Every finding on record at Preferred Care at Mercer

Based on observations, interviews, and policy review, the facility failed to prevent the build-up of grease, food crumbs, and dirt on fixed equipment, behind cooking equipment and on walls and floors for one of one kitchen, as well as failing to clean and maintain two of three ice machines in the facility. This deficient practice had the potential to affect 84 of 84 residents who received meals and beverages prepared in and served from the facility's kitchen and pantries. Findings include:1.During the initial kitchen tour and observation on 01/12/26 at 9:58 AM, the dishwasher revealed the tile wall and floor behind and underneath the dishwasher, covered in dark blackish-brown debris consisting of grease, food debris and dust and dirt. The debris was observed covering the surface and undercarriage of the heating unit. The observation also revealed the dark blackish-brown debris on the legs of the steam table, food preparation tables and shelves, and build-up of grease and residue on the outside of the gas range and the double ovens.During an interview on 01/12/26 at 10:03 AM, the Dietary Manager (DM) was asked about the soiled surfaces behind and under the dishwasher and peripheral equipment, and he/she advised that they tried to clean them daily. During observations on 01/14/26 at 10:51 AM and on 01/15/26 at 8:35 AM, the range, double ovens, steam table, and preparation surface areas behind and beneath the equipment remained soiled. During an interview on 01/15/26 at 8:35 AM, the DM was asked about the areas, and he/she stated that they tried to remove the debris with a pressure washer but had not been successful. He/she did, however, reveal that the area behind and underneath the dishwasher had been thoroughly cleaned and was free of debris. 2. During an observation on 1/14/26 at 10:30 AM, the 100 Unit ice machine revealed a slimy, brownish colored substance on the inside and outside of the chute. Located on the machine was a document titled, Ice Machine Inspection - Quarterly. The document also included the location of the inspection/log, Long term unit, for the year 2025. Per the log, the coils and motor were cleaned, and the filter was checked and replaced, but not dated. The log was signed off by the Maintenance Director (MD) for each quarter. An observation of the ice machine on the sub-acute unit, on 01/15/25 at 8:35 AM, revealed the same brownish colored substance on the chute, along with slimy blackish-brown and white bio-growth on the metal areas of the chute assembly. The unit also included a log that revealed the coils and motor were cleaned, dated 12/13/25, and the filter was checked and replaced quarterly.During an interview on 01/15/25 at 9:10 AM, the Housekeeper (HK) 1 was asked who was responsible for the ice machines and he/she advised that maintenance was responsible for maintaining the ice machine. During an interview on 01/15/26 at 11:28 AM, the MD stated that the maintenance department was responsible for wiping down the machine daily, the ice machine regularly, which included taking the machine apart every 90 days to clean the internal parts. Review of the U.S. Food and Drug Administration's (FDA) 2022 Food Code, dated 01/08/25 and located at https://www.fda.gov/food/fda-food-code/food-code-2022, page 114, revealed ice makers should be cleaned, (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.Review of the facility's policy titled, General Kitchen Sanitation, dated June 2019, revealed The Facility recognizes that food-borne illness has the potential to harm patients/residents. All Dietary employees will maintain clean, sanitary kitchen facilities in accordance with the county health department regulations and the current Federal and State Food Codes in order to minimize the risk of infection and food borne illness. Step one of policy procedure revealed to Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food contact surfaces and equipment. NJAC 8:39-17.2(g)

Based on observation, record review, interviews, and facility policy review the facility failed to implement pharmacy processes for labeling medications, including controlled substances (CS), for four of four medication carts (Medication Carts One and Two on [NAME] Unit; Medication Carts One and Two on Ewing Unit) observed for medication storage and labeling of 27 sample residents. This failure had the potential risk of drug diversion, theft, improper handling of returns, all impacting patient safety and compliance.Findings include:During observation of medication cart one on the [NAME] Hall on 01/13/26 at 1:00 PM, Licensed Practical Nurse (LPN) 2 revealed routine and controlled medications blister pack labels and controlled substance inventory log sheets located in medication cart one, which reflected See MD [Medical Doctor] orders as medication administration directions for use in accordance with the physician's orders.During an interview on 01/13/26 at 1:15 PM, LPN2 said that the nurses who received the medications including controlled substances, from the pharmacy, were responsible for ensuring the resident's name, prescribing doctor, directions for medication administration, the Rx (prescription) number, the name of the issuing pharmacy, and the Rx issue date reflected on the medication blister pack(s) label and on the narcotic inventory sheet. LPN2 said that the pharmacist consultant also checked the medication labels and narcotic inventory sheets when on-site to conduct a medication cart audit. LPN2 said that See MD orders was not an actual direction for use, but a reference to the resident's medication administration record (MAR) for specific instructions.During observation of medication cart two on [NAME] Hall on 01/13/26 at 3:45 PM, Registered Nurse (RN) 2 revealed routine and controlled medications blister pack labels and controlled substance inventory log sheets located in medication cart two, which reflected See MD Orders as medication administration directions for use in accordance with the physician's orders.During an interview on 01/13/26 at 3:59 PM, RN2 said he/she reviewed the MAR for instructions to administer medications to the resident. RN2 said that See MD Orders printed as the instructions for use did not follow the medication rights for verification to check the medication label against the order in the MAR before giving to the resident. RN2 stated not verifying the medication label against the physician's order could potentially risk patient safety. RN2 said that controlled substances could be miscounted or incidents of drug diversion when the medication blister pack did not reflect the number of pills that should be administered.During random observations of medication cart one on 01/14/26 at 8:30 AM with LPN1 and medication cart two at 8:40 AM with the Long-term Unit Manager (LTUM) on the Ewing Hall revealed routine and controlled medications blister pack labels and controlled substance inventory log sheets, reflected See MD Orders as medication administration directions for use in accordance with the physician's orders.During an interview on 01/14/26 at 10:04 AM, the Sub-Acute Unit Manager ([NAME]) stated that See MD Orders, was a process throughout the facility to prevent the need for clarification or to question orders with the physician. He/she said that the physician's wrote orders in the hard chart and any clarification of orders would be done before entered into the electronic medical record (EMR). The [NAME] said that he/she checked the EMR after a new admit ensuring orders were entered correctly and matched the discharge orders. The [NAME] said that he/she periodically checked physician orders in the EMR that they were entered correctly.During a phone interview on 01/15/26 at 9:45 AM, the Certified Pharmacy Consultant (CPHC) said that he/she conducted medication cart audits at the facility to systematically check for regulatory compliance including proper labeling that aligned with the MARs/orders, which was essential for patient safety. The CPHC said that audits confirmed adherence to policies, identified system failures, provided education, and prevented errors with high-risk meds. The CPHC said that pharmacies in the State of New Jersey were not required to write out the instructions for use on the label of the drug card and that See MD Orders was appropriate.During an interview on 01/15/26 at 12:16 PM, the Director of Nursing (DON) said that the nurses and Unit Manager were responsible for overseeing procedures that prevented medication errors and drug diversion such as performing the medication rights, ensuring the medication label and MAR matched, in that it was the right medication, right dose, right form, given at the right time, to the right resident via the right route. The DON said that the pharmacy consultant also audited the medication carts every two to three months to ensure that the facility complied with policies and procedures. The DON said that the label instructed the nurse to See MD Orders and the MAR would indicate how to administer the medication.Review of the facility's policy titled, LTC [Long Term Care] Pharmacy Services, revised 06/19/23, provided by the DON, indicated, PURPOSE To ensure that all medications are properly labeled. POLICY All medications dispensed or stored in the pharmacy must be labeled as per procedure. PROCEDURE Medications dispensed to residents are appropriately and safely labeled. Any labeling that is consistent with law, regulation and professional practice Intravenous (IV) medication labels shall have labels that bear: The Resident's full name; The prescriber's name; The prescription number; The name and strength of drug; The quantity dispensed; The lot number; The date of Issue; The expiration date; The manufacturer's name if generic; Cautionary and/or accessory labels; Directions for use . NJAC 8:39-5.1(a)NJAC 8:39-29.1NJAC 8:39-29.4

Based on record review, interview, and facility policy review, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNOC) notification was provided timely for two of three residents (Resident 5 and R32) reviewed for beneficiary notification of 27 sample residents. This had the potential to affect all residents being discharged from services. Findings include:1. Review of R5's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/26 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated the resident's cognition was severely impaired.Review of R5's SNF [Skilled Nursing Facility] Beneficiary Notification Review form revealed Medicare Part A skilled services start date was 08/23/25 and the last day covered was 10/15/25. Further review revealed Advance Beneficiary Notice of Noncoverage (ABN) notification was dated 10/10/25 and had initials written on the signature line.Review of R5's Nurse's Note located in the Notes tab of the (EMR) and dated October 2025 and November 2025 revealed no documentation related to a discussion with R5 about notice of Medicare noncoverage. During an interview on 01/15/25 at 3:40 PM with R5's Responsible Party (RP) who stated he/she was never contacted about R5's right to appeal his/her therapy benefits ending. The RP stated he/she was never asked, and he/she did not give permission for R5 to sign the beneficiary form in his/her place. He/she said R5 would not have been able to understand what he/she was signing. The RP stated he/she would have liked to have been made aware about the right to appeal because he/she certainly would have thought about if he/she should have appealed had he/she been made aware. 2. Review of R32's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy.Review of R32's quarterly MDS with an ARD of 11/30/25 and located in the EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident's cognition was severely impaired. Review of R32's SNF Beneficiary Notification Review form revealed Medicare Part A skilled services start date was 09/23/25 and the last day covered was 11/04/24. Further review revealed ABN was dated 10/31/25 and it stated refused to sign. Review of R32s Nurse's Note located in the Notes tab of the (EMR) and dated October 2025 and November 2025 revealed no documentation related to a discussion with R32's responsible party (RP) about notice of R32's Medicare noncoverage. Further review revealed no note related to a discussion with R32 or her refusal to sign the form. During an interview on 01/15/25 at 12:15 PM, R32 was shown the NOMNOC and stated he/she was unable to read due to his/her cataracts. R32 stated he/she was not informed that he/she had a right to appeal. He/she said that was never said to him/her. R32 said he/she had no memory of refusing to sign the NOMNOC form.During an interview on 01/15/26 at 1:43 PM, the Social Services Director (SSD) said when a resident needed to be notified of noncoverage of Medicare he/she spoke with the family, and the residents and made them aware their benefits would be stopped. SSD stated he/she gave them their last covered day, and if they remained in the facility, he/she would explain to them their rights to appeal. SSD said he/she did not document those conversations in the EMR anywhere. He/she stated if there was an RP, he/she reached out to them. He/she said a resident who had a BIMS of lower than 10 would not be appropriate to sign the forms therefore he/she spoke to the family. He/she said she spoke with R5's RP who was unable to sign and stated the RP told him/her to have R5 sign the form. SSD said when he/she spoke with R32, he/she refused to sign the form but did not document that conversation in the EMR. SSD stated he/she usually documented that on the form, but he/she did not on R32's and he/she was unsure why he/she did not. During an interview on 01/15/26 at 2:05 PM, the Director of Nursing (DON) stated he/she was not clinical and did not want to provide his/her expectations related to something not clinical. Review of the facility's policy titled, Advanced Beneficiary Notices, revised 09/25 revealed it is the policy of the facility to provide timely notices regarding Medicare eligibility and coverage. NJAC 8:39-5.1(a)

Based on record review, interviews, and facility policy review, the facility failed to develop a care plan for one of two residents (Resident (R) 11) reviewed for behavioral-emotional status of 27 sample residents. This failure could interfere with the resident receiving proper psychological services to help maintain a comfortable, safe life. Findings include:Review of R11's admission Record located in the Profile tab of the electronic medical record (EMR) revealed he was initially admitted to the facility on [DATE] and readmitted on [DATE] with major depressive disorder, anxiety disorder, and post-traumatic stress disorder (PTSD), chronic. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/14/25 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R11 had intact cognition. The MDS also indicated R11 had diagnosis of PTSD. Review of R11's CAA [Care Area Assessment] Worksheet, dated 09/11/25, revealed R11's mood interview triggered an actual problem/need related to PTSD. Review of R11's Care Plan, under the care plan tab of the EMR, revealed there were no care plans addressing R11's diagnosis of PTSD.During an interview on 11/21/25 at 1:05 PM, the Director of Nursing (DON) stated he/she should have created a care plan for R11's PTDS diagnosis. The DON stated R11 saw a psychiatrist and acknowledged that because the diagnosis was listed on the comprehensive assessment and on his face sheet. The DON stated they should have created a care plan. Review of the facility's policy titled, Comprehensive Care Plans, dated 08/25, revealed It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that are identified in the resident's comprehensive assessment. NJAC 8:39-11.2(e) thru (i)NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure residents who were assessed as requiring an apron were provided with an apron while smoking for one of two residents (Resident (R) 105) reviewed for smoking out of 27 sampled residents. This has the potential to affect all residents who smoke. Findings include:Review of R105's admission Record in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnosis of unspecified disorders of the brain.Review of R105's admission Minimum Data Set (MDS) under the Minimum Data Set (MDS) tab of the EMR revealed an assessment was still in progress. No Assessment Reference Date (ARD) available. Review of R105's Care Plan located under the Care Plan tab of the EMR, dated 01/10/26, revealed R105 was care planned for addiction to nicotine. Interventions in place were that the resident required supervision while smoking. Review of R105's Nursing admission Assessment located under Assessments tab in the EMR, dated 01/12/26, revealed R105 was high risk for smoking and required an apron while smoking. During observations on 01/14/26 at 10:00 AM and 2:00 PM revealed R105 smoking without an apron. During an interview on 01/14/25 at 2:18 PM, the Activities Director (AD) stated all residents who wanted to smoke were assessed on admission or when they informed staff they wished to smoke. The AD stated nursing completed the assessment and would verbally inform him/her when a resident required an apron. The AD stated he/she had access to review the smoking assessments, but he/she did not review R105. He/she said Subacute Unit Manager ([NAME]) informed him/her R105 was a safe smoker and did not require an apron while smoking. The AD said he/she was unaware R105's assessment indicated he/she was high risk or that he/she required an apron. During an interview on 01/14/26 at 2:40 PM, the [NAME] stated he/she did not remember telling the AD that R105 was assessed as a safe smoker. He/she reviewed the smoking assessment, dated 01/12/26, and agreed it indicated he/she was a high-risk smoker and required an apron. He/she said based on the assessment he/she should be wearing an apron and not smoking without one. During an interview on 01/15/26 at 2:05 PM the Director of Nursing (DON) stated a smoking assessment was completed for all residents wishing to smoke. The DON stated nursing staff would communicate that information to the activity's director and that the information on the assessment should be followed if they did or did not require adaptive equipment while smoking. He/she said the interdisciplinary (IDT) team should have reviewed R105's smoking assessment along with the AD. He/she said patient safety had to be maintained and that he/she expected whatever was on the assessment to be followed or if there was any discrepancy that should be addressed prior to a resident smoking. The DON said when he/she completed R105's assessment she clicked the wrong button, but it was not reviewed, and it should have been. Review of the facility's policy titled, Resident Smoking Policy, revised 10/25, revealed this facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Residents who smoke will be further assessed, using the Safe Smoking Evaluation to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. NJAC 8:39-5.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; for one of four residents (Resident (R) 105) reviewed for side rails out of 27 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment. Findings include:Review of R105's admission Record in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnosis of unspecified disorders of the brain.Review of R105's admission Minimum Data Set (MDS) assessment under the MDS tab of the EMR revealed an assessment was still in progress. The Assessment Reference Date (ARD) was not available. Review of R105's Care Plan located under the Care Plan tab of the EMR, dated 01/10/26, revealed R105 was care planned for 1/4 side rail use. Review of R105's Physician Orders located under the Orders tab in the EMR, dated 09/08/25, revealed,1/2 side rails per resident request and to promote a sense of security and to assist with transfers and bed mobility.Review of R89's Nursing admission Assessment located under Assessments tab in the EMR, dated 01/10/26, revealed no documentation that alternates were explored prior to bed rail/side rail use.During observations on 01/12/25 and 01/13/25, there were side rails on both sides of R105's bed. During an interview on 01/15/26 10:20 AM the Subacute Unit Manager ([NAME]) stated on admission, staff would assess for repositioning, and their mobility. The [NAME] stated he/she thought there was a process to assess alternates before, but it has been a while. He/she said they didn't complete the process of exploring alternatives, and he/she was unsure if that was part of the current process. He/she stated all side rails in the facility were already on the bed for resident use. During an interview on 01/15/26 at 2:05 PM, the Director of Nursing (DON) said side rails were on all the beds. The DON stated there was an assessment completed and they got the consent from the resident or responsible party. He/she stated if they did not give consent; the side rails were removed. He/she stated side rails were used as enablers and were only 1/4. He/she said they were not used as a restraint, and staff did not look at alternatives since they were not used as restraints. Review of the facility's policy titled, Proper Use of Side Rails, revised 11/25, revealed the purpose of these guidelines is to ensure the safe use of side rails as resident mobility aides and to prohibit the use of side rails as restraints. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide necessary treatment and services as ordered by the physician to promote the healing of a wound. The deficient practice was identified for 3 of 3 residents (Resident #1, #2, and #3) reviewed for wound care.The deficient practice was evidenced by the following: A review of Resident #1 admission Record revealed medical diagnosis which included but not limited to dementia and chronic kidney disease. Review of the most recent quarterly Minimum Data Set (MDS), an assessment tool revealed the resident had a Brief Interview of Mental Status (BIMS) of 12, meaning the resident had moderate cognitive impairment. A review of the physician orders showed the following order: Medihoney (wound/burn dressing gel) to right posterior hip topically every eight hours for wound healing. Cleanse with normal saline, apply Medihoney and calcium alginate (absorbs wound drainage) and cover with a foam dressing. The order was dated 10/29/25 and was an active order.A review of the Treatment Administration Record (TAR) showed the Medihoney order to be administered on day shift (7AM to 3PM), evening shift (3PM to 11 PM), and night shift (11PM to 7 AM). The TAR was signed as the treatment was completed, the last treatment being 11/3/25 on day shift.Review of Resident #1 Individualized Comprehensive Care Plan (ICCP) initiated 11/30/24 showed a focus of actual skin impairment related to bowel and bladder incontinence and impaired mobility. Interventions included but were not limited to administering treatment as ordered.On 11/3/25 at 10:40 AM, during unit tour with the Unit Manager (UM) the surveyor observed the dressing on Resident #1 right posterior hip. The dressing had a date of 11/2/25 with the words day shift written on the dressing.The surveyor then interviewed the UM regarding the dressing. The UM confirmed the dressing was dated 11/2/25 and said day shift. The surveyor asked why the TAR was signed as the dressing being changed three times after the 11/2/25 day shift dressing and she stated, Maybe there was a reason it wasn't done. A review of the admission Summary for Resident #2 revealed the resident was admitted to the facility with medical diagnoses which included but were not limited to diabetes and diabetic foot ulcer. A review of the admission MDS showed Resident #2 had a BIMS of 12, meaning the resident had moderate cognitive impairment.A review of the physician orders showed an order to apply Xeroform (gauze nonstick dressing to promote wound healing), then apply gauze pad, and wrap with Kling (gauze bandage) to left heel/graft daily every evening for wound care. The order was placed on 7/5/25 and then discontinued 7/7/25. On 7/10/25 the order was changed to calcium alginate to left heel topically after cleaning with normal saline solution and applying Santyl (ointment that removes dead tissue) ointment.A review of the ICCP for Resident #2, initiated on 7/4/25 showed a focus of impaired skin integrity with interventions which included but not limited to administer treatment as ordered.A review of the TAR showed that on 7/6/25 and 7/10/25 the TAR was blank, meaning the wound care was not provided. A review of the admission Summary for Resident #3 revealed medical diagnoses which included but were not limited to Multiple Sclerosis (progressive neurological disease), muscle weakness, and hypertension. A review of the most recent quarterly MDS revealed Resident #3 had a BIMS of 9, meaning the resident had moderate cognitive impairment.A review of the physician orders showed the following orders related to wound care: Calcium alginate, cleanse with normal saline solution apply calcium alginate and cover with foam dressing every day shift and every evening shift to right ischial wound.A review of the TAR showed the wound care was completed on 11/1/25 day and evening shift, 11/2/25 day and evening shift, and 11/3/25 day shift.On 11/3/25 at 10:45 AM, with the UM the surveyor observed the residents right ischial dressing. The dressing was dated 11/2/25 day shift. The surveyor asked the UM if the dressing would be dated 11/2/25 if it was completed on 11/2/25 evening shift and 11/3/25 day shift and the UM responded, No, it wasn't done.A review of Resident #3 ICCP initiated 4/22/25 showed a focus of actual skin integrity. Interventions included but were not limited to administer treatment as ordered.On 11/3/25 at 1:40 PM, the surveyor interviewed the Director of Nursing regarding wound care. The surveyor asked if the TAR is signed by the nurse what would that mean, and she responded that it should be done. The DON then presented the surveyor with progress notes of resident refusal that were created after the surveyor inquiry.The surveyor reviewed the policy titled, Pressure Ulcer/Wound Treatment Management, with a review date of 2/1/25. The policy was to promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with the current standards of practice and physician orders. Number one of the policy was that wound treatments would be provided in accordance with physician orders.N.J.A.C. 8:39-27.1(a)

Complaint #:2575153 Based on observation, interviews, medical record review, and review of pertinent facility documents, it was determined that the facility failed to administer medications with less than a 5% medication error rate. The surveyor observed one nurse administer medications to four residents with a total of 43 opportunities. Three errors were observed, which calculated to a medication administration error rate of 6.97%. This deficient practice was identified for two of four residents that were administered medications by 1 nurse on the first-floor sub-acute nursing unit.This deficient practice was evidenced by the following: 1.) On 08/01/2025 at 8:45 A.M., the surveyor observed the Registered Nurse (RN #1) preparing and administering medications for an unsampled resident. RN #1 removed a jar labeled as vitamin C 500 milligram (MG) tablets from the medication cart and poured one tablet into the medication cup with the other medications being prepared for the resident. RN #1 continued to prepare the resident's medication. At that time the surveyor observed the physician's order (PO) for vitamin C which indicated to administer one 250 MG tablet, not a 500 MG. The surveyor stopped RN #1 to confirm that she was finished preparing medication for the resident and was prepared to administer them. RN #1 reviewed the vitamin C order and stated, I didn't notice that. The RN obtained 250 MG tablets for administration to the resident. (error #1) During the same medication preparation and administration observation, the surveyor observed RN #1 place two carbamazepine (a medication used to treat seizures, nerve pain, and mental health disorders) chewable 100 MG tablets into the medication cup with other medications being prepared for the unsampled resident. The chewable tablets were administered to the resident with their other medications and swallowed by the resident without being chewed. RN #1 confirmed that the carbamazepine 100 MG tablets were swallowed along with the resident's other medications without being chewed. (error #2) A review of the unsampled resident's admission Record (AR) revealed that the resident was admitted with diagnoses including but not limited to epilepsy (brain condition that causes recurring seizures), unspecified, intractable, without status epilepticus; chronic kidney disease, unspecified; bipolar disorder (disorder that causes intense shifts in mood, energy levels and behavior), unspecified; and type 2 diabetes mellitus with unspecified complications. The most recent Minimum Data Set (MDS), an assessment tool dated 06/25/2025, was reviewed. The MDS revealed that the resident had a brief interview for mental status (BIMS) score of 12 out of 15, indicating that the resident's cognition was moderately impaired. A review of the resident's physician orders POs revealed the following orders: Ascorbic acid (commonly known as vitamin C) tablet 250 MG; give 1 tablet by mouth two times a day for supplement. carbamazepine tablet chewable 100 MG; give 2 tablets by mouth two times a day for seizures related to epilepsy, unspecified, intractable, without status epilepticus 2.) On 08/01/2025 at 10:00 A.M., the surveyor observed RN #1 prepare Resident #1's medications for administration. The surveyor observed RN #1 pour 30 milliliters (ML) of lactulose (a laxative medication also used to treat complications of liver disease) 10 grams (GM)/15 milliliter (ML) solution for administration to Resident #1. At that time the surveyor observed the PO for lactulose which indicated to administer 15 ML, not 30 ML. The surveyor stopped the RN #1 and confirmed that she was finished preparing medication for the resident and was prepared to administer them. RN #1 reviewed the lactulose order and confirmed that 15 ML was ordered. RN #1 poured 15 ML of Lactulose and administered it to Resident #1 with the resident's other medications. (error #3) A review of the Resident #1's AR revealed that the resident was admitted with diagnoses including but not limited to acute and subacute infective endocarditis (infection of the heart lining or valves); unspecified cirrhosis of the liver (healthy liver cells replaced by scar tissue); presence of cardiac pacemaker; hypo-osmolality (decrease in levels of electrolytes, chemicals, and other fluids in the blood) and hyponatremia (low sodium level in the blood); and irritable bowel syndrome (a chronic condition that causes abdominal pain and trouble with bowel habits). Resident #1's most recent MDS dated [DATE], was reviewed. The MDS revealed that the resident had a BIMS score of 15 out of 15, indicating that the resident's cognition was intact. The MDS further revealed that the resident was frequently incontinent of stool and was dependent on a helper for toilet transfers and toileting hygiene. A review of Resident #1's POs revealed the following order: Lactulose oral solution 10 GM/15 ML; give 15 ml by mouth three times a day for cirrhosis. An interview was conducted with RN #1 on 08/01/2025 at 1:40 P.M. RN #1 confirmed that she was prepared to administer 500 MG ascorbic acid to the unsampled resident and 30 ML of lactulose to Resident #1. RN #1 stated that she was unsure if the unsampled resident's carbamazepine should have been chewed. RN #1 confirmed that the resident swallowed the carbamazepine without chewing it. During the same interview, RN #1 stated that medications should have been administered ensuring: the right resident, right dose, right route, right medication, and right time. RN #1 stated that the process was to make sure that the right medication and dose were taken out for each resident, then to identify the resident, then to ensure that the resident took those medications. RN #1 stated that the process needed to be followed to make sure that residents received the treatments they needed. RN #1 further stated that if a resident received the wrong medication, and depending on the medication received, the resident could die. An interview was conducted with Unit Manager (UM #1) on 08/01/2025 at 3:02 P.M. UM #1 stated that the expectation was that medications were given following the rights of medication administration, facility policies, and physician orders. UM #1 further stated that if medications were not administered according to facility policies and her expectations, that harm could be caused to a resident and, that's the last thing we want. An interview was conducted with the Director of Nursing (DON) on 08/01/2025 at 3:46 P.M. The DON stated that the expectation every time medication was administered was that it was done according to the facility medication administration policy and the five rights of medication administration. The DON stated that the issues identified during that morning's medication administration observation did not meet her expectations for medication administration. The DON further stated that if medications were not administered according to the facility policy and the five rights of medication administration, the consequences to the resident could range from sneezing to death. A review of the facility's, Medication Administration policy with a reviewed date of 1/2025 revealed under, Policy Explanation and Compliance Guidelines; [.]11. Compare medication source (bubble pack, vial, etc.) with EMAR [electronic medication administration record] to verify resident name, medication name, form, dose, route, and time [.] 14. Administer medication as ordered in accordance with manufacturer specifications. NJAC 8:39-11.2(b)

Complaint #: 2575153 Based on interviews, record review, and review of other pertinent facility documents on 08/01/2025, it was determined that the facility failed to ensure that a resident (Resident #2) received the correct intravenous (IV) antibiotic medication. This deficient practice was identified for one of three residents reviewed for medication errors and was evidenced by the following: According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses including but not limited to peritoneal abscess (pocket of pus and infected fluid in the tissue lining the abdomen); sepsis (life-threatening condition caused by the body's response to an infection), unspecified organism; bacteremia (bacteria in the blood); pneumonia (inflammation and fluid in the lungs), unspecified organism; and other specified anxiety disorders (conditions that cause fear, dread and other symptoms out of proportion to the situation). According to the most recent Minimum Data Set (MDS), an assessment tool dated 07/28/2025, Resident #2 had a Brief Interview of Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. A review of the facility incident report dated 07/26/2025 at 6:26 P.M., was conducted. Under, Incident Description, the document revealed the following: Nursing Description: [Resident #2] received IV Ceftin [an antibiotic] instead of the ordered Daptomycin [an antibiotic]. Resident admitted to this facility on 07/23/205 after a brief stay at [hospital name] to complete IV [antibiotic] therapy for blood infection/MRSA [methicillin-resistant Staphylococcus aureus, a bacterium that is resistant to antibiotics] bacteremia. A facility Witness Statement, document from RN #2 with the date July 27 with a six written over the 7 was reviewed. The statement revealed that at 6:00 P.M., RN #2 brought two bags of IV medication into Resident #2's room, one belonged to Resident #2 and the other belonged to a different resident. RN #2 began the administration of Ceftin which belonged to another resident instead of the Daptomycin, which was the IV antibiotic prescribed to Resident #2. The statement further revealed that RN #2 noticed the error and stopped the Ceftin infusion in less than three minutes. The physician was notified, and the resident was monitored for signs of complication. Resident #2 was no longer at the facility. A closed record review was conducted. A review of the Order Summary Report (OSR), for Resident #2 revealed the following physician order (PO): Daptomycin-Sodium Chloride Intravenous Solution 700-0.9 MG [milligrams]/100 ML [milliliters]- %(Daptomycin-Sodium Chloride) Use 100 ml intravenously one time a day for Cholecrtectomy until 07/27/2025 23:59 [11:59 P.M.]. The order had a start date of 07/24/2025 and an end date of 07/27/2025. A further review of the OSR revealed no POs for Ceftin for Resident #2. A telephone interview was conducted with RN #2 on 08/01/2025 at 12:53 P.M. RN #2 stated that the medication administration process included verification of the resident's name, medication dose, medication route, and documentation. RN #2 stated that on 07/26/2025 he gave the wrong IV medication to Resident #2. RN #2 stated that he brought two medications into Resident #2's room (one for Resident #2, and one for a resident in another room). RN #2 stated that he administered Ceftin instead of daptomycin to Resident #2. RN #2 stated that prior to administering the medication, he verified Resident #2's identity but not the medication he was giving. RN #2 stated that he noticed the error as soon as he left the resident's room, which was in less than one minute. RN #2 further stated that following the rights of medication administration was important for preventing errors and that medication errors could cause allergy, itching, or diarrhea depending on the medication. An interview was conducted with the Unit Manager (UM #1) on 08/01/2025 at 3:02 P.M. UM #1 stated that the expectation was that medications were given following the rights of medication administration, facility policies, and physician orders. UM #1 further stated that if medications were not administered according to facility policies and her expectations, harm could be caused to a resident and, that's the last thing we want. An interview was conducted with Director of Nursing (DON) on 08/01/2025 at 3:46 P.M. The DON stated that the expectation every time medication was administered was that it was done according to the facility medication administration policy and the five rights of medication administration. The DON stated that when the wrong antibiotic was administered to Resident #2, the five rights of medication administration were not followed. The DON further stated that if medications were not administered according to the facility policy and the five rights of medication administration, the consequences to the resident could range from sneezing to death. A review of the facility's, Medication Administration policy with a reviewed date of 1/2025 revealed under, Policy Explanation and Compliance Guidelines; .10. Review EMAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with EMAR [electronic medication administration record] to verify resident name, medication name, form, dose, route, and time [.] 14. Administer medication as ordered in accordance with manufacturer specifications. NJAC 8:39-29.2 (d)

Complaint #: 2575153Based on observation, interviews, record review, and review of other pertinent facility documents it was determined that the facility failed to maintain appropriate infection control practices during medication administration in accordance with in nationally accepted guidelines for infection prevention and control and the facility's policies and procedures. This deficient practice was identified for 2 of 2 residents (Resident #1 and Resident #2) reviewed for infection prevention and was evidenced by the following:1. A facility incident report dated 07/26/2025 at 6:26 P.M., was reviewed. Under, Incident Description, the document revealed the following: Nursing Description: [Resident #2] received IV Ceftin [an antibiotic] instead of the ordered Daptomycin [an antibiotic]. [Resident #2] admitted to this facility on 07/23/205 after a brief stay at [hospital name] to complete IV [antibiotic] therapy for blood infection/MRSA [methicillin-resistant Staphylococcus aureus, a bacterium that is resistant to antibiotics] bacteremia. A facility Witness Statement, document written by the Registered Nurse (RN #2) with the date July 27 with a six written over the seven was reviewed. The statement revealed that at 6:00 P.M., RN #2 brought two bags of IV medication into Resident #2's room, one belonged to Resident #2 and the other belonged to a different resident. RN #2 then administered another resident's IV antibiotic to Resident #2. Resident #2 was no longer at the facility. A closed record review was conducted. According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses included but were not limited to: peritoneal abscess (pocket of pus and infected fluid in the tissue lining the abdomen); sepsis (life-threatening condition caused by the body's response to an infection), unspecified organism; bacteremia (bacteria in the blood); pneumonia (inflammation and fluid in the lungs), unspecified organism; and other specified anxiety disorders (conditions that cause fear, dread and other symptoms out of proportion to the situation). According to the most recent Minimum Data Set (MDS), an assessment tool dated 07/28/2025, Resident #2 had a Brief Interview of Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. A review of the Order Summary Report (OSR), for Resident #2 revealed the following physician orders (POs): Maintain contact isolation precautions due to MRSA; every shift for isolation precautions. The order start date was 07/23/2025. Midline single lumen (vascular access device used for infusion therapies) RUA (right upper arm) measurement 4.5 Fr (French) 15 CM (centimeters) long. The order start date was 07/23/2025. Daptomycin-sodium chloride intravenous solution 700-0.9 MG [milligrams]/100 ML [milliliters]. Use 100 ml intravenously one time a day until 07/27/2025 11:59 P.M. The order had a start date of 07/24/2025 and an end date of 07/27/2025. A review of the Care Plan (CP) for Resident #2 revealed a Focus, that the resident required enhanced barrier precautions (EBPs) related to a wound, a midline catheter, and MRSA. Interventions included but were not limited to: clear signage posted on or near the room door; good hand hygiene when entering or leaving the room; and maintaining EBP for the duration of the stay, until wound healing, or removal of the indwelling device. The CP for Resident #2 also included a Focus, that the resident had MRSA bacteremia. Interventions included but were not limited to: observation of standard precautions (minimum set of interventions considered standards of care that prevent the transmission of microorganisms); thorough cleaning of resident areas using disinfectants; and cleaning, disinfecting or sterilizing resident care equipment. A telephone interview was conducted with RN #2 on 08/01/2025 at 12:53 P.M. RN#2 stated that on 07/26/2025 he brought two bags containing intravenous (IV) medications into Resident #2's room (one for Resident #2, and one for a resident in another room). RN #2 stated that he then administered Ceftin instead of Daptomycin to Resident #2. 2.) A medication administration observation was conducted on 08/01/2025 at 10:13 A.M. The surveyor observed RN #1 during the administration of IV antibiotics to Resident #1. After exiting the room RN #1 returned wearing gloves that she touched the door and door handle with. RN #1 wearing the same gloves that she touched the door handle with then removed an empty IV medication bag from the IV pole and hung the new medication. RN #1 then set the IV pump and connected the new tubing to Resident #1's IV line while wearing the same gloves. A review of Resident #1's AR revealed that the resident was admitted with diagnoses that included but were not limited to acute and subacute infective endocarditis (infection of the heart lining or valves), and presence of cardiac pacemaker. Resident #1's most recent MDS dated [DATE], was reviewed. The MDS revealed that the resident had a BIMS score of 15 out of 15, indicating that the resident's cognition was intact. The MDS further revealed that the resident had central IV access on admission to the facility. A review of Resident #1's OSR revealed the following PO: Maintain enhanced barrier precautions due to IV line every shift. Every shift for enhanced barrier precautions. The order start date was 07/24/2025. A review of the CP for Resident #1 revealed a Focus, that the resident required EBPs related to the presence of an IV line. Interventions included but were not limited to maintaining EBP for the duration of the stay, until wound healing, or removal of the indwelling device. Interventions also included Educate and encourage good hand hygiene before entering and when leaving the room. The CP for Resident #1 also included a Focus, that the resident had a peripherally inserted central catheter (PICC) for the administration of intravenous medication. Interventions included but were not limited to, Perform hand hygiene before and after access with IV An interview was conducted with RN #1 on 08/01/2025 at 1:40 P.M. RN#1 stated that during medication administration observation that morning she touched items in the room including the pump, then touched the resident's PICC without washing her hands and changing gloves. An interview was conducted with the Unit Manager (UM #1) on 08/01/2025 at 3:02 P.M. UM #1 stated that the expectation was that nurses followed the rights of medication administration and good infection prevention (IP) practices during medication administration. The expectation was that nurses washed their hands and changed gloves prior to touching a resident's PICC if other items were touched first. UM #1 stated that touching other patient care items and then touching a resident's PICC did not meet her expectations for good IP practices. UM #1 stated that facility staff received continuing education on IP regularly. UM #1 further stated that if good IP practices were not followed patient harm or infections could occur. The facility's IP Nurse was not available for an interview. An interview was conducted with Director of Nursing (DON) on 08/01/2025 at 3:46 P.M. The DON stated that the expectation was for EBP and good IP practices to be followed for resident care. The DON stated that RN #1 taking medications for another resident into Resident #2's room was against the facility's IP and EBP policies. The DON stated that following good IP practices was important because the facility had a vulnerable population that was susceptible to bugs, to make sure staff was safe, and to prevent any transmissions. The DON further stated that the IP nurse, DON, UMs, Administrator, and Human Resources were responsible to ensure that IP practices were maintained in the facility. The facility's Hand Hygiene, policy with a created date of 8/10/24 was reviewed. The policy revealed under, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Under, Policy Explanation and Compliance Guidelines: the policy revealed, 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. [.] 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The facility's Medication Administration, policy with a created date of 1/2025 was reviewed. The policy revealed under, Policy Explanation and Compliance Guidelines: [.] 4. Wash hands/sanitize prior to administering medication per facility protocol and product. NJAC 8:39-19.4 (a) (1) (n)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that Minimum Data Sets (MDS), an assessment tool, were accurate. This deficient practice was identified for 1 of 22 residents (Resident #66) reviewed for MDS and was evidenced by the following: This is a repeat deficiency. On 07/17/2024 at 10:38 AM, the surveyor observed Resident #66 being wheeled down the hall. The resident's speech was difficult to understand, but they were loudly speaking about no respect. On 07/19/2024 at 8:49 AM, the Certified Nursing Assistant (CNA) stated that Resident #66 can be combative and yells. A review of the hybrid medical records (MR) revealed that Resident #66 was admitted with diagnoses which included but were not limited to; Schizoaffective disorder, bipolar type (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder) dated 09/29/2022, anoxic brain damage dated 09/29/2023, and epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors) dated 04/29/2022. A review of the Order Summary Report active orders as of 07/23/2024, included orders dated 12/01/2022, for Haloperidol 2 milligram (mg) . for Schizoaffective Disorder bipolar type, and dated 10/19/2023, psyche follow up related to Schizoaffective disorder. A review of the resident-centered, on-going Care Plan (CP) included but was not limited to a focus area uses psychotropic medications r/t (related to) behavior management disease process Schizoaffective disorder, bipolar type). A review of the Pre-Admission Screening and Resident Review (PASRR) dated 09/03/2022, identified Resident #66 as having a diagnosis of Schizoaffective disorder bipolar type. A review of nine Psychotropic Medication Use screening forms dated: 12/13/2022, 01/02/2023, 02/07/2023, 03/07/2023, 04/11/2023, 05/08/2023, 10/10/2023, 11/08/2023, and 12/13/2023 all documented Resident #66 had Schizoaffective disorder. A review of 11 psychiatric consult notes dated: 05/05/2023, 08/04/2023, 09/22/2023, 11/23/2023, 12/14/2023, 02/10/2023, 01/30/2024, 02/28/2024, 03/27/2024, 05/15/2024, and 06/26/2024 all documented Resident #66 had Schizoaffective disorder. A review of the MDS' Section I Psychiatric/Mood Disorder for Resident #66 revealed the following inaccuracies: Dated 06/04/2024: Bipolar yes, Psychotic disorder (other than schizophrenia) no, Schizophrenia yes. Dated 03/05/2024: Bipolar yes, Psychotic disorder (other than schizophrenia) no, Schizophrenia yes. Dated 12/11/2023: Bipolar yes, Psychotic disorder (other than schizophrenia) no, Schizophrenia yes. Dated 03/07/2023: Bipolar no, Psychotic disorder (other than schizophrenia) yes, Schizophrenia no. Dated 06/08/2023: Bipolar no, Psychotic disorder (other than schizophrenia) yes, Schizophrenia no. Dated 09/13/2023: Bipolar no, Psychotic disorder (other than schizophrenia) no, Schizophrenia no. On 07/23/2024, the surveyor requested to interview the MDS nurse, but the MDS nurse no longer worked at the facility. On 07/23/2024 at 10:46 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of additional surveyors. The DON stated the MDS coordinator was responsible to review hospital records, nursing notes, diagnoses, behaviors, smoking, and any updates. She stated that information would be used to review and capture diagnoses and that it was important to have accurate diagnoses to see what specialist may be needed, for the care plans, optimum patient outcomes, and that the MDS' were reviewed in care conferences. On 07/24/2024 at 9:35 AM, the DON acknowledged the discrepancies in the MDS' and stated that they have all been corrected and resubmitted. A review of the facility provided job description, MDS Coordinator (Nursing), signed and dated by the previous MDS nurse on 12/19/2022, included but was not limited to; Job Description . overseeing the full collaborative, interdisciplinary assessment and care planning process . collection and transmission of data . Principle Duties: completes accurate coding of the MDS with information obtained via medical record reviews, observations, and interviews with the facility staff, resident and family members. A review of the facility provided job description, Director of Nursing (Nursing), signed and dated by the DON on 08/15/2019, included but was not limited to; M. Supervise, by daily rounds and conferences, the work of all nursing personnel. AF. Supervise the MDS/Care Plan Coordinator to ensure that all MDS forms are completed accurately and in a timely manner. A review of the facility provided policy, Minimum Data Set Policy and Procedure, revised 09/2023, included but was not limited to; Policy: In compliance with federal and state regulations, each resident shall have a comprehensive assessment of his/her functional capacity recorded on a designated MDS form .General Information: The MDS Coordinator will be responsible . to keep assessment data current at all times. Suggested reference areas to support MDS completion: . b. current plan of care . c. MD (medical doctor) notes/orders . g. medication record/treatment record . h. medical consults . k. documentation from other disciplines.

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice by failing to document the use of oxygen in the Electronic Medical Record (EMR) for 1 of 2 residents (Resident #46) reviewed for respiratory care. This deficient practice was evidenced by: On 07/17/2024 at 10:30 AM during the initial tour, the surveyor observed Resident # 46 in bed. Resident # 46 was observed receiving oxygen through a nasal cannula (a tube delivering oxygen into the nose). The oxygen concentrator was set at 2 liters. On 07/18/2024 at 10:11 AM, the surveyor observed Resident # 46 in bed. Resident # 46 was observed receiving oxygen through a nasal cannula. The oxygen concentrator was set at 2 liters. A review of Resident # 46's Admission Record located in the EMR revealed that Resident # 46 was admitted to the facility with diagnoses that included but were not limited to encounter for palliative care, and heart failure (when the heart muscle doesn't pump blood as well as it should). A Review of Resident # 46's physicians orders located in the EMR revealed that he/she had an order to receive Oxygen at two liters per minute via nasal cannula as needed for shortness of breath. The order was started on 07/01/2024. A review of the July, 2024 Treatment Administration Record (TAR) did not reveal any documented use of oxygen for Resident # 46. On 07/23/2024 at 11:12 AM, during an interview with the surveyor, Licensed Practical Nurse (LPN) #1 said We give PRN [when required] orders upon request. We check the orders, inform the Doctor, sign the order out, and then check the resident in an hour to see if medication was effective. At that time, the surveyor asked to show where it was documented that Resident #46 was using oxygen on 07/17/2024 and 07/18/2024. LPN #1 replied, I don't see it documented anywhere. Lastly, the surveyor asked if the order for Oxygen should be signed out on the TAR. LPN #1 replied, Yes. On 07/24/2024 at 09:42 AM during an interview with the surveyor, the Director of Nursing (DON) said they [nursing staff] should be signing out the Oxygen use on the TAR. A review of the facility-provided policy titled, PRN Medications revised on 1/2024 revealed under section Policy Explanation and Compliance Guidelines that, 3. When administering a PRN medication: a. Verify physician's order for the medication. b. Document the reason voiced by the resident and or assessment findings that show why the resident needs the medication. Verify the reason is for the prescribed indication for the medication. c. Document the time of administration. d. Evaluate the effectiveness of the medication and document the findings. A review of the facility-provided policy titled, Oxygen Administration revealed under Procedures that, 9. Document initiation of oxygen in the resident medical record, including time, flow, indication and method: cannula or mask, in the TAR (Treatment Administration Record and or progress notes). Document use and resident reaction to oxygen. N.J.A.C. 8:39-29.2 (d)

Based on observation, interview, and record review it was determined that the facility failed to preserve the dignity and personal preference for one (1) of 12 residents, Resident #51. The deficient practice is evidenced as follows: On 11/15/22 at 10:30 AM, the surveyor observed the November 2022 activity calendar hanging on display in the hallway of the facility which did not reflect any actitives for Veteran's Day and it did not mention it as a holiday on the calendar. On 11/16/22 at 12:00 PM, the surveyor interviewed Resident #51 who stated that he/she observed the flag at the facility was flying outside on the flag pole and was frayed so he discussed it with his family and their family donated his/her dad's flag. Resident #51 stated the facility held the flag for four (4) months without putting the flag up and after asking the Admission Director several times over the four (4) months when the flag would be put up, the resident asked for the flag back out of frustration. Resident #51 further stated to the surveyor that he/she was a Veteran and on Veteran's Day which was last week 11/11/22, the facility did not do anything for the veteran's that day nor throughout the month which was very upsetting to him/her. On 11/16/22 at 12:15 PM, the surveyor interviewed the Activity Director (AD) regarding were there any Veteran's at the facility. The AD identified there were 12 veterans at the facility. The surveyor asked about the activities for Veteran's day and reviewed the November calendar with the AD. The AD stated there should have been an activity for Veteran's day and the calendar should have identified Veteran's day as a holiday on the calendar. The AD stated that there was a Veteran's day activity that Hospice came in to do back in August but did acknowledge that the facility should have done their own. The AD was aware of the donated flag but stated she was never given the flag and was not aware of the reason it was never put up. On 11/16/22 at 01:00 PM, the surveyor interviewed the Admissions Director (ADD) who stated that Resident #51 did donate the flag to the facility and the facility had the flag for several months. The ADD stated the resident followed up and asked about the flag until the flag was returned to the resident and his/her sister. The ADD added that the Licensed Nursing Home Administrator (LNHA) stated they needed a cherry picker to put the flag on the pole. On 11/16/22 at 02:50 PM, the surveyor discussed dignity and personal preference concerns with the LNHA, the Director of Nursing (DON), and his administrative team to ask if they had any residents who were Veterans in the facility and how many. Neither were aware that there were 12 veterans at the facility. The surveyor asked about Veteran's day activities and showed them the September, October, and November calendars. The November calendar did not identify Veteran's day as a holiday and neither showed any veteran da activities. The LNHA stated Veteran's day should have been identified as a holiday on the calendar and there should have been a Veteran's day activity on the calendar. The LNHA further stated that they were aware of the donated flag and had it for a couple of months but needed a cherry picker to put the flag up. The LNHA confirmed the flag had been returned to the family because the family asked for it back. The current LNHA who had been at the facility for two months nor the previous LNHA could provide any additional information to show that a cherry picker was ever contacted or attempted to be located to hang the flag. On 11/17/22 at 11:55 AM, the surveyor reviewed the policy titled, Resident Rights, dated 01/24/2022. The policy purpose was the facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. 5. Respect and dignity b. the right to retain and use personal possessions, including furnishings and clothing .C. right to reside and receive services in the facility with reasonable accomodation of resident needs and preferences .and 6. Self-determination .the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. NJAC 8:39-4.1(a) 12

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that the care and documentation of a resident's dialysis access site was maintained in accordance with professional standards of practice. This was identified for Resident #52, one (1) of one (1) resident reviewed for dialysis. This deficient practice was evidenced by the following: On 11/14/22 at 11:00 AM, the surveyor went to visit Resident #52 in the room. The resident was not there, and a unit staff member informed the surveyor that the resident was at dialysis. Review of the Admission Record from the electronic medical record (EMR) indicated that Resident #52 was admitted to the facility 12/2019. Review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 08/11/2022, indicated the resident had a Brief Interview of Mental Status of 15, meaning Resident #52 was cognitively intact. Review of the functional status section, Resident #52 was a one-person physical assistance for ambulation, transfer, dressing, and toileting. Medical diagnoses included, but not limited to end stage renal disease, hypertension (high blood pressure), diabetes (high blood sugar), dependence on dialysis, and muscle weakness. On 11/14/22 at 11:05 AM, the surveyor reviewed Resident #52 Physician Order Sheet (POS) which indicated the resident attended hemodialysis on Mondays, Wednesdays, and Fridays. Further review of the POS showed an order to monitor the residents AV fistula (an arteriovenous fistula is created to be utilized for a dialysis access) in the right upper arm for signs and symptoms of bleeding and infection and an order for no lab work or blood pressures to the right upper arm. On 11/15/22 at 01:02 PM, the surveyor reviewed the Treatment Administration Record (TAR) which showed that the resident was not to have blood pressures in the right arm. The TAR was signed every shift by the nursing staff. The surveyor then reviewed the vital signs section of the EMR. Under the blood pressure section of the EMR, it was documented that 63 of 217 blood pressures taken between 08/24/22 and 11/16/22 were documented as taken in Resident #52 right arm. On 11/15/22 at 01:10 PM, the surveyor reviewed the resident's current care plan which showed the following focus: resident needs dialysis (Hemodialysis) related to end stage kidney disease and has an AV fistula access right arm. One of the interventions included no blood pressures or blood work in the right arm. On 11/16/22 at 11:12 AM, the surveyor interviewed unit Licensed Practical Nurse (LPN #1), who was caring for Resident #52. The surveyor asked where the residents dialysis access was and LPN #1 stated the right arm. She further stated we check for thrill and bruit (sound and feeling to assess for function) and no blood pressures in the right arm. The surveyor asked LPN #1 if the EMR showed that the blood pressure was done in the right arm what would you think, and the LPN stated, that the blood pressure was checked in the right arm. On 11/16/22 at 01:00 PM, the surveyor made the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) aware of the issue that the documentation of the blood pressure site on dialysis resident with an AV fistula had discrepancies. On 11/17/22 at 10:00 AM, the surveyor reviewed the policy titled, Dialysis Management, dated 01/19/22. Under the procedure section, number 15 stated to assure plan of care indicates which limb contains the vascular access. Blood pressures and draws should not be done on the access arm. On 11/17/22 at 10:10 AM, the survey team met with the DON and the LNHA. The surveyor asked the DON what she would think if she looked at the EMR and saw documentation of blood pressures in the right arm and the DON told the surveyor, Yes I understand, it's a documentation error. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of the medical record and other facility documentation, it was determined that the facility failed to follow physician orders related to the use of oxygen for one (1) of two (2) residents (Resident #76) reviewed for respiratory care. This deficient practice was evidenced by: This deficient practice was evidenced by the following: On 11/07/22 at 11:32 AM, the surveyor observed Resident #76 in his/her room. An oxygen concentrator was observed to the left side of his/her bed. The surveyor observed that Resident #76 was not utilizing the oxygen. On 11/07/22 at 01:24 PM, the surveyor observed Resident #76 in bed. The surveyor observed that Resident #76 was not utilizing the oxygen. Resident # 76 stated that he/she uses the oxygen at night. On 11/09/22 at 11:07 AM, the surveyor observed Resident #76 in a meeting. The surveyor observed that Resident #76 was not utilizing oxygen. On 11/10/22 at 09:20 AM, the surveyor observed Resident #76 not utilizing oxygen. He/She stated that he/she used oxygen last night but had removed it already. The surveyor reviewed Resident #76's medical record which revealed the following: According to Admission Record, Resident #76 was admitted to the facility with diagnoses that included but was not limited to heart failure. The Order Summary Report for Resident #76 had a Physician Order (PO) dated October 2022 for Oxygen three (3) liters per minute via nasal cannula continuous. every shift Keep oxygen saturation >91% every shift The September, October, and November 2022 Treatment Administration Record (TAR) reflected that Resident #76 received oxygen three (3) liters per minute via nasal canula continuously. The Admission Minimum Data Set (MDS) an assessment tool dated 8/25/2022 indicated that Resident was cognitively intact and utilized oxygen. The Progress Notes dated 08/30/22 through 11/09/22 for Resident #76 were reviewed. The surveyor did not observe any progress note which reflected that Resident # 76 removed his/her oxygen. During an interview on 11/10/22 at 01:38 PM, CNA#2 stated that Resident #76 used oxygen everyday but will take it off and put it back on when he/she feels like it. During an interview on 11/10/22 at 01:41 PM, RN #2 stated that Resident #76 used oxygen, but the resident removed the oxygen. She stated that the oxygen order should be changed to as needed since the resident's oxygen saturation levels are within normal limits. During an interview on 11/17/22 09:08 AM, the Director of Nursing (DON) stated if oxygen is ordered continuously then it should be on continuously. On 11/17/2022, the DON provided the surveyor with the facility Medication Administration Policy with a reviewed date of 03/10/2022. The policy reflected that if a patient refuses an order or the status of patient changes that they no longer require an order, the physician will be notified. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to implement a comprehensive care plan for one (1) of 20 residents (Resident #76) reviewed for the implementation of a care plan. This deficient practice was evidenced by the following: On 11/07/22 at 11:32 AM, the surveyor observed Resident #76 in his/her room. An oxygen concentrator was observed to the left side of his/her bed. The surveyor observed that Resident #76 was not utilizing the oxygen. On 11/07/22 at 01:24 PM, the surveyor observed Resident #76 in bed. The surveyor observed that Resident #76 was not utilizing the oxygen. Resident # 76 stated that he/she uses the oxygen at night. On 11/09/22 at 11:07 AM, the surveyor observed Resident #76 in a meeting. The surveyor observed that Resident #76 was not utilizing oxygen. On 11/10/22 at 09:20 AM, the surveyor observed Resident #76 not utilizing oxygen. He/she stated that he/she used oxygen last night but had removed it already. The surveyor reviewed Resident #76's medical record which revealed the following: according to Admission Record, Resident #68 was admitted to the facility with diagnoses that included but was not limited to heart failure. The Order Summary Report for Resident #76 had a Physician Order (PO) dated 9/2022 for Oxygen 3 liters per minute via nasal cannula continuous, every shift keep oxygen saturation >91% every shift The Admission Minimum Data Set (MDS) an assessment tool dated 08/25/2022, indicated that Resident was cognitively intact and utilized oxygen. The care plan for Resident #76 was reviewed. The care plan for respiratory impairment does not have an intervention which reflected that the resident refused or removed his/her oxygen. During an interview on 11/10/22 at 01:38 PM, CNA #2 stated that Resident #76 uses oxygen everyday but takes it off and puts it back on when he/she feels like it. During an interview on 11/10/22 at 01:41 PM, RN#2 stated that Resident #76 uses oxygen but the resident removes the oxygen. When asked if the refusal should be documented, RN#2 confirmed it should. During an interview on 11/17/22 at 10:11 AM, the Director of Nursing (DON) stated the refusal of oxygen should have been care planned for Resident #76. On 11/21/22 at 12:00 PM, the DON provided the surveyor with the facility Care Plan Process Policy with a reviewed date of 01/24/2022. The policy reflected that the interdisciplanary team maintains care plans on a current status. N.J.A.C. 8:39-11.2 1, 2

Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to ensure that an accurate Minimum Data Set (MDS), an assessment tool, was completed. This deficient practice was identified for 4 of 6 annual assessments of residents who were incorrectly coded as non-smoking (Residents #29, #62, #64, #65) and was evidenced by the following: 1. The surveyor reviewed the Admission Record for Resident #29 which reflected that the resident was admitted with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness of one side of the body). The surveyor reviewed the Annual MDS tool with reference date of 06/30/2021 which identified the resident as a non-smoker. The surveyor observed the resident's name on the facilities' Safe Smoking List. The surveyor also located the resident's last quarterly safe smoking evaluation dated 10/6/2022. On 11/10/2022 at 12:10pm, the surveyor interviewed MDS Coordinator who stated that this resident should be identified as a smoker. 2. The surveyor reviewed the Admission Record for Resident #62 which reflected that the resident was admitted with diagnoses that included osteomyelitis (infection of the bone) and tobacco use. The surveyor reviewed the Annual MDS tool with reference date of 01/21/2022 which identified the resident as a non-smoker. The surveyor observed the resident's name on the facilities' Safe Smoking List. The surveyor also located the resident's last quarterly safe smoking evaluation dated 11/9/2022. On 11/10/2022 at 12:10pm, the surveyor interviewed MDS Coordinator who when asked if this resident should have been identified as a smoker responded, yes. 3. The surveyor reviewed the Admission Record for Resident #64 which reflected that the resident was admitted with diagnoses that included muscular sclerosis (a disease resulting in nerve damage that disrupts communication between the brain and body) and tobacco use. The surveyor reviewed the Annual MDS tool with reference date of 01/25/2022, which identified the resident as a non-smoker. The surveyor observed the resident's name on the facilities' Safe Smoking List. The surveyor also located the resident's last quarterly safe smoking evaluation dated 10/27/2022. On 11/10/2022 at 12:10pm, the surveyor interviewed MDS Coordinator who when asked if this resident should have been identified as a smoker responded, yes, he is on the [safe smoking] list. 4. The surveyor reviewed the Admission Record for Resident #65 which reflected that the resident was admitted with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness of one side of the body. The surveyor reviewed the Annual MDS tool with reference date of 02/19/2022 which identified the resident as a non-smoker. The surveyor observed the resident's name on the facilities' Safe Smoking List. The surveyor also located the resident's last quarterly safe smoking evaluation dated 08/20/2022. On 11/10/2022 at 12:10pm, the surveyor interviewed MDS Coordinator who when asked if this resident should have been identified as a smoker responded, yes. During the interview with MDS Coordinator, she explained that smoking residents are identified through their medical record, nurse's assessments, and progress notes. In addition, MDS Coordinator confirmed that residents identified on the Safe Smoking List should also be identified as smoking on the Annual MDS Assessment. Review of facility policy titled Resident Smoking Policy, Policy No: ROP-29, Created 11-17, revealed under #6, that, All residents will be asked about tobacco use during the admission process, and during each quarterly, or comprehensive MDS assessment process. NJAC 8:39-33.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure staff wore appropriate personal protection equipment (PPE) in accordance with nationally accepted guidelines for infection prevention and control upon entering a resident's room (Resident #433) that was identified as COVID-19 Persons Under Investigation (PUI). According to the U.S Centers for Disease Control and Prevention (CDC) guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 09/23/22, included resources for Recommended Infection Prevention and Control (IPC) practices, specifically the Personal Protection Equipment (PPE). The guidelines included, HCP [healthcare personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 [COVID-19] infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face. This deficient practice was evidenced by the following: On 11/03/22 at 10:35 AM, during the initial tour the Registered Nurse/Unit Manager (RN/UM #1) for the Mercer Unit, who informed the surveyor that Resident #433 was newly admitted on [DATE] and was a COVID-19 PUI for the next seven (7) days. On 11/03/22 at 11:14 AM, the surveyor observed Resident #433 sitting in a chair talking on the phone with the door opened. The surveyor then observed the Nursing Assistant (NA) enter the room of Resident #433 wearing an N95 respirator mask and eye protection. The NA entered the room without donning (putting on) a gown. The door remained opened, and the surveyor observed the NA donned gloves and made the resident's bed. On 11/03/22 at 11:16 AM, the surveyor interviewed Registered Nurse #1, who stated upon entry into a PUI room staff and visitors where required to wear a gown, N95 mask, a pair of gloves and eye protection. On 11/03/22 at 11:17 AM, the NA exited the resident's room and removed her gloves. The NA then proceeded and tied the back of a gown for a visitor. On 11/03/22 at 11:18 AM, the surveyor interviewed the NA who stated she was scheduled to take her exam to become a Certified Nursing Assistant (CNA) soon. The surveyor continued to interview the NA who stated she was required to wear a gown, gloves, and goggles upon entry to a PUI room. She further stated she was required to wear the full PPE every time she entered those rooms. The NA explained, she did not need to wear a gown inside the room because Resident #433 did not have COVID-19. The NA then stated, she actually didn't know she was required to wear inside the room until Registered Nurse (RN #1) informed her. The NA confirmed she was in-serviced by the Director of Nursing (DON) on Infection Control and the required PPE. The NA stated the importance of wearing a gown was to stay COVID-free and to protect yourself and the residents from the potential spread. The surveyor and the NA reviewed the signage posted outside the resident's room door together. The NA acknowledged she should have donned the full PPE which included a gown prior to entering a PUI room. The NA concluded, to be honest I've been going inside the rooms without a gown and that she just wore her goggles and an N95 mask. On 11/03/22 at 11:23 AM, the surveyor observed the NA who applied alcohol-based hand rub (ABHR), donned a yellow disposable gown, a pair of gloves and entered another PUI room. At that time, the surveyor reviewed the signage located on the wall next to the PUI room which reflected stop droplet precaution everyone must wear: PPE gown, mask or respirator, goggles or face shield, and gloves. On 11/03/22 at 11:26 AM, the surveyor observed the NA exited the room and by the door doffed (removed) the gown and gloves and placed them into the designated black trash bin and then applied ABHR. On 11/15/22 at 10:45 AM, the surveyor interviewed RN/UM #1, who stated the required PPE for PUI rooms included gloves, eye protection, N95 mask and a gown. RN/UM #1 stated if even a staff member was going into the room a make a bed, they were required to wear the full PPE. She explained the importance of wearing the full PPE which include a gown was for protection and to prevent the potential spread of an infection. RN/UM #1 stated that the NA was new to the Mercer Unit where the PUIs were located. She further stated that all staff are educated, and that the NA should have known what she was required to wear upon entry into the PUI rooms. RN/UM #1 concluded between the Infection Preventionist (IP) and herself they are always educating the staff. On 11/15/22 at 12:46 PM, the surveyor interviewed the DON who stated if staff anticipated direct care to a resident, then they were expected to wear a gown, gloves, N95 mask and eye protection. The DON acknowledged the NA should have worn a gown inside the room. On 11/15/22 at 01:26 PM, the DON informed the surveyor she investigated to get clarity and confirmed from the NA, RN, and RN/UM #1 that the NA should have worn a gown prior to entering a PUI room even if the NA was just in there to make the resident's bed. The DON stated she could not justify the NA not wearing a gown inside the PUI room. She further stated the rooms were too small and there was no way they could maintain six (6) feet (ft) from each other especially since the resident had a roommate. A review of the in-services PPE don/doff, droplet/contact/standard precaution dated 04/04/22 and 08/18/22, reflected the NA was in attendance. A review of the NA's Personal Protection Equipment (PPE) Competency Validation Donning and Doffing Standard Precautions and Transmission Based Precautions dated 06/23/22, reflected she completed the appropriate steps for donning and doffing. A review of the facility policy Infection Control Program and Surveillance Plan dated reviewed 01/12/22, reflected General infection control practices, including personal protective measure, hand hygiene and guidelines for Standard and Transmission-Based Precautions. A review of the facility policy COVID-19 Testing and Cohort Plan dated revised 03/10/22, reflected New or readmitted asymptomatic patients/residents who are not up to date with all recommended COVID-19 vaccine doses and have a viral test negative for SARS-CoV-2 upon admission or readmission: these patients/residents should be placed in quarantine and cared for using full PPE (gown, gloves, eye protection that covers the front and sides of face, and NIOSH-approved N95 or equivalent or higher-level respirator), even if they have a negative test upon admission. NJAC 8:39-19.4(a)

Based on observations, interviews, and review of facility documentation it was determined that the facility failed to provide a clean and sanitary environment for one (1) of 20 residents reviewed (Resident #3). This deficient practice was identified by the following On 11/15/22 at 10:30 AM, the surveyor observed the floor in Resident #3's room was dirty and needed to be cleaned. There was dirt built up on the floor and woodwork. The surveyor also observed that there was no toilet paper or paper towels in the bathroom and the resident could use the bathroom independently. The bathroom floor was also dirty. Review of the Electronic Medical Record (EMR) revealed that Resident #3 had a Brief Interview of Mental Status of 03, meaning the resident had severe cognitive impairment. Review of the most recent annual Minimum Data Set (MDS), an assessment tool dated 08/10/22 indicated Resident #3 was a set-up help only for ambulation in room and corridors, and a one-person physical assist for dressing and eating. Medical diagnoses included, but not limited to chronic obstructive pulmonary disease (constriction of the airways making breathing difficult), major depressive disorder, lack of coordination, hyperlipidemia (high blood cholesterol), and chronic kidney disease. On 11/15/22 at 10:15 AM, the surveyor observed Resident #3 standing outside of the room in the hallway. On 11/15/22 at 10:33 AM, the surveyor entered room [ROOM NUMBER]. The resident was still standing in the hallway just outside the door holding onto a wheelchair. The resident was not able to be interviewed due to a cognitive impairment. When the surveyor entered the room, the surveyor observed a large dried brown area on the floor that appeared to be dried liquid or food splashes. The surveyor also observed in several areas of the room there were multiple loose black and brown particles on the floor surrounding the resident's bed and in the area in front of the dresser. The surveyor then entered the bathroom and there was no toilet paper or paper towels. The caulk surrounding the base of the toilet had a black substance on it. The floor was covered with what appeared to be shredded white paper. On 11/15/22 at 10:42 AM, the surveyor interviewed a housekeeper who was on the unit sweeping the hallway who in fact was the Housekeeping Director (HD). The HD entered the room with the surveyor and the HD was shown the floor in the room and the HD had no comment. The surveyor then asked the daily process for rooms being cleaned. The HD told surveyor that first the trash was pulled, then the room was swept and mopped. The HD was shown the areas of concern on the floor and the bathroom, and the HD said it's his department that should fill the paper products. He could not speak to why the resident had no paper products in the bathroom. The surveyor asked the HD how often the rooms received a deep cleaning, which included buffing the floors and the HD said deep cleaning was getting done on a monthly schedule room by room, but it was paused due to Covid-19. On 11/15/22 at 11:32 AM, the surveyor asked the facility for the housekeeping policy and the deep cleaning calendar. On 11/15/22 at 11:55 AM, the surveyor reviewed a cleaning schedule for deep cleaning provided by the facility. room [ROOM NUMBER] was on the schedule for 10/24/22. The surveyor asked if a log was signed or there was any documentation to show that the room was done, and nothing was provided. On 11/16/22 at 10:15 AM, the surveyor interviewed a unit Certified Nursing Assistant (CNA #1) regarding the cleaning of the rooms. CNA #1 told the surveyor deep cleans happened on the day shift. CNA #1 was shown dust in a resident's room, and CNA #1 told surveyor We need better housekeepers. On 11/16/22 at 11:55 AM, the surveyor reviewed the policy titled, Complete Room Cleaning, dated 01/01/2000. The policy purpose was the Complete Room Cleaning schedule ensures that each resident room is discharge cleaned on a monthly basis. On 11/17/22 at 10:10 AM, the Licensed Nursing Home Administrator (LNHA) provided surveyor with documentation that room [ROOM NUMBER] was found to be in an environmentally unsatisfactory condition, lacking toilet paper, and paper towels. NJAC 8:39-31.4 (a)

Based on observations, reviews of facility policies, and staff interviews, it was determined that the facility failed to follow droplet precautions for infection control practices during the COVID-19 pandemic for 2 of 4 Residents (Residents #1 and #2). In addition, the facility staff failed to follow COVID-19 guidelines during transport of supplies from an outside vendor for 1 of 2 Employees (E) #3. The finding include: An observation on 4/2/20 at 8:52 AM, during a tour of the Subacute unit, revealed rooms [ROOM NUMBER] had their entry door closed and heavy plastic was attached to the frame of the door, sealed with a zipper. In addition, signage of a stop sign, which read Droplet Precautions Everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. The poster included two a person with goggles and another with face shield. Two additional posters indicated donning and doffing of PPE, which included gown, mask or respirator, goggles or face shield, and gloves. A plastic three drawer storage unit was located to the right of the door which contained masks, gowns, gloves, and face shields. The Unit Manager confirmed that the residents in these three rooms were considered presumptive positive for COVID- 19. At 8:55 AM, Employee #1 was sandwich between the medication cart and Resident #1's room. The employee, who had facial hair, was wearing a N95 mask, a yellow disposable gown, and gloves. He was preparing medications for the resident. In an interview, he was asked by this surveyor if he had been fit tested for the mask he was wearing. He replied, he was. He was then asked by this surveyor to describe the type of testing. He stated that he wasn't. The Unit Manager stated that no one in the facility was tested . He was observed removing his gloves and told this surveyor he was going to wash his hands and entered the resident's room without gloves, a face shield or goggles. Within a few seconds, he pushed the plastic and broke the room's threshold to come out of the room to get the resident's medication wearing the mask and yellow gown. The Unit Manager was present and made him go back into the doorway, telling him he cannot come out once he has entered with the PPE he had when he entered and she handed him the cup of medications, gloves, and a shield. At 9:15 AM, another observation revealed Employee #1 was outside Resident #2's room preparing an Insulin syringe. At this time he was wearing a surgical mask, yellow gown and gloves. He was asked does he always wears PPE when preparing resident's medications. He stated that he has to go into rooms to take the blood pressure because of parameters, so he doesn't want to pour the medication because if he brought the medication into the room and then took the blood pressure he would have to waste the medication if the pressure didn't meet the parameter. He also stated that he can't wear a face shield the facility provided because it fogs up. An observation at 11:38 AM revealed the receptionist, who was wearing gloves and a mask, and Employee #2, who had her mask down around her neck and no gloves, were in the front vestibule of the facility and lifting boxes onto a wheeled cart to bring closed cardboard boxes into the building. Employee #2 was holding the boxes up against her unprotected clothing. An observation at 11:45 AM revealed Employee #3, who is the designated housekeeper for the isolation rooms, was in room [ROOM NUMBER] with a wet mop, wearing hair cover, gloves, yellow gown and mask. When questioned by this surveyor, why she wasn't wearing gloves and was she aware of how long cardboard could be infected? She pulled her mask up, and smiled. At 11:55 AM, the Director of Nursing was told of the above observations. She stated that she herself gave the staff education yesterday regarding the CDC guidelines, looks like more education is needed. Employee #1 was already counseled and retrained. Review of the undated COVID-19 Emergency Plan policy reads, 1. All admissions and readmissions are screened for COVID-19 prior and upon admission 2. All admissions/readmissions will be placed on Droplet precautions upon admission for a 7-day period and monitored for s/s of respiratory illness or fever. 3. A staging room or a wing of a unit designated for admission 4. Residents who has signs of respiratory illness or fever will be placed in droplet precautions until resolution of symptoms. Review of the revised 3/20/2020 Clinical Management Novel Coronavirus COVID-19 policy reads, It is the policy of the facility to comply with evidence-based guidelines provided by CDC (Centers for Disease Control and Prevention) and NJDOH ( New Jersey Department of Health), concerning management of residents/patients with Novel Coronavirus COVID-19 c) RESIDENT IN FACILITY EXHIBITING SYMPTOMS (PUI) (Person Under Investigation). 1. Residents will be assessed for changes in status consistent with symptoms of respiratory illness. 2. If a resident is showing Fever and respiratory symptoms (not diagnosed with [REDACTED].b) Determination of resident's PUI will be completed. Coordinate with local NJDOH for approval for COVID-19 testing if criteria met .e) Initiate droplet precautions f) Use face masks or N95 mask if available and appropriate PPE (Personal Protective Equipment) .H. Personal Protective Equipment PPE and Strategies to Conserve PPE 1. Bundle care and minimize facility staff entering to an isolation room. 2. Place residents in step down unit, designated for known COVID-19 residents. 3. Cohorting or dedicating staff to work in the unit or symptomatic residents. 4. Extended wear same facemask, same eye protection. Remove only gloves and gowns between caring for residents. Perform hand hygiene between residents. continuing to wear the same eye protection, or face masks (extended use).