Every finding on record at New Vista Nursing & Rehabilitation CTR

Based on record review, interviews, and facility policy review, the facility failed to ensure a physician-ordered laboratory test was performed and failed to ensure results were reported to the ordering physician for one (1) of one (1) resident (R)2 reviewed.Findings include:The review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/08/26 revealed the following diagnoses: syncope and collapse, unspecified dementia, unspecified mental disorder, and Parkinson's disease without dyskinesia. The Brief Interview for Mental Status (BIMS) score was 3, indicating severe cognitive impairment.A review of the Orders tab in the Electronic Medical Record (EMR) showed a physician order dated 09/02/25 by MD 1 for Recheck test for Trichomonas in November 2025.However, the Results tab in the EMR revealed no documentation that the ordered laboratory test was performed, nor were any laboratory results reported to the ordering physician During an interview on 04/09/26 at 6:04 PM, the Director of Nursing (DON) confirmed that the ordered test was not performed and no results were reported to the ordering physician. A review of the facility's policy titled Carrying Out Physician's Orders, effective date 02/04/03, revised on 01/15/26, revealed its purpose is to Ensure physician's orders are carried out accurately and consistently to maintain compliance with regulatory standards and ensure patient safety. Key points include:1. All physician orders shall be carried out by the RN/LPN on duty. 6. All admission orders shall be checked by the RN/LPN of the incoming shifts and by the respective Unit Manager.NJAC 8:39-11.2(b)

Based on interviews, record reviews, and facility policy review, the facility failed to thoroughly investigate an allegation of Staff to Resident Abuse and did not follow its policy titled Reporting & Investigation Policy, which states that all staff must receive periodic refresher training on the recognition of abuse and neglect. This deficient practice was identified for 1 out of 10 residents (Resident R#3) reviewed for abuse allegations, as evidenced by the following: Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/26 revealed that R3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia (without behavioral disturbance), psychotic disturbance, mood disturbance, anxiety, and Psychotic disorder with delusions due to a known physiological condition. R3 had a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment.Review of the facility's investigation of the alleged abuse incident revealed the following: Review of the Facility Reporting Incident Data and Analysis Yield (FRIDAY) dated 02/29/26 (sic) and signed by the former Director of Nursing (FDON) revealed that Certified Nursing Aide (CNA) 6 was suspected of abusing R3.The investigation revealed: On 10/02/25, a [AGE] year-old cognitively impaired resident was observed with a new left periorbital injury and stated she was hit by an aide. No staff witnessed the incident, and multiple staff reported no injury earlier that morning. The involved CNA denied abuse and was suspended pending investigation. Due to lack of evidence, witnesses, and the resident's severe cognitive impairment, the allegation was unsubstantiated. Required notifications were completed, and the resident continues to be monitored.The report failed to reveal if other residents or the CNA were interviewed about the incident. The last abuse training was completed on 6/26/25, and no refresher training was offered to staff. Law enforcement was not called, and R3 was not sent to the hospital for evaluation.Review of progress notes dated 10/02/2025 located on the Progress Notes tab of the Electronic Medical Record (EMR) revealed the following: On 10/01/2025: Resident was noted by social worker to have bruising on the left upper eyelid. Resident denied pain or visual changes. Full body assessment completed with no additional injuries noted. Resident was calm and resting in bed. Vital signs were stable. Physician notified; X-ray of left orbital area ordered. Family notified. X-ray completed; results pending.Follow-up note dated 10/03/2025 located on the Progress Notes tab of the EMR: Resident observed with bluish discoloration to the left periorbital area. Resident continued to deny pain, blurred vision, or headache. X-ray results negative for fracture or contusion. Resident monitored with no adverse findings. Resident noted to have declining mobility and coordination, requiring assistance with transfers. Resident was combative during morning care.R3 was care planned for combativeness and physical and verbal aggression toward staff. The MD ordered an X-ray, but R3 was not sent to the hospital for evaluation.During an interview on 04/09/26 at 1:27 PM, attending physician (MD) 1 stated that standard protocol typically warrants hospital transfer and possible CT imaging for such a peri-orbital injury. Nursing homes may attempt in-house monitoring with neuro checks; however, there are circumstances where hospital evaluation is required. MD1 stated they were not the one who handled the matter but would have sent R3 to the ER for evaluation and a possible CT scan due to the injury being in the head area. MD1 stated an X-ray may not have picked up a deeper injury.During an interview with the DON on 04/09/26 at 6:04 PM, they confirmed that an X-ray was ordered for R3, but R3 was not sent to the ER, and law enforcement was not called.Review of the facility policy titled Reporting & Investigation Policy updated 03/2025 revealed the following: The purpose is to ensure that all alleged violations of resident rights, abuse, neglect, mistreatment, or other adverse incidents (reportable events) are promptly reported, thoroughly investigated, documented, and corrected in accordance with state and federal law . and All staff receive training upon hire and periodic refresher training on: recognition of abuse/neglect, resident rights, facility reporting requirements, how to complete incident reports, how to protect residents during investigation. The facility maintains records of training dates, attendees, and curriculum. NJAC 8:39-27.1(a)(b)

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness and, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following:On 7/16/25 at 10:02 AM, in the presence of the Food Services Director (FSD), the surveyor observed the following:1. In the food preparation area, the surveyor observed red colored, sticky debris on the tubing of the juice dispenser and observed a spillage of clear liquid below the juice dispenser legging. 2. On oven number 1, the surveyor observed 5 of 12 oven knobs soiled with a white colored substance and 1 of 2 oven handles soiled with a white substance. On oven number 2, the surveyor also observed 7 of 11 oven knobs soiled with a thick brown colored substance.3. In the walk in freezer, the surveyor observed approximately 3 inches thick of ice build up on the brown box underneath the condenser unit and approximately 3 inches of ice build up on the floor next to the brown box, which was also located underneath the condenser unit.4. In the dry storage room, the surveyor observed two dry food storage containers containing rice and flour, both of the lids were opened to the air. The FSD stated that the containers lids should have been closed. On a shelf in the dry storage room, the surveyor observed a thermometer which read 78 degrees Fahrenheit (F) and the FSD stated that the dry storage room is always warm, and that she was aware that the temperature should be between 50 and 70 degrees F. 5. In the dry storage room, on a shelf with cans which were in rotation for use, the surveyor observed a number 10 sized can of sliced carrots with 4 separate 1 inch sized dents on the body of the can and 1 number 10 sized can of marinara with a 4 inch dent on the body of the can.A review of the policy titled Perishable Foods, dated 1/1/2027, revealed that all foods should be securely covered, dated and labeled. A review of the policy titled Dented Can, dated 1/1/2027, revealed that all dented cans should be placed on a designated shelf marked Dented Cans.A review of the policy titled CCS Food Storage Criteria, undated, which revealed hat dry food storage temperatures meet FDA or state standards (usually a maximum of 50 degrees F to 70 degrees F.)On 7/21/25 at 2:14 PM, the surveyor discussed the above concerns with the Administrator, Director of Nursing (DON) and Assistant DON.NJAC 8:39-17.2(g)

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure a.) removal of a discontinued antianxiety controlled drug (Clonazepam 0.5 milligrams half-tablet) from [DATE] until surveyor inquiry causing a medication error and accurate documentation on the declining inventory log for 1 of 6 medication carts inspected, b.) accurate documentation for the administration and removal of an antianxiety controlled drug (Alprazolam) for 1 of 6 medication carts inspected and c.) accurate documentation of medication administration and timely receipt of a medication (Lactulose [a medication that assists removal of ammonia from the body]) to prevent borrowing from another resident's supply for 1 of 5 residents observed during the medication administration. The evidence was as follows:1.) On [DATE] at 11:23 AM, the surveyor conducted a medication cart inspection for the active controlled drugs, in the presence of the Registered Nurse (RN #1) on the 4 [NAME] unit. At that time, the surveyor observed Resident #168's bingo card (a multidose card containing individually packaged medications) for Clonazepam 0.5 milligram (mg), half-tablet = 0.25 mg which had a remaining balance of 14 half-tablets. The surveyor then reviewed the matching Individual Patient Controlled Substance Administration Record (a declining inventory log) for Resident #168's Clonazepam 0.5 mg tablet half-tablet = 0.25 mg which reflected a remaining balance of 15 half-tablets. The declining inventory log had not corresponded with the remaining number of Clonazepam 0.5 mg half-tablets for Resident #168. On [DATE] at 11:36 AM, the surveyor continued the medication cart inspection, in the presence of the RN #1 on the 4 [NAME] unit. The surveyor observed Resident #173's bingo card of Clonazepam 1 mg tablets that had a remaining balance of 52 tablets. The surveyor then reviewed the declining inventory log for Resident #173's Clonazepam 1 mg tablets which reflected a remaining balance of 51 tablets. The declining inventory log was last signed by the administering nurse (RN #1) on [DATE] at 9:00 AM. The declining inventory log had not corresponded with the remaining number of Clonazepam 1 mg tablets for Resident #173. On [DATE] at 11:44 AM, the surveyor reviewed the facility's Record of Narcotic Use Drug Count and Syringe Count (a shift-to-shift count/sign in sheet, used to account for the controlled drugs and syringes within the medication cart) for [DATE], reflected that the inventory counts were performed on three shifts (7:00 AM, 3:00 PM and 11:00 PM), daily from [DATE] at 7:00 AM to [DATE] at 7:00 AM by two nurses, the outgoing shift and the incoming shift. RN #1 confirmed that the shift-to-shift count was conducted that morning her and another nurse and there were no discrepancies reported. RN #1 was unable to speak to the declining inventory log discrepancies for Resident's #168 and #173. A review of the Medication Review Report (MRR) for Resident #168 reflected a discontinued physician's order (PO) dated [DATE], for Clonazepam tablet 0.5mg, give 0.5 tablet by mouth two times a day related to anxiety disorder, give 0.5-tab total of 0.25 mg. A review of the [DATE], electronic medication administration record (eMAR) for Resident #168 reflected there was no active PO for Clonazepam. A review of the MRR for Resident #173 reflected an active PO dated [DATE], for Clonazepam tablet 1 mg, give 1 mg by mouth every 12 hours for anxiety. A review of the [DATE], eMAR for Resident #173 reflected the last administration of the Clonazepam 1mg was on [DATE] at 9:00 AM given by RN #1. On [DATE] at 1:43 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), and the Director of Nursing (DON), the surveyor discussed the concern regarding the declining inventory log discrepancies for Resident's #168 and #173. On [DATE] at 10:51 AM, the survey team met with the LNHA, the DON, and the Assistant Director of Nursing (ADON). The ADON stated she had performed an investigation regarding the discrepancies and identified that there was a medication error. The ADON explained the discontinued Clonazepam 0.5 MG half-tablet labelled for Resident #168 was administered to Resident #173 and that RN #1 had signed the inventory control log for Clonazepam 1 mg tablets. The DON stated the primary physician was notified of the error. The ADON further stated that a medication incident report form was filed, and education was provided to RN #1 who committed the error. The DON stated that Resident #168's Clonazepam which was discontinued on [DATE] should have been removed from the active inventory to avoid a medication administration error. 2. On [DATE] at 11:44 AM, the surveyor conducted a medication cart inspection for the active controlled drugs, in the presence of the Licensed Practical Nurse (LPN #1) on the 4 East unit. On [DATE] at 11:59 AM, the surveyor observed Resident #152's bingo card for Alprazolam 0.25 mg which had a remaining balance of seven (7) tablets. The surveyor then compared the bingo card against the declining inventory log for Resident #152's Alprazolam 0.25 mg tablets which reflected a remaining balance of six (6) tablets. The declining inventory log was last signed by the administering nurse on [DATE] at 9:00 AM. The declining inventory log had not correlated with the remaining number of tablets for Alprazolam. On [DATE] at 12:14 PM, the surveyor interviewed LPN #1, who stated that the shift-to-shift count was conducted that morning without discrepancies. At that time, LPN #1 could not speak to the discrepancy for Resident #152's Alprazolam and was unable to speak to whether she had administered the 9 AM dose. LPN #1 added that she would let the DON know of the concern. A review of the [DATE] eMAR for Resident #152 reflected daily administration of the 9 AM Alprazolam 0.25mg from [DATE] to [DATE]. Further review of the declining inventory log had not reflected the removal of Alprazolam 0.25 mg on [DATE]. On [DATE] at 1:43 PM, the survey team met with the LNHA, and the DON. The surveyor discussed the discrepancy regarding Resident #152's Alprazolam inventory and eMAR documentation. On [DATE] at 10:51 AM, the survey team met with the LNHA, DON and ADON. The ADON stated that she had investigated the discrepancy for Alprazolam for Resident #152 and LPN #1 had pre-signed the declining inventory log without administering the medication to Resident #152 on [DATE]. In addition, the ADON explained that the nurse who signed the eMAR on [DATE] had not administered the Alprazolam. A review of the facility provided policy for Medication Storage updated on [DATE], reflected under purpose was to ensure all medications were stored safely, securely. and to maintain resident safety and medication safety. Controlled Substances discrepancies must be reported and investigated immediately. Disposal of Medications (expired or discontinued) must be disposed of according to federal and state regulations. A review of the Narcotic Control Management Policy, updated on [DATE], indicated that each dose must be documented on the Medication Administration Record and Controlled substance Log immediately after administration. A narcotic count be performed before and after each administration. REFER to F759 Example #2 3. On [DATE] at 9:07 AM, the surveyor observed LPN #2 preparing to administer nine (9) medications to Resident #212 which included Lactulose. LPN #2 stated that according to the eMAR, the resident had a PO for Lactulose 20 grams (GM) per 30 milliliters (ML) but was only able to pour 15 ML because that was left in the bottle. LPN #2 added that he had reordered the Lactulose solution for Resident #212 from the provider pharmacy and would have to check later with the Staffing Coordinator (SC) to see if the medication had been delivered to get more. LPN #2 explained that the SC was responsible for checking with the nurses to make sure medications were being reordered from the provider pharmacy. LPN #2 added that he would have to call the physician and let them know he gave 15 ML. The surveyor reviewed the electronic medical record for Resident #212. A review of the resident's admission Record reflected that the resident had diagnoses, which included but not limited to, Type 2 Diabetes Mellitus (DM) (a diminished response to insulin causing inadequate control of glucose blood levels), schizophrenia, convulsions and neurosyphilis (a form of syphilis, a bacterial infection, that has spread to the central nervous system). A review of the most recent comprehensive quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated [DATE], reflected the resident had a brief interview for mental status (BIMS) score of 13 out of 15, indicating that the resident had an intact cognition. A review of the resident's MRR reflected a PO with a start date of [DATE] for Lactulose Oral Solution 20 GM/30 ML Give 30 ML by mouth three times a day for ammonia level Give 30 ML = 20 GM. A review of the electronic progress notes (EPN) for Resident #212 revealed a medication administration note on [DATE] at 20:50 (9:50 PM) by LPN #2 which indicated awaiting supply for Lactulose solution. There were no notes on [DATE] regarding the physician being called for the administration of a 15 ML dose of Lactulose solution at the administration time of 9 AM. On [DATE] at 9:21 AM, the surveyor interviewed the DON who stated when a medication was not available then the nurses were to call the provider pharmacy to find out when the medication would be delivered and if necessary, there was another emergency pharmacy that they could call. The DON also stated that she had started as the DON approximately three months ago and had instituted a daily auto refill procedure that the SC oversaw to check with each unit to make sure refills were ordered. The DON explained that the nurses could reorder medication electronically but were required follow-up. The DON added that an in-service regarding the process was done in [DATE]. The DON also explained that the physician would need to be called and made aware if a medication was unable to be administered as ordered and there should be documentation. The DON then stated that she would have to check what had happened with the Lactulose solution for Resident #212. The DON also added that Lactulose solution was not a medication that was listed in the facility back up supply. On [DATE] at 10:52 AM, the surveyor interviewed RN #2, who stated that she was the medication nurse that day for Resident #212. RN #2, in the presence of the surveyor, reviewed the medication cart and was unable to locate Lactulose solution for Resident #212. RN #2 then checked the computer and stated that the Lactulose had been delivered but could not find it and would have to check. RN #2 acknowledged that she had signed for the 9 AM administration of Lactulose solution. RN #2 reviewed the medication cart again and removed a bottle labeled for an unsampled resident #1 for Lactulose 10 GM/15 ML. RN #2 stated that she had used that Lactulose solution to administer the dose to Resident #212. RN #2 added that she didn't have Resident #212's bottle of Lactulose and had to give the medication. On [DATE] at 12:59 PM, the surveyor interviewed the DON who stated that the nurses were not to use another resident's medication. A review of the unsampled resident's MRR revealed a PO dated [DATE] for Lactulose Oral Solution 10 GM/ML (Lactulose) Give 15 ML by mouth one time a day every other day for elevated ammonia levels. On [DATE] at 12:32 PM, the surveyor interviewed the Consultant Pharmacist (CP #1) via telephone who stated that she was not the specific CP #2 for the facility but could speak to any questions. CP #1 stated as per the facility contract, they do not perform medication administration observations for the facility and the nursing administrative staff was responsible for that. CP #1 stated that if a medication was not available, the nurses should check the back up supply first, then call the physician if they cannot administer the medication as ordered to make them aware and get follow up instructions. On [DATE] at 10:50 AM, the survey team met with the LNHA, DON and ADON. The DON stated that she was contacting RN #2 to inform her that the nurses were not to borrow medications from another resident. A review of the facility policy dated as reviewed [DATE] for Administering Medications provided by the DON reflected The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. In addition, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. NJAC 8:39-11.2(b), 29.2 (a)(d), 29.4(g)

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 3 (three) of the 7 residents (Residents #24, #88, and #140) reviewed for reasonable accommodations of needs/preferences.This deficient practice was evidenced by the following: 1. On 7/16/2025 at 10:50 AM, the surveyor observed Resident #24 in bed, awake. The surveyor observed that there was no available call light near the resident's bedside. The surveyor observed a call bell unit on the wall that had two outlets, one for each resident. The outlet on the side of Resident #24, did not have a call light cord connected to it. The surveyor asked the resident about the location of the call light and they stated that they were unsure of its location. On 7/17/2025 at 9:50 AM, the surveyor observed the resident inside the room; there was no physical call light available near the resident. When the surveyor interviewed the resident, the resident stated they did not know. On 7/17/2025 at 10:02 AM, the surveyor interviewed the Certified Nurse Assistant (CNA#1), who stated that the resident should have an available call light and was unaware that the resident did not have one. CNA#1 added that she would log in the maintenance book of the missing call light. On 7/21/25 at 12:13 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #24, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #24 was admitted with diagnoses that included but were not limited to unspecified dementia (loss of memory), other diseases classified elsewhere, and major depressive (feelings of sadness) disorder. A review of the recent quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care), which was dated 5/17/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that the resident had severe impairment of cognition. Further review of the Q/MDS, as reflected in section GG, revealed that the resident required supervision for daily living activities. A review of the individual comprehensive care plan (ICCP) report initiated on 4/27/22 focused on the resident's risk of falls related to psychoactive drug use. Interventions included, but were not limited to, ensuring the call light was within the resident's reach and encouraging the resident to use the bell to call for assistance. 2. On 7/16/2025 at 11:04 AM, the surveyor observed Resident #88 asleep in bed. The resident's call light was observed wrapped around the resident's side rails. The call light was not connected to the outlet and was lying on the floor. On 7/17/2025 at 9:37 AM, the surveyor observed that the resident was awake and able to answer the surveyor's inquiries. The surveyor observed that Resident #88's call light was attached to the siderails but not connected to the outlet. The resident stated that they were unaware that the call bell was not connected to the outlet. The resident added they tried not to scream for help, but it takes 10-15 minutes for the staff to respond to their call. On 7/17/2025 at 10:00 AM, the surveyor interviewed CNA#2, who stated that the call light must be pulled out from the outlet but could not explain what had happened. She added that the call bell should be within the resident's reach and functioning correctly. The CNA#2 connected the call light to the outlet and noted that it was not functional. She stated she would tell the maintenance about it. On 7/21/25 at 9:54 AM, the surveyor reviewed the hybrid medical record of Resident #88, which revealed the following:A review of the AR reflected that Resident #88 was admitted with diagnoses that included, but were not limited to, hypertensive heart disease without heart failure, and major depressive disorder. A review of the most Q/MDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 9 out of 15, indicating moderate cognitive impairment. Further review of Q/MDS, reflected in section GG, revealed that the resident depends on staff assistance for daily living activities. A review of the ICCP report initiated on 9/21/23 focused on the resident's risk for falls related to gait/balance problems and psychoactive drug use. Interventions included, but were not limited to, placing the call light within reach and encouraging the resident to use it. 3. On 7/16/2025 at 10:49 AM and on 7/17/25 at 9:40 AM, the surveyor observed Resident #140 in bed, awake, unable to answer the surveyor's inquiries. The surveyor observed the call light was located behind the cabinet which was located at least 3-4 feet away from the resident. On 7/17/2025 at 10:05 AM, the surveyor interviewed CNA#2, who stated that all residents should have a call light and that it should be within easy reach in case the resident needs assistance. CNA#2 took the call light from behind the cabinet and placed it on top of the resident's right hand. A review of the AR reflected that Resident #140 was admitted with diagnoses that included, but were not limited to, vascular dementia (loss of memory caused by brain damage). A review of the recent Q/MDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 0 (zero) out of 15, indicating severe cognitive impairment. Further review of Q/MDS, reflected in section GG, revealed that the resident depends on staff assistance for daily living activities. A review of the ICCP report initiated on 9/21/23 focused on the resident's risk for falls related to blindness, gait/balance problems, psychoactive drug use, and seizure (abnormal activity in the brain) disorder. Interventions included, but were not limited to, placing the call light within the resident's reach. On 7/17/2025 at 10:05 AM, the surveyor interviewed CNA#2, who stated that all residents should have a call light and that it should be within easy reach in case the resident needs assistance. On 7/17/2025 at 10:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the call light should be placed within the resident's reach. On 7/17/2025 at 10:20 AM, the surveyor interviewed the maintenance staff, who stated that they usually conduct rounds in the morning from the 3rd to the 5th floor. The maintenance staff stated if the staff did not report it to the maintenance log book, they could not tell which room needed to be fixed. He added that he does not have time to check each room; instead, he relied on the information in the log book. On 7/22/2025 at 11:21 AM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant DON (ADON). The DON stated that the staff should ensure the call light was within the resident's reach, functioning correctly, and properly connected to the outlet. A review of the facility policy titled Call Light Answering, updated in March 2018, revealed under Procedure: 8. When providing care to residents, be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light. 10. Notify the maintenance department and enter defective call light location(s) in the maintenance log, if the facility has such a log. 11. Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. NJAC 8:39-31.8(c)9

Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician a.) signed and dated monthly physician orders and b.) wrote physician progress notes each month. The deficient practice was observed for 2 of 35 residents (Resident #53, #248) reviewed and occurred over a 3 month period. The evidence is as follows: 1.The surveyor reviewed the hybrid (electronic and paper) medical record for Resident #53 on 7/21/25, which revealed the primary medical doctor (PMD) had not signed monthly Medication Review Reports (MRR) for the prior 3 months. Additionally, the PMD had not documented monthly Physician Monthly Follow-Up Notes (PMFN) for the prior 3 months.The surveyor interviewed the Nurse Unit Manager (NUM) on 7/21/25 at 11:00 am. The NUM confirmed the medical record did not contain April, May, or June 2025 MRRs or PMFNs. She stated there was a stack of printed MRRs in the nursing office to be signed by the PMD. She stated the PMD would be in later that day to sign them.On 7/21/25 at 11:00 am the NUM provided the surveyor with MRRs for April, May, and June 2025 which had been signed by the PMD, but not dated. 2.The surveyor reviewed the hybrid medical record for Resident #248 on 7/21/25 at 11:30 am which revealed the PMD had not signed monthly MRRs for the prior 3 months. Additionally, the PMD had documented not documented monthly PMFN for the prior 3 months.The surveyor interviewed the Nurse Unit Manager (NUM) on 7/21/25 at 11:38 am. The NUM confirmed the medical record did not contain April, May, or June 2025 MRRs or PMFNs.The survey team interviewed the PMD on 7/21/2025 at 10:35 AM He stated he thought physician visits should be documented every 90 days. He stated he was catching up with his notes.The surveyor discussed the concerns with the Administrator and the Director of Nursing (DON) on 7/21/25 at 1:30 pm.The DON told the survey team on 7/22/25 that the PMD was educated on the facility policy and the regulation for documentation of monthly notes and signing of monthly physician orders. The surveyor reviewed the facility Physician Orders Policy, updated 5/2025. The policy indicated all care and treatment provided to residents will be based on timely physician orders which are clear, complete, dated, and signed according to regulatory timeframes.NJAC 8:39-11.2; 23.2

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation performed on 7/17/25, the surveyors observed four (4) nurses administer medications to five (5) residents. There were 32 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 6.25 %. This deficient practice was identified for one (1) of five (5) residents, (Resident #212), that were administered medications by one (1) of four (4) nurses. The deficient practices were evidenced as follows: 1.On 7/17/25 at 9:07 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) preparing to administer nine (9) medications to Resident #212 which included Humalog (Insulin Lispro) (a fast-acting insulin-a medication used to lower blood sugar). LPN #1 reviewed a paper that he had recorded Resident #212's blood sugar (BS) result of 156. He stated he had obtained the BS from the resident before they had eaten breakfast and according to the electronic medication administration record (EMAR) the resident had a physician's order (PO) for insulin coverage which indicated to administer two (2) units (U) based on the BS result of 156.On 7/17/25 at 9:22 AM, the surveyor observed LPN #1 administer subcutaneously (under the skin) two (2) U of Insulin Lispro to Resident #212. The surveyor observed that there were no meal trays on the unit. On 7/17/25 at 9:23 AM, the surveyor interviewed LPN #1 who stated that breakfast that day was around 8:10 AM to 8:30 AM and had taken the BS prior to the meal tray coming to the unit and had not wanted to disturb the resident while they were eating to administer the Insulin Lispro. LPN #1 acknowledged that according to the EMAR the PO had an administration time of 7:30 AM and indicated to be administered before a meal. (ERROR #1)The surveyor reviewed the electronic medical record for Resident #212.A review of the resident's admission Record reflected that the resident had diagnoses, which included but not limited to, Type 2 Diabetes Mellitus (DM) (a diminished response to insulin causing inadequate control of glucose blood levels), schizophrenia, convulsions and neurosyphilis (a form of syphilis, a bacterial infection, that has spread to the central nervous system).A review of the most recent comprehensive quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 6/1/25, reflected the resident had a brief interview for mental status (BIMS) score of 13 out of 15, indicating that the resident had an intact cognition. A review of the resident's Medication Review Report (MRR) reflected a PO with a start date of 10/3/24 for HumaLog injection Solution 100 U/ML (milliliter) (Insulin Lispro) Inject as per sliding scale: if 0-150 = 0 U, 151-200 =2 U; 201-250 =4 U; 251-300 = 6U; 301-350 = 8 U; 351-400 =10 U, 401- 450 = 12 U Call MD (physician) if BS less than 60, greater than 450, subcutaneously before meals (AC) for DM. A review of the resident's individualized Care Plan Report had a focus area of Diabetes Mellitus with a revision date of 1/18/24 and interventions, which included but not limited to, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness and Fasting Serum Blood Sugar as ordered by doctor.On 7/18/25 at 9:21 AM, the surveyor interviewed the Director of Nursing (DON) who stated that insulins should be administered before a meal. The DON added that she would expect the nurses to take a BS, then administer the insulin before a meal according to the BS results when there was a coverage PO.On 7/21/25 at 12:32 PM, the surveyor interviewed the Consultant Pharmacist (CP #1) via telephone who stated that she was not the specific CP #2 for the facility but could speak to any questions. CP #1 stated as per the facility contract, they do not perform medication administration observations for the facility and the nursing administrative staff was responsible for that. CP #1 also stated that she would expect the time of administration of insulins to depend on the mealtime and would have a PO indicating before a meal. In addition, the CP #1added fast-acting insulins should be administered 15 minutes before eating a meal. On 7/21/25 at 12:32PM, the surveyor was provided a Med-Pass Nursing Competency form for LPN #1 by the DON, dated 10/20/24, that was completed by the Supervisor/Registered Nurse (S/RN). The form indicated a checkmark for NO for Give AC (before a meal), PC (after a meal) and time specific meds on time and a comment of redirected. The DON explained that the S/RN performed a medication pass observation with LPN #1 and the NO meant LPN #1 had not administered on time either an AC, PC (after meals) or time specific med and was redirected meaning LPN #1was educated to follow the correct administration time. The DON added that she was unaware of any other follow-up with LPN #1. The DON stated that the CP #2 was not responsible for performing medication administration observations.On 7/22/25 at 10:50 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON and Assistant Director of Nursing (ADON). The DON stated LPN #1 was educated on administering Insulin Lispro before a meal and not to wait until the resident has eaten.A review of the facility policy dated as reviewed May 2024 for Administering Medications provided by the DON reflected Medications are administered in a safe and timely manner, and as prescribed. In addition, the policy interpretation and implementation included but not limited to; 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). A review of the facility policy dated as September 2014 for Insulin Administration provided by the DON reflected for Preparation The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. In addition, the policy indicated that the onset of action (how quickly the insulin reaches the bloodstream and begins to lower blood glucose) for the rapid acting type of insulin was 10-15 minutes.The Patient Information for Humalog (insulin lispro) injection for subcutaneous use revealed Humalog is a rapid-acting insulin. Inject Humalog within 15 minutes before or right after eating a meal.The manufacturer specifications for Humalog (Insulin Lispro) revealed Humalog should be given within 15 minutes before a meal or immediately after a meal. REFER to F755 EXAMPLE #32.On 7/17/25 at 9:07 AM, the surveyor observed LPN #1 preparing to administer nine (9) medications to Resident #212 which included Lactulose (a medication used to lower ammonia levels in the blood) solution. LPN #1 stated that according to the EMAR, the resident had a PO for Lactulose 20 grams (GM) per 30 ML but was only able to pour 15 ML because that was all that was left in Resident #212's bottle. LPN #1 added that he had reordered the Lactulose solution for Resident #212 from the provider pharmacy and would have to check later with the Staffing Coordinator (SC) to see if the medication had been delivered to get more. LPN #1 explained that the SC was responsible for checking with the nurses to make sure medications were being reordered from the provider pharmacy. LPN #1 added that he would have to call the physician and let them know he gave 15 ML.On 7/17/25 at 9:20 AM, the surveyor observed LPN #1 administer 15 ML of Lactulose solution to Resident #212. Upon returning to the medication cart, the surveyor observed LPN #1 sign the EMAR for the PO Lactulose Oral Solution 20 GM/30 ML Give 30 ML by mouth three times a day for ammonia level Give 30 ML = 20 GM for the 9 AM administration time. (ERROR #2)The surveyor reviewed the electronic medical record for Resident #212.A review of the resident's admission Record reflected that the resident had diagnoses, which included but not limited to, Type 2 Diabetes Mellitus schizophrenia, convulsions and neurosyphilis.A review of the most recent comprehensive quarterly MDS dated [DATE], reflected the resident had a BIMS score of 13 out of 15, indicating that the resident had an intact cognition. A review of the resident's MRR reflected a PO with a start date of 3/30/25 for Lactulose Oral Solution 20 GM/30 ML Give 30 ML by mouth three times a day for ammonia level Give 30 ML = 20 GM.A review of the electronic progress notes (EPN) for Resident #212 revealed a medication administration note on 7/17/25 at 20:50 (9:50 PM) by LPN #2 which indicated awaiting supply for Lactulose solution. There were no notes on 7/17/25 regarding the physician being called for the administration of a 15 ML dose of Lactulose solution at the administration time of 9 AM.On 7/18/25 at 9:21 AM, the surveyor interviewed the Director of Nursing (DON) who stated when a medication was not available, the nurses were to call the provider pharmacy to find out when the medication would be delivered and if necessary, there was another emergency pharmacy that they could call. The DON also stated that she had started as the DON approximately three months ago and had instituted a daily auto refill procedure that the SC oversaw to check with each unit to make sure refills were ordered. The DON explained that the nurses could reorder medication electronically but required follow-up. The DON added that an inservice regarding the process was done in May 2025. The DON also explained that the physician would need to be called and made aware if a medication was unable to be administered as ordered. The DON then stated that she would have to check what had happened with the Lactulose solution for Resident #212.The DON also added that Lactulose solution was not a medication that was listed in the facility back up supply.On 7/18/25 at 10:52 AM, the surveyor interviewed Registered Nurse (RN #1), who stated that she was the medication nurse that day for Resident #212. RN #1, in the presence of the surveyor, reviewed the medication cart and was unable to locate Lactulose solution for Resident #212. RN #1 then checked the computer and stated that the Lactulose had been delivered but could not find it and would have to check. On 7/18/25 at 12:59 PM, the surveyor interviewed the DON who stated that she had called the provider pharmacy earlier. The DON, in the presence of the surveyor, had the SC call the provider pharmacy. The SC stated that she was told the Lactulose was out on delivery. The DON stated that the provider pharmacy usually made three deliveries a day. Then, the SC stated that she was going to check if the Lactulose had been delivered to the wrong unit.On 7/18/25 at 1:21, the SC stated that she just came from the unit and the provider pharmacy delivery person was there making a delivery. The SC stated she checked the package and Resident #212's Lactulose solution was delivered.On 7/21/25 at 12:32 PM, the surveyor interviewed the Consultant Pharmacist (CP #1) via telephone who stated that she was not the specific CP #2 for the facility but could speak to any questions. CP #1 stated as per the facility contract, they do not perform medication administration observations for the facility and the nursing administrative staff was responsible for that. CP #1 stated that if a medication was not available the nurses should check the back up supply first, then call the physician if they cannot administer the medication as ordered to make them aware and get follow up instructions.On 7/22/25 at 11:15 AM, the surveyor was provided an inservice dated 7/21/25 for LPN #1. The DON stated that liquid medications had to be reordered when medication was running low and were not included in the daily auto refill report.A review of the facility policy dated as reviewed May 2024 for Administering Medications provided by the DON reflected The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. In addition, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. NJAC 8:39-11.2(b), 29.2(a)(d)

Based on observation, interview, and policy review, the facility failed to ensure enough linen supplies were available for staff to provide resident care including towels and washcloths for resident use for two of two residents (Resident (R) 4 and R10) and to include all 262 census residents in the facility. As a result of this deficient practice the facility had the potential of not meeting basic cleanliness needs of the residents to maintain a homelike environment. Findings include: During a phone interview on 03/25/25 at 4:17 PM, Complainant (C) 4 stated, spoke to a staff member who explained there was not enough linen provided for the staff to provide the necessary care after C4 found the R4 in a soiled brief, so then R4 could not be changed. During an interview on 03/26/25 at 9:30 AM, the Director of Building Services explained linen disappeared when sent up to the floors, ended up in the garbage, hidden by staff, or staff were giving it to families. During an interview on 03/26/25 at 1:10 PM, Certified Nursing Assistant (CNA) 1 and CNA 4 verbalized there were not enough linens to provide care for all of the residents on the floor. They stated sometimes, the CNA's needed to go to another unit to get enough linen supplies or call downstairs for laundry to get more. They stated if the laundry staff answered the phone, they would request 10 towels, and the linen staff brought six. They stated many times; they did not answer the phone when calling to request more linen. During an interview on 03/25/25 at 1:25 PM, Licensed Practical Nurse (LPN) 5 verbalized hearing a lot of complaints from the CNAs that they often ran out of needed linen to provide basic resident care. During an interview on 03/27/25 at 1:50 PM, LPN5 explained there was not enough linen to meet the needs of the residents. LPN5 stated residents would request an extra towel or washcloth, and the CNA must tell them No due to the supply needed for other residents. LPN5 stated sometimes the residents took the towels off the cart to meet their needs. LPN5 stated when calls were made to laundry to request more linen, the phone was not answered so CNAs were not supported for what was needed. She stated there was never enough when the supply was one towel per resident. LPN5 stated the average census on unit 3E (East) was 46-47 residents and 90 percent (%) of the residents used briefs and towels; and washcloths were needed for each brief change. LPN5 stated brief changes were made at least twice a shift and as needed for the residents. She stated when the unit was cold, like today, the residents asked for blankets and there were not enough blankets for the residents' needs. During an interview on 03/26/25 at 5:44 PM, R10 stated that staff were short on linen and not enough gowns or towels. R10 reported the facility only gave the CNAs two towels for nine residents. R10 stated this happened on all shifts and on all days of the week. During an interview on 03/27/25 at 2:50 PM, the Staffing Office Scheduler (SCH) confirmed the average census on each nursing unit was for the third floor, E and W (West), about 46-47 residents on each side, for fourth floor, E and W, 46-48 residents on each side, and on fifth floor, E and W, 47 on one side and about 38 on the other side. During an interview on 03/27/35 at 1:34 PM, the Housekeeping Aide (HKPG) 2 working with the linen explained a large cart was filled for each nursing unit with 40 towels and 40 sheet sets for each cart. She stated a cart was sent to each unit on each shift. During an interview on 03/27/35 at 3:37 PM, the Director of Nursing (DON) stated the expectation was there was enough linen supplied to the CNA staff to provide the needed and necessary resident care. The DON confirmed the linen use was high on the day shift since the shift usually bathed some of the residents each day, there were two meals on the shift and residents wearing briefs needed changing more often on the day shift. Review of the facility policy titled, Quality of Life - Homelike Environment, revised on 05/2017, revealed The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .Clean bed and bath linens that are in good condition.

Based on interviews, record reviews, and facility policy reviews, the facility failed to report three allegations of abuse for three of six residents (Resident (R) 12, R13, and R16) reviewed for abuse allegations and one allegation of misappropriation for one of three residents (R5) reviewed for misappropriation of property to the state survey agency within two hours out of a total sample of 19 residents. This had the potential to allow continued abuse and misappropriation of property for all residents in the facility. Findings include: 1. a. Review of R12's admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility in June 2024 with diagnoses which included paranoid schizophrenia and major depressive disorder. R12 was discharged from the facility in September 2024. b. Review of R13's admission Record located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility in March 2023 with diagnoses which included legal blindness, diabetes mellitus, end stage renal disease, and dependence on renal dialysis. Review of the facility Accident and Incident Log provided by the facility did not include an incident between R12 and R13 on 06/20/24. Review of a facility document titled Investigation Report Sheet, dated 06/19/24, Registered Nurse (RN) 3 stated I was working Wednesday 06/19/24 when [R12] who don't see well and his/her roommate [R13] ask [R13] too [sic] get his/her urinal and he/she was trying to help and I intervened and [AA2] from activities saw and I was able to assist [R13] with urinal. I asked [R12] what was he/she doing, he/she said the man/woman ask for urinal to pee. Review of a facility document titled Investigation Report Sheet, dated 06/19/24 by Social Worker (SW) 3, stated The social worker was making rounds on the unit and stopped in to see residents. Both residents were fine. One resident says he/she had asked for help with urinal because he/she had to pee. Both residents are blind. Nursing staff stated that they intervened when they saw this occurring. Review of a document provided by the facility titled, Investigation Report Sheet by Activities Assistant (AA) 2, dated 06/20/24, revealed I Activities Assist [AA 2] witnessed [R12] inappropriately touching [R13] on top of his/her clothes between his/her legs. I reported it to a CNA (unknown) to witness what I was seeing. He/She was then separated from [R13] by the CNA. Happened 06/19/24. Review of an untitled document provided by the facility dated 06/20/24 by Social Worker (SW) 4 stated, Hello [SW5], I went to investigate the complaint about [R13] and [R12]. The Activities [NAME] informed that she saw [R12] touching [R13] on his/her two laps. I took [R13] to his/her room, and he/she stated that [R12] touched him/her on his/her two laps .[R13] requested that he/she or [R12] should be moved to another room as soon as possible. SW4 and SW5 no longer worked at the facility. Review of the facility document titled, Reportable Event Record/Report, dated 06/20/24 at 3:30 PM by SW5, stated that an unspecified event occurred in the residents [sic] room. A description of the event stated, CNA shared that she saw [R12] touching [R13] inappropriately. c. Review of the facility Accident and Incident Log provided by the facility included an incident between R12 and R16 on 08/02/24. Review of R16's admission Record located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility in November 2011 with diagnoses which included hemiplegia and hemiparesis following cerebral infarction and unsteadiness on feet. Review of R12's Progress Notes located in the EMR under the Progress Notes tab, dated 08/02/24 at 10:13 PM, indicated at 9:00 PM on 08/02/24, R16 was heard yelling out, assigned nurse arrived at the room noting R12 standing by the roommate and yelling. The nurse attempted to redirect the R12 became more aggressive, hostile, and using profanity. Review of the facility document titled, Reportable Event Record/Report, dated 08/02/24 at 10:00 AM [sic], stated [R12] had a psychotic episode and room mate [R16] was in the same room at the time .[R12] psychotic episode and threw objects around room causing resident to be fearful and curtain to brush against his/her shoulder .[R16] was present [sic] in the room .yelled for help due to room mates behavior as he/she was scaredhe [sic] may hurt him/her. He/She informed that he/she just wanted to get out from the room aide moved him/her out and supervisor assessed no injures [sic] and upon interview stated he/she never hit me but when he/she was throwing things around only the privacy curtain touched my shoulder. During an interview on 03/26/25 at 3:35 PM, the Director of Nurses (DON) stated that the incident between R12 and R13 was a staff-to-staff issue and not necessarily something between the residents. She stated she was not aware that the incident was alleged sexual abuse and stated that she would report the incident at that time. The DON stated she was not aware that AA2 had reported R12 had inappropriately touched R13 in the private area. The DON confirmed that any suspected abuse should be reported to the State Agency immediately/within two hours. The DON stated the previous Social Worker (SW5) was the Abuse Coordinator up until October 2024, since that time she (DON) was the Abuse Coordinator. During an interview on 03/26/25 at 4:51 PM the Quality Assurance department confirmed that the State Agency had not received any reportable incidents from the facility since 05/24/24. During an interview on 03/27/25 at 12:17 PM the Social Services Director (SSD) stated that he was not aware that he was the Abuse Coordinator and was unfamiliar with the requirements of being the Abuse Coordinator. The SSD stated this was the first time that it was his responsibility as the Abuse Coordinator role. He stated the above incidents occurred prior to this SSD's employment at the facility. The SSD began employment six weeks ago. 2. Review of R5's admission Record located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility in April 2024 with diagnoses which included quadriplegia and hypertension. Review of R5's Progress Note, dated 07/07/24 at 6:21 PM and located in the EMR under the Progress Notes tab, stated .Uncooperative with assigned CNA [Certified Nursing Assistant] accusing staff of stealing his money and not caring for him properly . During an interview on 03/27/25 at 6:30 PM, Licensed Practical Nurse (LPN) 6 stated that she did not know who the abuse coordinator was, but that any suspected abuse should be reported immediately to a supervisor. During an interview on 03/27/25 at 6:40 PM, LPN5 stated that she did not recall the abuse coordinator's name, but if she suspected abuse it should be reported to the unit manager, a nurse, Social Worker, or the Ombudsman immediately. During an interview on 03/27/25 at 6:22 PM, the DON stated that she was not aware of R5 having any money missing or accused staff of taking his/her money. When the DON was made aware of a grievance dated 07/07/24 made by R5 with concerns of staff taking his/her money, she stated that should have been documented as a behavior, and that she wasn't sure if he/she had money in the first place to be taken. Her expectation was that staff should present this information at the morning meeting. The DON felt that staff needed to have more education regarding addressing resident behaviors. Review of the facility's policy titled, Abuse Investigation and Reporting, revised 07/17, revealed All reports of resident abuse, neglect, exploitation, misappropriation of resident property, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . All alleged violations involving abuse .and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility .2. An alleged violation of abuse . or misappropriation .will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury .

Based on interviews, record reviews, and facility policy review, the facility failed to properly investigate two allegations of abuse for three out of seven residents (Resident (R) 12, R13, and R16) reviewed for abuse and one incident of misappropriation of property for one of three residents (R5) reviewed for misappropriation of property of 19 sample residents. This failure had the potential for ongoing abuse and misappropriation of property. Findings include: 1. a. Review of R12's admission Record located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility in June 2024 with diagnoses which included paranoid schizophrenia and major depressive disorder. R12 was discharged from the facility in September 2024. b. Review of R13's admission Record located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility in March 2023 with diagnoses which included legal blindness, diabetes mellitus, end stage renal disease, and dependence on renal dialysis. Review of the facility document titled, Reportable Event Record/Report, dated 06/20/24 at 3:30 PM, by Social Worker (SW) 5 revealed that an unspecified event occurred in the residents [sic] room. A description of the event revealed CNA shared that she saw R12 touching R13 inappropriately. Review of the incident packet documentation between R12 and R13 provided by the facility included witness statements by Registered Nurse (RN) 3 dated 06/19/24, SW3 dated 06/19/24, Activities Assistant (AA) 2 dated 06/20/24, SW4 dated 06/20/24, and SW5 dated 06/20/24. There were no investigation notes or investigation summary indicating that a full investigation had been completed related to suspected sexual abuse. 2. Review of R5's admission Record located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility in April 2024 with diagnoses which included quadriplegia and hypertension. Review of R5's Progress Notes located in the EMR under the Progress Notes tab indicated the resident had concerns with staff taking his money. Review of R5's documentation provided by the facility included a Grievance, dated 07/07/24, revealed that R5 accused staff of stealing his money. No further investigation was provided by the facility. 3. Review of R16's admission Record located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility in November 2011 with diagnoses which included hemiplegia and hemiparesis following cerebral infarction and unsteadiness on feet. Review of the facility document titled, Reportable Event Record/Report, dated 08/02/24 at 10:00 AM [sic], revealed [R12] had a psychotic episode and room mate [R16] was in the same room at the time .[R12] psychotic episode and threw objects around room causing resident to be fearful and curtain to brush against his/her shoulder .[R16] was present [sic] in the room .yelled for help due to room mates behavior as he/she was scared he/she [sic] may hurt him/her. He/She informed that he/she just wanted to get out from the room aide moved him/her out and supervisor assessed no injures [sic] and upon interview stated he/she never hit me but when he/she was throwing things around only the privacy curtain touched my shoulder. During an interview on 03/26/25 at 3:35 PM, the Director of Nurses (DON) confirmed that investigations were not completed by the previous Abuse Coordinator for the incidents on 06/19/24, 07/07/24, or 08/02/24 but should have been. The DON stated that the new Social Services Director (SSD) was the Abuse Coordinator and was responsible for reporting concerns to her so she could report and assist in completing investigations. Review of the facility's policy titled, Abuse Investigation and Reporting, revised 07/17, revealed All reports of resident abuse .misappropriation of resident property .shall be reported .and thoroughly investigated by facility management .The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms .interview person(s) reporting incident .any witnesses to the incident .staff members .other residents .Witness reports will be obtained in writing .5. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator .

Based on interview, record review, and policy review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) was documented to clarify resident/resident representative the choice between cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR), were thoroughly completed to include a date and physician signature for three of three residents (Residents (R) 9, R1, and R10) of 19 sample residents. This failure had the potential to affect the accuracy of POLST forms used when transferred from the facility to communicate resident/resident representative choice. Findings include: 1. Review of R9's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date in [DATE] with a readmission date in [DATE] and medical diagnoses to including dementia and other cerebrovascular disease. Review of R9's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R9 was severely cognitively impaired. Review of the code status located under the header and face sheet in the EMR on [DATE] for R9 documented full code. Review of the paper chart for R9 documented two undated POLST forms. One form stated DNR, allow for natural death and lacked a date and physician signature. The second form stated full code and lacked a date and physician signature. Review of R9's EMR under the Prog Notes tab revealed a note by Social Worker (SW) 3 documented on [DATE] at 12:26 PM, The resident [Family Member (FM) 1] had spoken to the nurse and social services and the resident's [FM1] discussed putting a DNR order in place. During an interview on [DATE] at 2:01 PM SW3 explained the process for completing the POLST form was once the request was made by the resident/resident representative for DNR, the form was to be followed up by nursing to get the physician signature and complete the form with date and signature. SW3 stated the process was not followed and should have been. During an interview on [DATE] at 3:39 PM, Licensed Practical Nurse (LPN) 1, after reviewing the EMR and the paper chart, stated the choice to do CPR or not if R9 stopped breathing was unclear and needed to be verified. During an interview on [DATE] at 3:42 PM, Registered Nurse (RN) 3 reviewed the EMR and paper chart for R9 and stated the POLST documentation was incomplete due to lacking a date and physician signature. RN3 stated the EMR was where to look to know wishes of the resident to be full code or DNR. RN3 stated for R9 it was not clear, therefore if R9 stopped breathing the choice would be to do a full code. 2. Review of R1's admission Record located in the EMR under the Profile tab, revealed an admission date in [DATE], readmission date in [DATE], and discharged in [DATE] with medical diagnosis that included chronic obstructive pulmonary disease. Review of R1's annual MDS located in the EMR under the MDS tab with an ARD of [DATE] revealed a BIMS score of 15 out of 15, indicating R1 was cognitively intact. Review of the closed record for the code status located under the header and face sheet in the EMR for R1 documented DNR. Review of the paper chart for R1 revealed an undated POLST form signed by R1 indicating DNR and lacked a date and physician signature. During an interview on [DATE] at 2:01 PM, SW2 confirmed the POLST form was incomplete without a date and physician signature. 3. Review of R10's admission Record located in the EMR under the Profile tab, revealed an admission date of [DATE], with a readmission date in [DATE] and medical diagnoses that included pneumonia and chronic obstructive pulmonary disease. Review of R10's quarterly MDS located in the EMR under the MDS tab with an ARD of [DATE], revealed a BIMS score of 15 out of 15, indicating R10 was cognitively intact. Review of the code status located under the header and face sheet in the EMR on [DATE] for R10 documented full code. Review of R10's physician orders located under the Orders tab of the EMR, dated [DATE] at 12:53 PM, documented Full Code/CPR (cardiopulmonary resuscitation). The order was a phone order entered by the Registered Nurse Supervisor and lacked a physician signature in the EMR system. Review of the paper chart for R10 revealed a document titled Advanced Directive/Living Will, signed and dated [DATE], answered the question I do or do not, wish to be resuscitated (CPR) with the words do not circled and document signed by R10, SW3, and one other witness. During an interview on [DATE] at 2:01 PM, SW3 confirmed R10 code status in the EMR was full code and the form dated [DATE] was unfamiliar to SW3 and stated, the code status for R10 was uncertain about the choice of the resident for full code or DNR. During an interview on [DATE] at 2:10 PM, SW1 confirmed the POLST form for R10 was incomplete unless dated and signed by the physician. During an interview on [DATE] at 2:17 PM, the Social Services Director (SSD) confirmed the process for the completion of the POLST was to be followed up by nursing for the physician's signature. He stated the date on the form represented the conversation between the resident and/or resident representative and the physician. SSD stated residents with a BIMS 11 or higher could sign for themselves. The SSD acknowledged the stated process was currently not working very well. During an interview on [DATE] at 3:00 PM, the Administrator stated the POLST form was incomplete without the date and physician's signature and the Administrators expectation was the POLST form should be completed with date and physician's signature. During an interview on [DATE] at 3:37 PM, the Director of Nursing (DON) explained that the social workers were to give the POLST to the DON to follow up, have the forms completed by the physician, and update the EMR. The DON confirmed this practice was not consistent and some of the POLST forms had not been presented to the physician for signature. The DON stated the POLST form was incomplete if the date and signature were not on the form. Review of the facility policy titled, Quality of Life - Resident self Determination and Participation, revised on 12/16, revealed [To] gather information about the residents' personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record. Review of the facility policy titled, Advanced Directives, revised on 12/16, revealed The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive .The definition of Do Not Resuscitate (DNR) - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used.

Based on interviews, record reviews, and facility policy reviews, the facility failed to resolve grievances for two of three residents (Resident (R) 3 and R5) reviewed for grievances of 19 sample residents. Specifically, the facility failed to resolve grievances related to misappropriation of funds and transportation concerns related to medical appointments. This failure had the potential to violate resident rights for all residents residing in the facility. Findings include: 1. Review of R3's admission Record located in the electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility in July 2021 with diagnoses including type two diabetes, bipolar disorder, hypertension, and bladder cancer. Review of R3's Resident Concern Form provided by the facility and dated 06/16/24, revealed R3 states that the unit clerk continuously messes up his/her doctor appointment. She gets dates mixed up, she'll forget transporter or transportation. The action section at the bottom of the form was blank. During an interview on 03/25/25 at 1:06 PM, R3 stated that he/she had ongoing concerns regarding his/her medications not being given on time and occasionally staff running out of medications. R3 stated that he/she recently told the Administrator that he/she was not going to talk to anyone else about his/her grievances because nothing ever changes or happens to remedy the problems. 2. Review of R5's admission Record located in the EMR under the Resident tab revealed the resident was admitted to the facility in April 2024 with diagnoses including quadriplegia, hypertension, muscle weakness, and benign prostatic hyperplasia. Review of R5's Social Service Intervention form provided by the facility and dated 06/23/24, revealed identified problem: 6:00 PM Pt [patient] called 911 states staff is taking to [sic] long to respond. Refuse [sic] to go out to the hospital. Several attempts were made to attend to pt needs. Follow-up at the bottom of the form was blank. Review of R5's Social Service Intervention form provided by the facility and dated 07/07/24, revealed identified problem: Refusing all staff from 3-11 PM on Sunday evening accusing staff of stealing his/her money and now washing him/her properly. Follow-up at the bottom of the form was blank. During an interview on 03/26/25 at 10:25 AM, the Social Services Director (SSD) stated that he started working at the facility six weeks ago and since that time he started a Grievance Binder. The previous SSD that was employed in June-July 2024 was not available for interview and was terminated in October 2024. During an interview on 03/27/25 at 12:05 PM, R5 stated that in July he/she had taken a nap and when he/she woke up his/her money was gone. He/She stated he/she notified the police, and they told him/her that since it was a small amount of money to talk to the staff about it. He/She stated he/she notified Social Worker (SW) 5 and no resolution was offered. Regarding the complaint in June, he/she stated that it was not uncommon for staff to take almost an hour to assist him/her when he/she pressed the call light. He/She stated he/she did not know why they wanted to take him/her to the hospital. He/She stated no solution was provided, and no one had spoken with him/her about concerns with staff taking too long to assist him/her. During an interview on 03/27/25 at 6:38 PM, the DON stated that she was aware of R3's concerns and that SW5 should have addressed the grievance and then the interdisciplinary team (IDT) should have resolved the concerns. Review of the facility's policy titled, Grievances/Complaints, Filing, revised 04/17, revealed .The Administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is Social Worker .Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within 5-10 working days or review immediately depending on the nature of the grievance .The Administrator will review the findings with Grievance Officer to determine what corrective actions, if any, need to be taken .The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems .

Based on interviews, record reviews, and facility policy review, the facility failed to ensure that a medical appointment was identified and implemented following a surgical procedure according to professional standards of practice for one of three residents (Resident (R) 8) reviewed for medical appointments of 19 sample residents. This failure had the potential to negatively impact on the residents' health status. Findings include: Review of R8's admission Record located in the electronic medical record (EMR) under the Resident tab indicated he/she was admitted to the facility in August 2022 with a primary diagnosis of acute cerebrovascular insufficiency. Review of R8's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/06/25 included a Brief Interview for Mental Status (BIMS) score of six out of 15 indicating R8 was severely cognitively impaired. Review of R8's Care Plan located in the EMR under the Care Plan tab and revised 04/11/24 included cholecystectomy status. Review of R8's Progress Notes located in the EMR under the Progress Notes, dated 04/05/24, revealed Pt [patient] disoriented sent to [Hospital Name] per MD [Medical Doctor] request . Review of R8's Progress Notes located in the EMR under the Progress Notes, dated 04/10/25, revealed readmission received from [Hospital Name] via stretcher @ 710pm [sic], Alert/Responsive, S/P [status post] Lapraroscopic [sic] Cholecystectomy [gall bladder removal], Abd [abdominal] anterior surgical incision x4 . on PO [oral] Abt [antibiotic] ciprofloxacin and metronidazole x12 days d/t [due to] cholecystitis, total dependence with all ADL's [activities of daily living] . Review of [Hospital Name] document titled, Discharge Education, dated 04/10/24, revealed .Please call . to make an appointment in the ACC [ambulatory care center] Clinic in two weeks . Review of [Hospital Name] document, dated 11/07/24, titled, After Visit Summary revealed .Return in about 3 (three) months (around 02/07/25) .Today's Visit you saw [Name] on Thursday November 7, 2024. The following issue was addressed: Abnormal weight loss . During an interview with R8's Complainant (C) 8 on 03/26/25 at 5:05 PM stated that R8 had his/her gall bladder removed in April 2024 and did not receive his/her follow up visit two weeks after the surgery. She notified the facility, and the visit was never scheduled. During an interview on 03/27/25 at 1:00 PM, the Unit Clerk (UC) stated she was not employed with the facility in April 2024 and did not know why the surgical follow up appointment was not scheduled. UC stated that the facility protocol was for the Clerk to review the packet of information that returned with the resident after hospitalization or a physician appointment. UC reviewed the Log Book that was kept by staff of all resident medical appointments and stated C8 did not have any appointments in late April 2024 or early May 2024 that would have correlated with the needed follow up visit. UC confirmed that R8 was to have a follow up visit in February 2025 per the hospital visit notes, dated 11/07/24. UC stated she called the physician's office that confirmed that no follow up visit had been made for February 2025 and no pending appointments were noted. During an interview on 03/27/25 7:15 PM, the Director of Nursing (DON) reviewed the hospital discharge documents for R8 dated 04/10/24 and stated she did not see any physician orders that would indicate that an appointment was to be scheduled. Her expectation was for the nurse re-admitting the resident after hospitalization or an appointment should review the documentation with recommendations for any appointments. The DON stated the recommendation should have been then relayed to the physician to ensure that they wanted it scheduled. She stated a progress note would have been made as to what was determined. She stated in the absence of the Clerk; the nurse would be responsible for ensuring appointments were scheduled. During an interview on 03/27/25 at 7:21 PM, Registered Nurse Supervisor (RN Sup) confirmed that R8 had been discharged from the hospital on [DATE] and documentation recommended that he/she have a follow-up appointment in two weeks status post gall bladder removal. RN Sup stated that she had not seen the documentation nor was she aware that the resident had missed follow-up appointments. Review of the facility policy titled, Health, Medical Condition and Treatment Options, Informing Residents of, revised 12/16, did not include information regarding ongoing treatment.

Based on interview, record review, and review of facility policy, the facility failed to maintain a complete and accurate medical record for one of 19 sampled residents (Resident (R) 3). Specifically, the nursing staff failed to document the completion of physician orders on the resident's medication administration records. This failure had the potential to affect accuracy of records. Findings include: Review of R3's admission Record located in the electronic medical record (EMR) under the Resident tab indicated he/she was admitted to the facility in July 2021with a primary diagnosis of diabetes mellitus. Comorbidities included bipolar disorder, benign prostatic hypertrophy, hyperlipidemia, malignant neoplasm of the bladder, and major depressive disorder (MDD). Review of R3's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/13/25 included a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R3 was cognitively intact. Medications included antipsychotics, antidepressants, antihypnotics, and anticoagulants. Review of R3's Care Plan located in the EMR under the Care Plan tab and initiated 07/22/21 included administration of medications as ordered. Review of R3's Order Summary located in the EMR under the Orders tab included orders for -Atorvastatin calcium oral tablet 10 MG (milligram) one tablet to be given by mouth (PO) at bedtime (HS) for hyperlipidemia starting 04/10/24, -Eszopiclone oral tablet 1 MG one tablet PO at HS starting 07/15/24, -Gabapentin oral capsule 100 MG one capsule PO four times per day (QID) starting 05/15/24, -Omeprazole capsule delayed release (DR) 20 MG one capsule PO every morning (AM) for gastroesophageal reflux disease (GERD) starting 04/10/24, -hydroxyzine pamoate oral capsule 25 MG one capsule PO at HS for anxiety, eszopiclone oral tablet 1 MG one tablet PO at HS for insomnia starting 07/15/24, -Seroquel oral tablet 100 MG one tablet PO at HS for bipolar disorder starting 04/13/24, -Tamsulosin HCL oral capsule 0.4 MG capsule one capsule PO in AM and one capsule in the afternoon starting 04/10/24, and -Trazodone HCL oral tablet 50 MG one tablet PO at HS for depression starting 02/13/25. Review of R3's Medication Administration Record (MAR) provided by the facility for the month of November 2024 included -Atorvastatin calcium oral tablet 10 mg, eszopiclone oral tablet 1 mg, hydroxyzine pamoate oral capsule 25 mg, -Seroquel oral tablet 100 mg tablet, and trazodone HCL oral capsule 100 mg were documented on 11/29/24 as 9 indicating the nurse should enter a progress note regarding medication availability/medication administration, -Omeprazole capsule delayed release 20 mg documented as blank on 11/08/24, 11/23/24, and 11/29/24, -Tamsulosin hydrochloride (HCL) oral capsule 0.4 mg capsule documented as 9 on 11/29/24 at 9:00 AM, documented as 9 on 11/29/24, and -Gabapentin oral capsule 100 mg documented as blank on 11/14/24 and 11/18/24 for 10:00 PM dose, 10/23/24 documented as blank for 6:00 AM dose, and documented as 9 on 11/29/24 for 10:00 PM dose. Review of R3's MAR provided by the facility for the month of December 2024 included omeprazole capsule delayed release 20 mg documented as blank on 12/14/24, tamsulosin hydrochloride (HCL) oral capsule 0.4 mg capsule documented as 9 on 12/05/24 at 9:00 AM, 12/07/24 at 6:00 PM, 12/09/24 at 6:00 PM, 12/10/24 at 9:00 AM, 12/11/24 at 9:00 AM, 12/12/24 at 9:00 AM, 12/30/24 at 9:00 AM, and 12/31/24 at 9:00 AM. Review of R3's MAR provided by the facility for the month of February 2025 included atorvastatin calcium oral tablet 10 mg, eszopiclone oral tablet 1 mg, hydroxyzine pamoate oral capsule 25 mg, and Seroquel oral tablet 100 mg, trazodone HCL oral tablet 50 mg tablet, and gabapentin oral capsule 100 mg on 02/07/25 documented as blank and omeprazole capsule delayed release 20 mg documented as blank on 02/01/25. Review of R3's MAR provided by the facility for the month of March 2025 included eszopiclone oral tablet 1 mg on 03/11/25 documented as 9, omeprazole capsule delayed release 20 mg documented as blank on 03/06/25 and 03/22/25, tamsulosin HCL capsule 0.4 mg documented as 9 on 03/12/25, and gabapentin oral capsule 100 mg documented as blank on 03/06/25 6:00 AM, 03/13/25 10:00 PM and 03/21/25 10:00 PM. During an observation on 03/27/25 at 1:35 PM of the medication cart containing R3's medications, it was confirmed that all medications prescribed for R3 were available on the medication cart. During an interview on 03/25/25 at 1:06 PM, R3 stated that sometimes staff told him/her medications had been ordered and then he/her went without his medications. Specifically, he/she recalled being out of tamsulosin, Seroquel, and eszopiclone. During an interview on 03/27/25 at 1:35 PM, Licensed Practical Nurse (LPN) 8 stated that she currently had R3's medications available but sometimes he/she would run out of tamsulosin because the health insurance was holding up authorization. When this happened, she would put in a progress note and also document on the 24-hour nursing report. LPN8 stated she thought this had happened at least three times that she was aware of but could not recall the dates. During an interview on 03/27/25 at 7:14 PM the Director of Nurses (DON) stated that R3 worried about his/her Seroquel and eszopiclone running out. In the past she had checked the medication cart to confirm that the medications were on hand. After reviewing the MARs for November-December 2024 and February-March 2025, the DON stated that she was not sure why there were blank spaces in the MAR other than they had experienced their internet down in the past. She stated she wasn't sure what the dates were when the incident occurred. She stated regarding MAR's having 9 documented; this typically meant that the medication wasn't available, or medication was possibly pending insurance approval for payment. The DON stated that it was the expectation that if a medication was not available or not given the nurse should have entered a progress note, notified the physician, and documented if the medication could be given late or held until the medication was available. The DON confirmed that documentation was not available in the EMR to determine if medications were administered, held, or were unavailable. The DON stated additionally, the pharmacy performed MAR audits and had identified documentation issues as of the facility's annual survey in February 2024. She stated she was not aware that documentation errors were still occurring. During an interview on 03/27/25 at 7:36 PM, Registered Nurse Supervisor (RN Sup) stated that it was her expectation that all nurses documented whether medications were administered and if 9 was entered, a progress note should be entered in the EMR indicating the circumstances. Review of the facility policy titled, Documentation of Medication Administration, revised 04/07, revealed .A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR) .reason(s) why a medication was withheld, not administered, or refused (as applicable) .

REPEAT DEFICIENCY Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store and discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 01/29/234 at 9:24 AM, the surveyor in the presence of the Food Service Director (FSD) and a Federal Surveyor (FS) observed the following during the kitchen tour: 1. On a tray cart, the surveyor observed multiple 6 ounce (oz) disposable individual cups that the FSD stated the contained rice crispy cereal. No labels with made or use by dates noted. FSD stated the cereal cups were put together yesterday but could not state why they were not labeled. 2. The juice machine was observed with a clear tubing from orange juice with brown colored spots on the tubing. FSD unable to state what the brown spots were but would call the service company to change the tubing. 3. Dietary aide (DA #1) was observed preparing salads with lettuce, cucumbers, and carrots. The Surveyor further observed DA #1 unwrapping the lettuce from plastic wrapper and not washing lettuce prior to chopping lettuce for salad. Both DA #1 and FSD both stated the lettuce does not need to be washed prior to prepping. Surveyor further observed manufactures plastic wrap for the lettuce that stated, wash before eating. The FSD instructed DA #1 to wash all lettuce that was being used for today's salads. FSD stated the lettuce they normally are delivered in ready to use straight from the bag, but the lettuce they were delivered was different from their normal delivery. 4. Surveyor observed nine (9) individually wrapped loafs of white bread, all not labeled. The FSD stated all bread came from single box that was labeled with a delivery date, but unable to produce that box or state if individual breads should be labeled. 5. In dry pots and pans area, the surveyor observed 2, 1/4 tray pans with wet nesting, FSD stated all pots and pans in that area should be dry. 6. Surveyor observed the FSD perform hand hygiene. The FSD failed to scrub hands with soap for 20 seconds before rinsing as well as turning off the faucet with contaminated paper towels that the FSD used to dry their hands. FSD stated she used contaminated paper towel because the towel dispenser did not have any clean towels. Surveyor observed paper towels next to dispenser. FSD acknowledged hand washing was completed incorrectly. 7. Surveyor observed multiple packages of opened hamburger buns, not labeled with open or use by date. The FSD stated they do not label individualized packages of bread or buns, all bread products are labeled on the box they are delivered in, but unable to produce the box the hamburger buns were delivered in. 8. In the chef preparation area. The surveyor observed crumb-like debris in-between the upper and lower ovens of the dual standing oven. The FSD stated the ovens should be clean and wiped down after each use and when visibly soiled. 9. Surveyor observed a dual oven with six (6) range stove top and griddle. The FSD stated both ovens were not currently working. Inside the right side oven, surveyor observed two boxes of Adobo seasoning. FSD stated, sorry that should be in there, they staff likes to take that home. In the left oven, surveyor observed two pots with a handle, the first contained partially melted butter with brown colored spots on non-melted area and second pot had used cooking grease/oil. Both pots were covered with plastic wrap and was dated 01/28/24. FSD stated, nothing should be stored inside those ovens, the butter and oil must have been left over from yesterday and not properly disposed of. The FSD had the Chef dispose of the butter and oil. 10. On top of the flat top griddle was a removable cast iron flat top griddle that was observed with black debris. The FSD stated, the cast iron griddle should be cleaned after each use. 11. In the walk-in refrigerator #1, the surveyor observed multiple items stored 18 inches from top of ceiling as well as a black dust-like debris on light bulb and connected wiring. The FSD stated they had a food delivery was today and that was the reason for items being stored 18 inches from ceiling but could not explain the dust-like debris. 12. In walk-in refrigerator #2, the surveyor observed multiple items stored 18 inches from ceiling. The FSD could not state why the food items were stored that high. 13. In the walk-in freezers. Surveyor observed multiple items stored 18 inches from ceiling. The FSD could not state why the food items were stored that high. 14. In the dry storage area, all opened seasonings were observed with open dates, but no use by/discard dates noted. The FSD stated once the seasoning are opened, they are good for one year. 15. In the dry storage area, the air conditioning unit (AC) was observed with a thick layer of black colored debris on the vent. The FSD stated, they would call maintenance to clean the AC unit immediately. The FSD unable to state when the AC unit vent was last cleaned because the AC unit is cleaned by the maintenance department. 16. In the dry storage area, the surveyor observed multiple broken, partial moved, and missing ceiling tiles. The FSD stated the facility had been doing some repairs in the dry storage area but could not state why the ceiling tiles had not been replaced or put back. On 01/31/24 at 9:40 AM, the FSD provided the surveyor with multiple facility policies. The policies were titled; dating and Labeling Policy with a revised date 1/24/2017, Pot Washing Policy with created date 1/1/2017, Handwashing/Hand Hygiene with a revised date December 2009, and Food Storage, no date available. The policy for dating and labeling states under the procedure section, 2. Label products in storage with date the package was opened .7. Keep all storage areas clean and dry. The pot washing policy states under the procedures section, 10. Air dry all clean and sanitized pots and wares. The hand washing and hand hygiene policy states under the procedures section, 3. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least fifteen (15) seconds under moderate stream of running water, at a comfortable temperature .4. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. The food storage policy states under the storage section of the policy, Dry and staple foods must be stores on shelving at least 6 (inches) from the floor and 18 from the sprinkler heads in clean well-ventilated rooms .All fruits and vegetables upon receive shall be stored properly and must be wash before using for food preparation. On 02/05/24 at 01:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of nursing (DON). The LNHA stated all the kitchen issues will be addressed and corrected by the FSD immediately. No further comments made. NJAC 8:39-17.2(g)

Based on interviews, and review of pertinent facility provided documents, it was determined that the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. This failure had the potential to affect all 273 residents who currently live in the facility. Refer to F607E, F728E, F730E, F804D, F883E, and S0560 The deficient practice was evidenced by the following: On 01/29/24 at 10:22 AM, during the entrance conference held with the facility's Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor in the presence of another surveyor requested information regarding the QAA (Quality assessment and assurance) committee, last three quarters sign in sheets for QAPI meetings, and QAPI plan. On 02/05/24 at 01:09 PM, the surveyor reviewed the facility provided QAA (a committee composition and frequency of meetings in nursing facilities requires facilities to develop and implement appropriate plans of action to correct identified quality deficiencies) Committee Information did not include the Infection Preventionist as members. Further review of the provided documents, the facility's QAPI Policy was last reviewed in December 2021. The listed QAPI procedure included that the QAPI will be reviewed annually and upon any significant change at the facility. In addition, the QAPI Program did not have a review date. The QAPI Plan included departments: Social Services (SS), Housekeeping/Maintenance (H/M), Nursing: All 2019 POCs (plan of corrections), Infection Control (IC), MDS (Minimum Data Set), Admissions, Food Services (FS), Dietician, Rehab and Recreation. The goal descriptions for departments: SS, H/M, IC, and FS were on December 31, 2019. The goal descriptions for departments: Nursing, MDS, and Admissions were in 2019. The goal description for the Dietician was to be completed by the 10th of each month in 2019 and Recreation was each month in 2019. There was no documented evidence in the minutes and the documents that were provided to the surveyor to confirm plans of action, developed and implemented appropriate plans of action to correct identified quality deficiencies for the last four years. A review of the above information showed that the last QAPI Plan was for 2019. On 02/06/24 at 10:07 AM, the surveyors met with the LNHA and discussed the QAPI and QAA. The surveyor asked the LNHA how often the facility reviews the QAPI plan, QAA, and Program. The LNHA stated that I review every quarterly before the upcoming QAPI. The surveyor showed the LNHA the provided QAPI Plan, QAA Committee Information, QAPI Program, and QAPI Plan. The surveyor then notified the LNHA of the above findings and concerns. At that same date and time, the LNHA had no answer when asked by the surveyor why the QAPI plan was for 2019. Later on, the LNHA showed a piece of paper with no title and not dated. The LNHA stated that the untitled and undated paper was the facility's QAPI plan. The surveyor reviewed the paper in the presence of another surveyor, then asked the LNHA if that was the QAPI plan and why there was no goals determined in each department: Human Resources, MDS, Rehab, Activities, SS, Dietitian, FS, and Maintenance. Also, the surveyor asked why Nursing and Infection Control were not included, and the LNHA did not respond. The heading statement that was documented in the provided piece of paper of the LNHA included: QAPI all documents uploaded in [electronic medical record]. Appointments. I will help them set up an audit. The document was not reflective of a comprehensive QAPI plan as stipulated in the facility's previously submitted QAPI plan for 2019. On that same date and time, the surveyor asked the LNHA based on the back and forth communications between the facility management and the survey team, what were the areas of concerns that the survey team had identified that the facility were not able to identify in their QAPI. The LNHA stated that the surveyor's identified concerns about employee files, non certified Nursing Aides, staffing, vaccinations of staff and residents, and other areas of concerns with food temperature. On 02/06/24 at 11:30 AM, the survey team met with the DON and LNHA, and the surveyor notified the facility management of the above concerns. The LNHA further stated that there was no additional information that the facility could provide and the survey team could proceed with the decision-making. A review of the facility's QAPI Policy dated 12/2021 included that it is the policy of the facility to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, resident quality of life, and residents' choice. The QAPI Plan will be reviewed annually and upon any significant change at the facility. On 02/06/24 at 01:35 PM, the survey team met with the LNHA, the DON, and the Business Office Personnel for an exit conference, and there was no additional information provided by the facility management. N.J.A.C. 8:39-33.1(a)(b); 33.2(b)(d); 34.1(a)(b)(d)

Based on the interview and review of pertinent facility documentation, the facility failed to have the Infection Preventionist present for three (3) of three (3) quarterly Quality Assurance Performance Improvement (QAPI) meetings. This failure had the potential to affect all 273 residents who currently live in the facility. The deficient practice was evidenced by the following: On 02/05/24 at 8:45 AM, the surveyor in the presence of the Social Services Director interviewed the Licensed Nursing Home Administrator (LNHA) regarding the submitted QAPI Attendance for the last three quarters: 5/11/23, 9/07/23, and 11/30/23. The surveyor asked the LNHA to confirm who attended the last three quarters of QAPI because the 5/11/23 QAPI Attendance did not include the title and department for some attendees. During an interview, the LNHA confirmed that on 5/11/23, 9/07/23, and 11/30/23 there was no Infection Preventionist (IP) who attended the quarterly QAPI meetings. The LNHA acknowledged that IP was part of the key members of the QAPI team that should be present in the QAPI meetings. A review of the facility's provided QAA (Quality Assessment and Assurance, a committee composition, and frequency of meetings in nursing facilities requires facilities to develop and implement appropriate plans of action to correct identified quality deficiencies) Committee Information that was provided by the Nursing Clerk showed that the QAPI Meetings are held quarterly in the 2nd-floor conference room. Also, according to the QAA Committee Information, the members included the Medical Director (MD), Administrator (or LNHA), Director of Nursing (DON), Admissions Director, FSD (Food Service Director), Director of Building Services, Director of Recreation, Director of Social Services, Director of Rehabilitation, MDS Supervisor, Dietician, Pharmacy Consultant, and [company name] Pharmacy. Further review of the QAA Committee Information above revealed that the IP was not included in the list of members. On 02/05/24 at 01:21 PM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above concerns. 02/06/24 at 10:07 AM, the two surveyors met with the LNHA and discussed the QAPI and QAA. The LNHA again confirmed that no IP attended the last three quarters of QAPI meetings. The LNHA also confirmed that the QAA Committee Information that was submitted above did not include the IP as part of the committee list and the LNHA had no answer why the IP was not listed. On that same date and time, the surveyor asked the LNHA what were the areas that the survey team had identified as concerns during the survey period and the facility did not identify. The LNHA stated a few concerns that the survey team identified as concerns were testing for COVID-19 and vaccinations for both residents and staff. The LNHA confirmed that they were all important parts of infection control which is the Infection Preventionist's responsibility. A review of the facility's QAPI Policy dated 12/2021 included that it is the policy of the facility to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, resident quality of life, and residents' choice. The Quality Assessment and Assurance Committee consists at a minimum of: The Administrator, DON, Medical Director, or his/her designee; at least three other members of the facility's staff. On 02/06/24 at 01:35 PM, the survey team met with the LNHA, the DON, and the Business Office Personnel for an exit conference, and there was no additional information provided by the facility management. NJAC 8:39-33.1 (b)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide the residents with a safe, comfortable, clean, and homelike environment. This deficient practice was identified in one (1) of three (3) residents' rooms, (Resident #132) and one (1) of two (2) dining areas on the 4th floor observed during environmental rounds. This deficient practice was evidenced by the following: 1. On 01/30/24 at 8:25 AM, the surveyor observed Resident #132 on the bed with an air mattress, indwelling catheter in use, and head of the bed elevated approximately 45 degrees while on tube feeding (TF, a way to provide nutrition when a resident cannot eat or drink safely by mouth) pump, at 75 ml/hr (milliliters per hour). The surveyor observed that the TF pole with scattered dried brownish color and resembled the color of the milk that was hung on the pole, and the surrounding floor area with the same dried brownish color. On that same date and time, the surveyor observed that the resident was on oxygen (O2) at 2 LPM (liters per minute) via a nasal cannula (N/C, a device that delivers extra oxygen through a tube and into the resident's nose) attached to a concentrator (is a type of medical device used for delivering oxygen to individuals with breathing problem). The concentrator had an accumulation of black and grayish substances around the concentrator. The electric fan was in use with an accumulation of a grayish substance around the metal part where it was blowing air. The fan was near the foot part of the resident's bed. The nightstand table near the window, the second drawer was broken, and no cover. On 01/30/24 at 02:06 PM, the surveyor asked Licensed Practical Nurse #1 (LPN#1) the assigned nurse of the resident to accompany the surveyor to Resident #132's room. Inside the resident's room, both the surveyor and LPN#1 observed the electric fan and the O2 concentrator with an accumulation of grayish and blackish substances, the TF pole and the floor beneath had brown dried substances, and the nightstand table near the window second drawer was broken with no cover. On that same date and time, the LPN stated that the dried brownish was from the milk residue, and she was not sure who should be cleaning it, LPN#1 confirmed it should be cleaned. The LPN further stated that the concentrator should have been cleaned. The LPN wiped out the concentrator with gloves on and noted grayish substances. The LPN also stated that it was the responsibility of the housekeeper to clean the dust around the fan and she will notify the housekeeper. On 02/01/24 at 8:46 AM, the surveyor interviewed LPN#2 regarding the resident. The LPN informed the surveyor that Resident #132 was cognitively impaired and required total assistance with adls (activities of daily living), on pleasure food but declined to eat, and currently on TF. Afterward, the surveyor asked LPN#2 to accompany the surveyor inside the resident's room. Both the surveyor and LPN#2 observed that the electric fan was in use with an accumulation of dust, the floor where the TF pole was located had dried milk from the formula, and the nightstand's second drawer was broken. LPN#2 confirmed the observation and stated that he will ask Maintenance for the fan and drawer and that the floor should have been cleaned. The surveyor reviewed the hybrid (a combination of paper-based and electronic health records that primarily involves tracking and storing a resident's health records in several formats and places) medical records of the resident as follows: Review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to dysphagia oropharyngeal phase (difficulty swallowing), gastrostomy status (resident with TF), altered mental status unspecified, and need for assistance with personal care. The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, an ARD (assessment reference date) of 12/23/23, and Section C Cognitive Skills for Daily Decision Making showed that the resident's cognition was severely impaired. Section K Swallowing/Nutritional Status revealed that the resident was on TF. On 02/05/24 at 10:48 AM, the surveyor interviewed the Director of Nursing (DON) regarding the above concerns and findings. The DON stated that there should be no broken supplies and equipment inside the resident's room, and if the nurse was aware, it should be logged in the maintenance book. She further stated that the room should be cleaned. 2. On 01/31/24 at 12:12 PM, the surveyor observed 4 East during lunchtime. There were a total of five tables in the dining area. The 1st table was toward the nursing station and the 5th table was toward room [ROOM NUMBER], 443, 444, and 445. In the dining area, near the 5th table, in front of rooms [ROOM NUMBERS], the surveyor observed that there was a commode that was placed in the hallway, the leg part of the commode was noted with brownish, rust-like substances. Furthermore, in the same dining area, the surveyor observed across was room [ROOM NUMBER] and outside the room in the hallway were two blocks of wood. Inside room [ROOM NUMBER], the bed near the door (from 442-A), had a nightstand table that was broken, with a missing wood cover for the first drawer, at that time the Certified Nursing Aide (CNA) was inside room [ROOM NUMBER] washing her hands. Afterward, the surveyor interviewed the CNA when she came out of the room, and the surveyor asked why there were two blocks of wood outside the room. The CNA confirmed that was the broken part of 442-A's nightstand table for the 1st drawer and she did not know who put it outside. The CNA further stated that it should not be placed outside in the hallway for safety. The CNA confirmed that the broken nightstand table was for Resident #49. The surveyor then asked the CNA about the commode outside which was near Table 5 and in the hallway as well. The CNA stated that she did not know who the commode for and that it should not be there. The CNA took the wood but did not remove the commode from the hallway while the residents were eating in the dining area. On that same date and time, Resident #71 who was seated at Table 5 with three other residents, confirmed that a staff left the commode and the resident did not identify the staff. The resident further stated that someone left the commode because the lunch came and had to distribute the trays to the resident. The resident also stated that she was not bothered because the resident knew that it would be removed later. On 01/31/24 at 12:25 PM, both the surveyor and LPN#3 observed the commode in the dining area. The LPN stated that she did now know who put the commode in the dining area. She further stated that the commode should not be there and would ask the CNA to take it out. At that same time, LPN#3 asked the CNA to remove the commode. The surveyor observed the CNA dragged the commode away from the 4 East dining area. On 01/31/24 at 3:02 PM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) for the facility's policy regarding the environment. On 02/05/24 at 01:21 PM, the survey teams met with the LNHA and DON. The surveyor notified the facility management of the above concerns and findings. On 02/06/24 at 11:30 AM, the survey teams met with the DON and LNHA for facility responses regarding the above findings and concerns. The LNHA informed the surveyors that the facility had a log for cleaning the O2 concentrators in the building. The LNHA stated that the facility had no cleaning log or accountability for other items that should include the TF and electric fans. On that same date and time, the DON informed the surveyors that the nurse did not put it in the log for maintenance of the broken nightstand table. She further stated that the log was the nursing communication to the maintenance for repairs. Furthermore, the DON stated that the wood should not be there for safety. The DON further stated that the commode should not be in the dining area. The surveyor then asked why was it important that the commode was not in the dining area, and the facility management did not respond. A review of the facility's Quality of Life-Homelike Environment Policy that was provided by the LNHA, with a revised date of August 2009 that included residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include cleanliness and order and personalized furniture and room arrangements; pleasant. On 02/06/24 at 01:35 PM, the survey teams met with the LNHA, the DON, and the Business Office Personnel for an exit conference. There was no additional information provided by facility management. NJAC 8:39-31.2 (e), 31.4(a)(b)(f)

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for five (5) of seven (7) newly hired licensed staff reviewed, Staff #2, #4, #5, #7, and #10 evidenced by the following: On 02/05/24 at 10:03 AM, the surveyor reviewed ten randomly selected new facility employee files. The review for license verification for seven of the new licensed employees revealed the following: 1. Review of Staff Member #2 (SM2), an Occupational Therapist, hired on 5/02/22, had a New Jersey Division Consumer Affairs (NJDCA) license verification printout (used to verify the status of a license for license verification) dated 11/03/22. The verification was completed after the staff member was hired. There was no documented evidence that SM2's license was verified prior to the date of hire (doh). 2. Review of Staff Member #4 (SM4), a Registered Nurse, hired on 12/05/23, did not have a NJDCA license verification printout. There was no documented evidence that SM4's license was verified prior to the doh. 3. Review of Staff Member #5 (SM5), a Licensed Practical Nurse, hired on 6/21/22, had a NJDCA license verification printout dated 10/19/22. The verification was completed after the staff member was hired. There was no documented evidence that SM5's license was verified prior to the date of hire (doh). 4. Review of Staff Member #7 (SM7), a Certified Nursing Assistant (CNA #1), hired on 8/28/23, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. There was no documented evidence that SM7's license was verified prior to the doh. 5. Review of Staff Member #10, a Certified Nursing Assistant (CNA #2), hired on 3/13/23, had a NJDOH online Public Registry license verification printout which did not include the date that the verification was done. There was no documented evidence that SM10's license was verified prior to the doh. On 02/05/24 at 10:47 AM, in the presence of the Licensed Nursing Home Administrator (LNHA), the surveyor interviewed the Director of Activities (DOA) who worked previously in the Human Resources (HR) department regarding the process for new employee hiring. The DOA stated that when she worked in HR she would perform license verification and that she used two different websites, one for CNAs and one for RNs as well as LPNs. The surveyor asked if the license verification printouts were dated (to show which date they were performed). The DOA was not sure if they were or were not dated. The DOA explained that the doh was the first physical day that the employee worked at the facility. The DOA verified that the license verification should be done prior to them starting, the doh. On 02/05/24 at 11:42 AM, the DOA reviewed the employee files and confirmed that the five employees did not have documented evidence that the license verifications were done prior to the doh. On 02/05/24 at 01:08 PM, the surveyor interviewed the Director of Nursing (DON) regarding the license verification. The DON stated that the license verification should be dated and done prior to the doh. On 02/05/24 at 01:53 PM, in the presence of the survey team and two federal surveyors, the surveyor discussed their concern with the LNHA and DON regarding the five newly hired employees lacking documented evidence that their licenses were verified prior to their doh. On 02/06/24 at 9:26 AM, the LNHA stated that the facility did not have a specific policy for new employee hiring other than the checklist. The LNHA provided two documents in lieu of a policy regarding new hires. The first document was an Employee File Check List which included the following: The following shall be completed on each new employee as it pertains to his/her job Verification of License with Board of Nursing (if applicable) Date verified. The reviewed employee files did not include this or any check list. The second document was not titled but had entry areas for information that included the following: New Hire Orientation will be scheduled on .Original Documents Needed Any licenses or certificates pertaining to your position. A review of the facility provided policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure dated 2022, included the following: The Facility will not employ or otherwise engage individuals who: A. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. B. Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. C. Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. The facility did not provide any additional information. N.J.A.C. 8:39-43.15(a)

Based on observations, interviews, and review of medical records and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. This deficient practice was identified for four (4) of 38 residents (Residents #19, #36, #132, and #267) reviewed for a care plan. This deficient practice was evidenced by the following: 1. On [DATE] at 12:54 PM, the surveyor observed Resident #19 in their room with tube feeding (TF, a way to provide nutrition when a resident cannot eat or drink safely by mouth). The surveyor reviewed the hybrid (a combination of paper-based and electronic health records that primarily involves tracking and storing a resident's health records in several formats and places) medical records of Resident #19 as follows: Resident's Admission Record (AR, admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; other cerebrovascular diseases (a group of conditions that affect blood flow and the blood vessels in the brain), hemiplegia unspecified affecting unspecified side (indicates partial paralysis), aphasia (a language disorder that affects a person's ability to communicate), heart failure, and essential hypertension (occurs when a resident have abnormally high blood pressure that's not the result of a medical condition). The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care with assessment reference date (ARD) [DATE] showed in Section C Cognitive Skills for Daily Decision Making that the resident's cognition was severely impaired. Section N Medications revealed that the resident received an anticoagulant (commonly known as a blood thinner, a chemical substance that prevents or reduces coagulation of blood, prolonging the clotting time) medication during the last seven days. The February 2024 Order Summary Report (OSR) revealed a physician order (PO) date of [DATE] for Apixaban (an anticoagulant medication used to treat and prevent blood clots and to prevent stroke) tablet (tab) 2.5 mg (milligram) to give one tab via TF every 12 hours (hrs) of VTE (Venous thromboembolism is a condition that occurs when a blood clot forms in a vein) related to abnormal coagulation profile. The above order for Apixaban was transcribed to the February 2024 electronic Medical Records (eMAR) and signed daily by nurses as administered. A review of the personalized care plan revealed that the resident did not have a plan of care for an anticoagulant. On [DATE] at 8:48 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) who informed the surveyor that Resident #19 was cognitively impaired and required total care with activities of daily living (adls). The LPN stated that the resident was recently hospitalized and came back three weeks ago with a diagnosis of pneumonia (lung infection) from the hospital. On that same date and time, LPN#1 stated that it was the responsibility of the Unit Manager (UM) to initiate, develop, and update the resident's care plan. The LPN further stated that there was no UM for one and a half (1 ,d+[DATE]) years and he did not know who does the care plan now. The LPN also stated there should be a care plan for anticoagulants. On [DATE] at 10:55 AM, the surveyor interviewed the Director of Nursing (DON) regarding the above concerns and findings. The DON stated that there should be a care plan for anticoagulants. 2. On [DATE] at 8:25 AM, the surveyor observed Resident #132 on the bed with an air mattress, indwelling catheter in use, and head of the bed elevated approximately 45 degrees while on TF pump, at 75 ml/hr (milliliters per hour). The surveyor reviewed the hybrid medical records of Resident #132. The AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to dysphagia oropharyngeal phase (difficulty swallowing), gastrostomy status (resident with TF), altered mental status unspecified, and need for assistance with personal care. The qMDS with an ARD of [DATE], and Section C Cognitive Skills for Daily Decision Making showed that the resident's cognition was severely impaired. Section N revealed that the resident received an opioid (a broad group of medicines used to relieve pain and are considered controlled medications) medication during the last seven days. The February 2024 OSR revealed a PO date of [DATE] for Percocet oral tab ,d+[DATE] mg (Oxycodone [contains opioid] with Acetaminophen) to give one tab via TF two times a day for severe pain 30 minutes prior to wound treatment. The above order for Percocet was transcribed to the February 2024 eMAR and signed twice a day by nurses as administered. A review of the personalized care plan revealed that the resident did not have a plan of care for pain. On [DATE] at 8:46 AM, the surveyor interviewed LPN#1 regarding Resident #132. The LPN informed the surveyor that the resident had multiple hospital-acquired wounds and was currently on pain medication. The LPN further stated that the resident should have a care plan for pain. He confirmed that he was not responsible for initiating and developing a care plan because it was the responsibility of the UM. On [DATE] at 10:57 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) in the presence of the survey team. The MDSC/RN informed the surveyor that the care plan was the responsibility of the admitting nurse to start the care plan for example for falls, skin, certain medications including anticoagulants, and pain. The MDSC/RN stated that upon admission, the next morning when she came to work, the MDSC/RN also updated and revised the care plan. She further stated that anyone from nursing including the DON and UM can write a care plan that requires a nursing care plan. She further stated that as an MDSC/RN, care plans also are reviewed during a quarterly MDS and any comprehensive MDS and that would be her responsibility to make sure that care plan was there. At that same time, the surveyor asked the MDSC/RN if the nurses in the unit were aware that they were responsible to initiate and update the care plan. The MDSC/RN stated, I know from previous DON that all nurses knew that they will do the care plan, but I did not talk to nurses if they were aware. The MDSC/RN informed the surveyor that she started to work at the facility in [DATE]. Furthermore, the surveyor asked the MDSC/RN why was it important that the resident have a personalized care plan for anticoagulants. The MDSC/RN stated that so the staff knows how to monitor side effects like bruising. In addition, the surveyor asked the MDSC/RN why was it important for the resident to have a personalized care plan for pain. The MDSC/RN stated that it was important to make sure that pain is controlled. On [DATE] at 10:48 AM, the surveyor interviewed the DON regarding the above concerns, and the DON stated that there should be a pain care plan. On [DATE] at 01:21 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The surveyor notified the facility management of the above concerns. On [DATE] at 11:30 AM, the survey team met with the DON and LNHA. The DON that she added an anticoagulant care plan after the surveyor's inquiry for Resident #19. The LNHA further stated that the care plan for pain for Resident #132 was added after the surveyor's inquiry. 3. On [DATE] at 01:01 PM, the surveyor observed Resident #36 in their room watching television. Resident #36 stated they are a smoker, and the smoking area is on the 6th floor. The resident further stated that the facility staff holds onto their cigarettes and lighters. The surveyor reviewed the hybrid medical records of Resident #36 as follows: Resident's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and major depression disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The annual MDS (aMDS) with an ARD [DATE] showed in Section J, that Resident #36 was a current tobacco user. Resident #36 last smoking assessment (an assessment may help the facility determine how you can help a patient who smokes. Variables worth assessing include amount smoked. degree of dependence (e.g., cigarettes per day, time to first cigarette) patterns of smoking) dated [DATE], indicated under Section E. Safety subsection 9. Plan of care is used to assure resident is safe while smoking, was checked of as yes. A review of Resident #36's care plan, last reviewed on [DATE], did not show a resident focused care plan for smoking. A review a Federal Guideline 42 CFR 483.25(H)(1) and (2) also requires that the care plan for residents that states, when smoking reflects specific information and that the resident's plan of care be reviewed and revised periodically as needed. On [DATE] at 11:17 AM, the surveyor interviewed the DON. The DON stated, on admission or re-admission the nursing department and MDS department create a care plan for each resident. The DON further stated all residents who are smokers, should have an individualized care plan that addresses the resident's goals and interventions with regards to smoking. On [DATE] at 01:21 PM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above concerns. A review of the facility's Safe Smoking Policy that was provided by the LNHA with a revised date of [DATE] stated under the procedure section; 1. Any resident who wishes to smoke will be assessed by the nurse on admission and quarterly. 4. On [DATE] at 10:54 AM, the surveyor reviewed the closed record for Resident #267, who expired in the facility. The surveyor reviewed the hybrid medical records of Resident #267 as follows: The [DATE] OSR revealed a physician order date of [DATE] for DNR (Do Not Resuscitate) DNI (Do Not Intubate) DNH (Do Not Hospitalize) Pt (patient) has cancer and choose palliative care. A review of Resident #267's nursing progress notes revealed a nursing note dated [DATE] at 11:55 PM, Resident placed on Palliative Care. Now DNR, DNI, DNH. The closed care plan dated [DATE] did not show a resident focused care plan for palliative care. On [DATE] at 11:17 AM, the surveyor interviewed the DON. The DON stated, on admission, re-admission and/or as changes occur the nursing department and MDS department create and update care plans for each resident. The DON further stated any residents who are placed on palliative care, should have an individualized care plan that addresses the resident's goals and interventions with regards to palliative care. On [DATE] at 01:21 PM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above concerns. On [DATE] at 11:30 AM, the survey team met with the DON and LNHA. The LHNA stated all the care plan concerns have reviewed and resident care plans will be updated as needed. A review of the facility's Care Plans-Comprehensive Policy that was provided by the LNHA with a revised date of [DATE] included an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. A review of the facility's Palliative/End-of-Life-Care Clinical Protocol that was provided by the LNHA with a revised date of [DATE] revealed under the assessment and recognition section, 3. The physician will review the resident's decision-making capacity and help the staff obtain maximum participation in the care plan. Under the treatment and management section of the policy it revealed, 5. Nursing staff will implement comfort measures identified in the comprehensive care plan. On [DATE] at 01:35 PM, the survey team met with the LNHA, the DON, and the Business Office Personnel for an exit conference, and there was no additional information provided by the facility management. NJAC 8:,d+[DATE].2 (e)

Based on interview, record review, and facility policy review, the facility failed to ensure two of two residents (Residents (R) 4 and R17) reviewed were free from resident-to-resident physical abuse. This resulted in harm when R4 was hit with a metal object and sustained nine sutures to the face, a laceration to the left cheek, and bruise to the left eye. Additionally, R17 was hit with a metal bar and sustained facial trauma and a human bite mark on his forearm. Findings include: Review of the New Jersey Department of Health (NJ DOH) Reportable Event Record/Report, provided by the NJ DOH, dated [DATE] and completed by the Director of Nursing (DON), revealed R4 and R17 had a physical altercation with a metal object. Further review of the Reportable Event Record/Report revealed the metal object was described as round with 6 holes in it, some sort of bracket, not a metal bar, that both residents stated was in a drawer in their room. Per the Reportable Event Record/Report the object did not match any facility equipment or hardware and was immediately removed. Review of R4's Admission Record printed from the facility's electronic medical record (EMR) showed a facility admitted [DATE] with medical diagnoses that included bipolar disorder, depressive disorder, and abnormalities of gait and mobility. During an interview on [DATE] at 4:25 PM, R4 related there had been an incident between him and his former roommate and he received seven stitches from a metal bar he was hit with over the television volume. Review of R4's EMR Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R4 had intact cognition and no behaviors. Review of R4's EMR Care Plan tab revealed no care plan for behaviors prior to the altercation on [DATE]. Review of R4's EMR Progress Notes tab showed a nurse's note written by Licensed Practical Nurse (LPN) 5 on [DATE] at 12:49 AM, that stated, Resident came to the nurses [sic] station at about 10:58 PM with blood to his face and shirt. He stated that his roommate [R17] hit him several times with an iron bar which he presented to the nurse. I went to the room to take the statement from the roommate [R17]. Roommate [R17] stated that it was that [R4] hit him first with the bar on his right face. Both were cleaned, first aid treatment applied, MD's [physicians] and families made aware. Review of R17's Admission Record printed from the facility's EMR showed a facility admitted [DATE], readmitted [DATE], with medical diagnoses that included schizophrenia and major depressive disorder. Review of R17's EMR MDS with an ARD of [DATE] revealed a BIMS of 15 out of 15 indicating R17 had intact cognition and no behaviors. Review of the EMR Care Plan tab revealed no behavior care plan prior to the altercation. Review of R17's EMR Progress Notes showed a note written by LPN5 on [DATE] at 1:30 AM that stated, Note Text: Resident in room [room number, B bed] came to the nurse's station at about 10.58 PM [sic] with blood to his face and shirt. He stated that his room mate [sic] hit him several times with an iron bar which he presented to the nurse. I went to the room to take the statement from the resident [R17's name]. [R17's name] stated that it was his room mate [sic] that hit him first with the bar on his right face. He had an [sic] hematoma to each of his right face and jaw. R17 had since expired, unrelated to the altercation, and was not available for an interview. Further review of R4 and R17's EMR Progress Notes did not show documentation of any confrontations between the roommates or any other resident in the months preceding the incident. Both residents were sent to the hospital emergency room and R4 returned from the hospital with multiple laceration sites; left temporal which required three staples, right temporal which required three staples, left forehead which required three sutures, the left cheek was laceration was closed with derma bond, and a bruise to the left outer eye. R17 returned from the emergency room with a diagnosis of facial trauma, abrasions of multiple sites, and a human bite mark of forearm. R17 was prescribed a broad-spectrum antibiotic, twice daily for seven days. Review of the facility incident report showed the residents were separated with R4 moving to a different unit on a different floor. There was no determination on where the metal object came from since both residents were able to sign themselves out into the community and may have obtained the metal object while on a leave of absence. Interview with the Director of Nursing (DON) on [DATE] at 2:08 PM stated the residents had no history of behaviors. After the incident the residents were separated and sent to the hospital. We followed our procedure for resident to resident [altercations]. When asked to review the resident to resident altercation procedure, the DON stated they did not have a written procedure to provide regarding resident to resident abuse procedure. Due to conflicting statements from R4 and R17, the facility was not able to determine who the aggressor was, who had the metal object, or where the metal object came from. Review of the facility policy titled Abuse Reporting and Response, reviewed [DATE], revealed, Procedure 1. Our facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. This citation is related to Intake NJ 00160829.

Based on observation, interview, medical record review, and other facility documentation, it was determined that the facility failed to: a) identify residents exposed to COVID-19 as persons under investigation (PUI); b) implement mitigation strategies to prevent the transmission of COVID-19; c.) follow their Outbreak Response Plan to address the care of resident's who had been exposed to a COVID-19 positive individual; and d.) employ a full-time infection preventionist who had the appropriate education and training. This deficient practice was identified for 15 out of 17 residents (Resident #1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17) reviewed during a focused COVID-19 infection control survey, and for 2 of 3 nursing units. Part A: On 4/13/21, the facility became aware that a 3:00 PM to 11:00 PM Certified Nurse Aide (CNA #1) tested positive for COVID-19 via a rapid [MEDICATION(S)] test (a rapid test that detects the presence of protein [MEDICATION(S)] from [CONDITION(S)]-CoV-2). On 4/14/21, CNA #1 had a PCR test (a laboratory test performed to detect the genetic material that is specific to the [CONDITION(S)]-CoV-2 virus) performed. The facility became aware on 4/16/21 that the PCR test for CNA #1 was negative for COVID-19. On 4/16/21 the surveyors reviewed the 4/12/21 resident care assignment for CNA #1 on the 3:00 PM to 11:00 PM shift and identified that CNA #1 provided direct resident care to 14 residents who resided on the fourth floor (Resident #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17). Ten of the fourteen residents on CNA #1's assignment, (Resident #4, #5, #6, #8, #9, #11, #12, #13 #16, and #17) were fully vaccinated for COVID-19. The facility failed to identify these 14 residents who were exposed to COVID-19 as PUI. Upon a known exposure to a COVID-19 positive staff member, the facility failed to place these residents on TBP to mitigate the spread of the COVID-19 virus. During the survey conducted on 4/16/21, the surveyors toured the fourth floor. They observed that no residents were identified as PUI, and there was no signage posted on any of the resident room doors to identify that the residents who resided on the fourth floor were on droplet TBP. There were no personal protective equipment (PPE) bins that contained the necessary PPE (N95 masks, gowns, gloves, face shields/goggles) for TBP. Staff caring for the well non exposed residents were observed entering the resident's rooms wearing only surgical masks, no eye protection, and staff were unaware of the appropriate TBP or protocol that should have been implemented upon a known exposure to the COVID-19 virus. The facility's failure to identify residents on the well non-exposed fourth-floor unit as being exposed to the COVID-19 virus or implement mitigation strategies to prevent the spread of the COVID-19 virus posed a serious and immediate threat to the health, safety, and well-being of all well non-exposed residents. This resulted in an Immediate Jeopardy (IJ) situation that began on 4/13/21 when the facility was notified of the confirmed COVID-19 rapid positive test result for CNA #1. The facility's Administration was notified of the IJ on 4/16/21 at 4:27 PM. The immediacy was removed on 4/20/21 at 3:30 PM based on an acceptable removal plan implemented by the facility and verified by the surveyors during an on-site revisit survey conducted on 4/21/21. The evidence was as follows: On 4/16/21 from 9:28 AM to 10:16 AM, the surveyors conducted an entrance conference with the person who identified himself as the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Interim Registered Nurse/Infection Preventionist (IRN/IP) and Licensed Practical Nurse/Assistant Director of Nursing (LPN/ADON). The surveyors asked the administrative team the type of PPE that the facility staff was required to wear when entering a room for a PUI or COVID-19 positive resident. The DON stated that there were no COVID-19 positive residents or PUI residents currently in the facility. The DON said if there were COVID-19 positive or PUI residents, the staff would be required to wear full PPE. The DON stated full PPE included wearing an N95 mask, face shield or goggles, gown, gloves, and a surgical mask worn over the N95 mask. During the entrance conference, the DON stated CNA #1 traveled to [NAME] Rico and neglected to tell the facility that she traveled until after her positive rapid COVID-19 test result was received on 4/13/21. The DON stated that CNA #1 returned to work on 4/07/21, and at that time, the facility conducted a rapid [MEDICATION(S)] test, and the result was negative. The DON stated that CNA #1 then tested positive for COVID-19 via a rapid [MEDICATION(S)] test performed at a doctor's office on 4/13/21. The DON stated that CNA #1 informed the facility that she went to the doctor because she was not feeling well. The surveyors asked the administrative team what their actions were after confirmation that a staff member who provided direct care to residents, tested positive for COVID-19. The IRN/IP stated that if the staff member were present in the facility when they found out about the positive COVID-19 rapid [MEDICATION(S)] test result, they would have immediately been sent home, and the facility would follow up with a second PCR test. The IRN/IP further stated that the residents who were cared for by the COVID-19 positive staff member would then be assessed for signs and symptoms of COVID-19 and be rapid [MEDICATION(S)] tested for the COVID-19 virus. The surveyors asked the IRN/IP if the Center for Disease Control (CDC) or New Jersey Department of Health/Communicable Disease Services (NJDOH/CDS) provided guidance for the care of residents that were exposed to COVID-19 to be placed on TBP after exposure to a COVID-19 positive staff member. The IRN/IP stated that she would have to double-check on that and could not answer. At 10:36 AM, the surveyors conducted a tour of the fourth floor (rooms 401 through 453) and observed that no residents were on TBP. The surveyors toured the entire fourth floor unit, and signs that would indicate a resident was on TBP were not observed outside of any of the residents' rooms. There was no signage that indicated to stop and don PPE before entering resident rooms. The surveyors further observed that there was no available PPE in bins located outside of resident rooms. Staff were observed walking throughout the unit wearing only a surgical mask. Staff were also observed entering and exiting resident rooms wearing only surgical masks, no eye protection, and without donning or doffing additional PPE. The Surveyor conducted the following interviews on the fourth floor: At 10:38 AM, Surveyor #1 interviewed the Licensed Practical Nurse, Unit Manager (LPN/UM). The LPN/UM was observed wearing a mask, and she stated it was a regular mask and not a KN95 or N95; The LPN/UM was not wearing eye protection. She said there were no residents on TBP and the staff just wore surgical masks. At 10:42 AM, Surveyor #1 interviewed the LPN/ADON, who was observed wearing a surgical mask and no eye protection. She stated a surgical mask was the only requirement for staff to wear when providing care for the residents on the fourth floor. At 10:46 AM, Surveyor #1 interviewed a housekeeping staff who identified herself as the 4 East housekeeper (HK #1). She was observed wearing a surgical mask and no eye protection. The HK #1 stated there were no COVID-19 positive residents on the floor, and she did not need to wear a special mask when she cleaned the resident rooms. At 10:46 AM, Surveyor #2 interviewed the Licensed Practical Nurse #1 (LPN #1), who was observed wearing a surgical mask and no eye protection. LPN #1 stated that there were no residents who resided on the fourth floor on TBP. LPN #1 noted that facility staff was only required to wear a surgical mask when caring for the well, non-exposed residents. LPN #1 further stated that if a resident was on TBP, the unit manager would notify the staff and that the resident would be moved to another unit. At 10:48 AM, Surveyor #1 interviewed a physical therapist (PT) who was observed wearing a KN95 mask and no eye protection. Surveyor #1 inquired to the PT if any residents on the fourth floor required TBP. The PT stated, I think this is a COVID-free unit because there are no TBP signs. She was then observed entering a resident's room. At 10:55 AM, Surveyor #1 observed HK #1 enter a resident's room, wearing only a surgical mask and no other PPE, and proceeded to mop the floor in a resident's room. At 11:08 AM, Surveyor #2 observed CNA #2 wearing a surgical mask. CNA #2 stated that there were no residents who resided on the fourth floor on TBP. CNA #2 further said that she always wore a surgical mask when she took care of the residents. At 11:11 AM, Surveyor #2 observed HK #1 enter a resident's room on the fourth floor wearing a surgical mask. When HK #1 exited the room, Surveyor #2 interviewed HK #1, who stated that she wore a surgical mask when she entered the resident's rooms. The HK #1 said that she never wore eye protection, a gown, or gloves when entering the resident's rooms unless the resident was on TBP. The HK #1 further stated that there were no residents who resided on the fourth floor on TBP. At 11:15 AM, Surveyor #2 observed HK #2 enter a resident's room on the fourth floor wearing a surgical mask and swept the floor. No residents were observed in the room. When HK #2 exited the room, Surveyor #2 interviewed HK #2, who stated that she was required to wear a mask and gloves when entering the resident's rooms. HK #2 said that if a resident was on TBP, she would be required to don full PPE. HK #2 further stated that no residents who resided on the fourth floor were on TBP. At 11:18 AM, Surveyor #1 interviewed the DON and the LPN/ADON in the facility conference room. At 11:20 AM, the DON stated he just now got the PCR test results back for CNA #1 and provided Surveyor #1 with a copy. The test results revealed a negative test result for [CONDITION(S)] CoV-2, Swab, with a data collection date of 4/14/21 at 4:07 PM and the report date of 4/16/21 that was not timed. The DON stated the reports were not timed. The IRN/IP and person who identified himself as the LHNA joined the interview, and the IRN/IP said she was the facility contact for the local Department of Health (LDOH). At 11:26 AM, Surveyor #2 observed the LPN/UM on the fourth floor wearing a surgical mask. Surveyor #2 interviewed the LPN/UM, who stated that the residents on the fourth floor were considered well non-exposed, and there were no residents who resided on the fourth floor on TBP. The LPN/UM stated that if a staff member tested positive for COVID-19, contact tracing would be completed. The LPN/UM noted that the facility management reviewed the resident care assignment for CNA #1 after they found out that CNA #1 tested positive for COVID-19 and the facility then initiated COVID-19 monitoring for the residents and performed a rapid [MEDICATION(S)] test on all the staff and the residents that were on CNA #1's assignment. The LPN/UM stated CNA #1 worked the 3:00 PM to 11:00 PM shift on 4/12/21 and developed signs and symptoms of COVID-19 the next day (4/13/21). The LPN/UM further stated that CNA #1 went to see her doctor because of her symptoms, and she tested positive for COVID-19 at the doctor's office. The LPN/UM further stated that a CNA's job responsibilities included providing direct hands-on care for the residents and included toileting, showering, transferring, and helping the residents with eating. At 12:22 PM, both surveyors conducted a telephone interview with the LDOH. The LDOH stated her responsibility of the LDOH was to monitor the facility for new cases of COVID-19 and ensure the facility was following the necessary isolation and quarantine standards, ensure they are properly disinfecting, and following the regulations for testing residents and staff. The LDOH stated she was made aware of the COVID-19 + staff member on 4/13/21. The surveyors inquired to the LDOH regarding the facility's responsibility if a CNA tests positive for COVID-19. The representative from the LDOH stated the facility definitely must quarantine the residents that were cared for by the CNA and test and retest the residents. The LDOH said the facility should have started the TBP as soon as they were made aware the staff member tested positive, and the facility has been doing this for over a year and should have known the guidance. At 1:09 PM, the Surveyors interviewed the IRN/IP. The IRN/IP stated she had been in the Infection Preventionist (IP) role for three years and that last year, she was supposed to go for infection control training. She stated she completed five modules of the CDC training, and she had not had a chance to finish it. She said, I am still trying to work on it. Surveyor #1 inquired to the IRN/IP if she had anyone she worked with regarding any infection control concerns. The IRN/IP stated she would collaborate with the DON on infectious disease issues. At 3:01 PM, the surveyors interviewed the IRN/IP regarding her current role in the facility. The IRN/IP stated she was the full-time MDS coordinator. The surveyors showed her the IP job description and inquired if that was her job description. The IRN/IP said, no. A review of the facility outbreak line list dated 4/16/21 indicated that CNA#1 tested COVID-19 positive on 4/13/21 using COVID-19 rapid [MEDICATION(S)] test procedures. The comment section of the facility's outbreak line list indicated, Staff had herself tested outside due to symptoms, rapid test was done yesterday 4/13/21 outside and was positive, PCR test done 04/14/21- pending result. A review of CNA #1's Summary of Todays' Visit with an outside physician dated 4/13/21 indicated that CNA #1 had contact with and suspected exposure to other [CONDITION(S)] communicable diseases. A further review of CNA #1's Summary of Today's Visit indicated that CNA #1 had a [CONDITION(S)]-CoV-2 rapid ag (COVID-19) positive test result. A review of CNA #1's PCR COVID-19 test result dated 4/16/21 indicated a negative test result. A review of CNA#1 assignment sheets dated 4/12/21 indicated that the CNA #1 provided direct resident care on the 3:00 PM to 11:00 PM shift on the 4th floor to 14 well non exposed residents, (Resident #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17). Out of the 14 residents on CNA #1's assignment, 10 out of 14 residents, (Resident #4, #5, #6, #8, #9, #11, #12, #13 #16, and #17) were fully vaccinated for COVID-19. These 14 well non exposed residents remained negative and not on TBPs according to the facility's outbreak line list. A review of the IRN/IP Certificate of Training for the role of Infection Preventionist indicated that on 7/08/20, Module 1- Infection Prevention & Control Program from the CDC Nursing Home Infection Preventionist Training Course was completed. A review of the IRN/IP Certificate of Training for the role of Infection Preventionist indicated that on 7/08/20, Module 2- The Infection Preventionist from the CDC Nursing Home Infection Preventionist Training Course was completed. A review of the IRN/IP Certificate of Training for the role of Infection Preventionist indicated that on 7/31/20, Module 3- Integrating Infection Prevention and Control into the Quality Assurance Performance Improvement Program from the CDC Nursing Home Infection Preventionist Training Course was completed. A review of the IRN/IP Certificate of Training for the role of Infection Preventionist indicated that on 8/02/20, Module 4- Infection Surveillance from the CDC Nursing Home Infection Preventionist Training Course was completed. A review of the IRN/IP Certificate of Training for the role of Infection Preventionist indicated that on 8/02/20, Module 5- Outbreaks from the CDC Nursing Home Infection Preventionist Training Course was completed. There was no further documentation provided that the IRN/IP completed any additional training from the CDC Nursing Home Infection Preventionist Training Course Program. A review of a statement written by the Infectious Disease Care Physician (IDCP) provided to the New Jersey Department of Health (NJ/DOH) post-survey dated 4/19/21, indicated that he had interviewed CNA #1 who stated that she had accompanied a close family member to the doctor because the immediate family member had a fever. The IDCP further indicated in his letter that CNA #1 was asymptomatic, had a prior history of COVID-19, her rapid test was positive, and CNA #1 had not been vaccinated for COVID-19. The IDCP indicated, the preliminary analysis erroneously [mistakenly] notes that the staff member was unwell and indicated for testing. The IDCP further stated in his letter that the facility followed their Outbreak Response Plan, and no isolation or patient movement was indicated. The IDCP statement contradicted the current Center for Disease Control (CDC), NJDOH/CDS guidance, and the facility's Outbreak Response Plan. A review of a statement written by CNA #1 provided to the NJ/DOH post-survey dated 04/19/21 indicated, I, [name redacted], Certified Nursing Assistant, brought my [family member redacted] to his physician on March 12, 2021, to be tested for Covid-19. While there, I was routinely tested , and the doctor said that I was positive for a rapid [MEDICATION(S)] COVID-19 test. I had no symptoms of the virus and was recovered from a prior Covid-19 infection. CNA #1 did not indicate when she previously had tested positive for COVID-19 in her statement. On 4/20/21 at 12:53 PM, Surveyor #2 conducted a telephonic post-survey interview with CNA #1, who stated that she had brought her close family member to a clinic on 4/13/21, not on March 12, 2021, as written in her statement. CNA #1 said that she had returned from [NAME] Rico on Sunday, 4/04/21, and her first day back at work was Wednesday, 4/07/21. CNA #1 stated that she was rapid [MEDICATION(S)] tested her first day back to work on 4/07/21, and the test came back negative. CNA #1 further stated that she lived with her close family member, who she accompanied to the clinic. Surveyor #2 asked CNA #1 if she or her immediate family member presented with symptoms of COVID-19 when she brought her close family member to the clinic on 4/13/21. CNA #1 stated that she had a cough, and her immediate family member had a high fever. This statement provided by CNA #1 contradicted what the IDCP and CNA #1 wrote in their statements provided to the NJDOH post-survey. This statement corroborates what was told to the surveyors by the Administrative team at the entrance conference on 4/16/21, confirming what was said to Surveyor #2 during the interview with the LPN/UM 4/16/21, and corroborates what was documented on the facility's outbreak line listing dated 4/16/21. The IJ was identified on 4/16/21 to the person who identified himself as the LNHA, DON, IRN/IP, and LPN/ADON were notified of the IJ at 4:27 PM. A removal plan was accepted on 4/20/21 at 3:30 PM, which included that residents who were identified as coming into close contact with CNA #1 remained in their rooms, were considered PUI, and placed on TBP in accordance with CDC guidelines. The facility updated its Outbreak Response Plan in accordance with the most recent CDC guidelines for COVID-19, all licensed staff were in-serviced, and the IRN/IP completed her training required for the Infection Preventionists' role on 4/18/21. The implementation of the removal plan was verified on-site on 4/21/21. On 4/21/21 at 10:36 AM, the surveyors toured the 4th floor of the facility and verified through observations, interviews with facility staff, and review of in-service education, facility documentation, and review of the updated Outbreak Response Plan updated on 4/20/21 that the Removal Plan had been implemented. A review of the Certified Nursing Aide Position Title implemented and dated 1/09/99 indicated the CNAs were responsible for providing direct resident care activities such as bathing residents, combing resident's hair, cleaning and cutting the resident's fingernails, and shampooing the resident's hair. A review of the Certified Nursing Aides job description further indicated that the CNAs were responsible for assisting the residents in and out of bed and in walking and transporting the residents throughout the facility via wheelchair or stretcher. A review of the Infection Control Coordinator Position Title implemented and dated 1/09/99 position summary indicated that the Infection Control Coordinator assists and supports the translation of the nursing philosophy of the facility into nursing practice by participating in the planning, implementation and evaluation of the nursing care delivery system. In addition, he/she provides residents and personnel with established guidelines to follow in prevention and spread of contagious, infectious, or communicable disease. The Infection Control Coordinator Position title indicated that the Infection Preventionist responsibilities included ensuring that all infection control policies and procedures were implemented and followed. The Infection Preventionist was responsible for conducting rounds throughout the facility to assure compliance with State and Federal guidelines. The Infection Control Coordinator Position Title indicated the Infection Preventionist required a minimum of three years full-time or equivalent clinical experience, a minimum of two years experience in long-term care with one year of experience in a supervisory role. The Infection Control Coordinator Position title further indicated that specific education for the Infection Preventionist required, Annual attendance of an Infection Control Seminar and comprehension of New Vista Nursing and Rehabilitation Center Infection Control Manual are also required. A review of the facility's Outbreak [Response] Plan reviewed 9/2020 indicated that the Infection Preventionist would serve as the point of contact for the local, state, and federal agencies and would be responsible to keep up to date with the changing guidance. The facility's Outbreak Plan further indicated that COVID-19 TBP was used with suspected, symptomatic, exposed, confirmed residents, and residents within 14 days of admission or readmission to the facility. The Outbreak Response plan reflected that all staff PPE included the use of a gown, gloves, mask (preferably N95 respirator), and eye protection. A further review of the facility's Outbreak Plan indicated, Cohort 2 residents are those that have been exposed to a confirmed COVID (+) case. COVID-19 transmission-based precautions will be implemented for these residents for a minimum of 14 days following exposure. A review of the guidance of the NJDOH/CDS Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated revised 03/25/21 included that cohort 2 COVID-19 negative, exposed consisted of both symptomatic and asymptomatic residents who tested negative for COVID-19 with an identified exposure to someone who was positive regardless of vaccination status. These individuals should be quarantined for fourteen days from the last exposure, regardless of test results or vaccination status. The guideline further included that residents in cohort 2 should be quarantined for 14 days and initially tested . If testing is negative, the resident should be retested five to seven days post-exposure. If the resident remained negative, the resident should complete the remainder of the 14-day quarantine period. The guideline further included that residents in cohort 2 should be placed on TBP using the COVID-19 recommended PPE of an N95 mask, eye protection, gloves, and isolation gowns. Further review of guidance from NJDOH/CDS COVID-19 Exposure Risk Assessment Template for Patients in Post-acute Care Setting dated 3/22/21 included that individuals cared for within an inpatient healthcare setting should not test out of COVID-19 quarantine. The guidance further indicated, Given the need for often extensive and close contact between patients/residents and healthcare personnel (HCP), a 14-day quarantine period continues to be recommended for close contacts to a suspected of confirmed COVID-19 case. This option maximally reduces post-quarantine transmission risk and is the strategy with the greatest collective experience at present. Shortening quarantine time may increase the risk for COVID-19 transmission when compared to the currently recommended 14-day quarantine. The variability of [CONDITION(S)]-CoV-2 transmission observed to-date indicates that there may be settings (e.g., with high contact rates) where even a small risk of post-quarantine transmission could result in a substantial spread, The guidance further indicated that there were no changes in infection prevention and control recommendations for fully vaccinated residents who were identified as having close contact with a suspected or confirmed COVID-19 case. On 4/16/21 at 11:31 AM, Surveyor #2 entered the 5th floor and observed a stop sign outside of Resident #1's door, which indicated to stop and see the nurse before entering the room. Surveyor #2 further observed a plastic bin containing PPE, which contained gowns, gloves, and face shields outside of Resident #1's room. At 11:46 AM, Surveyor #2 observed HK #3 enter Resident #1's room and sweep the floor in the resident's room. The surveyor observed HK #3 only wearing a surgical mask inside of the resident's room. HK #3 exited the resident's room, and Surveyor #2 attempted to interview HK #3, who stated that she did not speak English. At 11:49 AM, Surveyor #2 interviewed HK #3 with the Social Worker's assistance, who acted as a translator. HK #3 stated that the resident was on TBP and she should have worn a gown, gloves, and a face shield while cleaning the resident's room. At 11:52 AM, Surveyor #2 conducted an interview with LPN #2 on the 5th floor, who stated that the stop sign outside of Resident #1's door was there because the resident was a new/readmission to the facility and was on observation and quarantined for 14 days. LPN #2 further stated that the PPE required to be donned before entering the resident's room included a gown, gloves, face shield, N95 mask, or double surgical mask if no N95 mask was available. The surveyor reviewed the medical record for Resident #1. A review of Resident #1's Admission Record indicated that the resident was admitted to the facility within the last 14 days. Part B: The noncompliance remained on 4/21/21 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Based on observation, interview, medical record review, and other facility documentation, it was determined that the facility failed to ensure that staff appropriately don (put on) personal protective equipment (PPE) for a resident who was on droplet/transmission-based precautions (TBP). This deficient practice was identified for 1 of 2 staff observed for implementation of infection control practices on the fourth floor during the removal plan visit on 4/21/21 and was evidenced by the following: On 4/21/21 at 10:40 AM, during a tour of the fourth floor, Surveyor #2 observed a stop and see nurse before entering sign located on the left door frame of Resident #17's room. The surveyor further observed a plastic bin outside of the resident's room that contained gloves, surgical masks, face shields, and both washable and disposable gowns. Resident #17 resided in the room by himself/herself. At 11:10 AM, Surveyor #2 observed a staff member sitting on the vacant bed inside Resident #17's room wearing a surgical mask. The staff member was not observed wearing additional PPE. The surveyor further observed Resident #17 inside the room, seated in his/her wheelchair wearing a surgical mask. The staff member was not observed providing direct contact to the resident. The surveyor observed the staff member in the resident's room for approximately 20 seconds. When the staff member exited Resident #17's room, Surveyor #2 interviewed the staff member who identified himself as an Occupation Therapist (OT). The OT stated that the stop sign outside the resident's door meant that the resident was on COVID observation, and before entering the resident's room, he was required to don full gear, which consisted of a gown, gloves, face shield, and a surgical mask. The OT further stated that he was unsure if he had to wear a respirator (N95 mask) but had been fit tested for one. The OT noted that he didn't don additional PPE prior to entering the resident's room on TBP because he didn't see the stop sign and further stated, that was my mistake. The OT noted that the purpose of donning PPE before entering a resident's room on TBP was to prevent the spread of infection. At 11:18 AM, the surveyors interviewed the LPN/UM, who stated that only staff who provided direct patient care had to don full PPE before entering a resident's room who was on TBP. The LPN/UM further stated that if someone were just going to drop off a tray containing food to a resident on TBP, they would not need to don full PPE. The LPN/UM further stated that a resident who was on TBP for COVID-19 was on droplet and contact TBP. At 11:29 AM, the surveyors interviewed the Occupational Therapist/Rehab Director (OT/RD), who stated that she provided in-service education to all of her staff and taught her staff that if there was a resident with a stop sign outside their door, the therapy staff were required to ask the nurse on the unit what PPE they were required to don prior to entering the resident's room. The OT/RD further stated that she educated all her staff throughout the Pandemic that all residents on TBP who were considered PUI and on observation related to COVID-19 required full PPE to be donned before entry of the resident's room. The OT/RD stated that full PPE consisted of an N95 respirator, a surgical mask covering over the N95 mask, face shield, gown, and gloves were required to be donned before crossing the threshold of the resident's room regardless of direct contact with the resident. The OT/RD further stated that there was no excuse for not donning full PPE before entering a resident's room on TBP because the COVID-19 virus was deadly, and the PPE prevented the spread of infection to other residents and staff members. At 12:12 PM, the surveyors interviewed the DON, who stated that he provided staff with Infection Control education throughout the Pandemic and re-inserviced all staff on 04/16/21 and throughout the weekend that full PPE such as an N95 respirator mask, surgical mask over, face shield, gown, and gloves was required to be donned prior to entering a resident's room who was on TBP related to exposure to COVID-19. A review of the facility's Outbreak Plan undated 4/20/2021 included under Isolation Protocol that all employees, health care workers and visitors who enter the room of a resident with confirmed or suspected COVID 19 will adhere to COVID-19 transmission-based precautions. The document also included that COVID-19 Transmission-based precautions were used with suspected, symptomatic, exposed, or confirmed residents and that all staff wear PPE consisting of a gown, gloves, mask (preferably N95 respirator) and eye protection. According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, COVID-19 Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing homes updated 03/29/21 indicated that a skilled nursing or long term care facility needed to assign one or more individuals with training in infection control to provide on-site management of the infection control program. The CDC guidance further indicated, This should be a full-time role for at least one person in facilities that have more than 100 residents. A further review of the U.S. CDC guidelines, COVID-19 Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing homes indicated in regard to managing residents who had close contact with someone with [CONDITION(S)]-CoV-2 infection, the residents who had close contact with someo

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) an effective system of cohorting Covid-19 positive, persons under investigation (PUI) and residents not exhibiting symptoms (non-ill or asymptomatic) of [MEDICAL CONDITION]; b.) Personal Protective Equipment (PPE) was available outside of the Covid-19 resident rooms and that staff follow proper PPE use between COVID-19 positive residents and residents not exhibiting symptoms (non-ill or asymptomatic) to control the spread of infection in a facility experiencing a COVID-19 outbreak. This deficient practice was identified during tour on 3 of 3 nursing floors (3rd-5th floor) conducted on 04/20/2020. On 04/20/2020, the surveyor reviewed the facility's COVID-19 outbreak response measures to include the resident and staff line list, infection data tracking/surveillance sheets, and other pertinent documents the facility provided as they related to COVID-19. The documents revealed that there was no system in place to identify or track the resident cohort group who were non-ill to prevent their exposure to [MEDICAL CONDITION]. Upon observation and interview, it was identified that there was no designation of staff to care solely for the Covid-19, PUI and non-ill residents on all nursing units throughout the facility. The Covid-19 and PUI residents were located throughout the units on each floor and were not cohorted to one area to minimize the exposure risk to non-ill, non-exposed residents. The surveyor identified, on the 4th floor (West), a Covid-19 positive resident (Resident #1) readmitted to the facility during the survey and placed in a room with a non-ill/non PUI resident (Resident #2). The facility staff were aware of Resident #1's readmission and that he/she was Covid-19 positive. There was no signage on the door to indicate it was a Covid-positive room nor was there PPE outside of the room. Staff were unaware that there was a non-ill, non-PUI resident (Resident #2) that was already residing in the room that Resident #1 was admitted to. The facility took action to move Resident #2 after surveyor inquiry. The surveyor observed a Registered Nurse (RN #1) on the 5th floor (East) at the medication cart. RN #1 then entered a Covid-19 positive room and exited without doffing PPE. There was no PPE available outside of the Covid-19 positive room. RN #1 returned to the medication cart where she performed hand hygiene, prepared medication and then entered a non-ill/non-PUI resident room, wearing the same PPE. In accordance with facility provided documents as of 04/20/2020 and interview, the surveyor discovered that the facility had a census of 215 with 47 confirmed Covid-19-positive; 33 PUI deaths with 22 deaths confirmed Covid-19 positive (55 total); and 17 PUIs between 03/23/2020-04/20/2020 with the latest onset of symptoms on 04/17/2020. The facility's failure to adequately conduct surveillance to identify and track the non-ill resident cohort group, effectively isolate Covid-19 positive from a non-ill/non-PUI resident, and use PPE appropriately to address the risk of cross-contamination posed a serious and immediate threat to the safety and wellbeing of all non-ill residents residing in the facility. This resulted in an Immediate Jeopardy (IJ) situation that began on 04/20/2020 at 11:45 PM. The facility provided an acceptable Removal Plan on 04/24/2020 at 3:00 PM. The Removal Plan implementation was verified by the surveyor during an on-site visit on 04/28/2020. The deficient practice was further evidenced by the following: During the entrance conference with the acting Director of Nursing (DON), Administrator and Owner on 04/20/2020 at 7:00 PM, the Owner explained that today was the Administrator's first day. The former Administrator had to leave to attend to family business. The DON stated that she was appointed recently to be the acting DON and she was also the Infection Control Coordinator as well as the Minimum Data Set (MDS) Coordinator for the facility. She stated the facility had a census of 215 with 47 confirmed cases of Covid-19 with 17 PUIs and no pending test results. The DON stated each nursing floor has two units (East and West) and that the Covid-19 positive and PUI residents were not separated into one area and were on every floor and unit. The DON stated that staffing has been a challenge and that staff were not designated to care for a specific cohort group. In reference to PPE, the DON stated that PPE was provided at the start of the shift and if extra PPE was needed it would be available. The Owner stated that the facility has been in contact with the Local Health Department. a.) On 04/20/2020 at 8:30 PM, during a tour of the 4th floor, the surveyor interviewed the Certified Nursing Assistant (CNA #2) regarding infection control protocols for Covid-19 residents. CNA #2 was wearing a gown and respirator mask. CNA #2 stated she is given a respirator mask when she arrives and disposes of it at the end of her shift. She stated she does not change her respirator or wear a mask over the respirator when caring for Covid-19 positive residents. She explained that she tries to go into the Covid-19 rooms last. CNA #2 stated she wears a gown, gloves and respirator into the Covid rooms and when she comes out she would remove her gown and gloves. When asked where she would place the used PPE, she pointed to the trash can attached to the treatment cart and said, I put it there. The treatment cart was stationed in the hallway outside of a glass-windowed room near the nurses' station, and across from occupied resident rooms. The surveyor noted that the treatment cart trash receptacle had a clear trash bag, had no containment lid and contained a yellow gown. CNA #2 stated she could not remember if that was a gown that was used in an isolation room or not. CNA #2 added that after she disposed of the gown, she would ask the nurse for a new one because they don't keep them outside of the rooms. On 04/20/2020 at 8:40 AM, the surveyor interviewed CNA #4 regarding infection control practices when caring for Covid-19 residents. CNA #4 stated she entered the Covid-19 rooms wearing a gown, mask and double gloves. She stated she removes the gown and gloves, places the PPE in a receptacle within the room, washes hands and exits the room. She stated she then would ask the nurse for a new gown. CNA #4 pointed to the glass-windowed area near the nurses' station and stated that sometimes, they keep the PPE in there. During the above interview with CNA #2 on 04/20/2020 at 8:40 PM, she stated that a Covid-19 resident (Resident #1) just came (from the hospital) into room [ROOM NUMBER]. Together, the surveyor and CNA #2 observed room [ROOM NUMBER] with no isolation signage on the door, no PPE outside of the room, and two resident occupants. In addition, there were three residents listed on the room's name plate, located on the wall outside the room door. CNA #2 confirmed the observation and stated she did not know why there were three names listed as one bed was unoccupied. CNA #2 confirmed that the second occupant was Resident #2 and that she did not think he/she was Covid-19 positive. CNA #2 stated she thought that the returning resident (Resident #1) was Covid-19 positive but would need to check with the nurse. The surveyor inquired about the nurse in-charge of the unit and was informed that the nurse assigned to the unit was the acting DON, who was not available on the floor at the time. Review of the 04/20/2020 Daily Staffing Schedule reflected that the acting DON was assigned to the 4th floor West Unit along with CNAs #2 and #4 for 36 residents on 04/20/2020 for the 3 PM-11 PM shift. On 04/20/2020 at 8:50 PM, the surveyor interviewed Licensed Practical Nurse (LPN #1) on the 4th floor East Unit, who was seated at the nurses' station. LPN #1 stated that the gowns were kept in the bottom of the medication cart. He pulled open the bottom drawer of the medication cart, that was within the nurses' station, and revealed yellow gowns. He stated that this was where the gowns were kept and if staff needed one, they would just ask. LPN #1 stated they were trying to preserve the gowns. Review of Resident #1's medical record revealed a NJ Universal Transfer Form, dated 04/20/2020, which indicated that the resident was transferred from the hospital to the nursing home at 3:30 PM. The form revealed that the resident had a [DIAGNOSES REDACTED]. Review of Resident #2's physician order sheets, progress notes, and medication administration records revealed the resident was asymptomatic for Covid-19 and that there were no physician ordered tests or treatments for Covid-19 prior to 04/20/20. Review of the resident Line Listing and Symptom Monitoring log used to document Covid-19 positive and PUI residents, provided by the DON on 04/20/2020, revealed that Resident #1 and #2 were not listed on either documents. On 04/20/2020 at 10:00 PM, the surveyor interviewed the acting DON who stated that on readmission, Resident #1 was placed in room [ROOM NUMBER], which was unoccupied. The surveyor informed the acting DON that room [ROOM NUMBER] was occupied by Resident #2. The acting DON placed a call to the 4th floor and confirmed that both Resident #1 and #2 were in room [ROOM NUMBER] and that stated that shouldn't have occurred. The acting DON then placed a call to the Admissions Staff who stated that the room was empty. The acting DON explained to the Admissions Staff that the room was already occupied by Resident #2. The acting DON stated to the surveyor and Admissions Staff that Resident #2 was not Covid-19 positive, was not a PUI, and had no Covid symptoms. She stated that typically residents were readmitted to their same rooms when they return from the hospital. After survey inquiry, the staff moved Resident #2 to another room. On 04/20/2020 at 11:08 PM, during a subsequent interview, the acting DON confirmed that neither Resident #1 and #2 were on the Line Listing and stated that the list needed to be updated. Review of the facility's Outbreak of 2019 Novel Coronavirus (2019-ncoV) policy dated 03/05/2020, provided by the Administrator on 04/20/2020, reflected that upon identification of a Coronavirus outbreak the facility will immediately isolate the patient. The policy does not address the separation and cohorting of Covid-19 positive, PUI and non-ill resident groups. Review of the facility's Infection Control policy dated, 06/2019, that was provided by the Administrator on 04/21/2020 by email, reflected that clear double bags should be used for disposal of contaminated materials (gowns, masks, etc.). Review of the facility's Infection Control Policy, dated 06/2019, provided by the Administrator by email on 04/21/2020, revealed that there was no guidance regarding the facility's isolation process for identifying rooms on isolation precautions and the provision of the PPE necessary to enter an isolation room. The consultant DON was notified of this on 05/06/2020 and provided an Isolation Room Set-up Positive Covid-19 policy, dated 04/29/2020 and revised 05/06/2020, by email on 05/06/2020. The policy indicated that an Isolation Caddy with PPE should be placed outside room that will include gowns, gloves and procedure masks. The Covid-19 room would be indicated by red tape and the PUI room indicate by yellow tape. Neither policy provided information regarding how to identify a room on transmission-based precautions not related to Covid-19. Review of the In-Service Attendance Records, provided by the Owner by email on 05/05/2020, revealed that CNA #1 attended the CDC Coronavirus Info/Infection Prevention & Handwashing in-service dated 01/25/2020 and the Common Human Coronaviruses in-service dated 03/05/2020. According to an email received from the consultant DON on 05/06/2020, competencies were done at the time of the in-service. LPN #1 had a handwashing competency dated 03/09/2020 with no corresponding in-service record. CNA #2 had a handwashing competency dated 03/04/2020 with no corresponding in-service record. CNA #4 had handwashing competency dated 03/04/2020 with no corresponding in-service record. The surveyor noted that CNAs #2 and #4 did not follow the correct process during the competency and needed to be corrected by the evaluator. b.) During the entrance conference on 04/20/2020 at 7:04 PM, the acting DON stated PPE was provided to all staff at the start of the shift and was available if staff needed extra. The acting DON stated that PPE was worn in the isolation room but clean PPE was needed after being in a COVID-19 positive room. On 04/20/2020 at 7:38 PM, the surveyor observed the 5th floor East unit. Upon entering the unit, the surveyor observed room [ROOM NUMBER] with a Stop Contact and Droplet precaution sign on the door. There was a gray cloth four-pocket hanging [MEDICATION NAME] on the door which was empty, with no PPE readily available for staff. The door was closed and had two resident names listed as occupants. On 04/20/2020 at 7:41 PM, the surveyor observed the 5th floor East unit with a staff member standing at the medication cart in the common area. The staff member was identified as the only Registered Nurse (RN #1) working on unit. RN #1 wore the following PPE: a gown, face mask and a face shield as she administered the medications. On 04/20/2020 at 7:51 PM, the surveyor observed RN #1 walk across the entire unit to room [ROOM NUMBER]. RN #1 knocked on the door and completely entered the room, wearing the same PPE observed earlier, to speak to Resident #3. RN #1 exited the room, walked across the entire unit past the medication room, and back to the medication cart wearing the same PPE. Without changing PPE, RN #1 sanitized her hands at the medication cart, prepared medications and entered room [ROOM NUMBER]. RN #1, still wearing the same PPE, administered medications to Resident #4 by the window. There was no signage on the door of room [ROOM NUMBER]. During an interview with the surveyor on 04/20/2020 at 8:15 PM, the 5th floor East Unit CNA #3 stated there was additional PPE in the unit medication room available for the staff. CNA #3 pointed out the unit medication room which was located at the nurses' station. room [ROOM NUMBER] was across from the nurses' station. During an interview with the surveyor on 04/20/2020 at 8:19 PM, RN #1 stated that room [ROOM NUMBER] was a COVID-19 positive room. RN #1 stated that the correct process was to enter the COVID-19 positive room wearing gloves, mask and gown and upon exit, she should have performed hand hygiene and changed her PPE in order to contain the infection. RN #1 stated that she had not changed her gown because that was the only one she had. She added that additional PPE was available upon request. Review of Resident #3's medical record revealed a laboratory report, dated collected 04/09/2020 and first reported on 04/11/2020. The lab report revealed that [DIAGNOSES REDACTED]-CoV-2 (Coronavirus Covid-19) was detected (positive for Covid-19). Review of Resident #4's physician order sheets, progress notes, and medication administration records revealed the resident was asymptomatic for Covid-19 and that there were no physician ordered tests or treatments for Covid-19 prior to 04/20/20. Review of the resident Line Listing and Symptom Monitoring log used to document Covid-19 positive and PUI residents, provided by the DON on 04/20/2020, revealed that Resident #3 was positive for Covid-19. Resident #4 was not listed on the Line Listing or Symptom Monitoring Log as a PUI or Covid-19 positive resident. Review of the In-Service Attendance Records, provided by the Owner on 05/05/2020, revealed that RN #1 and CNA #3 attended the CDC Coronavirus Info/Infection Prevention & Handwashing in-service dated 01/25/2020 and the Common Human Coronaviruses in-service dated 03/05/2020. Review of the Centers for Disease Control and Prevention (CDC), The COVID-19 Long-Term Care Facility Guidance, dated 04/02/2020, revealed Healthcare personnel should adhere to Standard and Transmission-based Precautions when caring for patients with [DIAGNOSES REDACTED]-CoV-2 infection. Review of the CDC, Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, dated 04/13/2020, linked Guidelines for Isolation Precautions which revealed, Standard Precautions that health care workers should remove and discard PPE before leaving the patient's room. Review of the facility, Infection Control P&P, dated 06/2019, revealed the purpose was to control the spread of infection and included wear a gown when entering the room and remove the gown before exiting the room. Review of the Centers for Medicare and Medicaid Services (CMS), LTC Infection Control Worksheet, Facility Self-Assessment Tool, referenced the 2019 Nursing Home Infection Control Worksheet (ICWS). The ICWS revealed, section H. Transmission-Based Precautions, H.10. gloves and gowns are removed and properly discarded, and hand hygiene is performed before leaving the resident care environment. On 04/20/2020 at 11:45 PM, the surveyors met with the acting DON, Administrator and Owner who were advised at that time of the failure to appropriately identify and track residents who were asymptomatic and PUI, and cohort Covid-19 positive residents; and appropriately cohort staff assignments to reduce the transmission of COVID-19 while ensuring PPE was immediately available and used appropriately. In addition, the administrative staff was advised that the improper infection control protocols placed the non Covid-19 positive residents in an Immediate Jeopardy (IJ) situation. The IJ began on 04/20/2020 at 11:45 PM and the immediacy was removed on 04/24/2020 at 3:00 PM based on an acceptable Removal Plan which included the following: Cohorting all Covid-19 positive and PUI residents on the 5th floor East Unit and using colored indicators ton the doors to differentiate the PUI from the Covid-19 positive resident rooms. A temporary separation wall was erected to limit access to and from the Covid-19 unit. Dedicated staff have been assigned to the Covid-19 unit with PPE available and accessible prior to entering the unit and at various locations within the unit. All staff were educated on the Covid-19 unit and reeducated, with return demonstration, on hand hygiene and donning/doffing of PPE. The implementation of the removal plan was verified on-site on 04/28/2020. On 04/28/2020 at 10:38 AM, the surveyor toured the Covid-19 unit and verified though observation, interviews with facility staff, and review of in-service education and revised facility documents that the Removal Plan had been implemented. NJAC 8:39-19.4; 27.1 (a)