Every finding on record at Reformed Church Home

Based on observations, interview, and review of facility provided documents, it was determined that the facility failed to maintain proper kitchen sanitation practices to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 4/21/26 at 9:50 AM, during a tour of the kitchen with the Food Service Director (FSD), the surveyor observed a stainless steel utility rack with stacked pans on each shelf, all turned upside-down. The FSD identified this as the pan rack. The surveyor observed the following:1. Eleven pans stacked together on the second shelf from the top. The FSD identified these as 2-inch full size pans. The FSD separated the 2nd and 3rd pans in the stack which revealed they were dripping a clear thin liquid. The pans were visibly wet on the inside and outside surfaces. The FSD acknowledged the pans should not be stacked together while wet, and acknowledged they were improperly wet-nested (the practice of stacking or storing recently washed dishes or kitchenware while still wet, creating a moist environment that promotes bacterial growth). The FSD removed the stack of pans to the pot washing area to be rewashed.2. Two pans stacked together on the top rack identified by the FSD as 4-inch-deep chafing pans. When removed from the shelf and separated by the FSD, these pans were visibly wet and dripping. The FSD stated his staff was responsible for putting items from the dishwasher onto a drying rack, then once dry, the pans were moved to the pan rack. The FSD acknowledged the chafing pans were still wet when stacked on the pan rack. The FSD removed them to the pot washing area to be rewashed. At 10:30 AM the surveyor observed seven (7) pans stacked together right-side-up on the counter in front of the cooking area. The FSD stated the pans were set there to be used for lunch and identified these as 2-inch half pans. The FSD separated the pans, which were visibly wet on the inside and outside surfaces between them. The FSD acknowledged they were wet-nested. The FSD removed them to the pot washing area to be rewashed. On 4/23/26 at 8:46 AM, in the presence of the FSD, the surveyor observed several pans stacked upside-down on the pan rack. The FSD separated a stack of pans identified as half pans on the second shelf from the top, which revealed visible moisture between the pans. The FSD acknowledged the pans were not completely dried before being stacked. The FSD removed the stack of pans to the pot washing area to be rewashed. On 4/27/26 at 10:27 AM, the Administrator and the Director of Nursing were made aware of the above concerns. A review of the facility policy provided by the Administrator, titled Sanitizing of Equipment last reviewed January 2008 reflected Policy: All personnel will follow standard procedures. to ensure the safety of food served.Purpose: To ensure equipment used in the meal preparation is thoroughly cleaned and sanitized preventing injury and food-borne illness.Procedure:.8. Remove equipment from sink and place on the clean drying rack ensuring that the solution will drain completely. Allow to air dry. Do not stack until completely dry. NJAC 8:39-17.2(g)

Based on interviews, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete a background check for 1 out of 48 employees (Employee #1). This deficient practice was identified for newly hired employees reviewed since last survey of 12/11/24. This deficient practice was evidenced by the following:On 4/21/26 at approximately 10:16 AM, during the entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), all newly hired employee files for active and inactive employees from 12/11/24 to the current date.A review of the employee personnel files revealed the following:For Employee #1, a Certified Nursing Assistant (CNA) with a date of hire 1/12/26, there was no evidence of a background check prior to the start of employment. On 4/24/26 at 12:02 PM, the surveyor interviewed the Staffing Coordinator who stated that Employee #1 was on orientation following a CNA on a unit with residents on 1/12/26. On 4/27/26 at 8:55 AM, the surveyor interviewed the LNHA who stated that background checks are to be completed for employees prior to hire. She further stated that This background check slipped by us. The LNHA acknowledged that for Employee #1 the background check should have been completed prior to the employee working on the unit for orientation. On 4/27/26 at 10:12 AM, the surveyor interviewed the Director of Human Resources who stated that Employee #1's background check was missed and wasn't completed prior to hire. She further stated that it was a human resources error. She acknowledged that the background check should have been completed prior to hire. On 4/27/26 at 10:16 AM, the LNHA and DON were made aware of the above concerns regarding background checks for newly hired employees. The LNHA stated that they had no additional information for the above concerns. On 4/27/26 at 10:24 AM, the LNHA stated that background checks should be completed prior to hire to ensure the employee can provide appropriate care for residents. A review of the facility's Human Resources policy, dated as reviewed 1/24 revealed.The Human Resources Department will coordinate the employment process for all new staff to include: candidate selection, background investigations, and references. to ensure that all employment related procedures are completed in a consistent and timely fashion.No offer of employment shall be made without completion of a criminal background check unless approved by the Director of Human Resources. The applicant must be informed that the offer is contingent upon successful completion of the background check. A review of the facility's Abuse Policy policy, dated as reviewed 2025 revealed .The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention.It is the policy of RCH to screen employees and volunteers prior to working with residents. Screening components include verification of references, certifications and verification of license and criminal background check.Before new employees are permitted to work with residents, the employment history provided by the prospective employee will be verified as well as appropriate board registrations and certifications regarding the prospective employee's background.A criminal background check (which includes the sex offender check) will be conducted by Human Resources, on all prospective employees. NJAC 8:39-9.3(b)

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure professional standards of nursing practice were followed by offloading (use of a device or specialized surface to decrease the risk of pressure injury) a resident's heels according to the physician's order. This deficient practice was identified for 1 of 1 resident (Resident #14) reviewed for prevention of pressure injury and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/22/26 at 10:03 AM, during the initial tour, the surveyor observed Resident #14 in their bed, without a cover over their legs. Resident #14 was wearing dark blue socks that went above their ankles, and pants with wide pantlegs. Resident #14 stated they had twisted their ankle during a fall in January and was receiving therapy to be able to walk again. The resident stated the staff had to assist with putting their pants and socks on. At 11:00 AM, the surveyor interviewed the Registered Nurse (RN #1) who stated Resident #14 needed extensive assistance with care and had no skin breakdown (damage to healthy skin and underlying tissues). RN #1 stated she provided care to Resident #14 to prevent skin breakdown. In the presence of the surveyor, RN #1 reviewed Resident #14's electronic treatment administration record (eTAR) and stated Resident #14 had heel booties (cushioned pillows that wrap around the foot, secured by velcro, to protect heels from pressure) to prevent breakdown. RN #1 acknowledged she signed off (entered her initials electronically) that the heel booties were in place that morning. RN #1 stated if her initials were on the eTAR, that meant the heel booties were on the resident. At 11:50 AM, in the presence of the surveyor, RN #1 went into Resident #14's room, where the heel booties were not observed. RN #1 looked on and under Resident #14's bed, in their bedside stand, and in their closet. RN #1 acknowledged she could not locate heel booties for Resident #14. At 11:58 AM, RN #1 spoke to the surveyor in the hallway, acknowledging my mistake, [Resident #14] didn't have them (heel booties), I am going to get them now. On 4/24/26 at 10:40 AM, the surveyor interviewed the Unit Manager (UM)/RN who acknowledged it was her responsibility to review and update the care plan for Resident #14. She stated Resident #14 does not have any skin breakdown or wounds. She stated to prevent breakdown the resident should have had heel booties to float their heels off the mattress. The UM/RN, in the presence of the surveyor, reviewed the eTAR for Resident #14. The UM/RN stated the nurse's initials on the eTARS indicated the heel booties were on the resident, and it was the nurse's responsibility to ensure they were on. The surveyor reviewed the electronic medical record (EMR) for Resident #14. A review of the Resident Face Sheet, an admission summary, reflected the resident was admitted with diagnoses which included but were not limited to syncope (temporary loss of consciousness/fainting) and collapse, pulmonary hypertension (high blood pressure in the arteries of the lungs), and sprain of unspecified ligament of left ankle. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 12/26/25, reflected the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident was cognitively intact. Further review of the MDS reflected the resident was at risk of developing pressure ulcers/injuries. A review of the Physician's Orders reflected an order dated 4/11/26 to apply heel protectors/booties when in bed. Check placement every shift. A review of the April eTAR reflected the order to apply heel protectors/booties when in bed. Further review reflected nurses' initials for each shift of each day starting on April 11, indicating the heel protectors/booties were applied when in bed and placement was checked. A review of the Care Plan Activity Report, an individualized comprehensive care plan, reflected a focus area for Skin effective 12/10/25.the resident was at risk for skin breakdown due to impaired mobility / impaired body movement.Interventions included heel protectors. A review of the undated facility-provided document titled Wound and Skin Care Protocols reflected the following:.Care interventions are directed toward minimizing and/or eliminating the effects of the causal/contributing factors pressure, moisture, friction/shear and nutrition.Pressure:.3. Heels are extremely vulnerable and must be elevated completely off bed surface. NJAC 8:39-27.1(e)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure professional standards of nursing practice were followed by administering oxygen therapy according to the physician's order. This deficient practice was identified for 1 of 1 resident (Resident #52) reviewed for respiratory care and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 4/21/26 at 11:11 AM, during an initial tour, the surveyor observed No smoking, Oxygen (O2) in use signage at Resident #52's room door. The surveyor observed Resident #52 watching TV in their bed while receiving O2 via nasal cannula (NC) (a flexible tube placed in the nares) connected to an O2 concentrator (a medical device to provide supplemental O2 therapy to people who have lower O2 levels) which indicated a setting of 1 liter per minute (L/min). The resident did not speak to how much O2 they were on.On 4/22/26 at 12:23 PM, the surveyor observed Resident #52 sitting in their wheelchair receiving O2 via NC, which was connected to the O2 concentrator set at 1 L/min. The surveyor reviewed the electronic medical record (EMR) for Resident #52A review of the Resident Face Sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; Acute (severe or sudden) and Chronic (a condition, disease or situation that lasts for a long time or is constant) respiratory failure (a serious condition where the lungs cannot properly move O2 into blood or remove carbon dioxide) with hypoxia (low levels of O2 in your body tissue), respiratory conditions due to smoke inhalation (breathing in), and shortness of breath. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 2/21/26, revealed the resident had a Brief Interview for Mental Status of 11 out of 15, indicating the resident had moderately impaired cognition. Further review of the MDS revealed the resident was receiving O2.A review of the Physician's Orders revealed a Physician Order (PO) dated 4/7/26 for: O2 via NC continuous at 2 L/min to maintain SpO2 (a measurement of how much O2 your blood is carrying as a percentage of the maximum it could carry) at 92% or higher.A review of the April 2026 Medication Administration Record (MAR) for Resident #52 revealed nurses' signatures for each shift indicating the resident was being administered continuous O2 at 2 L/min to maintain their SpO2 at 92% or higher. On 4/22/26 at 12:23 PM, the surveyor interviewed the Registered Nurse (RN) who stated they needed a PO for O2 administration, so they knew how much O2 was needed and whether it was to be administered continuously or as needed. The RN stated she had only one resident (Resident #52) who was on O2 at 2L/min and the resident was maintaining their SpO2 between 95-97%. The RN stated during her rounds at the beginning of her shift, she checked how much O2 Resident #52 was on. The surveyor accompanied the RN to Resident #52's room and observed the resident's O2 concentrator which indicated a setting of 1 L/min. The RN acknowledged that during rounds she should have made sure Resident #52's O2 was set to the amount that was ordered by the physician. The RN stated if the resident was on a low amount of O2, they could go into respiratory distress.On 4/22/26 at 12:50 PM, the surveyor interviewed the RN/Unit Manager (UM) who stated if a resident had shortness of breath and their SpO2 was low, they would notify the physician to obtain O2 orders. The surveyor reviewed Resident #52's O2 PO with the RN/UM and the RN/UM stated the resident should be on continuous O2 at 2L/min. The surveyor made the RN/UM aware of the above-mentioned concerns for Resident #52. The RN/UM stated the expectation for the nurses was to make sure the resident was on O2 at the right setting as per PO prior to signing the MARs. The RN/UM acknowledged that the O2 order was clearly for 2L and further stated technically oxygen is a medication, and they (the nurses) should be following POs.On 4/23/26 at 11:24 AM, the surveyor made the Director of Nursing (DON) aware of the above-mentioned concerns for Resident #52. The DON stated the nurses were signing off the MARs for how many liters of O2 the resident was getting. The DON further stated that the expectation for the nurses was to follow POs for O2 administration. On 4/23/26 at 12:04 PM, the survey team met with the Licensed Nursing Home Administration (LNHA) and the DON. The surveyor made the facility administration aware of the above-mentioned concerns for Resident #52. A review of the facility policy Oxygen Administration reviewed 2026 revealed under Procedure: 1. Check for MD (physician)/Nurse Practitioner (NP) order. A review of the facility job description titled, Staff Nurse provided by the DON included but was not limited to; Under Essential Functions: Communicates with physician/ Advanced Practice Nurse (APN) and transcribed, documents, and implements physician's orders. NJAC 8:39-11.2(b); 27.1(a)

Complaint # NJ 179632 Based on observation, interviews, review of medical records and facility documents, it was determined that the facility failed to follow fall prevention interventions as written on the resident's individual comprehensive care plan (ICCP). This deficient practice was identified for 1 of 4 residents (Resident # 44) reviewed for accidents. This deficient practice was evidenced by the following: On 12/04/24 at 12:30 PM, during the initial tour of the 1st floor unit, the surveyor observed Resident #44 in a reclining chair in the day room with other residents and staff members. The surveyor observed a thick cushioned fall mat leaning against the wall in the resident's room. The surveyor reviewed the electronic medical record (EMR) for Resident # 44. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Parkinson's disease (is a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and dementia in other diseases classified elsewhere, unspecified severity, with behavior disturbance (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions.) A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 7/12/24, revealed Resident #44 had a Brief Interview for Mental Status of 6 out of 15, indicating the resident was severely cognitively impaired. Further review of the MDS, revealed the resident required substantial/max assistance, helper does more than half the effort. A review of the Fall Risk Assessment-Eight Category completed on 8/5/2024 revealed Total: 17 High Risk! A review of Resident # 44's ICCP revealed a Focus: FALLS, Resident is at risk for fall due to: impaired mobility .9/1/24-had fall .interventions included: Mattress to the right side of bed. Bed in lowest position, Active Effective: 6/4/2021 .Hourly visual checks when resident is in bed, Active Effective: 6/23/2023 . Keep floor bed even with a thick floor mat, and 2 landing strips next to each other on the right side of bed when resident is in bed, Active effective: 6/24/2021. A review of facility progress notes revealed a nursing note dated 09/01/2024 at 01:14 AM, Called to patient room observed with hematoma (a bruise) to the left forehead and laceration 1 cm x 1/2cm to the left forehead redness to both knees and left shoulder positive ROM (range of motion) to all extremities called MD (medical doctor) via service and received call back and received TVO (telephone verbal order) to send patient to the ER (emergency room ) to rule out head injury. A review of the facility provided investigation revealed: An investigation was conducted, and it was determined that the bed had been lowered but the floor mats identified in the care plan (CP) were not in place at the time of the fall . The CNA (Certified Nursing Assistant) lowered the bed prior to leaving the room but at the time of the fall the floor nurse noted that bed was not in the lowest position. Further reviewed revealed: Summary: We could not substantiate abuse, but we did identify that the care plan was not followed for falls. On 12/06/24 at 11:00 AM, the surveyor interviewed the Director of Nursing (DON), who stated the CNA caring for the resident was an agency CNA who did not know the resident. She stated the nurse gave the CNA report but was unable to verify exactly what was said. The DON stated a form Resident Care Needs was made so all staff can be made aware of resident's needs. On 12/06/24 at 1:23 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated Resident #44 was always in the day room so that staff can observe the resident. She also stated that the resident liked to socialize. The RN/UM stated all falls should be on the CP. She then stated the CP purpose was to know what care the resident needs and how to get the best outcomes for residents. On12/09/24 at 9:31 AM, the surveyor interviewed Resident #44's assigned CNA, who stated she knows the resident well. She stated when the resident was in bed, the bed must be in the lowest position and the thick fall matts need to be next to the bed to keep the resident safe. She stated she knows this because I reviewed the care plan. A review of the facility's policy Fall Risk Assessment revised 1/2019, revealed Procedure: 3. Residents with a score of 10 or more will be considered risk for falls and interventions will be implement. 4. A person-centered Fall Care Plan will be developed, and interventions will be reviewed with each new fall, quarterly, annually, and significant change assessment, and as needed. NJAC 8:39-27.1 (a)

Based on observation, interview and record review it was determined that the facility failed to report a bruise of unknown origin to the New Jersey Department of Health (NJDOH) for 1 of 1 resident reviewed for bruise of unknown origin (Resident #21). Findings included: On 08/02/23 at 10:00 AM, the surveyor toured the 200 unit of the facility and observed Resident #21 seated in the bed, watching television. The surveyor observed a bluish discoloration to the resident's left jaw. When asked about the discoloration, the resident replied, I don't know. On 08/02/23 at 12:01 PM, the surveyor returned to the unit to observe the lunch meal. The surveyor heard some noise and profanities coming from Resident #21's room and the curtain was drawn. The surveyor knocked at the door and the staff prompted the surveyor to enter the room. The surveyor observed Resident #21 seated on the bed. The surveyor also observed two Certified Nursing Assistants (CNAs) at the resident's bedside. The CNAs were about to transfer Resident #21 to the wheelchair and the resident kept repeating, No. Resident #21 was flailing his/her hands in an attempt to not be transferred, and was using abusive language towards the CNAs. On 08/03/23 at 11:30 AM, the surveyor reviewed Resident #21's electronic medical record which revealed: The Admission Face Sheet (an admission summary) reflected that Resident #21 was admitted to the facility with diagnoses which included but were not limited to, altered mental status and Alzheimer's disease with late onset and dementia. Review of the Admission Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care dated 06/19/23, reflected that Resident #21 was severely cognitively impaired and scored 6/15 on the Brief Interview for Mental Status (BIMS). Resident #21 required extensive to total assistance of two persons physical assist with bed mobility and transfer. Section E of the MDS which addressed behavior, indicated on E 0200 (section A) that Resident #21 exhibited some physical behavior symptoms directed at others (e.g., hitting, scratching, grabbing). A review of the 24-hour Report dated 07/27/23, from 11:00 PM-07:00 AM revealed the following: Bruise to left side of lip and left side of chin. A review of a Progress notes dated 07/28/23 timed 07:41 AM, indicated the following: Note: Daily Skin Observation Note. Affected area Status: New. Comment: Bruise to resident's left side of lip/ chin noted during rounds. Unable to explain what happened. Family informed. MD (medical doctor informed). On 08/04/23, the surveyor requested all investigative reports for Resident #21 for review. On 08/04/23 at 11:15 AM, the Director of Nursing (DON) provided 2 Incident/Accident Investigation reports. Review of the Incident/accident Investigation dated 07/12/23 timed 9:30 AM, revealed during a 2-person transfer, Resident #21 sustained an abrasion. Another Incident/Accident Investigation dated 07/27/23 timed 11:30 PM, indicated, Bruising to left side of lip/chin noted during rounds by assigned Aide. Assessed, Denies pain, Resident unable to explain what happened due to cognitive impairment. The surveyor reviewed the incident report dated 07/27/23, and noted that four statements were attached to the incident investigation report. One statement was from the RN who worked the 11:00 PM- 07:00 AM shift dated 07/27/23 timed 11:30 PM, revealed the following: Notified by assigned Aide during change of shift that she noticed a bruise on the left side of resident's lip. Went into resident's room with outgoing nurse to assess. Bruise noted to left side of lip/chin. Resident unable to explain what happened. No pain to touch. Family notify MD (Medical Doctor) office made aware. Assistant Director of Nursing notified. Another statement from the CNA who first identified and reported the bruise indicated the following: Around 11:10 PM, when I was doing my round, I noticed a bruise to the patient's left side of her lip, I went to tell the nurse. The CNA assigned to Resident #21 on the 07:00 AM-3:00 PM shift, wrote: Yesterday I was assigned to Resident #21 I did not noticed any bruise on her/him. A statement from the RN Nursing Supervisor, who worked on 07/27/23, the 3:00 PM-11:00 PM shift indicated the following: I worked the shift as a supervisor and as a floor nurse on the 3rd floor. When I saw Resident #21 in the day room at approximately at 8:00 PM, Resident #21 did not have a bruised face. Later, when assigned nurse gave me report, she told that no incident, no skin change this shift. Another statement from another RN dated 07/29/23, revealed that she worked on 07/27/23 during the day shift and there was no bruise on the resident's face. She observed the resident in the dayroom listening to music around 3:30 PM. The surveyor reviewed the nursing assignment from 07/25/23 to 07/29/23. The facility did not provide any statement from the staff assigned to Resident #21 on 07/27/23 for the 3:00 PM-11:00 PM shift. The surveyor then asked the DON what is the process to investigate an injury of unknown origin. The DON stated the facility would collect statement from all staff involved in the resident care for 24 to 48 hours. The DON also added the incident of 07/27/23 was not an injury of unknown origin. The surveyor asked the DON for any reportable incident that was reported to NJDOH. The DON informed the surveyor that this incident was not reported to NJDOH since the Registered Nurse Unit Manager (RN/UM) concluded what had happened. On 08/10/23 at 09:30 AM, the surveyor conducted a telephone interview with the CNA who first observed and reported the bruise on 07/27/23 at 11:10 PM. She confirmed that she observed the bruise during round and reported it to the nurse immediately. On 08/10/23 at 10:30 AM, the surveyor conducted a telephone interview with the RN who wrote the incident report. The RN confirmed she was the nurse who observed the bruise to Resident #21's lip and left chin and completed the incident report on 07/27/23 at 11:30 PM. The RN indicated that when she entered the resident's room with the Licensed Practical Nurse (LPN) who worked the 3:00 PM-11:00 PM shift, the resident was in bed. She assessed the bruised area on the left chin and lip which was not there the day before. The RN indicated that she assessed the area, assessed the resident for pain. She asked the resident what happened, the resident was confused and could not provide any information. She reported to the Nursing Supervisor, and called the physician and the responsible party in the morning. She informed the UM and the DON also in the morning. On 08/10/23 at 12:01 PM, the surveyor conducted a face to face interview with the RN Unit Manager who concluded that the bruise was from the drinking cup. The Unit Manager stated she stood at the door and observed the resident eating while watching television. She stated she assumed that the bruise could be from the drinking cup and the bruise was an injury of unknown origin and should be further investigated to rule out abuse. On 08/11/23 at 11:30 AM, an interview was conducted again with the DON, the DON stated that the RN/UM's conclusion seemed logical so she did not consider the bruise as an injury of unknown origin and did not report it to the NJDOH [Department of Health]. On 08/14/23 at 10:09 AM, the surveyor interviewed the Assistant Administrator. She indicated that she reviewed all investigations in conjunction with the Administrator. The DON was responsible to complete the investigation and submitted it for review. She was told in the morning meeting that the bruise was from the drinking cup. She did not review the investigation. The team then asked the Assistant Administrator to elaborate on the process for an injury of unknown origin. She stated that We have to investigate. The supervisor will inform the DON who will follow the process. The components of the investigation protocol must be followed. The facility must obtained statements from all staff involved in the resident's care for 24-48 hours. We need the statements and then we review the statements. The Assistant Administrator further stated They [the facility] have to get the statements. The Assistant Administrator stated to be honest, in morning meeting they told me that they already knew the cause of the bruise, I never reviewed it. The survey team then asked the Assistant Administrator if she had reviewed the investigation, would she have told them that statements were missing? She replied, I would have told them to get the statements. The survey team then asked the Assistant Administrator what the facility's definition was of an injury of unknown origin. The Assistant Administrator stated, when we don't know the origin. On 08/14/23 at 10:22 AM, the Assistant Administrator showed the surveyor that she did not sign the investigation nor review the summary provided by the UM. She stated clearly that although she was responsible to determine the causal factor after reviewing all statements, she did not make nor sign the determination that the bruise was from the drinking cup. Her expectation was that the facility would thoroughly investigate injuries of unknown origin and complete the required documentation per the facility policy. On 08/14/23 at 11:42 AM, the LPN who worked the 3:00 PM - 11:00 PM shift on 07/27/23, returned the call and informed the survey team that she did not write a statement on 07/27/23. The LPN further stated that when she returned to work on 07/28/23, the DON stated that the issue with the bruise was resolved, she was not asked to provide a statement. When asked to elaborate regarding the incident, she stated she could not remember if she went to the room with the RN and observed the bruise. A review of the facility abuse policy last revised 2023, indicated the following: Injuries of Unknown Origin: An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Under Reporting and Response, it is stated that all alleged violations involving abuse, or mistreatment including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made and no later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. NJAC 8:39-9.4(f)

Based on observation, interview and document review it was determined that the facility failed to serve foods at an acceptable temperature for 1 of 18 residents reviewed (Resident #67) and for 1 of 3 resident units (2nd floor). The deficient practice was evidenced by the following: On 08/02/23 at 10:33 AM, during an interview with Resident #67, the resident expressed concerns over the meal temperature. On 08/04/23 at 7:24 AM, the surveyor observed the breakfast meal distribution from the 2nd floor remote food service kitchen. Three meal trucks left the kitchen at that time and arrived on A, B, C Wings and the surveyor observed the meal cart that arrived on the B Wing at 7:26 AM. The cart contained seven trays and was left on the unit for distribution. On 08/04/23 at 7:27 AM, one staff member removed a meal tray for service to a resident. On 08/04/23 at 7:31 AM, 4 trays remained and 1 staff delivered the meals. On 08/04/23 at 7:43 AM, the last tray (17 minutes from when the trays arrived on the unit) was to be served, and the surveyor proceeded to test the meal temperatures. 08/04/23 7:44 AM, in the presence of another surveyor, the test tray revealed the following food temperatures: scrambled eggs 119 degrees Fahrenheit (F), oatmeal 128 F, 4 ounces milk 63 F, 4 ounces juice 62 F. On 08/04/23 at 8:02 AM, the surveyor relayed the test tray food food temperatures to the Regional Director of Operations for the food management company (RDO). The RDO stated that the standard was 140 F for serving hot foods and 40 F for serving cold foods. The surveyor showed the RDO the food temperatures and asked if they were acceptable and he stated, no. On 08/04/23 at 8:05 AM, the surveyor requested a food temperature policy. On 08/04/23 at 9:40AM, the Food Service Director provided a Meal Temperature Policy dated January 1, 2021. the Temperature Records and Taste Panel Evaluation Form Revealed, 3.Recommended Service Temperatures, Cold Food 40 F or below, Other Entrees: 160 F . NJAC 8:39-17.4 (a)2

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate a bruise of unknown origin that was identified on 07/27/27. This deficient practice was identified for 1 of 1 resident (Resident #21) reviewed for a bruise of unknown origin and was evidenced by the following: On 08/02/23 at 10:00 AM, the surveyor observed Resident #21 with a bluish discoloration to the left chin. The surveyor inquired about the discoloration, the resident stated, I don't know. On 08/02/23 at 1:15 PM, the surveyor interviewed a CNA about Resident #21. Upon inquiry, the CNA informed the surveyor that Resident #21 could be combative with care, but if you explained what you were about to do the resident would cooperate. On 08/03/23 at 11:30 AM, the surveyor reviewed Resident #21's electronic medical record which revealed: The Admission Face Sheet (a summary document) reflected that Resident #21 was admitted to with diagnoses which included but were not limited to, altered mental status, Alzheimer's disease with late onset, and dementia. Review of the Admission Minimum Data Set (MDS) dated [DATE], an assessment tool used by the facility to prioritize care, reflected that Resident #21 scored 6 /15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was severely cognitively impaired. Resident #21 required extensive to total assistance of two persons physical assist with bed mobility and transfer. A review of Resident #21's Plan of Care (PC) initiated on 06/27/23, reflected a care plan with a Focus for abusive behavior. The goal was for staff to approach the resident calmly and unhurriedly, explain all procedures and reason before performing. Encourage Resident #21 to make choices in the timing of care. The interventions included: If possible-stop giving care when resident is anxious and try later. Attempt to refocus behavior to something positive when the resident is exhibiting anxious behavior. Acknowledge and validate feelings. Monitor behaviors target behaviors. 2 staff assist during care and transfers. Provide emotional support during resident care and transfers to help alleviate anxiety. Review of an Incident/Accident investigation dated 07/27/23, timed 11:30 PM and signed by the Registered Nurse (RN) assigned to the 200's Unit, revealed that Resident #21 was noted with a bruise to the lip and left chin. There was no measurement documented for the bruise and the RN indicated that the resident was unable to explain what had happened due to cognitive impairment. The incident report listed the immediate actions taken were an assessment was completed, the bruise was noted, vital signs were taken and the physician and responsible party were notified. A review of the Progress Notes dated 07/28/23 timed 07:41 AM, revealed the following under Daily Skin Observation: Status: New. Comment: Bruise to resident's left side of lip/chin noted during rounds. Unable to explain what happened. A review of the conclusion Incident/Accident Investigation report dated 07/27/27 provided by the DON revealed that the Unit Manager (UM) concluded on 07/28/23 that the bruise was from the drinking cup. The Assistant Administrator did not sign to indicate that she reviewed and agreed with the conclusion. The Unit Manager did not interview the staff who provided care to Resident #21 on the 3:00 PM-11:00 PM shift A review of the assignment sheets from 07/25/23 to 07/29/23, revealed that the staff assigned to Resident #21 on 07/27/23 for the 3:00 PM-11:00 PM shift were not included to provide statements. There was not a statement from the Licensed Practical Nurse (LPN) who cared for Resident #21. The Certified Nursing Aides (CNAs) involved with the resident's care during the 3:00 PM-11:00 PM shift were not interviewed, nor asked to provide statements. According to the Plan of Care, Resident #21 required two person physical assist during care and transfer. The surveyor reviewed a nursing note dated 07/28/23 time 07:41 AM. The note was signed by the RN who wrote the incident report. The note revealed: Bruise to resident's left side of lip/chin noted during round. Unable to explain what happened. Family and Physician notified. The physician's Order sheet was reviewed and there was no new orders. There were no entries from the Nurse Practitioner or the physician regarding the bruise. The nursing Progress notes for 07/28/23 during the 3:00 PM-11:00 PM shift entered at 4:12 PM, failed to document anything regarding the resident's bruise. The nursing progress note documented no behavioral problems. The nursing progress notes dated 07/29/23 timed 8:10 AM, documented the following: S/P [Status post] incident day 2/3. Bruising to lip/chin persist. The nursing progress notes dated 07/29/23 timed 2:30 PM, indicated, S/P fall day 2, small ecchymosis to left of face noted, denied pain at site. Left hip and shin redness noted, skin intact. The facility failed to provide any fall incident reports for review. On 08/03/23 at 9:25 AM, the surveyor observed Resident #21 in bed and appeared more alert. The surveyor observed that the resident ate 100% of their breakfast and that the bruise was still visible to the left chin area. On 08/10/23 at 12:30 PM the surveyor interviewed the Director of Nursing (DON) regarding the investigation provided. The surveyor reviewed the assignment sheet with the DON. The DON stated that the CNA assigned to the resident was an agency CNA and she confirmed that she did not get a statement. The DON further stated that the bruise was not identified as an injury of unknown origin. The DON would not elaborate regarding the determination that was made by the UM. On 08/10/23 at 1:15 PM, during an interview with the UM, she revealed that the same night [referring to 07/27/23] she received an email from the nurse regarding the incident. When asked to provide the email, she stated that she could not retrieve the email. The UM further added that on 07/28/23 during the breakfast meal, she observed Resident #21 eating breakfast while watching television and she concluded that the bruise could have been from the drinking cup. The UM added that she did not observe the injury, nor interview the resident and confirmed that the bruise was an injury of unknown origin and should be investigated. The Surveyor then asked the UM to elaborate on the investigative process for an injury of unknown origin. The UM added statements from all staff involved with the resident over a period of 24-48 hours should be obtained. The surveyor again reviewed the Incident/Accident Investigation report dated 07/27/23, and noted that four statements were attached to the incident investigation report. One statement was from the RN who worked the 11:00 PM- 7:00 AM shift dated 07/27/23 timed 11:30 PM, revealed the following: Notified by assigned Aide during change of shift that she noticed a bruise on the left side of resident's lip. Went into resident's room with outgoing nurse to assess. Bruise noted to left side of lip/chin. Resident unable to explain what happened. No pain to touch. Family notify MD (Medical Doctor) office made aware. Assistant Director of Nursing notified. Another statement from the CNA who first identified and reported the bruise indicated the following: Around 11:10 PM, when I was doing my round, I noticed a bruise to the patient's left side of her lip, I went to tell the nurse. The CNA assigned to Resident #21 on the 7:00 AM-3:00 PM shift, statement indicated: Yesterday I was assigned to Resident #21. I did not noticed any bruise on [her/him]. A statement from the RN Nursing Supervisor, who worked the 3:00 PM-11:00 PM, shift indicated the following: I worked the shift as a supervisor and as a floor nurse on the 3rd floor. When I saw Resident #21 in the day room at approximately at 8:00 PM, Resident #21 did not have a bruised face. Later, when the assigned nurse gave me report, she stated that no incident, no skin change this shift. Another statement from another RN dated 07/29/23, revealed that she worked on 07/27/23 during the day shift and there was no bruise on the resident's face. She observed the resident in the dayroom listening to music around 3:30 PM. On 08/10/23 at 11:30 AM, the surveyor conducted a face to face interview with the RN Unit Manager who concluded that the bruise was from the drinking cup. The Unit Manager stated she stood at the door and observed the resident eating while watching television. She stated that she observed a line from the upper lip extended to the chin. She did not have any input from the direct care staff regarding the resident's behavior the evening when the bruise was discovered. She further stated that since no one knew what happened, she came to a reasonable conclusion the bruise could have been from the drinking cup. The UM added that the bruise was an injury of unknown origin and should be further investigated to rule out abuse. On 08/11/23 at 11:10 AM, the surveyor conducted a telephone interview with the CNA who first observed and reported the bruise on 07/27/23 at 11:10 PM. She confirmed that she observed the bruise during rounds and reported it to the nurse immediately. On 08/11/23 at 11:43 AM, the surveyor conducted a telephone interview with the RN who documented the incident report. The RN confirmed she was the nurse who observed the bruise to Resident #21's lip and left chin and completed the incident report on 11/27/28 at 11:30 PM. The RN indicated that when she entered the resident's room with the Licensed Practical Nurse (LPN) who worked the 3:00 PM-11:00 PM shift, the resident was in bed. She assessed the bruised area on the left chin and lip which was not there the day before. The RN indicated that she assessed the area, assessed the resident for pain. She asked the resident what happened, the resident was confused and could not provide any information. She reported to the Nursing supervisor, and called the physician and the responsible party in the morning. She informed the UM and the DON also in the morning. There were no entries from either the physician or the Nurse Practitioner regarding the bruise dated 07/27/23 in the medical record. The surveyor attempted to interview the Nursing Supervisor on 08/10/23, 08/11/23 and 08/14/23. The Nursing Supervisor who worked the 3:00 PM-11:00 PM shift, returned the call on 08/14/23 but declined to comment on the incident. On 08/11/23 at 11:30 AM, an interview was conducted again with the DON, the DON stated that the RN/UM's conclusion seemed logical so she did not consider the bruise as an injury of unknown origin and did not proceed further with the investigation. When asked about the staff statement from the staff that worked the 3:00 PM-11:00 PM shift, the DON stated that she stopped the investigation since she concluded what had happened. On 08/14/23 at 09:18 AM, an interview was conducted with the DON regarding the investigation. The DON maintained that the bruise was not an injury of unknown origin. The surveyor then reviewed the facility abuse policy which included the criteria that must be met for injury of unknown origin which revealed: According to the facility's policy an injury should be classified as an injury of unknown source when both of the following conditions are met: 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident. 2. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. On 08/14/23 at 10:09 AM, the survey team interviewed the Assistant Administrator in charge of the facility investigations. The Assistant Administrator stated that she was told that the staff observed a bruise and the causal factor was identified. The Assistant Administrator further stated that she was not provided with the investigation for review and she had been informed by the DON that the investigation was completed. The Assistant administrator stated, That was my mistake. I did not review the Incident/Accident Investigation. It is not a complete investigation, we need statements. On 08/14/23 at 10:22 AM, the Assistant Administrator showed the surveyor that she did not sign the investigation nor review the summary provided by the UM. She stated clearly that although she was responsible to determine the causal factor after reviewing all statements, she did not make nor sign the determination that the bruise was from the drinking cup. Her expectation was that the facility would thoroughly investigate injuries of unknown origin and complete the required documentation per the facility policy. On 08/14/23 at 11:42 AM, the LPN who worked the 3:00 PM- 11:00 PM shift on 07/27/23 returned the call and informed the survey team that on 07/27/23, she did not write a statement regarding the bruise. The LPN further stated that when she returned to work on 07/28/23, the DON stated that the issue with the bruise was resolved and she was not asked to provide a statement. When asked to elaborate regarding the incident she stated she could not remember if she went to the room with the RN and observed the bruise. The surveyor then asked the LPN if she was aware of the facility's process when an injury of unknown origin was identified. The LPN stated that whoever discovered the bruise should write a statement. She could not provide the rationale for not writing a statement on 07/27/23 after she observed the bruise. Review of the facility's administrative policy and procedures dated 02/2023 indicated the following: Policy: It is the policy of the facility that all incidents are reported, recorded, and analyzed for causal factors and trends. Corrective and/or preventive measures will be implemented as indicated. Incident Documentation: Each incident will be documented on the Incident Report form. All sections of the form [NAME] be completed. Incident Investigation An investigation will be initiated on all reported incidents. An incident Investigation Report form will be completed at the time of the incident. At the time of the incident, all nursing staff assigned to the unit will complete written statements regarding the incident when the incident is not witnessed. All nursing staff assigned to the unit during the previous two shifts will complete written statements when the incident is not witnessed. Additional statements may be warranted during the investigation. All statements must be signed by the writer, including any statements from everyone. NJAC 8:39-4.1(a)

Based on observation, interview, record review and other facility documentation, it was determined that the facility failed to to minimize the potential spread of infection to residents during observation of the medication pass and during dining observation. This deficient practice was identified for 1 of 2 nurses observed during the medication pass on 1 of 3 floors (second floor) and for 1 of 1 Certified Nursing Assistants (CNA) observed during dining services on 1 of 3 floors (third floor). This deficient practice were evidenced by the following: 1. On 07/27/21 at 8:35 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medication to the first resident and then wash her hands for 10 seconds. The LPN then donned a pair of gloves to both hands and placed a medicated patch onto the same resident. The LPN removed the gloves, washed her hands for 10 seconds and then proceeded to give medication to a second resident. On 07/27/21 at 9:17 AM, the LPN proceeded to a third resident's room to administer medications. The LPN realized that the resident was ordered a dose of Vitamin C 500 milligrams (mg) tablets and there was no remaining supply of this item on the medication cart. The LPN walked to the medication storage room, opened the door of the room, opened the door of the cabinet and removed a bottle of Vitamin C 500 mg tablets. The LPN then closed the cabinet door, the door of the medication storage room, and returned to the medication cart. The LPN then prepared and administered medications to the resident, without performing hand hygiene. During an interview with the surveyor on 07/28/21 at 9:50 AM, the LPN stated that according to the facility's policy, hand washing should occur before and after putting gloves on and before and after giving medication to a resident. The LPN further stated that the handwashing process included rubbing hands with soap for 20 seconds, prior to rinsing with water. At that time, the surveyor informed the LPN that she washed her hands for 10 seconds on two occasions and the LPN stated she understood the surveyor's concerns. The LPN acknowledged that hand hygiene should have occurred after she obtained the bottle of Vitamin C 500 mg from the storage room and prior to administering medication to the resident. A review of the LPN's Observation of Hand Hygiene competency, completed on 06/17/21, included Hands are wet from wrist to fingertips, Soap is placed, and hands are rubbed vigorously for at least 20 seconds (scrub all surfaces of hands including palms, back of hands, fingers and nails. 2. On 07/28/21 at 11:55 AM, during lunch dining services on the third floor C Wing, the surveyor observed a CNA perform hand hygiene. The CNA turned on the faucet, applied soap, lathered her hands, scrubbed them under the stream of water, rinsed her hands, and then used a paper towel to dry both hands. The CNA used a separate paper towel to turn off the faucet. During an interview with the surveyor on 07/28/21 at 11:59 AM, the CNA stated that the process for handwashing was to turn on the water, rinse hands with the water, apply soap to hands and scrub hands together under the steam of water, then rinse both hands and dry with paper towels and turn off water with a separate paper towel. A review of the CNA's Observation of Hand Hygiene competency, completed on 06/17/21, included Hands are wet from wrist to fingertips. Soap is placed and hands are rubbed vigorously for at least 20 seconds (scrub all surfaces of hands including palms, back of hands, fingers and nails. The competency form was not specific regarding hands being rubbed vigorously, outside the stream of water. During an interview with the surveyor on 07/29/21 at 10:37 AM, the Infection Preventionist (IP) stated that the process for handwashing included to wet the hands, lather for at least 20 seconds or sing the Happy Birthday song twice, scrub between fingers, wrists and hands, rinse hands, use a paper towel to dry the hands and then use another paper towel to shut off the faucet. The IP stated the process was not specific regarding lathering inside the stream of water or outside the stream of water but ideally you should lather and scrub outside the stream of water. During a follow up interview with the surveyor on 07/29/21 at 11:38 AM, the IP stated that the staff were educated to lather and scrub their hands and that she should have been more specific regarding the lathering of hands for 20 seconds, outside the stream of water. During an interview with the survey team, in the presence of the Administrator, on 07/29/21 at 1:26 PM, the Director of Nursing (DON) stated that hand hygiene should occur before and after giving medications and before and after donning gloves. The DON further clarified that proper hand washing involved rubbing the hands for 20 seconds, usually outside the stream of water. A review of the facility's undated Medication Administration policy revealed that a person administering medication should use proper hand hygiene, before beginning a medication pass, prior to handling any medication and after coming in direct contact with a resident. A review of the facility's Hand Hygiene policy, revised December 2019, included the procedure for handwashing as follows: 1. Wet your hands with clean running water (warm or cold), turn off the tap, and apply soap. 2. Lather your hands by rubbing then together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 3. Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from the beginning to end twice. 4. Rinse your hands well under clean, running water. 5. Dry your hands thoroughly using a clean, single use towel. 6. Use towel to turn off faucet. NJAC 8:39-19.4(a)(1)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to administer medications and maintain a medication error rate of less than 5%. This deficient practice was identified for 2 of 2 nurses who were observed during medication pass. There were a total of 30 medication opportunities, administered to four residents, on two units (First Floor and Second Floor) during the medication pass. There were two errors observed (Residents #6 and #51), which resulted in a medication error rate of 6%. This deficient practice was evidenced by the following: The surveyor observed the Licensed Practical Nurse (LPN #1) administer medications to Resident #6 on 07/27/21 at 8:36 AM, on the second floor. The LPN prepared seven medications, consisting of a total of 11 dosage units (tablets and capsules) for the resident, including the following: one tablet of [MEDICATION(S)] 40 milligrams (mg) (for edema), one capsule of Cranberry 425 mg (supplement), one tablet of [MEDICATION(S)] 25 mg (for overactive bladder), four tablets of Calcium [MEDICATION(S)] 250 mg (calcium supplement), one tablet of [MEDICATION(S)] 50 mg (for anxiety disorder), two tablets of Vitamin C 500 mg (supplement), and one tablet of Losartan 50 mg (for hypertension). During the time that the LPN was preparing medications for the resident, she also placed a bottle of Multivitamin tablets on the medication cart, but did not remove any tablets from the bottle, prior to returning it into the drawer of the medication cart. The LPN confirmed which medications were placed in the medication cup by naming each of them and then confirmed there were a total of 11 dosage units within the cup. The LPN then proceeded to the bedside of Resident #6 and administered the medication, despite the surveyor's request to return to the cart first. The surveyor asked the LPN to return to the medication cart with him once again, after the resident took his/her medication. During an interview with the surveyor at this time, LPN #1 reviewed and counted the medications which were present in the medication cup, prior to administration. She indicated that there were a total of 11 dosage units in the cup, before she gave them to the resident, in accordance with review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon doing so, the LPN determined and acknowledged that the resident's Multivitamin was not included with the other medications, and it was ordered by the physician. The LPN further stated that there should have been a total of 12 dosage units prepared and confirmed that one medication, the Multivitamin, was missing. The LPN gestured the number one with her index finger to the surveyor while speaking to him. The surveyor obtained and reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor observed another LPN (LPN #2) administer medications to Resident #51 on 07/28/21 at 8:47 AM, on the first floor. The LPN prepared several medications for administration to the resident, including a [MEDICATION(S)] 4% patch, which was incorrectly labeled as a [MEDICATION(S)] 5% patch. ([MEDICATION(S)] patches are a topical (local) medication placed on the skin in a particular area of the body, in order to help treat pain.) The LPN administered all of the other medications in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN then removed the [MEDICATION(S)] 4% patch from its container, dated it, initialed it, and asked the resident to turn over, so that she could place the patch onto Resident #51's back. The surveyor asked LPN #2 to return to the cart with him, before placing the patch on the resident. During an interview with the surveyor at this time, the LPN reviewed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN confirmed that the box containing the [MEDICATION(S)] 4% patches were labeled as [MEDICATION(S)] 5% patches. The LPN further stated that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor obtained and reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the surveyor on 07/29/21 at 1:24 PM, the Director of Nursing (DON) acknowledged that the omission of the Multivitamin tablet by LPN #1 and administration of an incorrectly tabled [MEDICATION(S)] Patch by LPN #2 were both errors, since they were not consistent with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's undated Policy and Procedure Medication Administration policy reflected medications are to be administered in accordance with written orders by the attending physician and Advanced Practical Nurse. The policy further references the need to administer the right dosage of medication. NJAC 8:39 - 29.2(d)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) appropriately assess a traumatic skin laceration for a resident, b.) obtain and implement a physician's orders [REDACTED]. This deficient practice was identified for 1 of 3 residents reviewed for wounds, Resident #239 and was evidenced by the following: On 11/4/19 at 11:00 AM, the surveyor observed Resident #239 and his/her representative in the room. The surveyor interviewed the resident representative who stated that the resident was being discharged home that day, but that he/she had a concern that the resident had sustained an acute traumatic skin laceration (a deep cut that goes beneath the skin surface) to the left lower extremity on 9/2/19 which occurred during a transfer from a wheelchair. He/She further told the surveyor that the facility notified him/her of the incident that occurred on 9/2/19, but was not made aware of the severity of the laceration. The resident representative then showed the surveyor a picture of the traumatic skin laceration to the lower leg on his/her personal cellphone dated 9/6/19. The surveyor reviewed the picture and the acute laceration appeared to be bloody, deep and had irregular edges. The surveyor observed the resident's left lower extremity in the presence of the resident's representative. The laceration area appeared to have shown signs of healing from the picture dated 9/6/19, and was now a small, jagged open wound covered in 100% yellow slough (dead tissue). The resident's skin was thin, fragile, and [MEDICAL CONDITION] (swollen). The surveyor reviewed the medical record for Resident #239. A review of the Resident Face Sheet (and admission summary) reflected that the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/15/19 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated the resident had moderately impaired cognition. A review of the resident's individualized comprehensive care plan (ICCP) dated 8/9/19 reflected a focus area for skin protection, and that on 9/2/19 the resident sustained [REDACTED]. documentation included that on 9/9/19 the left lower extremity wound was irregular in shape, reddened, and that the center of the wound was noted with slough, and subsequently an antibiotic was ordered. The interventions included to monitor the skin condition, use long pants, and provide a wound treatment as ordered. A review of the facility's Incident/Accident Report (I/AR) dated 9/2/19 completed by the Registered Nurse (RN) who worked the 7:00 AM - 3:00 PM shift on 9/2/19 documented that the resident obtained a skin tear (a wound caused by shear, friction, or [MEDICATION NAME] force resulting in separation of the skin layers) to the left lower leg which was 9 centimeters (cm) in length. The I/AR reflected that that the injury occurred while the resident was at physical therapy when two therapists were transferring the resident from his/her wheelchair. The I/AR further reflected that the RN had to apply pressure to the wound for five minutes for the bleeding to subside and then applied a padded foam dressing to the wound area. The I/AR reflected that the resident representative was notified of the injury, and a message was left with the resident's physician answering service. The I/AR did not include evidence of a physician's orders [REDACTED]. A review of the (MONTH) 2019 Physician order [REDACTED]. It wasn't until 9/4/19 that a wound treatment was ordered by the physician. The initial order dated 9/4/19 specified to cleanse the left lower extremity with normal saline, pat it dry, cover with a petroleum dressing, gauze, and wrap with kling wrap once daily. A review of the (MONTH) 2019 Treatment Administration Record did not reflect a physician's orders [REDACTED]. A review of the resident's progress notes dated 9/6/19 reflected the Nurse Practitioner (NP) assessed the wound for the first time, four days after the laceration occurred. A review of the facility's Educational Conference (EC) dated 9/7/19 reflected that the RN who worked on 9/2/19 during the 7:00 AM - 3:00 PM shift was verbally counseled regarding the incident. The EC included, You should perform accurate assessment of the injury, call another nurse or supervisor to help out when in doubt. Call MD (Medical Doctor) for appropriate treatment, may need to send the resident to the hospital for wound management immediately following incident. Make sure there is a treatment in place for any kind of wound. The RN signed that she read and understood the EC. A review of a second EC dated 9/23/19 reflected that a second RN who worked on 9/3/19 on the 7:00 AM - 3:00 PM shift was counseled for applying an inappropriate wound treatment when there was no active physician's orders [REDACTED]. You mentioned to the Unit Manager that it did not look like a skin tear, looking more like a laceration wound but nothing further was done like referral to APN (Advanced Practitioner Nurse) /MD. Wound was left without treatment order on 9/3/19 . The 7:00 AM - 3:00 PM RN who worked on 9/3/19 indicated in a hand-written statement that she notified her Registered Nurse/Unit Manager (RN/UM) because she felt the wound did not look like a skin tear and appeared to look more like a laceration. The hand-written statement further indicated that on 9/9/19 when the RN assessed the traumatic skin laceration, after not working the weekend, noticed a change in the wound's appearance and condition. The wound was reddened somewhat [MEDICAL CONDITION] and that slough had formed on the outer edges. The RN proceeded to notify the physician and obtained a physician's orders [REDACTED]. A review of the resident's initial wound consultation assessment dated [DATE] completed by the wound care NP reflected that the resident was seen for the evaluation and management for a laceration to the left lower extremity. The documentation reflected that the resident had a full thickness ulceration that consisted of 40 percent necrosis (dead tissue) and 60 percent granular (healing tissue) areas. The documentation in the assessment further reflected that the resident was receiving an antibiotic treatment for [REDACTED]. On 11/8/19 at 10:09 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident was alert with forgetfulness and able to make his/her needs known. The CNA stated that she remembered the resident had something on his/her left leg only because she recalled seeing a bandage on it. On 11/12/19 at 9:26 AM, the surveyor interviewed the RN who worked the 7:00 AM - 3:00 PM shift RN on 9/3/19 who stated she was the regular nurse assigned to care for the resident. The RN stated that the resident was admitted to the facility with a right femur fracture, was non weight bearing to the affected leg and required two people for transfer when the resident was first admitted to the facility. The RN further stated that the resident sustained [REDACTED]. The surveyor asked the RN what was the difference between a skin tear and a laceration. The RN described the resident's laceration as having more depth and was irregular in shape. The RN stated she told the RN/UM to take a look at the laceration. The RN stated that the next day when she came into work on 9/4/19 there was a treatment order in place for the laceration. The RN/UM stated that if an incident occurred it was the nurses responsibility to fill out an incident report, notify the family, the physician, and implement an appropriate treatment order for the injury. The RN further stated that the resident required antibiotic treatment soon after the injury occurred, and the wound was healing upon discharge from the facility. On 11/12/19 at 9:39 AM, the surveyor attempted to conduct a phone interview with the RN who worked on 9/2/19 when the traumatic laceration occurred. The RN did not respond to the voicemail. On 11/12/19 at 9:42 AM, the surveyor interviewed the RN/UM who stated that the resident was alert with forgetfulness. The RN/UM stated that the resident sustained [REDACTED]. The RN/UM stated that he thought the resident's left lower leg had encountered the wheelchair causing the laceration. The RN/UM stated, after the fact the laceration was not a simple skin tear as initially thought, and a 'laceration' would be a better word for it. The RN/UM stated that when an incident occurred, the nurse working was responsible for assessing the resident and providing first aid care. Then the nurse should notify the physician, obtain an order and notify the family. The RN/UM was unsure if the 7:00 AM - 3:00 PM shift RN working on 9/2/19 had obtained a physician's orders [REDACTED]. so a medically appropriate treatment could be put in place. On 11/12/19 at 11:29 AM, the surveyor interviewed the Director of Nursing (DON) who stated that when an incident occurred specific to the resident's skin the nurse would initiate an incident report and investigate the cause so the facility could implement a preventative measure to prevent another incident from taking place. The DON further stated that if a treatment needed to be put in place related to a skin injury, the facility would call the resident's physician and receive a physician's orders [REDACTED]. On 11/13/19 at 9:54 AM, the surveyor interviewed the NP in the presence of the Licensed Nursing Home Administrator (LNHA) and DON, and the survey team. The NP stated that she worked full time at the facility and was very involved in the resident's case. She stated that the resident was very compromised and had multiple co-morbidities. The NP acknowledged that a treatment to the laceration was not implemented in a timely manner. The NP further stated that upon discharge home, the laceration had healed and it was completed closed and a little cocoa-butter would take care of the discoloration. She added that she had talked to the family representative about the that already. (This did not correspond with the surveyor's observation on 11/4/19 and with the RN interview on 11/12/19 at 9:26 AM that the wound was healing, and the resident's discharge instructions). A review of the facility's Wound Tracking Policy and Procedure dated 6/2019 indicated, 2. If the resident has a wound(s), the nurse will notify the physician and obtain treatments orders and notify the family. A review of the facility's Incident Reporting Policy and Procedure dated 6/2019 included, It is the policy of Reformed Church Home that all incidents are properly reported, recorded and analyzed for casual factors and trends. Corrective and/or preventative measures will be implemented as indicated. The Incident Reporting Policy and Procedure further indicated, 1. Incidents will immediately be reported to the nurse, supervisor and/or unit manager, as well as the attending physician. Depending upon the severity of the incident, the Director of Nursing, and/or the Administrator is to be contacted. A review of an Inservice Education (IE) dated 9/7/19 reflected that the nurses working at the facility were educated on the difference between a skin tear and a laceration. The documentation provided to the nurses in the in-service indicated that a skin tear consisted of three types of classifications. The IE indicated, Type 1 wounds are linear have a flap with no loss of skin. If the wound has a flap, it should always be repositioned to cover the wound base. Type 2 wounds have partial loss of skin, and the flap doesn't cover the wound base when repositioned. Type 2 wounds have total loss of flap. The IE further indicated, A laceration is a deep cut or tearing of your skin. Accidents with knives, tools, and machinery are frequent causes of lacerations. In the case of deep lacerations, bleeding can be rapid and extensive. NJAC 8:38-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to appropriately implement transmission-based precautions in accordance with nationally accepted guidelines to prevent the spread of infectious disease. This deficient practice was identified for 1 of 1 residents reviewed for transmission-based infections (Resident #78), and was evidenced by the following: On 11/4/19 at 10:30 AM, the surveyor observed a Stop See Nurse sign and a bin containing personal protection equipment (PPE), including disposable gowns, gloves, and masks used to prevent transmission of an infection. The bin was located outside Resident #78's room. The resident was not in his/her room. The surveyor observed a Housekeeper wearing only gloves inside the bathroom emptying the resident's garbage. The Housekeeper placed the garbage bag into his housekeeping cart at the door. The Housekeeper then donned a mask and a gown from the PPE bin. The Housekeeper informed the surveyor that this was an isolation room, so he needed to wear gloves, a mask, and a gown when inside the room. The Housekeeper continued that he was about to clean the bathroom so wearing PPE was necessary to clean the bathroom, but that it was not necessary to wear the PPE when emptying the garbage. The Housekeeper proceeded into the bathroom and placed his blue plastic caddy which contained chemical cleaning solutions directly onto the resident's bathroom floor. At 11:19 AM, the surveyor observed Resident #78 sitting in his/her wheelchair by the stored medication and treatment carts outside of the activity room. The resident refused to be interviewed by the surveyor. At 11:30 AM, the surveyor observed Certified Nursing Aide (CNA) #1 wearing only gloves inside Resident #78's room and the CNA #1 was adjusting the resident's floor mats. The resident was not observed in the room. CNA #2, who wore only a mask and gloves assisted CNA #1 in the resident's bedroom, and then closed the door behind her. The surveyor then observed CNA #2 open the door and dispose the resident's garbage inside the communal garbage bin in the hallway. CNA #2 then used her same gloved hands to open the PPE bin and remove a new garbage bag, she then closed the resident's door. At 11:47 AM, the surveyor observed Resident #78 in the dining room eating lunch. The resident refused to speak with the surveyor. The surveyor reviewed the medical record for Resident #78. A review of the Resident Face Sheet (an admission record) reflected that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/11/19 reflected that the resident had a brief interview for mental status (BIMS) score of 10 out of 15, which indicated a moderately impaired cognition. It further included that the resident was frequently incontinent (loss of functional control) of the bladder. A review of the laboratory report for a collected urine specimen dated 11/1/19 indicated that the resident had a urinary tract infection [MEDICAL CONDITION] with ESBL (extended-spectrum beta-lactamases) (a resistant-bacteria that is transmissed through direct contact), and that contact precautions (transmission-based precautions with the use of gowns and gloves) were indicated. A further review of the report indicated that the Advance [MEDICATION NAME] Nurse (APN) wrote directly on the report with the date of 11/1/19 to implement contact precautions and intravenous antibiotic treatment for [REDACTED]. A review of the (MONTH) 2019 electronic Medication Administration Record [REDACTED]. A review of the resident's individualized, comprehensive care plan (ICCP) included a focus area dated effective 11/1/19 for a UTI with interventions that included to maintain contact isolation. On 11/7/19 at 8:19 AM, the surveyor observed CNA #2 open the resident's door from the inside with a mask on and removed a gown from the PPE box outside the door, then closed the resident's door from the inside. At 8:46 AM, the CNA left the resident's room wheeling Resident #78 to the dining room. The CNA wore a mask, but no gloves or gown. The CNA then proceeded to multiple areas of the unit including the nurse's station, hallway and activity room wearing the same mask. The CNA then grabbed a new mask from the cabinet by the nurse's station, and brought the mask to the activity room, where she changed masks. The used mask was disposed of in the garbage in the activity room. At 12:23 PM, the surveyor observed Resident #78 sitting in his/her wheelchair by the nurse's station. The surveyor observed CNA #2 wheel the resident to his/her room wearing no gloves or gown. On 11/8/19 at 8:21 AM and 11:08 AM the surveyor observed the resident outside of his/her room in common areas including but not limited to the nurse's station, activity room, hallways, and dining room, in which other residents were within the vicinity of Resident #78. On 11/12/19 at 9:00 AM, CNA #2 stated that Resident #78 at times voiced he/she needed to use the bathroom, but the resident was incontinent of bladder. The resident had PPE outside his/her room for an infection, and upon entry to the room, gown and gloves were to be donned. The CNA stated that she wore a mask because she had not received the influenza vaccine. The CNA continued that the PPE was disposed of inside the red garbage cans in the bathroom. The garbage was then disposed of separately then the rest of the building's garbage. The CNA added that the resident was allowed out of his/her room while on contact precautions. At 9:22 AM, the resident's Licensed Practical Nurse (LPN) informed the surveyor that the resident needed total assistance with care needs. The resident was on contact precautions for ESBL in the urine, which meant before entering his/her room, gown, gloves, and mask were to be donned to prevent the spread of infection. The LPN stated that it was ok that the resident was out of the room because the precautions were only utilized when in direct contact with the resident. At 10:37 AM, the Registered Nurse/Unit Manager (RN/UM) informed the surveyor that the resident was on contact precautions for ESBL in the urine, which meant prior to entering the resident's room, gloves, mask, and gown were to be donned. Prior to leaving the room, the PPE was disposed of in the garbage in the bathroom. The RN/UM stated that the resident was allowed out of his/her room since the urine was contained inside his/her incontinent brief. At 10:49 AM, the Housekeeping Supervisor informed the surveyor that if there was PPE outside a resident's room, the housekeeper asked the nurse what he/she needed to wear prior to entering the room. Residents that were on contact precautions had separate garbage and linen receptacles in their bathrooms for disposal. Garbage disposal went directly from the resident's room to the outside garbage collector, and the linen went directly to the laundry room to be washed separately. The Housekeeping Supervisor added that for all rooms, chemicals were brought off the cart as needed, and the blue plastic caddies should not leave the cart or be placed on the floor. At 11:07 AM, the Director of Nursing (DON), informed the surveyor that she was the Infection Preventionist. The DON stated that contact precautions involved donning gloves and gowns when performing tasks that involved secretions. The DON specified for contact precautions for ESBL in the urine, staff wore gowns and gloves when entering the resident's room. The resident was allowed outside of his/her room since the ESBL was contained inside the incontinence brief. The DON acknowledged that the resident was frequently incontinent of urine. At 1:27 PM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), Assistant Administrator, and survey team, stated that the facility used the Center for Disease Control (CDC) as the national guidelines for contact precautions. The DON added that the CNA who left Resident #78's room wearing a mask, wore the mask because she had not received the influenza vaccine. The DON then acknowledged that the CNA should not have worn PPE from a contact precaution room outside that room. On 11/13/19 at 10:09 AM, the DON, in the presence of the LNHA, Assistant Administrator, APN, and survey team stated that per the facility's policy, the resident was allowed out of his/her room if on contact precautions. The DON provided information from the CDC dated 2007 for Guidelines to Isolation Precautions. The DON stated that she had nothing more recent from the CDC to provide the survey team. At this time, the APN stated that the resident was incontinent, but he/she was toileted frequently. The APN also stated that since the resident was dressed, no one would be in contact with the ESBL so he/she could come out of the room. The Assistant Administrator stated that the point of contact precautions was that staff wore PPE when care was rendered. The LNHA stated that the thought process was that the urine was contained in the resident's incontinence brief, so it was okay for the resident to partake in communal dining and activities as usual. The surveyor reviewed the facility's Policy and Procedure Contact Isolation Precautions dated revised (MONTH) 2019, which included all residents requiring isolation precautions (ESBL) will be on contact isolation precautions according to CDC guidelines. The surveyor reviewed the CDC guidelines for Implementation of Personal Protective Equipment in Nursing Homes to Prevent Spread of Novel or Targeted [MEDICAL CONDITION] (MDROs) updated (MONTH) 26, 2019 which included contact precautions were intended to prevent transmission of infectious agents, like MDROs (example ESBL), that are spread by direct or indirect contact with the resident or the resident's environment. The guidelines also included that contact precautions required the use of gown and gloves on every entry into a resident's room. Residents on contact precautions should be restricted to their rooms except for medically necessary care and restricted from participation in group activities. NJ 8:39-19.4

Based on observation, interview and record review, it was determined that the facility failed to provide a justification for the continued use of a urinary catheter from (MONTH) (YEAR) through (MONTH) (YEAR) to prevent the risk of developing Urinary Tract Infection [MEDICAL CONDITION] for 1 of 2 residents sampled for urinary catheters, Resident #89. This deficient practice was evidenced by the following: During the initial tour on 10/24/18 at 9:30 a.m., the surveyor observed Resident #89 laying on the bed with an indwelling catheter bag hung on the lower left side of the bed inside a privacy bag. A review of the Face Sheet (an admission summary) revealed that the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of hospital medical record revealed that on 11/8/17 the bladder training protocol was done and the urinary catheter was removed. A review of the 11/11/17 Attending Note from the hospital record revealed that the family had requested re-insertion of the urinary catheter because the resident was incontinent and had multiple wounds. A review of the 11/7/17 Discharge Minimum Data Set (MDS), an assessment tool, indicated that Resident #89 was cognitively impaired. The 11/7/17 Discharge MDS reflected that the resident was incontinent of urine and had a surgical wound, skin tear and moisture associated skin damage (MASD). On 11/20/17, a Comprehensive MDS showed that the resident was cognitively impaired and had a urinary catheter. In addition, a trial of a toileting program or bladder training were not attempted. The 11/20/17 Comprehensive MDS revealed that the resident had one Stage 2 pressure ulcer, surgical wound and stasis ulcer. A review of individualized care plan for Resident #89 contained an intervention dated 11/15/17 to evaluate for possible removal/discontinuation of the catheter. The care plan showed that the resident was treated for [REDACTED]. Further review of the care plan showed that the resident was re-admitted on [DATE] with a right above the knee amputation dehisced surgical wound, a right groin surgical ulceration, a left great toe arterial ulceration, and left inner buttock moisture associated skin damage. The surgical wounds were healed on 12/5/17. There was no documented evidence that the staff attempted to remove the urinary catheter when the wound healed on 12/12/17. In addition, there was no documented evidence that bladder retraining was trialed to justify the continued use of a urinary catheter for a total of 10 months from (MONTH) (YEAR) through (MONTH) (YEAR). On 10/29/18 at 9:40 a.m., the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM informed the surveyor that Resident #89 was initially admitted from another facility with multiple pressure ulcer and surgical wounds. She further stated that the resident was cognitively impaired and incontinent of both bowel and bladder elimination. On that same day and time, the RN/UM stated that the resident was transferred to the hospital on [DATE]. Resident #89 was re-admitted to the facility on [DATE] with a urinary catheter and a [DIAGNOSES REDACTED]. She further stated, that the facility did not attempt to remove the urinary catheter since re-admission and no bladder retraining was initiated. On 10/29/17 at 12:26 p.m., the surveyor informed the Administrator, Assistant Administrator and the Director of Nursing (DON) of the concern. The Assistant Administrator stated that she will get back to the surveyor regarding the Policy with regards to the justification of the use of the urinary catheter. On 10/30/18 at 9:19 a.m., the Physician and the Nurse Practitioner (NP) met with the surveyors. The Physician informed the surveyor that when the resident was re-admitted on [DATE], an order was obtained to retain the urinary catheter due to multiple wounds and history of [MEDICAL CONDITION]. A review of Resident #89's wound timeline provided by the Assistant Administrator revealed that the urinary catheter was used for diversion of multiple wounds, and that, the resident was treated for [REDACTED]. On 10/30/18 at 11:05 a.m., there was no further information provided. NJAC 8:39-27.1 (f) NJAC 8:39-27.2 (n)

Based on observation, interview and record review, it was determined that the facility failed to provide adequate indications and documentation of the rationale to support the use of an antibiotic for the treatment of [REDACTED]. This deficient practice was identified for 1 of 2 residents reviewed for the use of antibiotics (Resident #11). This deficient practice was evidenced by the following: On 10/24/18 at 9:26 a.m., the surveyor observed Resident #11 in the Day Room seated in a recliner chair. A review of the Face Sheet (an admission summary) revealed that resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS) assessment tool with an Assessment Reference Date (ARD) of 7/22/18, showed that Resident #11 had a brief interview for mental status (BIMS) score of 6 which indicated that resident was cognitively impaired. A review of (MONTH) (YEAR) Physician order [REDACTED]. A review of Nursing notes dated 10/9/18 showed that the resident was seen by the Nurse Practitioner (NP) due to the refusal of medications and with periods of refusal to eat meals and with a temperature of 98 degrees. The NP ordered [MEDICATION NAME] 100 mg po od. Further review of medical records showed that there was no documented evidence that the resident had active signs and symptoms of UTI. On 10/26/18 at 9:15 a.m., the Registered Nurse/Unit Manager (RN/UM) informed the surveyor that Resident #11 was cognitively impaired, with on and off behavior of paranoia from admission last year, with [DIAGNOSES REDACTED]. On that same day and time, the RN/UM stated that it was the NP who ordered the [MEDICATION NAME] for UTI [MEDICATION NAME] on (MONTH) 9, (YEAR), with no stop date because the resident had on and off behavior of refusing medications and meals. She further stated, that there were no further signs symptoms except for the behavior which was no different with or without antibiotics. In addition, she informed the surveyor that the last urinalysis was done on 9/14/18, when the resident was treated with [MEDICATION NAME] for 7 days. On 10/26/18 at 9:35 a.m., the Certified Nursing Assistant (CNA) informed the surveyor that she was the regular aide for Resident #11. She stated that the resident was cognitively impaired, with periods of incontinence and displayed behavior that was much better compared to last year when the resident was admitted to the facility. On that same day at 9:40 a.m., the Director of Nursing (DON) informed the surveyor that she was in charge of the Infection Control and Antibiotic Stewardship of the facility. She stated that the facility followed McGeer's Criteria for UTI's. The DON further stated that the physician and the NP had to look for the signs and symptoms, urinalysis and laboratory results prior to ordering antibiotic that would be the basis of their assessment and evaluation of the resident. A review of the (MONTH) (YEAR) Infection Control Tracking Sheet provided by the DON showed that the resident was on antibiotic [MEDICATION NAME] for UTI with a stop date of 10/18/18. At that time, the DON was not aware that the [MEDICATION NAME] was ordered with no stop date. A review of the McGeer's Criteria for UTI provided by the DON revealed that the facility did not follow the required criteria for Antibiotic Stewardship. On 10/26/18 at 11:15 a.m., the surveyor informed the Assistant Administrator of the concern and stated that she will get back to the surveyor. On 10/29/18 at 8:35 a.m., the NP informed the surveyor that the facility followed the McGeer's criteria for UTI's and that the [MEDICATION NAME] was ordered on [DATE] as a [MEDICATION NAME]. She further stated that she should have documented the justification for the use of antibiotic [MEDICATION NAME] and why the McGeer criteria was not followed. On 10/30/18 at 9:19 a.m., the physician and the NP both acknowledged that there was no documented evidence to justify the use of antibiotic [MEDICATION NAME]. A review of the undated Infection Prevention and Control Policy for Antibiotic Stewardship Program provided by the DON reflected that, to implement an Antibiotic Stewardship Program which will promote appropriate use of antibiotics while optimizing the treatment of [REDACTED]. This policy is intended to limit antibiotic resistance in the post-acute care setting while improving treatment efficacy, resident safety, and reducing treatment-related cost. NJAC 8:39-29.2(d)

Based on observation, interview and record review, it was determined that the facility failed to administer medications with less than a 5% medication error rate. During the medication pass, the surveyor observed two (2) nurses administer medications to four (4) residents with 30 opportunities. There were two (2) errors observed for 2 of 4 residents, (Residents #40 and #90), which calculated to a 6.6% medication error rate. The evidence was as follows: 1. On 10/26/18 at 08:29 a.m., during the medication pass, the surveyor observed the Registered Nurse (RN1) administer Nine (9) medications which included one Calcium [MEDICATION NAME] 500 mg tablet and one [MEDICATION NAME] (Iron) 325 mg tablet to Resident #90. At the medication cart, the RN1 stated that the resident was readmitted to the facility on [DATE], and there was a clarification that she needed to review with the physician regarding two (2) Calcium orders on the electronic Medication Administration Record [REDACTED]. On 10/26/18 at 09:04 a.m., the surveyor interviewed the RN1 who stated that she realized that the calcium and iron medications should not have been administered together. The RN1 added that she would be clarifying the time of administration for the calcium and iron because she did not know why the they had the same time of administration in the EMAR. The RN1 said that she knew that the Consultant Pharmacist (CP) also makes the recommendation to separate calcium and iron. The RN1 also stated that the separation instructions were usually added to the EMAR when the physician orders [REDACTED]. The surveyor reviewed the medical record for Resident #90. A review of the Resident Face Sheet reflected an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the EMAR reflected that the corresponding calcium and iron physician orders [REDACTED]. On 10/26/18 at 12:44 p.m., the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that calcium products should be separated from iron products by at least two hours. The CP added that she thought the nurses would know to separate calcium and iron because the recommendation has been made before and was a common separation. The CP also stated that the nurses would have to add the instruction to separate the calcium and iron in the EMAR. On 10/29/18 at 08:18 a.m., the surveyor met with the Assistant Administrator (AA) who stated that the facility received a faxed medication review request dated 10/26/18 from the CP, which indicated, to separate the Iron from the calcium by at least two hours to increase the absorption for Resident #90. The AA also stated that the CP had come to the facility on [DATE], and, that the monthly report was received on 10/26/18 which indicated the same information for the resident. The AA added that the reports from the CP could take a week to be processed. On 10/29/18 at 09:32 a.m., the surveyor interviewed the Unit Manager (UM1) who stated that cautionary warnings and instructions to separate medications were entered in the EMAR by the nurses. On 10/29/18 at 12:34 p.m., the surveyor team met with the Administrator, AA and Director of Nursing (DON) who acknowledged that cautionary warnings for medications and instructions from the CP were to be followed. Manufacturer specifications for calcium [MEDICATION NAME] reflected that when administered with iron products there was a decreased absorption of the iron. The AA provided a facility policy (YEAR) edition for Medication Administration and General Guidelines and stated that the policy was dated 3/1/18 when the provider pharmacy initiated services. A review of the policy indicated that medications are administered as prescribed in accordance with State Regulations using good nursing principles and practices. In addition, the policy reflected that the nurses administer medications after familiarizing themselves with the medication. 2. On 10/26/18 at 09:27 a.m., during the medication pass, the surveyor observed the RN2 administer six (6) medications which included one tablet of Daily Vite, a house stock product with a green label to Resident #40. At that time, the surveyor with the RN2 reviewed a physician's orders [REDACTED].#40. On 10/26/18 at 09:41 a.m., the surveyor with the RN2 reviewed the house stock medications in the medication cart. The RN2 stated that the Daily Vite which had a green label was the only multivitamin on the medication cart. The RN2 added that the Daily Vite was the product that she administered to Resident #40 because the physician's orders [REDACTED]. The RN2 also stated that there was a house stock product I Vite but that it was not to be administered for a physician's orders [REDACTED]. The RN2 was not sure what other house stock supply were available but thought the Unit Manager (UM) would have a list. On 10/26/18 at 09:45 a.m., the surveyor with the UM2 reviewed the house stock list and supply in the medication room on the first floor. The UM2 stated, that according to the list provided by the provider pharmacy, [MEDICATION NAME] was the product to be administered for multivitamin with minerals. The UM2 then stated that she thought the provider pharmacy had changed the house stock list because she did not have any supply of [MEDICATION NAME] in the medication room. The UM2 then stated, that the product Daily Vite with a green label, was a multivitamin but did not contain minerals. The UM2 also stated that she thought the house stock product I Vite was the product to be administered for multivitamin with minerals but was not sure. The UM2 then added that she would have to check with the provider pharmacy. On 10/26/18 at 12:44 p.m., the surveyor interviewed the CP via the telephone. The CP stated that I Vite was not an appropriate house stock product to administer for a physician's orders [REDACTED]. The CP also stated that she did not think Daily Vite contained minerals but would have to check with the provider pharmacy. The surveyor reviewed the medical record for Resident #40. A review of the Resident Face Sheet revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. On 10/29/18 at 10:17 a.m., the surveyor with the Pharmacist (RP) from the provider pharmacy reviewed the house stock list and supply in the medication room on the first floor. The RP stated that the house stock list was inaccurate because the provider pharmacy does not have [MEDICATION NAME] and there was no other house stock product listed for multivitamin with minerals. The RP also stated that I Vite was not to be administered for multivitamin with minerals because the product was specific for eye health and the physician's orders [REDACTED]. On 10/29/18 at 12:34 p.m., the surveyor team met with the Administrator, AA and DON who acknowledged that the RP had reviewed changes to be made to the house stock list and supply. NJAC 8:39-29.2(d), 29.3(a)(1), 29.4(a)(b)(3)(c)

Based on observation, interview, and record review, it was determined that the facility failed to always care for an indwelling urinary catheter in a manner designed to protect against infection. This deficient practice was identified for 1 of 2 residents reviewed for Indwelling Urinary Catheters, Resident #6, as evidenced by the following: On 7/16/17 at 9:15 a.m. during the initial tour of the unit, in the presence of the Unit Manager (UM), the surveyor observed Resident #4 in the dining room sitting in a high back wheelchair awake. The UM said that the resident was confused and had an indwelling catheter due to [MEDICAL CONDITION]. On 7/11/17 at 9:00 a.m. the surveyor observed the resident's indwelling catheter drainage bag in a plastic bag hanging on a grab bar in the resident's bathroom. The plastic bag was open and the drainage bag tubing was not capped which left it open to air and possible contamination. At 9:10 a.m. the UM went to the resident's room and confirmed the surveyor's observation. Review of the medical record revealed the resident had a history of [REDACTED]. At 9:45 a.m. the surveyor met with the Assistant Administrator and made her aware of the above findings. NJAC 8:39-27.1(a)

Based on observation, interview and review of the medical record it was determined that the facility failed to maintain physical privacy of a resident. This deficient practice was noted for 1 of 19 residents sampled for privacy, Resident #10, as evidenced by the following: During tour of the unit on 7/6/17 at 9:45 a.m. the Registered Nurse Unit Manager (RN-UM) told the surveyor that Resident #10 was alert and oriented, had a Subdural Hematoma and was status [REDACTED]. While the surveyor observed the lunch meal on 7/7/17 at 12:10 p.m., the surveyor observed Resident #10 seated at a table in the Bistro area with 2 other residents and a family member. The resident had food on the plate and appeared to still be eating. The surveyor observed a licensed nurse take the blood pressure of Resident #10 in front of the other residents and family member, and interrupted the resident's meal. The Assistant Administrator walked down the hall behind the surveyor and witnessed the licensed nurse taking the blood pressure. Review of the medical record on 7/7/17 at 12:20 p.m. revealed the resident was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. During a meeting with the Assistant Administrator and the Director of Nursing (DON) on 7/7/17 at 1:00 p.m. the surveyor informed them of the findings. The Assistant Administrator confirmed she witnessed the surveyors findings. NJAC 8:39-4.1(a)12 NJAC 8:39-4.1(a)16

Based on observation and interview it was determined that the facility failed to maintain aseptic technique and maintain a clean surface on the medication cart during medication administration, by placing a hearing aide directly on the top of the cart, after it was in the resident's ear. This deficient practice was noted for 1 of 3 nurses observed, and 1 of 4 residents sampled during medication administration observation, Resident #22, as evidenced by the following: During observation of the medication administration on 8/31/16 at 8:35 a.m. the surveyor observed the Licensed Practical Nurse (LPN) administer medications to Resident #22. After the LPN administered the medication, the LPN took the resident's hearing aide from a container and placed the left hearing aide in the resident's left ear and then placed the other hearing aide in the resident's right ear. The resident stated there was no noise noted in the hearing aide in the left ear so the LPN stated it must need a battery and took the hearing aide back to the medication cart with a package of new batteries. The LPN placed the hearing aid directly on the top of the medication cart with no barrier in place. The LPN changed the battery in the hearing aide, put it close to her own ear to hear if a noise was heard, and then brought the hearing aid back to the resident who was still in bed. The LPN confirmed the hearing aide was now working by asking the resident if it was ok and the resident confirmed it was now fine. The LPN then continued to the next resident to administer medication, but never cleaned the top of the medication where she had just placed the resident's hearing aide. On 8/31/16 at 1:45 p.m. the surveyor informed the Administrator, Assistant Administrator, and Director of Nursing (DON) of the findings. On 9/1/16 at 9:55 a.m. the surveyors met again with the Administrator and Assistant Administrator and they informed the survey team that the nurse involved with inaccurate technique of changing the hearing aide battery was in-serviced to ensure it would be done correctly. NJAC 8:39-27.1(a)

Based on interview, it was determined that the facility failed to offer the residents snacks at bedtime. This deficient practice was identified for 7 of 7 alert and oriented residents at the group meeting as evidenced by the following: On 8/31/16 at 10:30 a.m. the surveyor conducted a group meeting with 7 alert and oriented residents. The surveyor asked if they were offered a snack at bedtime. Seven of 7 residents said they were not offered a bedtime snack. Seven of 7 residents also said they were not offered snacks between dinner and bedtime. On 9/1/16 at 9:50 a.m. the survey team met with the Administrator and Assistant Administrator (AA). The AA said that depending on the floor, snacks were offered at times right after dinner as the residents left the dining room. The facility did not provide any documentation that indicated that the residents were offered a snack at bedtime. NJAC 8:39-17.4(b)

Based on observation, interview and record review it was determined that the facility failed to follow a physician's order for monthly pacemaker checks. This deficient practice was identified for 1 of 20 residents reviewed for medications, (Resident #7) as evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 8/3/15 at 9:45 a.m. during the initial tour the Unit Manager (UM) told the surveyor that Resident #7 was cognitively intact and required the assist of 1 staff member for all activities of daily living (ADL's). The surveyor observed the resident sitting in a wheelchair in the day room participating in the morning activity. On 8/4/15 at 1 p.m. the surveyor reviewed Resident #7's electronic medical record (EMR) and paper record. According to the EMR physician's monthly orders the resident had a physician order dated, 3/30/15 for Pacemaker checks every month. Review of the resident's paper record showed there were no documented results of the pacemaker checks in the record. On 8/4/15 at 1:45 p.m. the surveyor interviewed the UM concerning the monthly pacemaker checks. After the UM reviewed the paper record she agreed that the monthly pacemaker results were not there. The UM stated, I know they were done. I don't know why the results are not on the chart. I will call the X-Ray department and ask to have the results forwarded to me. On 8/4/15 at 2 p.m. the UM brought the faxed results of pacemaker checks that were done. There were reports for March/2015; May 2015 and June 2015. There were no exports for April/2015 and July/2015. On 8/5/14 at 2 p.m. the surveyor met with the Administrator, Assistant Administrator and the Director of Nursing who confirmed that the physician's order for monthly pacemaker checks were not done for April and July. NJAC 8:39-27.1(a)