 30 seconds due to fatigue and severe retropulsion (falling backward). The resident did not walk. The DPT did not recommend a Restorative Nursing Program that included ambulation because of the high risk of the resident falling backward while walking. The surveyor reviewed the Nurse's Notes and copies of the corresponding Incident Report/Fall Investigations copied by facility staff and given to the surveyor on 12/2/13 for incidents of falls as follows: 1. On 3/8/13 the nurse documented in the Nurse's Notes that the resident was observed sitting on the floor by the bed with the bed alarm sounding. The resident told the nurse s/he tried to turn off the lamp. The facility's nursing staff documented statements in the corresponding Incident Report/Fall Investigation that the fall occurred on 3/8/13 at 10:45 p.m. The RN concluded that a new intervention to prevent the resident from falling out of bed in a similar circumstance would be to make sure all lights are off when the resident was in bed and place a mat on the floor for safety. 2. At 11p.m. on 10/11/13 the nurse documented in the Nurse's Notes that the Certified Nursing Assistant (CNA) helped the resident to the bathroom and instructed the resident to pull the call button when done as the resident verbalized s/he needed more time. The RN documented that s/he was called to assess the resident in the bathroom after the resident fell . The RN observed the resident sitting on the floor between the wheelchair and toilet. The resident told the RN s/he tried to transfer to the wheelchair but missed it. The RN documented that the resident was alert and oriented with periods of confusion. The RN noted slight bruising of the left pelvic area and left knee. The RN called the physician who ordered an x-ray which was negative for fracture. The facility's nursing staff documented statements in the corresponding Incident Report/Fall Investigation that the fall occurred on 10/11/13 at 8:40 p.m. On 10/15/13 the RN noted in the Fall Investigation that the staff member was counseled on the importance of not leaving residents on the toilet unsupervised when alarms were ordered. The RN concluded that a new intervention to prevent the resident from falling in the bathroom was not to leave the resident unsupervised while in the bathroom unless the resident asked to be left alone for privacy. On 12/3/13 at 11:45 a.m., the surveyor asked the Registered Nurse Unit Manager (RNUM) if the intervention in the resident's care plan for preventing falls to "not leave the resident unsupervised while in the bathroom unless the resident asks to be alone for privacy" meant that the person who assisted the resident into the bathroom could leave the resident alone in the bathroom and go to help someone in another area of the unit. The RNUM stated that did not mean the assistant could leave the room. It meant they could afford privacy to the resident in the bathroom but needed to keep the bathroom door opened slightly, wait near the bathroom door, and listen to hear if the resident attempted to stand up without assistance. The facility nursing staff did not question the resident to determine why the resident did not put the call bell on as requested by the CNA or why the resident attempted to transfer back to the wheelchair unassisted, information that would be used to provide resident specific interventions for fall prevention. 3. On 11/17/13 at 7:30 p.m., the nurse documented in the Nurse's Notes that s/he was notified by the unit secretary that the resident fell in the shower/bathroom. The nurse who completed the Incident Report documented that the resident stated that s/he lost his/her balance. Resident #14 reported pain in the left wrist. The resident was sent to the hospital emergency room for x-ray. The nurse documented that the hospital confirmed the resident sustained [REDACTED]. The nurse documented that the resident returned at 1:15a.m. with a soft splint to the left hand. The facility's nursing staff documented statements in the Incident Report/Fall Investigation as follows: The fall occurred on 11/17/13 - the nursing staff did not document the time of the fall. The LPN (3-11 shift) documented in the statement that s/he and the charge nurse were notified by the unit secretary at 7:30 p.m. that the resident fell in the shower room. A CNA documented in his/her statement that s/he discovered Resident #14 in the shower room at 7:30 p.m. when entering the shower room with another resident. An RN on the 7-3 shift completed his/her statement of events on the Incident Investigation report on 11/18/13. The RN documented that s/he saw the resident with a family member before lunch on 11/17/13. The RN also documented that the resident was visited by two family members who took her to the Cafe to lunch but she did not see the resident return to the floor. On 12/4/13 at 12:20p.m., the surveyor interviewed the RN who completed the Incident Investigation report noted above on 11/18/13. The RN admitted that the resident's family members took the resident out on 11/16/13 and not on 11/17/13 as s/he indicated in the Investigation statement. The RN stated she did not remember whether it was 11/16 or 11/17 at the time s/he wrote her statement in the Incident Investigation. An LPN on the 7-3 shift completed his/her statement in the Incident Investigation form on 11/18/13 regarding the resident's fall on 11/17/13. The LPN noted that s/he last saw the resident at 1:30 p.m. The LPN answered the question in the Incident Investigation report that asked, "What time did the resident last eat and how much of the meal did they consume?" by writing, "Out to lunch with daughter downstairs." The LPN documented that s/he last saw the resident around 1 p.m. to give medications and the resident's family member was with the resident. On 12/5/13 the facility provided the surveyor with a copy of the CNA's Incident Investigation statement. In answer to the question, "What time did the resident last eat and how much did they consume?", the CNA answered, "She ate in the dining room 100%." In answer to the question, "Where did you last see the resident?", the CNA documented, "in the shower room." In answer to the question, "What time did you last see the resident?", the CNA documented, "before I left." In answer to the question, "Was the resident in the wheelchair or bed when you last saw them?", the CNA answered "She was on the toilet." In answer to the question, "What time did you last toilet your resident?", the CNA documented "Around 2 p.m." The CNA wrote a contradictory statement on the reverse side of the Incident Investigation form. The CNA documented that s/he took the Resident to the shower room to use the toilet. The CNA asked the resident to pull the string when finished, then the CNA left to care for another resident. The CNA stated she returned, took Resident #14 off the toilet and left the resident in the hallway outside the shower door. The CNA left to care for another resident and then went home. There was no evidence that the facility questioned the contradictory statements made by the CNA. The RN Unit Manager (RNUM) completed an Investigative Summary of the resident's fall and fracture and documented that Resident #14 had periods of confusion and forgetfulness. The RN also stated that Resident #14 was non-ambulatory (could not walk), and needed extensive assistance of one person for transferring and at times two assistants with the Vera Lift. The RNUM documented that the LPN on the 3-11 shift on 11/17/13 at 3:30 p.m. made rounds and saw a wheelchair and walker in the resident's room on the window side of the room. While giving 5p.m. medications the LPN asked the unit secretary and CNA if they saw the resident return to the unit. They both replied no. The CNA on the 3-11 shift also asked the RN and floor staff at 3:l5 when s/he did rounds and again at dinner time where the resident was and the RN told the CNA that Resident #14 was out with family. The RN told the UMRN that during shift change the 7-3 personnel reported that the family had the resident out to lunch and s/he was not sure if the resident had come back. The resident told the RNUM that she went to the bathroom earlier around 3 p.m. and fell on the floor, and it wasn't until 6 p.m. that someone came in. The Incident Report/Fall Investigation contained documented statements from facility nursing staff that the resident was found on the floor at 7:30 p.m. The conclusion drawn by the RNUM was that the resident was thought to be off the floor with family during the hours of 3p.m. to 7p.m. until the resident was observed on the floor in the shower room at 7 p.m. by a CNA. On 12/3/13 at 9:45a.m., the surveyor reviewed the Release of Responsibility for Leave of Absence (RRLOA) sheet in the front of the resident's medical record. The resident's family member took Resident #14 out on 11/16/17 at 3 p.m. The family did not take the resident out on 11/17/13 as indicated in the Incident Report/Fall Investigation for the fall incurred by the resident on 11/17/13. The surveyor interviewed the Unit Clerk who stated that when family members would take Resident #14 out of the building they would sign the resident out on the Leave of Absence sheet on the front of the medical record but that did not happen if the resident was taken off the floor but remained in the building. On 12/3/13 at 10:50 a.m., the surveyor observed the hall shower/bath room. The door to the room was heavy to open and opened inward from the hallway. On 12/4/13 at 9 a.m. the surveyor saw the resident eating breakfast. The surveyor asked the resident if s/he remembered the fall in the shower/bath room. The resident stated s/he did remember it. The surveyor asked the resident how s/he got into the bathroom and the resident replied, "A girl put me in there, my aid." The surveyor asked if the resident tried to get into the bathroom her/himself. The resident responded that s/he just told the nurse s/he had to go to the bathroom and the aid put her/him in the bathroom. Resident #14 stated the aid went home and s/he fell off the toilet but did not recall how it happened. S/he stated s/he didn't pull the call cord because after the fall, s/he couldn't reach it, then tried to open the bathroom door but it was too heavy. The resident told the surveyor his/her family did not visit that day. Resident #14 stated that after the fall his/her left arm hurt a little "but not too much." The surveyor interviewed the ADON and RNUM on 12/4/13 from 11:30 a.m. to 12:15 p.m. The ADON stated that the nurse on 3-11 and 7-3 may have gotten mixed up about which day the family took the resident out. Based on the sign out sheet (RRLOA), the resident went out with family on 11/16/13, the day before the fall incident and remained in the facility the entire day on 11/17/13, the day the resident fell . The ADON and RNUM also stated the family frequently took the resident out around the "campus" either for hours or most of the day and did not sign the resident out because if the resident remained on campus it was not required by the facility. They also explained that it was not required for the family to inform the facility staff the expected time the family would return the resident to the unit if the family stayed on the campus. Both the ADON and RNUM stated they did not call the family to check where the resident was on 11/17/13 and they also could not assume how the resident entered the shower/bath area that day. On 12/4/13 at 12:30 p.m. the surveyor interviewed the CNA assigned to the resident on 11/17/13. The CNA told the surveyor s/he put the resident in the hallway shower/bathroom at 2p.m. According to the CNA s/he came back to see if resident was ready to leave the bathroom but the resident wasn't. The CNA said his/her beeper went off so s/he again left Resident #14 alone in the bathroom to check on another resident. According to Resident #14' s care plan following the fall on 10/11/13, the intervention to prevent the resident from falling in the bathroom was not to leave the resident unsupervised while in the bathroom unless the resident asked to be left alone for privacy. If necessary, the CNA was to wait outside the door and listen for activity that alerted him/her to the resident's attempt to stand up from the toilet. However, the CNA did not follow the resident's care plan. The CNA stated s/he returned and took Resident #14 out of the bathroom around 2:20 p.m. but left the resident in the hallway by the bathroom. The surveyor asked why the CNA did not place the resident by the desk for safety and observation, as the resident was a high risk for falling. The CNA stated that another resident beeped and she ran to see what the other resident wanted. The CNA stated Resident #14 was still in the wheelchair in the corridor by the bathroom when she saw the resident as she came out of the other resident's room. The facility investigation given to the surveyor lacked evidence of a comprehensive investigation of the incidents that led to the resident sustaining a fall with fracture in the bathroom and not being found for several hours. Statements made by the facility nursing staff were inaccurate and inconsistent. There was no evidence that the facility attempted to clarify the inconsistent and inaccurate information and statements documented in the Incident Report/Fall Investigation. The CNA assigned to the resident did not follow the care plan intervention to remain with the resident while in the shower/bathroom. NJAC8:39-27.1(a)