Every finding on record at Regency Heritage Nursing and Rehabilitation Center

COMPLAINT #: 2727628 Based on interviews, medical record review, and review of other pertinent facility documents on 7/9/26 and 7/10/26, it was determined that the facility failed to: a) ensure that Resident #1's pressure ulcer was consistently evaluated by wound care and b) develop a comprehensive person-centered care plan (CP) that addressed skin conditions identified in Resident #1's comprehensive assessment. The deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for wound care and was evidenced by the following:Resident #1 was not at the facility at the time of the survey. A closed medical record review was conducted. A review of Resident #1's admission Record (AR) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to: rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood), chronic kidney disease, edema, and hypothyroidism. A review of Resident #1's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/10/25, which revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS revealed the following:-Resident had 1 Stage 2 pressure ulcer that was present at the time of admission-Treatments included: Turning/Repositioning, Nutrition/Hydration intervention, Pressure Ulcer/injury care, Application of nonsurgical dressings, Application of ointments/medications. A review of Resident #1's care plan (CP) did not reveal a focus related to skin conditions identified in Resident #1's MDS. A review of Resident #1's medical record revealed a New Jersey Universal Transfer Form dated 2/25/25 at 3 PM, which indicated that the resident arrived to the facility with a Stage 2 pressure ulcer on their sacrum. A review of Resident #1's progress notes (PN) revealed a nursing note dated 2/25/25 at 8:30 PM, which revealed that a skin assessment was done and that a Stage 2 pressure ulcer was observed on the resident's coccyx (tailbone). A review of Resident #1's physician orders revealed an order dated 3/5/25, which indicated that the resident was to have a wound care consult for noted redness on the scrotal area and bleeding around the right and left buttocks. a). Surveyor requested a wound care timeline for Resident #1 which was provided to the surveyor by the Assistant Director of Nursing (ADON). Upon review, surveyor noted that there were no wound measurements or weekly assessments documented between 3/5/25 and 3/26/25. Further review of the PN did not reveal any wound measurements between 3/5/25 and 3/26/25. During an interview on 7/10/26 at 1:42 PM with the ADON she stated that she recalled Resident #1 and that the resident was admitted with a wound. She further stated that a wound care practitioner is onsite weekly to evaluate each resident to determine whether wounds are improving, obtain new measurements and adjust treatments, as needed. In the presence of the surveyor, the ADON reviewed Resident #1's wound care timeline. The surveyor explained that a review of the timeline and the resident's medical record did not include documentation that Resident #1's wounds had been measured nor that the resident was assessed by the wound care nurse between 3/5/25 and 3/26/25. The ADON stated she was unsure what happened in this case, but that the resident should have been seen and assessed. During a telephone interview on 7/14/26 at 1:36 PM with the contracted Wound Care Practitioner, she stated that she did not recall the resident and no additional information to provide for this resident. No additional documentation was provided to the surveyor. b). During a joint interview on 7/10/26 at 4:36 PM with the ADON and the Licensed Nursing Home Administrator (LNHA), the ADON stated that a care plan was a snapshot of each resident's individual needs. She stated that it was composed of all aspects of what would drive a resident's care and that nursing was responsible for ensuring that it accurately reflected the care a resident required. In the presence of the surveyor, the ADON reviewed Resident #1's CP and stated that skin issues were part of this resident's core issues and that the resident's care plan should have included it as a focus, but it did not. Review of the facility's WOUNDS POLICY & DOCUMENTATION, revised 5/2026, revealed that pressure ulcer would be measured weekly by the Wound Care Nurse. Review of the facility's SKIN INTEGRITY PROGRAM, revised 5/2026, revealed that the facility would provide safe and effective care to manage treatment and promote healing which included the development of a comprehensive care plan for wound treatments and that documentation of appearance and condition of wounds would occur weekly. Review of the facility's Care Plans- Comprehensive policy, revised 5/2026, revealed that comprehensive care plans were based on assessments and that it was designed to .incorporate identified problem areas. NJAC: 8:39-11.2 (e); 27.1(a)(e)

COMPLAINT #2999892 Based on interviews, review of medical records and other pertinent facility documentation on 7/9/26 and 7/10/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice when staff failed to consistently document on the 24 Hour Vital Signs/Neuro Checks form for a resident who had an unwitnessed fall and was observed with redness on their face. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #8) and was evidenced by the following:A review of the admission Record revealed that Resident #8 was admitted to the facility with diagnoses that included but were not limited to: aphasia (a language disorder that affects your ability to speak and understand what others say), Crohn's disease (an inflammatory bowel disease that causes chronic inflammation of the gastrointestinal tract), and Bell's Palsy (a condition that causes sudden weakness in the muscles on one side of the face). A review of Resident #8's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/20/26, which revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was moderately impaired. Further review of the MDS revealed that the resident had one fall since their admission. Review of Resident #8's care plan (CP) indicated that Resident #8 had a focus related to the resident being at risk for falls and that the resident had an actual fall on 6/9/26. A review of Resident #8's Incident/Accident Report (IAR) dated 6/9/26 revealed that the resident was observed by staff on the floor in front of the facility's gazebo at 8:45 PM. Further review of the IAR revealed that the resident did not explain what happened and that they appeared groggy. Additionally, redness on the upper part of [Resident #8's] face was observed. The IAR was completed by Registered Nurse (RN #1) A review of Resident #8's 24 Hour Vital Signs/Neuro Checks form that was attached to the IAR revealed the following:9:30 PM Blood Pressure = 125/61, Pulse = 59, Respirations = 189:45 PM - Blank Entry10 PM - Blank Entry10:15 PM - Blank Entry10:30 PM Blood Pressure = 120/63, Pulse = 60, Respirations = 1811 PM - Blank Entry11:30 PM - Blank Entry The remaining boxes on the form were blank. A box at the top of the form noted:-Q (every) 15 min. (minutes) x4 - Meaning checks were to be completed four times in 15-minute intervals.-Q (every) 30 min. (minutes) x2 - Meaning checks were to be completed two times for the next 30-minute intervals.-Q (every) 60 min. (minutes) x2 - Meaning checks were to be completed two times for the next 60-minute intervals.-Q (every) 2 hours x2 - Meaning checks were to be completed two times for the next 2-hour intervals.-Q (every) 4 hours x4 - Meaning checks were to be completed four times for the next 4-hour intervals. During an interview on 7/10/26 at 3:58 PM with RN #1, she stated that in the event of an unwitnessed fall it was important to conduct neurological checks to monitor for any changes in the resident's baseline and to keep treating providers informed. She further stated that she recalled the night of Resident #8's fall and stated that the resident was found by another staff member on the floor near the gazebo. She further stated that initially the resident was unable to say what happened, but later motioned sliding out of the electric wheelchair. RN #1 reviewed the IAR and confirmed that she noted the redness was noted on the resident's face. She stated that because of the redness it was possible that Resident #8 hit their head during the fall. She stated that neurological checks would have been initiated. RN #1 reviewed the neurological check form and confirmed that she initiated the checks. She further confirmed that there were blanks on the sheet. She stated that the resident was alert and oriented and refused to have the checks done. When asked how refusals should be noted she stated that she should have documented the refusals. During a joint interview on 7/10/26 at 4:36 PM with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), the DON reviewed Resident #8's neurological check form and stated that the entire form should have been completed and that if the resident refused, it should have been documented so that all were aware of that. A review of the facility's CHARTING AND DOCUMENTATION policy, updated 5/2026, revealed that all observations must be documented in a resident's medical record, including if a resident refused a procedure. N.J.A.C. 8:39-27.1(a)

Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process on a resident who was discharged from hospice benefits. This deficient practice was identified for 1 of 3 residents reviewed for hospice (Resident #122). This deficient practice was evidenced by the following: On 6/19/25 at 9:22 AM, the surveyor observed Resident #122 lying in bed. The resident stated they were doing well today. On 6/19/25 at 11:14 AM, the surveyor reviewed the electronic medical record (EMR) which revealed orders for DNR (Do Not Resuscitate), DNI (Do Not Intubate), DNH (Do Not Hospitalize) dated 3/24/25. A physician order dated 1/25/25 was noted for [name redacted] hospice. On 6/19/25 at 11:14 AM, the surveyor reviewed the resident's Minimum Data Set (MDS) 3.0 Assessment History, an assessment tool, which revealed that a SCSA was not completed for the resident within 14 calendar days from the resident's hospice admission as required. The EMR revealed an annual (comprehensive) MDS was completed on 10/21/24 and quarterly MDS assessments were completed on 1/15/25 and 4/15/25. The quarterly assessment of 4/15/25, indicated a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment and diagnoses including hypertension (high blood pressure) and Alzheimer's disease (a progressive disease that impairs memory and other functions). On 6/24/25 at 10:55 AM, the surveyor interviewed the MDS Coordinator who stated that when a resident signed on to hospice, she received an email from the Assistant Director of Nursing (ADON). She stated that she then updated her (hospice) list, does the care plan and does the SCSA within fourteen days. After checking the EMR for Resident #122, she then stated that this SCSA should have been done by 2/7/25. She further stated, Maybe I overlooked that one, I will tell it to the ADON. On 6/25/25 at 1:55 PM, the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), ADON, and the [NAME] President of Business Development (VPBD) were notified of the above concern. On 6/26/25 at 10:39 AM, the DON stated Resident #122 did not need a SCSA due to returning from the hospital on 1/25/25 on hospice. She provided the surveyor with the RAI User's Manual October 2024, page 2-25, which included If a resident is admitted on the hospice benefit (i.e., the resident is coming into the facility having already elected hospice), or elects hospice on or prior to the ARD (Assessment Reference Date) of the admission assessment, the facility should complete the admission assessment, checking the Hospice Care item, O0110K1. Completing an admission assessment followed by an SCSA is not required. The surveyor indicated that this resident did not have an admission assessment, or a comprehensive assessment that indicated hospice care was in place. Further review of the RAI User's Manual page 2-25 also included, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election. An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. Review of facility provided policy Completion of the MDS, updated 1/2025 included: Policy: The MDS is a standardized data-collection tool that assists the Interdisciplinary Team to perform an accurate assessment by capturing information regarding the resident's functional status. The RAI User's Manual provided an item-by-item guide to the MDS, outlines the process of fathering this information and instructs the members of the Interdisciplinary Team on proper coding procedures for each MDS item. NJAC 8:39-11.2(i)

Based on observation, interviews, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 1 of 35 residents reviewed (Resident #122). This deficient practice was evidenced by the following: On 6/19/25 at 9:22 AM, the surveyor observed Resident #122 lying in bed. The resident stated they were doing well today. On 6/19/25 at 11:14 AM, the surveyor reviewed the electronic medical record (EMR) which revealed a physician order dated 1/25/25 for [name redacted] hospice. On 6/19/25 at 11:14 AM, the surveyor reviewed the resident's MDS 3.0 Assessment History, an assessment tool, which revealed that a quarterly assessment on 1/15/25, indicated a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment and diagnoses including hypertension (high blood pressure), Alzheimer's disease (a progressive disease that impairs memory and other functions), and currently receiving hospice care. On 6/26/25 at 1:09 PM, the surveyor interviewed the MDS Coordinator who checked the EMR and stated that Resident #122 was admitted to hospice on 1/25/25. When asked why hospice care was checked on the 1/15/25 MDS, she stated, Hospice should not have been checked. Sorry about that. On 6/26/25 at 1:16 PM, the surveyor interviewed the Director of Nursing regarding whether hospice should have been checked on the 1/15/25 quarterly MDS. She stated, Hospice should not be checked. We can modify that. Review of the facility provided policy Completion of the MDS, updated 1/2025 included: Policy: The MDS is a standardized data-collection tool that assists the Interdisciplinary Team to perform an accurate assessment by capturing information regarding the resident's functional status. The RAI User's Manual provided an item-by-item guide to the MDS, outlines the process of fathering this information and instructs the members of the Interdisciplinary Team on proper coding procedures for each MDS item. N.J.A.C 8:39-11.1

Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) accurate documentation for the inventory of a controlled medication (Marinol) for one (1) of five (5) medication carts, b.) refrigerated medications for discharged residents were removed from active inventory from one (1) of two (2) medication storage room refrigerators and, c.) accountability of the shift-to-shift inventory documentation for the count of controlled medications for one (1) of five (5) medication carts inspected. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practices were evidenced by the following: 1. On 6/25/24 at 9:41 AM, the surveyor with the Assistant Director of Nursing (ADON) inspected the G1 unit medication storage room. Upon inspection of the medication refrigerator, the surveyor, with the ADON, observed 22 capsules of Dronabinol (Marinol) [medication used as an appetite stimulant] 2.5 milligrams (MG) labeled for unsampled Resident #1. The ADON stated that Resident #1 was discharged from the facility. The ADON added that it was the responsibility of the nurses to remove all medications from the medication cart and refrigerator when residents were discharged . At that time, the ADON reviewed the A side medication cart for the corresponding Controlled Substance Administration Record (CSAR) for the Marinol but was unable to find it. The ADON added she thought the discharged unsampled Resident #1 was on that side but would have to check. On 6/25/25 at 11:05 AM, the surveyor was provided a copy of the CSAR for the Marinol labeled for unsampled Resident #1 by the Licensed Nursing Home Administrator (LNHA), who stated that the CSAR was in the back of the binder on the A side medication cart and was missed during the first check. A review of the CSAR revealed 60 capsules of Marinol were received on 3/22/25 and there were 23 capsules remaining. At that time, the surveyor asked the LNHA to review with the ADON, the CSAR which indicated 23 capsules of Marinol were remaining and the actual inventory of 22 capsules remaining was counted by the surveyor and the ADON. The LNHA stated that he would have to check. A review of the June 2025 Narcotics & Barbiturates Inventory & Certification Record (NBICR) for the A side medication cart revealed there were signatures for the 7 AM nurse incoming and the nurse outgoing on the 7AM shift for 6/25/25. According to the NBICR, The undersigned have jointly counted and certify to correct count of narcotics and barbiturates for this nursing unit. On 6/25/25 at 2:05 PM, the survey team met with the LNHA, Director of Nursing (DON), ADON and VP of Business Development. The ADON stated she was actively investigating the discrepancy of the Marinol capsules. The ADON acknowledged that the Marinol CSAR was in the binder of the A side medication cart and the count should have been checked and both the Marinol and CSAR should have been removed when the resident was discharged . On 6/26/25 at 9:38 AM, the survey team met with the LNHA, DON and ADON. The LNHA explained that according to the investigation performed by the ADON, unsampled Resident #1 was in the facility on 4/11/25 and a nurse removed a capsule but was unable to administer the medication and line 25 on the CSAR was documented as wasted and there was a documented progress note. Then, on 4/18/25 a nurse removed two (2) capsules of Marinol and signed over line 25 and line 24 which left line 23 open, indicating 23 capsules were remaining when the CSAR should have indicated 22 capsules were remaining. LNHA added that the nurse on 4/18/25 mistakenly removed (2) capsules and had to waste them. The LNHA added that the count for the Marinol was correct for 22 capsules. The LNHA, DON and ADON acknowledged that the CSAR read as 23 capsules remaining and should have been corrected and brought to the attention of nursing. A review of the CENSUS report provided by the LNHA revealed unsampled Resident #1 was discharged from the facility on 4/11/25. On 6/26/25 at 11:19 AM, the surveyor interviewed the Consultant Pharmacist (CP #1) via telephone who stated that she was not the actual CP for the facility, and that CP #2 completed on site visits to the facility but that she was a supervisor and could answer general questions because CP #2 was not available. CP #1 stated that unit inspections were performed every month. CP #1 added that they looked for expiration dating and may not be aware of residents that have been discharged and would think the nurses would remove discharged residents' medications from the medication cart and refrigerator. In addition, CP #1 stated that a spot check was done for controlled drugs and if there was a discrepancy then the CP #2 would bring the discrepancy to the attention of nursing. A review of the facility policy updated 1/2025 for Medication Storage provided by the LNHA, reflected The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, sanitary manner. In addition, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. A review of the facility policy updated 1/2025 for Managing Controlled Substances provided by the LNHA reflected, to provide proper ordering, storage, disposal and security of controlled drugs and included, On going inventory of controlled medications . 2. Counting Procedure conducted by 2 Nurses will confirm that the Declining Inventory matches the quantity of drugs in the container. 3. The signature of both nurses confirms that the count is complete and accurate. 4. Nursing Supervisor/Charge Nurse/ADON will be notified if there is a discrepancy in the count and an investigation will be initiated immediately. 2. On 6/25/25 at 9:41 AM, the surveyor, with the ADON, inspected the G1 unit medication storage room. Upon inspection of the refrigerated medications, the surveyor, with the ADON, observed an insulin (medication used to lower blood sugars) Lispro KwikPen (a disposable single-patient-use prefilled insulin pen) and two (2) Basaglar KwikPens labeled for unsampled Resident #2. The ADON stated that unsampled Resident #2 was discharged from the facility. The ADON also added that it was the responsibility of the nurses to remove all medications from the medication cart and refrigerator when residents were discharged . On 6/26/25 at 11:19 AM, the surveyor interviewed CP #1 via telephone who stated that she was not the actual CP for the facility, and that CP #2 completed on site visits to the facility but that she was a supervisor and could answer general questions because CP #2 was not available. CP #1 stated that unit inspections were performed every month. CP #1 added that they looked for expiration dating and may not be aware of residents that have been discharged and would think the nurses would remove discharged residents' medications from the medication cart and refrigerator. A review of the CENSUS report provided by the LNHA revealed unsampled Resident #2 was discharged from the facility on 6/16/25. A review of the facility policy updated 1/2025 for Medication Storage provided by the LNHA reflected, The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, sanitary manner. In addition, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 3. On 6/25/25 at 9:58 AM, the surveyor, with the Registered Nurse (RN #1), inspected the C side medication cart on the G1 unit. The surveyor asked RN #1 for the shift-to-shift nursing signature sheet for the counting of the controlled drugs stored in the medication cart. RN #1 removed the NBICR from a plastic holder and signed for the 7 AM Nurse Incoming dated 6/25/25. RN #1 stated that she had counted with the 11-7 nurse and thought she signed the sheet in the morning, but the nurse outgoing forgot to sign the sheet. RN #1 could not speak to any missing signatures on the NBICR. RN #1 acknowledged that the NBICR was to be signed by both nurses after verifying the count of all controlled drugs for that medication cart at the change of shift. The controlled drug count for the C medication cart was accurate. A review of the June 2025 NBICR for the C side medication cart revealed the following nurse signatures were missing: -6/22/25 3 PM Nurse Incoming -6/22/25 11 PM Nurse Outgoing -6/23/25 3PM Nurse Incoming -6/23/25 11 PM Nurse Outgoing -6/24/25 7 AM Nurse Incoming -6/24/24 11 PM Nurse Incoming and Nurse Outgoing -6/25/25 7AM Nurse Outgoing On 6/25/25 at 10:04 AM, the surveyor, with the ADON, reviewed the NBICR from the C side medication cart. The ADON stated before starting a shift the outgoing nurse was to verify with the incoming nurse, an accurate count of all controlled drugs in that medication cart. The ADON added that there should not be any missing signatures. On 6/26/25 at 11:19 AM, the surveyor interviewed the CP #1 via telephone who stated that she was not the actual CP for the facility and that CP #2 went on site to the facility but that she was a supervisor and could answer general questions because the CP #2 was not available. CP #1 stated that unit inspections were performed every month and if there were missing signatures on the shift to shift forms the unit inspection form would indicate that. A review of the Unit Inspection Report completed by the CP #2 on 6/9/25, indicated that the change of shift log was complete. A review of the facility policy updated 1/2025 for Managing Controlled Substances provided by the LNHA, reflected to provide proper ordering, storage, disposal and security of controlled drugs and included On going inventory of controlled medications. 1. Count must be performed by an incoming Nurse and outgoing Nurse. NJAC 8:39-29.4 (g)(k), 29.7(c)

Refer to F 881 Based on interview and review of pertinent facility documentation, the facility failed to a.) ensure the required committee members, the Infection Preventionist (IP), was present for one of four Quality Assurance and Performance Improvement (QAPI) meetings and b.) ensure antibiotic stewardship was presented for two of the four QAPI meetings. This deficient practice was evidenced by the following: On 6/18/25 at 10:57 AM, during entrance conference the surveyor requested the QAPI sign in sheets from April of 2024 to present. On 6/26/25 at 8:59 AM, the surveyor reviewed the In-Service sign in sheet;Topic: QAPI dated 8/27/24, which revealed the IP did not sign the sheet. On 6/26/25 at 11:27 AM, during the QAPI interview review, the Director of Nursing (DON) reviewed the In-Service sign in sheet; Topic: QAPI dated 8/27/24 and confirmed the IP did not sign the sign in sheet. She stated the purpose of the sign in sheet was to verify that everyone attended the meeting. The DON reviewed the QAPI book for the 8/27/24 meeting minutes and verified the IP was not on the sign in sheet. Further review of the minutes by the DON, did not reflect antibiotic stewardship was reviewed at the meeting. She also verified, at that same time, the QAPI minutes dated 4/29/25 revealed antibiotic stewardship was not presented at that meeting. A review of the facility's policy Quality Assurance Performance Improvement Program updated 4/2025 revealed, 2 .Review reports such as CMS Quality Indicator Profile, Infection Control Report .The Infection Preventionist will give report on the status of the facilities IPCP program. NJAC 8:39-33.1(a)(b)

Based on observation, interviews, record review, and review of pertinent facility documentation, it was determined that facility staff members failed to ensure infection control practices were implemented by not appropriately donning (put on) and doffing (remove) Personal Protective Equipment (PPE) and perform appropriate hand hygiene to prevent the spread of infection, in accordance with accepted national standards, Centers for Disease Control and Prevention (CDC) guidelines, before and after exiting one of one resident's room, (Resident #228), who was on Transmission Based Precautions (TBP) due to a Clostridium Difficile Infection (CDI) [infectious diarrhea that can be transmitted through direct contact], on one (1) of four (4) units. The deficient practice was evidenced by the following: According to the U.S. CDC guidelines for Transmission-Based Precautions dated 4/3/2024, indicated to Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. According to the U.S. CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings updated September 2024, indicated Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, C. difficile, noroviruses and other intestinal tract pathogens; RSV). In addition, Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores. On 6/18/25 at 10:21 AM, the surveyor interviewed the Registered Nurse (RN #1) who stated that Resident #228 was on TBP for C. Diff (CDI). On 6/18/25 at 10:34 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who verified that Resident #228 was on TBP. The ADON stated Resident #228 was a recent admission to the facility from the hospital and was on TBP because the resident had CDI from the hospital and was on Vancomycin (an antibiotic used to treat infections caused by bacteria) orally to treat C.Diff. On 6/18/25 at 11:19 AM, the surveyor observed a closed door to the room of Resident #228 with signage on the hallway wall near the closed door which indicated STOP CONTACT PRECAUTIONS STOP EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. The surveyor also observed a plastic bin with drawers containing PPE (gowns and gloves) and a bottle of alcohol-based hand rub (ABHR) on top. The surveyor reviewed the medical record for Resident #228. A review of the Face Sheet (an admission record) reflected diagnoses which included, but were not limited to, enterocolitis (inflammation in the small intestine and colon's inner lining) due to Clostridium difficile (CDI), not specified as recurrent. A review of the resident's interdisciplinary comprehensive Care Plans report (CP) dated as report period 6/9/2025 revealed an activity type Infection Control Precautions which included GI (gastrointestinal), requires use of TBP related to C.Diff (Contact). A review of the Physician Orders revealed a physician's order (PO), dated 6/16/25 for an antibiotic Vancocin (Vancomycin) HCL (hydrochloride) oral capsule 125 milligrams (MG) by mouth from June 16 to June 30, every 6 hours (Q 6 hours), Enterocolitis due to Clostridium difficile, not specified as recurrent. An additional PO dated 6/18/25, indicated Isolation Precautions, Contact Precautions: Diarrhea associated with C. Difficile, Stool. On 6/23/25 at 1:20 PM, the surveyor observed, in the hallway, the call light on, above the door for Resident #228's room with the door open and RN #2 in the hallway at the door of the resident's room talking to the resident. At that time, the surveyor interviewed RN #2 who stated that the resident was on Contact Precautions and that was why she was talking to the resident from the doorway because if she had to enter then she would have had to wear a gown and gloves. On 6/23/25 at 1:27 PM, the surveyor observed from the hallway, the Unit Secretary (US #1) enter Resident #228's room. US #1 moved a chair and touched the resident's side rail attached to the bed and turned the call light off, talked to the resident and then walked out of the room. US #1 then used the ABHR that was on top of the bin in the hallway outside the door. The surveyor did not observe US #1 donn gown and gloves before entering Resident #228's room or wash their hands with soap and water before exiting the room. . At that time, the surveyor interviewed US #1 who stated that the resident's call light was on, and she helped the nursing staff by answering call bell lights. US #1 added that the resident wanted the sheet pulled out. US #1 acknowledged that she walked into Resident #228's room without PPE and stated that she was just answering the call bell light and was not providing care. On 6/23/25 at 1:28 PM, the surveyor observed the Certified Nursing Assistant (CNA #1) enter Resident #228's room carrying a meal tray, placed the tray on the resident's overbed table and moved the overbed table and then walked out of the resident's room and put on gloves at the bin with PPE by the door. CNA #1 then walked back into Resident #228's room and moved the overbed table closer to the resident, set up the tray and helped position Resident #228 to sit upright. On 6/23/25 at 1:30 PM, the surveyor also observed from the hallway, after CNA #1 helped position Resident #228, CNA #1 walked to the door, moved a chair over that was by the door, closed the door part of the way, then reopened the door. The surveyor had not heard any sound of water running. Upon opening the door, the surveyor observed CNA #1 no longer had gloves on. CNA #1 then walked out of the room and proceeded to take another resident's meal tray from the meal truck. The surveyor had not observed CNA #1 donn gown and gloves when entering Resident #228's room and perform hand hygiene with soap and water before exiting the room. At that time, the surveyor interviewed CNA #1 who stated that she had worked at the facility since August 2024 and was aware Resident #228 was on contact precautions. CNA #1 also stated she did not have to wear a gown to deliver a meal tray because she was not providing care. CNA #1 added that the resident had a wound and if she was providing care like changing or showering would wear the gown for safety. CNA #1 also stated that she only needed gloves for bringing a meal tray and that she was supposed to wash her hands every time she went in and out of the room. CNA #1 added that she washed her hands when she closed the door and took off her gloves. CNA #1 could not speak to the timing of washing her hands. On 6/23/25 at 1:33 PM, the surveyor interviewed RN #3 who stated that Resident #228 was on contact precautions for CDI and that contact precautions meant you must wear a gown and gloves every time you enter the room. RN #3 added even for a meal tray. On 6/23/25 at 1:41 PM, the surveyor, in the presence of another surveyor, interviewed the Infection Preventionist (IP/RN) who stated she had two residents in the facility on TBP and Resident #228 was on contact precautions and was currently being treated for CDI. The IP/RN added that she followed CDC guidelines and for Contact Precautions expected the staff to wear a gown and gloves before entering the resident's room and removed before exiting the room and wash their hands with soap and water before exiting the room. The IP/RN added when staff went into the resident's room for any reason, they must wear gown and gloves and wash their hands. The IP/RN also stated that she had done inservicing on Contact Precautions and would provide a copy of the content that was reviewed. The surveyor reviewed two Inservice Sign-In Sheets for Infection Precaution Signage dated 6/10/25 and Isolation Signage dated 6/11/25, which indicated the presenter was the IP/RN. Each program was 10 minutes in length, and the brief description included, Airborne, Contact, Enhanced Barrier (EBPs), Droplet. In addition, handouts were attached for Infection Precaution Signage which included C Diff for a reason for Contact Precautions and the signage for contact precautions which was the same CDC Contact Precautions signage that was observed on the hallway wall at Resident #228's room with an additional handwritten Use soap + water for C. Diff under the Clean their hands, including before entering and when leaving the room. US #1 had signed the inservice dated 6/11/25. CNA #1 had not signed as attending either inservice. On 6/23/25 at 2:00 PM, the surveyor interviewed the Director of Nursing (DON) and ADON who acknowledged Resident #228 was on contact precautions for CDI and expected staff to wear a gown and gloves for any entry into the resident's room. The ADON added that upon exiting the room hand hygiene was to be performed, either ABHR or hand washing. The surveyor reviewed the above observations with the DON and ADON. On 6/26/25 at 9:38 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON and ADON. The LNHA stated that he had spoken with CNA #1 and she stated she had washed her hands after she closed the door. LNHA could not speak to the timing of washing hands. LNHA acknowledged that CNA #1 was supposed to wear a gown and gloves upon entry to the resident's room on Contact Precautions. The ADON stated that she had done inservicing with staff On Contact Precautions for CDI on 6/23/25 after surveyor observations. NJAC 8:39-19.4 (a) (1,2)

Based on interviews, record reviews and review of pertinent facility documents, it was determined that the facility failed to utilize an infection assessment tool prior to prescribing antibiotics and conduct an ongoing review of this process for their Antibiotic Stewardship (AS) Program. This deficient practice was identified for 2 of 3 residents reviewed for antibiotic use (Resident's #114 and #155). This deficient practice was evidenced by the following: On 6/18/25 at 9:50 AM, the surveyor interviewed the Infection Preventionist (IP) / Registered Nurse (RN) who stated that she started working at the facility in April 2025. She stated that the facility did not have a AS program in place and they were working on it. She stated she followed the Centers for Disease Control (CDC) [the national public health agency of the United States] and Association for Professionals in Infection Control (APIC) guidelines for antibiotic surveillance. The surveyor requested to review the AS program antibiotic tracking logs for the months of March, April and May 2025. A review of the facility provided Infection Control/Antibiotic Log's included, the resident's name and room number, the name of the antibiotic, the start and stop date of the antibiotic and the indication for the antibiotic. The log for May 2025 revealed that Resident #155 received Amoxicillin & Clavulanate 875 milligrams (mg)-125mg (an antibiotic) tablet by mouth twice daily from 5/05/2025 thru 5/12/2025 for a urinary tract infection. A review of the electronic medical record (EMR) confirmed that Resident #155 had a Physician's Order (PO) dated 5/06/2025, for Amoxicillin & Clavulanate 875mg-125mg (an antibiotic) give one tablet by mouth twice daily from 5/05/2025 thru 5/12/2025 for a urinary tract infection. A review of the EMR for Resident #114 revealed a PO dated 6/19/2025, for Ciprofloxacin 500mg (an antibiotic) tablet by mouth twice daily from 6/20/2025 thru 6/27/2025 for a urinary tract infection. On 6/25/25 at 10:58 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding the AS program. The ADON stated the facility used McGeer's Criteria (an assessment tool used to define and diagnose healthcare associated infections in long-term care facilities). She stated the nurses completed the McGeer's Situation-Background-Assessment-Recommendation (SBAR) form located in the EMR prior to the physician's order for antibiotics. She stated that the McGeer's surveillance should have been completed prior to the resident receiving antibiotics. On 6/25/25 at 01:00 PM, the surveyor reviewed the EMR alongside the ADON for Resident #114 and Resident #155's. The ADON was unable to locate the SBAR forms in the EMR and acknowledged that the McGeer's Criteria were not completed for either resident. She stated prior to the resident receiving an antibiotic the form should have been completed. On 6/26/25 at 10:25 AM, during an interview with the Director of Nursing (DON) and ADON. The DON stated the McGeer's SBAR form should have been completed on all residents who received antibiotic therapy. She acknowledged that she reviewed residents who received antibiotics and stated, some SBARs were not done. In addition, the DON stated the IP/RN was in the process of working on the AS program. She added that residents should have had a SBAR completed if they were started on antibiotics in the facility. The ADON stated that the purpose of the Antibiotic Stewardship Program was to eliminate unnecessary antibiotic use and the reduce the development of Multidrug Resistant Organisms (MDROs) [a living thing that can resist common antibiotics]. A review of the facility's policy, Antibiotic Stewardship revised 2025, revealed to treat infections and improve the use of antibiotics and included, Nursing staff will identify signs and symptoms of infection based on McGeer's Criteria for Long Term Facilities. Nurse will use the SBAR when suspected infection arises. NJAC 8:39-19.4 (e)

Complaint #s: NJ00185340, NJ00175616, NJ00183791 Based on interviews, record review, and review of pertinent facility documents on 04/24/2025 and 04/28/2025, it was determined that the facility failed to accurately and consistently document all the Activities of Daily Living (ADLs) of Residents #1,#2, and #3 in the Certified Nursing Assistant [CNA]Observation Sheet (COS)according to their facility's policy and procedure on ADL flow sheets. This deficient practice was observed in three out of five residents reviewed for ADLs documentation and was evidenced as follows: 1.According to Resident's Face Sheet (FS), Resident #1 was admitted to the facility with following diagnoses that included but not limited to cellulitis of left lower limb, moderate protein-calorie malnutrition, pain in left hip, dysphagia, muscle weakness, acute embolism and thrombosis of deep veins of lower extremity -bilateral, atrial fibrillation, sepsis, osteomyelitis of vertebra, generalized anxiety disorder, essential hypertension, Alzheimer's disease, and type 2 diabetes mellitus, depression, and anemia. Review of the Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities and helps the facility identify residents' health problems, dated 01/15/2025, showed that Resident #1 Brief Interview for Mental Status (BIMS) Summary Score is 01 which indicated Resident's cognition was severely impaired. The MDS further revealed in Section GG- Functional Abilities that the Resident was dependent and required staff assistance in completing her/his ADLs. Review of Resident #1's Care Plan (CP) dated 04/16/2025 under Problem Type: ADL Function: Problem Description: Bathing, Extensive Assist, 1 Person; Dressing, Extensive Assist, 1 Person; Personal Hygiene, Extensive Assist, 1 Person, Total Care, 1 Person; Eating, Total Care, 1 Person; Approaches: .provide set up, partial, total care with bathing; set up supplies for grooming/oral care; .monitor meal consumption and record, .provide assistance with dressing and hygiene as indicated on Kardex [care record]. Review of Resident #1's COS with Month/Year 2025 of April 2025 revealed blank boxes on the following dates associated with the type of ADLs that was provided to the Resident: a. Dietary Intake [Monitor Meal Consumption]: -Breakfast: 04/19/2025, 04/20/2025, 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/26/2025, 04/27/2025, 04/28/2025, 04/29/2025, and 04/30/2025. - Lunch: 04/19/2025, 04/20/2025, 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/26/2025, 04/27/2025, 04/28/2025, 04/29/2025, and 04/30/2025. - Dinner: 04/01/2025 to 04/30/2025. b. Toileting Checks: Toileting/Incontinence Care: -11p-7a [night Shift]: 04/01/2025 to 04/30/2025. -7am-3pm [morning Shift]: 04/19/2025, 04/20/2025, 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/26/2025, 04/27/2025, 04/28/2025, 04/29/2025, and 04/30/2025. -3pm-11pm [afternoon shift]: 04/01/2025 to 04/30/2025; 04/13/2025 was initialed. c. Bladder: -11p-7a: 04/01/2025 to 04/30/2025 -7am-3pm: 04/19/2025 to 04/30/2025 -3p-11pm: 04/01/2025 to 04/30/2025. d.Bowel: -11pm-7am: 04/01/2025 to 04/30/2025 -7am-3am: 04/19/2025 to 04/30/2025 -3pm-11pm: 04/01/2025 to 04/30/2025; 04/13/2025 was initialed. e. Turning and Positioning Q [every] 2 hours: -11pm-7am: 04/01/2025 to 04/30/2025 -7am-3pm: 04/01/2025 to 04/30/2025 -3p-11pm: 04/01/2025 to 04/30/2025. 2. According to Resident's FS, Resident #2 was admitted to the facility with the following diagnoses that included but not limited to acute respiratory failure with hypoxia, hypomagnesemia, chronic respiratory failure, dysphagia, anxiety disorder, and low back pain. Review of the Resident MDS, dated [DATE], showed that Resident #2 BIMS Summary Score was 15 which indicated Resident's cognition was intact. The MDS further revealed in Section GG- Functional Abilities that the Resident was dependent and required staff assistance in completing her/his ADLs. Review of Resident #2's Care Plan (CP) dated 01/29/2025 under Problem Type: ADL Function: Problem Description: Bathing, Total Care, 1 Person; Dressing, Total Care,1 Person; Personal Hygiene, Extensive Assist, 1 Person; Eating, Supervision, with set-up; Approaches: .provide set up, partial, total care with bathing; set up supplies for grooming/oral care; .monitor meal consumption and record, .provide assistance with dressing and hygiene as indicated on Kardex [care record]. Review of Resident #1's COS with Month/Year 2025 of April 2025 revealed blank boxes on the following dates associated with the type of ADLs that was provided to the Resident: a. Dietary Intake [Monitor Meal Consumption]: -Breakfast: 04/01/2025 to 04/30/2025. - Lunch: 04/01/2025 to 04/30/2025. - Dinner: 04/01/2025 to 04/30/2025. b. Toileting Checks: Toileting/Incontinence Care: -11p-7a [night Shift]: 04/01/2025 to 04/30/2025. -7am-3pm [morning Shift]: 04/01/2025 to 04/30/2025. -3pm-11pm [afternoon shift]: 04/01/2025 to 04/30/2025. c. Bladder: -11p-7a: 04/01/2025 to 04/30/2025 -7am-3pm: 04/01/2025 to 04/30/2025 -3p-11pm: 04/01/2025 to 04/30/2025. d.Bowel: -11pm-7am: 04/01/2025 to 04/30/2025 -7am-3am: 04/01/2025 to 04/30/2025 -3pm-11pm: 04/01/2025 to 04/30/2025. e. Turning and Positioning Q [every] 2 hours: -11pm-7am: 04/01/2025 to 04/30/2025 -7am-3pm: 04/01/2025 to 04/30/2025 -3p-11pm: 04/01/2025 to 04/30/2025. 3. According to Resident's FS, Resident #3 was admitted to the facility with the following diagnoses that included but not limited to shortness of breath, headache, gastro-esophageal reflux disease without esophagitis, unspecified dementia with unspecified severity, muscle weakness, stress incontinence, anxiety disorder, and anemia. Review of the Resident MDS, dated [DATE], showed that Resident #3 BIMS Summary Score was 07 which indicated Resident's cognition was severely impaired. The MDS further revealed in Section GG- Functional Abilities that the Resident was dependent and required staff assistance in completing her/his ADLs. Review of Resident #3's Care Plan (CP) dated 03/21/2025 under Problem Type: ADL Function: Problem Description: Bathing, Extensive Assist,1 Person; Dressing, Extensive Assist,1 Person; Personal Hygiene, Limited Assist,1 Person; Eating, Supervision, with set-up; Approaches: .provide set up, partial, total care with bathing; set up supplies for grooming/oral care; .monitor meal consumption and record, .provide assistance with dressing and hygiene as indicated on Kardex [care record]. Review of Resident #1's COS with Month/Year 2025 of April 2025 revealed blank boxes on the following dates associated with the type of ADLs that was provided to the Resident: a. Dietary Intake [Monitor Meal Consumption]: -Breakfast: 04/01/2025 to 04/30/2025. - Lunch: 04/01/2025 to 04/30/2025. - Dinner: 04/01/2025 to 04/30/2025. b. Toileting Checks: Toileting/Incontinence Care: -11p-7a [night Shift]: 04/01/2025 to 04/30/2025. -7am-3pm [morning Shift]: 04/01/2025 to 04/30/2025. -3pm-11pm [afternoon shift]: 04/01/2025 to 04/30/2025. c. Bladder: -11p-7a: 04/01/2025 to 04/30/2025 -7am-3pm: 04/01/2025 to 04/30/2025 -3p-11pm: 04/01/2025 to 04/30/2025. d.Bowel: -11pm-7am: 04/01/2025 to 04/30/2025 -7am-3am: 04/01/2025 to 04/30/2025 -3pm-11pm: 04/01/2025 to 04/30/2025. e. Turning and Positioning Q [every] 2 hours: -11pm-7am: 04/01/2025 to 04/30/2025 -7am-3pm: 04/01/2025 to 04/30/2025 -3p-11pm: 04/01/2025 to 04/30/2025. On 04/24/2025 at 1:35 pm [afternoon], the Surveyor interviewed Licensed Practical Nurse (LPN) #1 assigned to Unit [name] High Side. LPN #1 stated the Certified Nursing Assistants (CNAs) document their tasks [activities of daily living] in a folder in the nurses station. The binder was labelled as CAN checklist with log sheets inside titled the CAN Observation Sheet (COS). LPN #1 further stated the CNAs initialed the sheet according to the type of assistance in each ADL provided to the residents. LPN #1 the CAN would call her if it after CNAs gave shower or baths to residents to check their skin. On 04/24/2025 at 2:13 pm, the Surveyor interviewed Certified Nursing Assistant (CNA #1), CNA#1 stated they had COS binder where they signed and initialed what ADL it was for the resident. The Surveyor requested for the COS binder and asked CNA#1 if there was another binder that would include the other ADLS. CNA#1 provided the COS binder and stated if the boxes were signed or initialed meaning it was done. CNA#1 further stated the Assistant Director of Nursing (ADON) or Director of Nursing (DON) would get the books at the end of the month for their meetings. On 04/24/2025 at 3:14 pm, the Surveyor interviewed the Licensed Nursing Home Administrator (LNHA), DON, and the ADON. The LNHA and DON stated their CNAs document their ADLs in the ADL sheet in each Unit. The ADL sheet was the COS according to the DON and ADON. The DON stated after each shift these, COS are being filled out by the CNAs. DON further said the nurse supervisor would audit and go over the sheets and would perform in-services as needed. DON further stated if COS not filled out, DON said they would be omissions. LNHA stated if not filled out the ADLs were done but not documented. On 04/28/2025 at 1:40 pm, the Surveyor requested from facility for other documents pertaining to and would reflect the other ADLs such as personal hygiene, dressing, grooming/oral care as indicated in Residents Kardex [care record]. The facility was unable to further provide any pertinent documentations. Review of the facility's policy titled, Nursing Policy and Procedure, Subject: ADL Flow Sheet and updated 1/2025, states The ADL flow sheets will have all pertinent information concerning each individual resident .The ADL flow sheets, and shower book are an internal QA tool used by nursing administration to help ensure highest practical level of care is provided by the certified nurse aides . NJAC 8:39- 27.1(a)

Based on record review, interview and policy review, the facility failed to notify the resident's responsible party regarding a new diagnosis of pneumonia and a change in antibiotic for one (Residents (R) 434) of three resident reviewed for change in condition. Findings include: Review of R434's Admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnosis including pneumonia. Review of R434's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 04/02/23, revealed a Brief Interview for Mental Status (BIMS), score of three out of 15 which indicated severe cognitive impairment. Review of R434's Care Plan, located under the Care Plan tab of the EMR and dated 04/07/23, revealed The resident was care planned for presence of infection, pneumonia. Interventions in place were to note any abnormalities in the color/character of sputum, assess for local systematic signs or symptoms of infection and monitor temperature. Review of Physician Orders, dated 04/04/23 in the EMR under the Orders tab revealed, Augmentin 875 milligram (mg) oral tablet by mouth twice a day. Review of a Nurses Notes, in the EMR, under the Resident Services tab by Licensed Practical Nurse (LPN) 2 dated 04/05/23 indicated, results of chest x-ray left lower lobe infiltrate and small left pleural effusion. Review of a Nurses Notes, in the EMR, under the Resident Services tab by LPN2 dated 04/05/23 indicated, received call from pharmacy stating that resident has an allergy to Penicillin and should not be taking Augmentin. A call was made to the physician and order was received to discontinue Augmentin and to start resident on Azithromycin 500 mg now and 250 mg by mouth for five days. During an interview on 04/25/24 at 11:13 AM, LPN2 said as soon as staff identified anything different in a resident's condition, they were to notify the family. They would be expected to notify the family after a resident was diagnosed with pneumonia or after any change in a resident's medication. That should be documented in a nurse progress note. She said she remembered R434 had chest x-ray but could not remember anything specific. After reviewing the progress note dated 04/04/23 she remembered there was a cousin who was R434's responsible party (RP) and she said she tried to call the cousin but there was no answer, so she just left a message to call back. She said she never spoke with the RP. She said she should have documented that attempt it in progress note. She also said she tried to call the RP after there was a change in the antibiotics that R434 was prescribed but she did not document that either but should have. She said there was no documentation to show she tried to inform the RP about the residents change in condition. During an interview on 04/26/24 at 12:50 PM, the Director of Nursing (DON) said staff should make sure the family was notified within 24 hours after a resident's change in condition and it should be documented in the nurse's notes. The DON stated that there was no documentation in the EMR that the family was made aware of the pneumonia or the change in antibiotic medication. Review of the facility's policy titled Notification of change in Patient's Status updated 07/20/2023 revealed to keep the responsible party fully aware of a resident's status. It will be the policy for the facility to notify the following when there is a significant change in a patient's physical status. Family or Power of Attorney (POA) will be notified of any changes in a resident's physical status. Proper documentation will be entered on the residents' chart. Notification to family will be done within 24 hours from the time of condition of change. NJAC 8:39-13.1(C)

37283 40902 Based on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed after admission for three (Resident (R)154, R61 and R84) out of 12 residents reviewed for PASARR I. Findings include: 1. Review of R154's Admission Record, located in the Resident Information tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] and a readmission on 04/22/24 with diagnoses including unspecified psychosis, anxiety disorder and Bipolar disorder. Review of R154's PASARR I located under the Resident Documents tab in the EMR and dated 05/31/23 did not indicate any mental illness diagnosis. Review of R154's Diagnosis List, located under the Medical Diagnosis tab of the EMR and dated 04/22/24, revealed diagnoses of unspecified psychosis, anxiety disorder, depression, and bipolar disorder. During an interview on 04/25/24 at 2:21 PM, the Admissions Director (ADD) stated that it was her responsibility to review the PASARR level 1 and ensure it was completed accurately. She said she had all the resident's medical records information on admission to know what information should be on the PASARR I. She was aware that R154 had several mental illnesses diagnoses but she did not complete another PASARR level I since she did not think R154 would have screened positive for a level II. She did think another PASARR level I needed to be completed with all the correct mental illness information. During an interview on 04/26/24 at 12:46 PM the Director of Nursing (DON) stated any mental illness diagnosis should be listed on the PASARR I. 2. Review of R61's Admission Record located in the EMR under the Resident Information tab indicated admitted [DATE]. Review of R61's Diagnosis List, located under the Medical Diagnosis tab of the EMR revealed diagnosis of Schizophrenia. Review of R61's PASARR Level I Screen dated 03/24/23 located under the Resident Documents tab in the EMR indicated no mental illness and did not list a diagnosis of Schizophrenia. Interview on 04/25/24 at 02:12 PM, the ADD stated that the PASARR Level I screen is required for each admission from the hospital and should be reviewed for accuracy by the admissions coordinator. 3. Review of R84's Face Sheet located in the electronic medical record (EMR), resident's information tab, revealed an initial admitted [DATE] with diagnoses of bipolar disorder and Schizophrenia. Review of R84's PASARR located under the Resident Documents tab in the EMR revealed the document did not indicate a date. In addition, the document did not identify R84's diagnoses of bipolar disorder and Schizophrenia. During an interview with the DON on 04/26/24 at 12:46 PM, she stated the ADD would be responsible for completing the PASARR I and ensuring the document was accurate on admission of a resident to the facility. She stated that the ADD would be responsible for checking all of the residents' PASARR I for accuracy. NJAC 8:39-5.1(a)

Based on observations, interviews, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 9:53 to10:42 AM, the surveyors, accompanied by the Assistant Administrator (AA) observed the following in the kitchen: 1. In the dry storage room on a middle shelf a stack of Styrofoam bowls was removed from their original packaging. The bowls were uncovered, and the eating surface was exposed. On interview the AA stated, I'll take those. That shouldn't be like that. 2. On a middle shelf in the dry storage room a can of Cuts Hearts of Palm had a significant dent on the upper seam. The AA removed the can to the designated dented can area. 3. On a middle shelf in the Meat Walk-In Refrigerator a half pan covered with plastic wrap contained leftover salad, per the AA. The salad had a use by date of ,d+[DATE]. The AA removed the ,d+[DATE] pan of salad to the trash. 4. On a top shelf in the Meat Walk-In refrigerator two separate and opened packages of hot dogs wrapped in plastic wrap had no dates. The AA removed the hot dogs to the trash. 5. On a rear top shelf in the Produce Walk-In refrigerator a plastic container of horseradish with beets had a use by date of [DATE]. On the same shelf a full pan contained sliced tomatoes. The pan was covered with plastic wrap and had a use by date of ,d+[DATE]. The plastic wrap did not fully cover the tomatoes leaving them exposed. On the same shelf a container of macaroni salad and a container of Cole slaw had their lids partially opened, exposing the macaroni salad and Cole slaw to the air. The opened container of macaroni salad had no dates, and a white, unidentified liquid substance covered the lid. The AA removed both the macaroni salad and Cole slaw to the trash. 6. A half pan of diced pears covered with plastic wrap on a middle shelf of the Dairy Refrigerator had a use by date of ,d+[DATE]. On the same shelf, a half pan covered with plastic wrap contained what appeared to be oatmeal. The pan had no dates. On an upper shelf an opened package of soft, sliced cheese was wrapped in plastic wrap. The cheese had a use by date of [DATE]/21. The AA removed all food products to the trash. On [DATE] from 9:44 to 10:01 AM, the surveyor, accompanied by the Unit Secretary (US) and an Executive Administration (EA) member observed the following on the G1 unit pantry refrigerator designated for outside food: 1. On the inside shelf of the refrigerator door, an opened bottle of Light Zesty Italian Dressing & Marinade had a Best if used by date of SEP 25, 2020. On a lower shelf of the door, a brown paper bag was labeled with a resident name and room number. The bag contained what appeared to be an Asian style take out container with unidentified food. The bag had no dates. 2. On an upper shelf in the refrigerator, the surveyor observed (2) brown paper bags labeled with a resident name and room number. One bag stated, Please use for Monday ,d+[DATE] and the second brown paper bag was labeled with a resident name and room number and stated, Please use for Sunday ,d+[DATE]. In addition, on the same shelf a plastic bag contained unidentified food. The bag was labeled with a resident name and room number. The bag had no dates. 3. On a middle shelf of the refrigerator a plastic take out style container with a clear plastic lid appeared to contain leftover beef. The container had no name, room number, or dates. 4. On a bottom shelf of the refrigerator, a white Styrofoam take out style container contained unidentified food. The container had no name, date, or room number. On the same shelf a plastic clear sealable bag contained what appeared to be 3 pieces of loaf style bread. The plastic clear sealable bag had no name, or dates. The following sign was observed to be posted on the outside of the freezer door: Attention Residents and Families Please remember to label any items placed in this refrigerator with resident's name and date. Unlabeled items will be discarded. All food will be discarded after 72 hours. On interview with the US concerning the above observations the US stated, Ok, they are not labeled properly. The surveyor then questioned who was responsible for monitoring the refrigerator designated for outside food. The US deferred to the EA and the EA stated, I believe that nursing management monitors the refrigerator for expired food but I'm not certain. On [DATE] at10:32 AM in the L2 Pantry, the surveyor interviewed a Dietary Aide (DA) who was observed to be cleaning the refrigerator upon entry to the pantry. The DA stated, I am responsible for maintaining the nourishment refrigerator for the dietary supplies from the facility and the refrigerator and freezer that is used to store resident food from outside. I don't like to do the resident refrigerator because they put stuff in there and don't label it. On [DATE] from 10:01 to 10:20 AM, the surveyor, accompanied by the AA observed the following in the kitchen: 1. In the dish room, a (4) wheeled mobile cart contained cleaned and sanitized plates used for resident meals. The cart was under a wet metal shelf adjacent to the clean end of the high temperature dish machine. The plates were stacked with the food contact surface facing upward and not in the inverted position. The food contact surface was exposed. The high temperature dish machine was in operation at the time by the AA, as staff had gone on break. The AA was loading the dish machine with plastic racks used to hold dirty dishware so that the surveyor could observe the wash and rinse temperatures. The dish machine was observed to emit steam in the direction of the cart of cleaned and sanitized plates. The AA stated, They need to be covered. They shouldn't be left in that location. The AA instructed staff to rewash all plates on the cart. A review of a facility policy titled Dietary Services/Outside Food with effective date: ,d+[DATE], revealed under the heading Policy Interpretation and Implementation: 6. Non-perishable foods permitted to be retained in the resident's room must be stored in plastic containers with tight-fitting lids, except fruit. Perishable, prepared foods stored in refrigerators @ 40 F or below must be discarded after 72 hours. A review of a facility policy titled Dented Cans with effective date: [DATE], revealed under the heading Purpose: To assure all cans are dent free, in good condition, maintaining contents wholesome integrity. The following was revealed under the heading PROCEDURE: 1. Upon discovery, all dented cans shall be removed to a designated space to prevent use and return to vendor. 2. All dietary staff, have/will receive proper training to recognize and remove dented cans to The Dented Can Rack. A review of a facility policy titled Food Labeling/Dating, with effective date: [DATE], revealed under the heading POLICY: All food items must be labeled and dated. In addition, the following was revealed under the heading PROCEDURE: All food items shall be labeled and dated with a USE BY date once opened, not to exceed the manufacturer's expiration, best by or use by date according to the following parameters: All cooked food: 72 hours following preparation. Hard and Sliced Cheese: 14 days Cottage Cheese/Sour Cream: 7 days Purchased, prepared salads; Potato, Macaroni, Cole Slaw: 7 days In addition, the policy revealed under the heading RESPONSIBILITY: Food Service Director, Cooks, Food Service Staff N.J.A.C. 8:,d+[DATE].2(g)

Based on observations, interviews, record review and review of other facility documentation, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care, (Resident #34 and Resident #9). This deficient practice was evidenced by the following: 1. On 01/04/2022 at 10:32 AM, surveyor #1 observed Resident #34 lying in bed with the head of the bed elevated. Resident #34 had a [CONDITION(S)] ([CONDITION(S)]) (a surgical opening in the throat area with a tube for breathing) with a mask over the [CONDITION(S)] (used to deliver oxygen, humidification, and medications) connected to blue corrugated tubing. On the bedside table was a high output compressor with a water/humidification bottle (a machine used for administering humidification), a suction machine and a nebulizer machine (a machine used to deliver medications). The blue tubing was connected to a water/humidification bottle which was empty and had no water inside. There was also a tubing connected to an oxygen concentrator (a machine used to provide supplemental oxygen) and the blue corrugated tubing. There were no observed dates on the blue tubing, the oxygen tubing, the nebulizer tubing, or the suction machine tubing to indicate when the tubing were last changed. There was also a used suction catheter (used to remove secretions from the [CONDITION(S)]) connected to the suction tubing and hanging over the suction machine. The oxygen concentrator was observed to have dried tan substance on the top of the machine. On 01/05/2022 at 11:32 AM, surveyor #1 observed the assigned Registered Nurse (RN #1) perform tracheal suctioning for Resident #34. Upon completion, RN #1 coiled the used suction catheter and tubing up and placed it in the top drawer of a 3-drawer bed side chest. The suction catheter was lying on top of a white paper exposed and uncovered. RN #1 then left the room after removing gloves and performing hand hygiene. The surveyor observed minimal water in the humification bottle and a small tag on blue corrugated tubing dated 1/2/22 that was not observed by the surveyor on 1/4/22 with no other dates on the oxygen or suction tubing. On 1/05/2022 at 11:40 AM, RN #1 said that since she has been there, she has seen that they (other staff) place the used suction catheter attached to tubing in the drawer. She went on to say, No I don't think it is the facility policy and I don't know what the policy is. She said the tubings were changed days during week but was unable to be more specific. According to the Face Sheet, Resident #34 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set (MDS), an assessment tool dated 10/5/2021, revealed Resident #34 had severe cognitive impairment. The MDS also reflected that Resident #34 used a [CONDITION(S)], suctioning and oxygen. A review of the current Physician Orders did not include an order to change blue corrugated tubing, suction tubing, oxygen tubing, or nebulizer tubing. During an interview with surveyor #1 on 1/10/2022 at 9:22 AM, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) stated that the oxygen tubing, blue corrugated and suction tubing should be changed once a week and as needed as part of the order set for respiratory care. The ADON further said this would be documented on the Treatment Administration Record (TAR). The ADON went on to say that the suction order was as needed, and suctioning was a sterile procedure, and we should be using kits. She also said they should throw out the suction catheter after each use as it was no longer sterile. On 1/10/2022 at 9:28 AM, surveyor #1 reviewed the findings with the DON and ADON. The ADON stated that the suction catheter should not be hanging over the suction machine. The DON also stated the suction catheter should not be coiled up in a drawer after use. During an interview with surveyor #1 on 01/10/2022 at 12:54 PM, the ADON said she reviewed the Electronic Medical Record for Resident #34 and the order to change the tubing's weekly was not checked and would not show up on the TAR. She went on to say there is no documentation to indicate that the blue corrugated tubing, oxygen tubing, suction tubing or nebulizer tubing was changed. A review of a facility policy titled Suctioning [CONDITION(S)] Tube updated 2021, revealed disconnect catheter from tubing. Wrap catheter around the gloved hand. Pull the glove off and over the catheter. Discard in designated waste. The policy did not include documentation of when the suction tubing was to be changed. A review of a facility policy titled Respiratory-Oxygen Concentrators updated 9/2021, did not include documentation of when the oxygen tubing was to be changed. 2. During the initial tour on 01/04/2022 at 10:56 AM, surveyor #2 observed a nebulizer mask (covers the mouth and nose, used to administer medication in the form of a mist, directly into the lungs by inhalation) that was connected to a nebulizer machine (used to change liquid medicine into fine droplets that are inhaled through a mask) lying directly on the overbed table. The nebulizer was not in use. On 01/06/2022 at 10:46 AM, surveyor #3 observed a nebulizer mask attached to a nebulizer machine lying on the nightstand. The nightstand was out of reach from the resident. The mask was not in a bag and was lying directly on top of a box of gloves. The resident told surveyor #3 that he/she was waiting for the nurse to administer the nebulizer treatment. According to the Face Sheet, Resident #9 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #9's MDS, dated [DATE], revealed the resident had a Brief Interview for Mental Status of 14/15, which indicated that the resident was cognitively intact. A review of Resident #9's Care Plan, dated 09/15/2021, revealed that the resident received respiratory therapy and was to be monitored while taking an effective inhaler treatment. A review of a medication order dated 12/29/21, revealed that Resident #9 was receiving [MEDICATION(S)] HCL inhalation Nebulization Solution (a medication used to treat wheezing and shortness of breath) 0.63/3ML (milliliters), 1.0 vials via nebulizer from [DATE], Every Day at times: 12 am, 6 am, 12 pm, 6 pm for unspecified asthma, uncomplicated. A review of the Medication Administration Records for January 2022 revealed that Resident #9 had received the [MEDICATION(S)] HCL inhalation Nebulization Solution as ordered and at the times it was scheduled. During an interview with surveyor #3 on 01/10/2022 at 10:08 AM, RN #2 stated that nebulizer masks would be stored in a Ziploc bag while not in use to prevent any type of infection and to isolate bacteria. Surveyor #3 reviewed the findings with RN #2, and she stated that was not acceptable and that the mask should be thrown out. During an interview with surveyor #3 on 01/10/2022 at 10:43 AM, the DON stated that when nebulizer masks were not being used, they should be stored in a bag and dated for infection control purposes. Surveyor #3 reviewed the findings with the DON, and she stated, it should not be stored that way. A review of a facility policy titled Nebulizer Procedure with an effective date of 2021, revealed: Cleaning Nebulizer, after treatment: 2. Disassemble the nebulizer; 5. Line table surface with paper towel; 6. air dry and place on a Ziploc bag. NJAC 8:39-27.1(a)

COMPLAINT # NJ 5, NJ 4, NJ 6, NJ 0 Based on observation, interview, and review of facility provided documentation, the facility failed to a.) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 33 of 35-day shifts and 29 of 35 overnight shifts reviewed b.) ensure a resident was fed timely for 1 of 13 residents reviewed, (Resident #1) and c.) ensure call bells were answered timely for 3 of 13 residents reviewed (Resident #1, Resident #7, and Resident # 10 ) This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. 1. On 10/4/21 at 09:05 AM, Surveyors #2 and #3 entered unit L2 A-side. At that time, the surveyors observed the call bell lights illuminated above Resident #7 and Resident #10's room, indicating that the residents in those rooms needed assistance. The surveyors could also hear the centralized call bell system alarming at the nurses' station. The surveyors observed a staff member, who later was identified as the unit secretary (US), was delivering the breakfast trays at the end of the unit near Resident's #7's room. At that time, Surveyor #2 observed the call bell light remained illuminated above Resident #7's room. At 09:20 AM, the US delivered the breakfast tray to Resident #7 and turned off the call bell light for that room. At 09:22 AM, Surveyors #2 and #3 observed CNA #2 answer the call bell light for Resident #10. Surveyor #2 attempted to interview CNA #2 at that time, but CNA #2 stated that she had to finish helping a resident get dressed for a doctor's appointment. During an interview with Surveyor #2 and #3 on 10/4/21 at 10:24 AM, Resident #9 stated that showers were given when the staff had time because staffing was short. During an interview with Surveyor #2 and #3 on 10/4/21 at 10:28 AM, Resident #7, whose call bell light was on, stated that when the breakfast tray was delivered, they had requested a cup of ice and was still waiting to receive it. At 10:38 AM, Surveyor #1 observed Resident #7's call bell answered by the US, which stated the resident wanted ice. At 10:44 AM, Surveyor #1 observed the US deliver a cup of ice to the resident's room. During an interview with Surveyor #2 and #3 on 10/4/21 at 11:42 AM, CNA #2 stated she had 20 residents on her assignment. She noted that it was impossible for all the residents to get their showers on shower days with that many residents in her assignment. 2. On 10/4/21 at 10:09 AM, on the L-2 Unit, Surveyor #1 observed Resident #1's call light lit. At that time, the surveyor observed a staff member in the hall collecting breakfast trays. At 10:38 AM, the surveyor observed the MDS Coordinator enter Resident #1's room, left, and stated she needed to get another staff member to assist her to reposition the resident. At 10:47 AM, the MDS Coordinator and CNA #4 entered Resident #1's room and repositioned the resident. The surveyor entered the resident's room and observed a meal tray with uneaten scrambled eggs, an unidentified pureed substance, a full bowl of cereal, half-consumed milk, and an empty juice container. At 10:51 AM, the MDS Coordinator stated, Oh, you didn't eat, and proceeded to feed the resident. At that time, the surveyor asked the MDS Coordinator what time the resident's breakfast arrived. The MDS Coordinator stated, at 8:30 AM. The surveyor has asked the MDS Coordinator what time it was currently, and the MDS Coordinator looked at her watch and said, it's five to eleven. The surveyor questioned the time, and the MDS Coordinator stated, this should be heated up. The MDS Coordinator removed the tray and said she was going to heat the resident's breakfast. The surveyor was unable to locate the resident's assigned CNA. During a follow-up interview with the surveyor on 10/5/21 at 8:18 AM, the MDS Coordinator stated that she was not sure why Resident #1's breakfast tray was there that long and after she reheated the resident's breakfast, Resident #1 ate everything. During an interview with the surveyor on 10/5/21 at 9:22 AM, the Director of Nursing (DON) stated the call bell response time should be less than 10 minutes. The DON said that CNAs were responsible to feed the residents. She stated that Resident #1 could be finicky with eating, that the staff would try to feed the resident and would come back later. The DON stated Resident #1's breakfast tray should have been reheated before feeding the resident. The surveyor reviewed the 7-3 shift assignment sheets for Unit L2, and Unit G2 for 10/4/21 revealed that the census on each unit was 62, and three CNA's were assigned to each unit. A review of the 7-3 shift assignment sheet for Unit L2 and Unit G2 for 10/5/21 revealed that L2 had a census of 61 with four CNAs assigned, and G2 had a census of 62 with four CNAs assigned. The surveyor requested the following weeks of staffing: 8/8/2021, 8/22/21, 8/29/2021, 9/5/2021, and 9/26/221. A review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report revealed the following: 8/8/21 had 18 CNAs for 177 residents on the day shift (Required no more than 8 residents for each CNA). 8/8/21 had 13 total staff for 177 residents on the overnight shift (Required no more than 14 residents to each staff). 8/9/21 had 18 CNAs for 177 residents on the day shift. 8/9/21 had 12 total staff for 177 residents on the overnight shift. 8/10/21 had 21 CNAs for 177 residents on the day shift. 8/13/21 had 20 CNAs for 178 residents on the day shift. 8/14/21 had 17 CNAs for 178 residents on the day shift. 8/22/21 had 15 CNAs for 184 residents on the day shift. 8/22/21 had 13 total staff to 184 residents on the overnight shift. 8/23/21 had 16 CNAs for 182 residents on the day shift. 8/23/21 had 10 total staff for 182 residents on the overnight shift. 8/24/21 had 15 CNAs for 182 residents on the day shift. 8/25/21 had 17 CNAs for 182 residents on the day shift. 8/25/21 had 10 total staff for 182 residents on the overnight shift. 8/26/21 had 19 CNAs for 179 residents on the day shift. 8/26/21 had 10 total staff for 179 residents on the overnight shift. 8/27/21 had 17 CNAs for 179 residents on the day shift. 8/27/21 had 10 total staff for 179 residents on the overnight shift. 8/27/21 had 10 total staff for 179 residents on the overnight shift. 8/28/21 had 17 CNAs for 179 residents on the day shift. 8/28/21 had 10 total staff for 179 residents on the overnight shift. 8/29/21 had 15 CNAs for 179 residents on the day shift. 8/29/21 had 10 total staff for 179 residents on the overnight shift. 8/30/21 had 16 CNAs for 179 residents on the day shift. 8/30/21 had 12 total staff for 179 residents on the overnight shift. 8/31/21 had 17 CNAs for 179 residents on the day shift. 8/31/21 had 12 total staff for 179 residents on the overnight shift. 9/1/21 had 15 CNAs for 179 residents on the day shift. 9/1/21 had 12 total staff for 179 residents on the overnight shift. 9/2/21 had 16 CNAs for 179 residents on the day shift. 9/2/21 had 10 total staff for 179 residents on the overnight shift. 9/3/21 had 17 CNAs for 177 residents on the day shift. 9/3/21 had 10 total staff for 177 residents on the overnight shift. 9/4/21 had 17 CNAs for 177 residents on the day shift. 9/4/21 had 10 total staff for 177 residents on the overnight shift. 9/5/21 had 16 CNAs for 176 residents on the day shift. 9/5/21 had 10 total staff for 176 residents on the overnight shift. 9/6/21 had 16 CNAs for 176 residents on the day shift. 9/6/21 had 12 total staff for 176 residents on the overnight shift. 9/7/21 had 17 CNAs for 176 residents on the day shift. 9/7/21 had 12 total staff for 176 residents on the overnight shift. 9/8/21 had 16 CNAs for 176 residents on the day shift. 9/8/21 had 12 total staff for 176 residents on the overnight shift. 9/9/21 had 16 CNAs for 176 residents on the day shift. 9/9/21 had 10 total staff for 176 residents on the overnight shift. 9/10/21 had 16 CNAs for 175 residents on the day shift. 9/10/21 had 10 total staff for 175 residents on the overnight shift. 9/11/21 had 14 CNAs for 175 residents on the day shift. 9/11/21 had 10 total staff for 175 residents on the overnight shift. 9/26/21 had 12 CNAs for 178 residents on the day shift. 9/26/21 had 10 total staff for 178 residents on the overnight shift. 9/27/21 had 16 CNAs for 178 residents on the overnight shift. 9/27/21 had 10 total staff for 178 residents on the overnight shift. 9/28/21 had 17 CNAs for 178 residents on the day shift. 9/28/21 had 10 total staff for 178 residents on the overnight shift. 9/29/21 had 15 CNAs for 176 residents on the day shift. 9/29/21 had 10 total staff for 176 residents on the overnight shift. 9/30/21 had 15 CNAs for 175 residents on the day shift. 9/30/21 had 12 total staff for 175 residents on the overnight shift. 10/1/21 had 13 CNAs for 172 residents on the day shift. 10/1/21 had 11 total staff for 172 residents on the overnight shift. 10/2/21 had 16 CNAs for 170 residents on the day shift. 10/2/21 had 12 CNAs for 170 residents on the overnight shift. During an interview with the surveyor on 10/5/21 at 10:14 AM, the Administrator stated he was aware of the staffing ratios and that staffing was challenging. A review of a facility policy titled, Staffing dated March 2007, updated 21 revealed, Our facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants are available on each shift to provided needed care and services of each resident as outlined on the resident's comprehensive care plan. A review of the facility's policy and procedure Call Lights PROTOCOL, reviewed 21, POLICY: The purpose of this procedure is to respond to the resident's requests and needs. 8. Answer the resident's call as soon as possible. Steps in the Procedure 4. Do what the resident asks of you, if permitted. 5. If you have promised the resident you will return with an item or information, do so promptly. 6. If assistance is needed when you enter the room, summon help by using the call signal. A review of the facility's Call-Bells & Phone Triage In-Service sign in sheet dated 5/29/21, revealed that staff were in-serviced on the Topic:Brief description: Facility protocol: it is everyone Responsibility to respond to call-lights/bells. NJAC 8:39 5.1(a)

COMPLAINT # NJ 6 Based on observation, interview, review of the medical records, and other facility documentation, it was determined that the facility failed to follow the manufacturer's directions for the cleaning and disinfecting of glucometers (blood sugar monitoring device) for 4 of 4 residents (Resident #13, #1, #8, and #9) observed during blood sugar monitoring (fingerstick). This deficient practice was evidenced by the following: On 10/05/21, from 08:32 AM to 08:50 AM, the surveyor observed the medication pass and the Registered Nurse Charge Nurse (RN/CN) as she went from room to room to perform blood sugar checks (fingerstick) of residents on the second-floor unit L2. The surveyor observed the following: 1. On 10/05/21 at 08:32 AM, the RN/CN went into the med cart and removed two alcohol pads, one monitoring strip, one lancet, a glucometer (blood sugar monitoring device), and a plastic medicine cup in which she placed the lancet. The RN used an alcohol-based hand rub (ABHR) and then donned a pair of gloves. She placed the test strip into the machine, gathered the rest of the supplies, and went into Resident #13's room. She placed the plastic medicine cup on the overbed table. While holding the glucometer, she opened the alcohol wipe, wiped the resident's finger, and lanced the resident's finger to obtain blood. She placed the lancet into the plastic medicine cup. She collected the blood, obtained the results, and then placed the test strip into the medicine cup. She opened an alcohol pad, wiped the glucometer, removed her gloves, and discarded them into the trash can in the room. The RN then took the glucometer and the medicine cup to the medication cart, where she discarded the lancet and the test strip into the sharps container and placed the glucometer machine in the cart. The RN then used ABHR to perform hand hygiene. A review of Resident #13's face sheet indicated the resident was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 10/05/21 at 08:40 AM, the RN/CN repeated the same steps and took the glucometer with the test strip in the machine, a lancet, plastic medication cup, 2 alcohol pads, donned gloves, and went into Resident #1's room. The RN/CN obtained the blood, the reading and proceeded to follow the same steps of cleaning the machine with an alcohol wipe in the resident's room. She then removed her gloves and went to the medication cart. She placed the lancet and the test strip into the sharps container and placed the machine onto the cart. She used ABHR to perform hand hygiene. A review of Resident #1's Face Sheet revealed the resident was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On 10/05/21 at 08:45 AM, the RN/CN repeated the same steps and took the glucometer with the test strip in the machine, a lancet, plastic medication cup, 2 alcohol pads, donned gloves, and went into Resident #8's room. The RN/CN obtained the blood, the reading and proceeded to follow the same steps of cleaning the machine with an alcohol wipe in the resident's room. She then removed her gloves and went to the medication cart. She placed the lancet and the test strip into the sharps container and placed the machine onto the cart. She used ABHR to perform hand hygiene. Review of Resident # 8's Face Sheet indicated the resident was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. On 10/05/21 at 08:50 AM, the RN/CN repeated the same steps and took the glucometer with the test strip in the machine, a lancet, plastic medication cup, 2 alcohol pads, donned gloves, and went into Resident #9's room. The RN obtained the blood, the reading and proceeded to follow the same steps of cleaning the machine with an alcohol wipe in the resident's room. She then removed her gloves and went to the medication cart. She placed the lancet and the test strip into the sharps container and placed the machine onto the cart. She used ABHR to perform hand hygiene. Review of resident # 9's Face Sheet indicated the resident was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the surveyor on 10/05/21 at 10:25 AM, the RN/CN stated the protocol to clean the glucometer was to use an alcohol pad, and that was the process she was taught. During an interview with the surveyor on 10/05/21 at 10:40 AM, the Assistant Director of Nurses (ADON) stated each resident had their own glucometer. The cleaning process was to use bleach wipes that are present on the cart. During an interview with the surveyor on 10/05/21 at 11:00 AM, the RN medication nurse on L2 second floor stated she used alcohol pads when cleaning the glucometers after each use. She said she used alcohol pads because there are no other products to use to clean the glucometer. The nurse opened the bottom draw of the medication cart and showed the surveyor a container of bleach wipes. The RN stated she only used bleach wipes to clean the top of the medication cart. She stated the main difference between alcohol and bleach wipes was that bleach kills more pathogens (bacteria, viruses, or other microorganisms that can cause disease). During an interview with the surveyor on 10/04/21 at 12:20 PM, the Central Supply staff stated each medication cart had a glucometer, not each resident. During an interview with the surveyor on 10/04/21 at 01:45 PM, the Director of Nurses (DON) stated each resident should have their own glucometer. The nurses on the units should have requested more if there was one glucometer on the cart. The DON said to clean the glucometer, the nurses should use bleach wipes because the manufacture's information indicates to use bleach wipes, not alcohol wipes. During an interview with the surveyor, on 10/05/221 at 12:20 PM, the DON and the ADON both stated the two nurses were initially observed for medication pass by the ADON and passed their medication pass. The ADON said she could not recall the date on which she evaluated them, and there was no place on the form to write the date. During an interview with the surveyor on 10/04/221 at 2:30 AM, the ADON stated the second day of orientation includes nurse training on policies and procedures. She further stated the nurses are taught that each resident should have their own glucometer and to use bleach wipes to clean the glucometer. A review of the CN/RN and the RN checklists labeled Skills Competency Check List for Nurses indicated the nurse had been informed of the Accu check (glucometer) indicated by a checkmark under the training code I indicated initial. A review of a facility policy, dated 2019 and titled; Glucometer Cleaning, included but was not limited to; .wipe down glucometer with disinfecting bleach wipes and air dry for 10 seconds. A review of a facility policy dated 01/2013 titled Cleansing of non-critical reusable patient care equipment included but was not limited to; . cleaning and maintenance processes will follow manufacture's recommendations. A review of the Evencare G3 blood glucose monitoring system user's guide revealed the meter should be cleaned and disinfected between each resident. The glucometer is validated to withstand a cleaning and distinction cycle of ten times per day for an average period of three years. The products that have been approved for cleaning and disinfecting the Evencare G3 glucometer included : Dispatch Hospital Cleaner Disinfectant Towels with Bleach® (EPA Registration Number: -8) o [MEDICATION(S)] Micro-Kill+ (EPA Registration Number: -10) o Clorox Healthcare (EPA Registration Number: -12) o [MEDICATION(S)] Micro-Kill (EPA Registration Number: -1) NJAC 8:39-19.8 (c)

COMPLAINT # NJ 0 Based on record review and interview, it was determined that the facility failed to report an alleged verbal abuse violation to the New Jersey Department of Health (NJDOH) for 1 of 3 residents reviewed for abuse allegations; (Resident # 2). This deficient practice was evidenced by the following: According to the Face Sheet, Resident #2 was readmitted to the facility in 7/2021 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Quarterly Minimum Data Set (MDS), an assessment tool dated 6/30/21, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 15, which indicated that the resident's cognition was intact. A review of a Recommendation/Concern Form dated 9/13/21, and signed by the Director of Social Services (DOSS) revealed that Resident #2 was identified as the person concerned, and that the concern revealed that Resident #2 had expressed concern about verbal abuse from a Certified Nurses Aide (CNA). The concern form referred to the Administrator, Nursing, and the Social Worker. The Investigation and Resolution portion of the form revealed that the CNA was identified as CNA #1 and was immediately removed from the resident's care. Further review of the concern form indicated that the resident reported that no verbal abuse occurred and that the resident and CNA #1 had a personality clash. On 10/4/21 at 1:26 PM, the surveyor was provided an Investigation Summary by the Assistant Director of Nursing (ADON). The ADON stated that the allegation was not reported to the NJDOH. A review of an Investigation Summary dated 9/21/21 revealed that the facility received a phone call from the office of the Ombudsman, who had informed the facility that Resident #2 called their office and stated that a CNA verbally abused the resident. The investigation portion of the summary revealed that the ombudsman reported allegations of verbal abuse to Resident #2 by CNA #1. The summary revealed that the facility was previously aware of the allegations, and a thorough investigation was done. The Investigation Findings revealed that CNA #1 and Resident #2 had a personality clash, and CNA #1 was no longer assigned to Resident #2. A written statement dated 9/21/21 for Resident #2 completed by the ADON included that Resident #2 stated that there was not an incident of abuse and that the resident and CNA #1 did not like each other. Resident #2 said CNA #1 was mean and that the resident did not want CNA #1 assigned to them. The Investigation Summary was signed by the Director of Nursing (DON), ADON, and the DOSS. During an interview with the surveyor on 10/5/21 at 9:22 am, the DON stated that when there was an allegation of abuse, an investigation would be started, which would include interviewing residents, staff, and witnesses. If the abuse were substantiated, it would be reported to the NJDOH. The DON stated they received a call from the Ombudsman on 9/21/21 regarding Resident #2 and CNA #1. The allegation had already been investigated, and Resident #1 was removed from CNA #1's assignment on 9/13/21. The DON further stated that Resident #1 indicated that CNA #1 was verbally abusive but could not provide a specific example of what had happened. During an interview with the surveyor on 10/5/21 at 10:14 AM, the Administrator stated that the allegation of abuse was not reported to the NJ DOH because the facility was able to unsubstantiate the allegation within 15 minutes of the allegation on 9/13/21 through verbal interviews with the resident, residents on CNA #1's assignment and CNA #1. The Administrator stated when Resident #2 was interviewed, the resident said there was no abuse and that the resident did not like CNA #1. Resident #2 was removed from CNA #1's assignment. A review of a facility policy titled, Concern Forms Resident and Family Grievances revised 2021 included but was not limited to; Allegations of abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Investigation of the grievance shall include interviewing and taking written statements from appropriate staff and other involved persons, the department head will review results of the investigation with the administrator and take appropriate action. A review of a facility policy titled, Abuse Prohibition, revised in 2021, included, Upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee will.; 1) immediately report it to the appropriate agencies per state requirement Administrator or designee will report findings of all completed investigation to state agencies not later than 2 hours after the allegation is made, if event that caused the allegation involve abuse or result in serious bodily injury or in accordance with the state law and take all necessary corrective actions depending on the results of the investigation. NJAC 8:39 5.1 (a)

COMPLAINT # NJ 0 Based on record review, interview, and facility policy review, it was determined that the facility failed to thoroughly and timely investigate an allegation of verbal abuse for 1 of 3 residents reviewed for abuse; (Resident #2). This deficient practice was evidenced by the following: According to the Face Sheet, Resident #2 was readmitted to the facility in 7/2021 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Quarterly Minimum Data Set (MDS), an assessment tool dated 6/30/21, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 15, which indicated that the resident's cognition was intact. A review of a Recommendation/Concern Form dated 9/13/21, and signed by the Director of Social Services (DOSS) revealed that Resident #2 was identified as the person concerned, and that the concern revealed that Resident #2 had expressed concern about verbal abuse from a Certified Nurses Aide (CNA). The concern form was referred to the Administrator, Nursing, and Social Worker. The Investigation and Resolution portion of the form revealed that the CNA was identified as CNA #1 and was immediately removed from the resident's care. Further review of the concern form indicated that the resident reported that no verbal abuse occurred and that the resident and CNA had a personality clash. There were no written statements provided with the concern form from the alleged CNA, Resident #2, witnesses, or other cognitively intact residents that were on the CNA's assignment. During an interview with the surveyor on 10/4/21 at 12:09 PM, the DOSS stated that when there was an allegation of abuse, she, the Administrator, and the Director of Nursing (DON) are notified. An investigation would be started, which would include interviewing alleged staff, the resident, residents assigned to the CNA, and anyone else involved. She stated that a concern form was started when the Ombudsman called for Resident #2. The DOSS interviewed Resident #2, who said CNA #1 was verbally aggressive towards Resident #2. DOSS stated CNA #1 and Resident #2 had clashing personalities. An investigation was done, and Resident #2 was removed from CNA #1's assignment. The surveyor showed the DOSS the concern form and asked if there were written statements. The DOSS stated that she would provide them to the surveyor. During an interview with the surveyor on 10/4/21 at 12:34 PM, the Assistant Director of Nursing (ADON) stated that the process would be that the DOSS documents all interviews during an abuse allegation and would then bring them to the Administrator who would make the decision to report. The ADON stated that she wasn't aware of Resident #2's abuse allegation until the Ombudsman called. She said she spoke to CNA #1 and Resident #2, and it was very clear they didn't like each other. She stated that Resident #2 did not provide specific details regarding the alleged verbal abuse. On 10/4/21, at 1:26 PM, the surveyor was provided an Investigation Summary by the ADON. The ADON stated that the allegation was not reported to the New Jersey Department of Health. A review of an Investigation Summary dated 9/21/21 (8 days after the concern form) revealed that the facility received a phone call from the Office of the Ombudsman and informed the facility that Resident #2 called the Ombudsman's office and stated that a CNA verbally abused the resident. The investigation portion of the summary included that the Ombudsman reported allegations of verbal abuse to Resident #2 by CNA #1. The summary revealed that the facility was previously aware of the allegations, and a thorough investigation was done. The Investigation Findings revealed that CNA #1 and Resident #2 had a personality clash and that CNA #1 was no longer assigned to Resident #2. Attached to the investigation were statements from five residents, all dated 9/21/21, who had no concerns. A written statement for Resident #2 completed by the ADON included that Resident #2 stated that there was no abuse and that the resident and CNA #1 did not like each other. Resident #2 said CNA #1 was mean and that the resident did not want CNA #1 assigned to them. There was no statement for CNA #1. The Investigation Summary was signed by the Director of Nursing (DON), ADON, and the DOSS. During an interview with the surveyor on 10/5/21 at 9:22 am, the DON stated that when there was an allegation of abuse, an investigation would be started, which would include interviewing residents, staff, and witnesses. If the abuse were substantiated, it would be reported to the NJ DOH. The DON stated they received a call from the Ombudsman on 9/21/21 regarding Resident #2 and CNA #1. The allegation had already been investigated, and Resident #1 was removed from CNA #1's assignment on 9/13/21. The DON further stated Resident #2 said CNA #1 was verbally abusive but could not provide a specific example of what had happened. During an interview with the surveyor on 10/5/21 at 10:14 AM, the Administrator stated that the facility initially obtained verbal interviews for Resident #2, residents on CNA #1's assignment, and CNA #1 on 9/13/21. The Administrator stated upon interview that Resident #2 said there was no abuse and that the resident did not like CNA #1. Resident #2 was removed from CNA #1's assignment. He stated he also interviewed CNA #1 and determined it was not abuse. He noted the concern form was the record and that there was no other documentation from that date. During a telephone interview with the surveyor on 10/5/21 at 11:00 AM, CNA #1 stated that Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . However, recently Resident #2 was assigned to her. CNA #1 stated that Resident #2 said she (CNA #1) was abusive to Resident #1. CNA #1 stated she notified the ADON, and a meeting was held to remove Resident #2 from CNA #1's assignment. She noted the Administrator spoke to her (CNA #1) about the allegation, but she did not write a statement. On 10/5/21 at 12:45 PM, the Administrator provided the surveyor with a statement written for CNA #1 by the Administrator dated 9/13/21. The statement indicated that CNA #1 went to provide care for Resident #2; the resident cursed at CNA #1 and did not want CNA #1 to take care of her. The statement revealed that no incident had happened. Review of a facility policy titled, Concern Forms Resident and Family Grievances revised 2021 included but was not limited to; Allegations of abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Investigation of the grievance shall include interviewing and taking written statements from appropriate staff and other involved persons, the department head will review results of the investigation with the administrator and take appropriate action. A review of a facility policy titled, Abuse Prohibition, revised in 2021, included, Upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee will.; 1) immediately report it to the appropriate agencies per state requirement; 2)Conduct an immediate and thorough investigation that focuses a) whether abuse or neglect occurred and to what extent b) clinical examination for signs of injuries; if indicated; causative factors; and d) interventions to prevent injury. The investigation will be documented on the facility's investigation form and will be kept confidential. The Administrator or designee will report findings of all completed investigation to state agencies not later than 2 hours after the allegation is made if event that caused the allegation involve abuse or result in serious bodily injury or in accordance with the state law and take all necessary corrective actions depending on the results of the investigation. NJAC 8:39 4.1 (a)(5)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure: a) the appropriate use of personal protective equipment while conducting rapid [MEDICATION NAME] testing for COVID-19 and when caring for newly admitted residents who were under investigation for COVID-19; b) that gowns were not shared between residents that were under investigation for COVID-19; c) hand hygiene was performed in accordance with the U.S. Centers for Disease Control and Prevention (CDC) guidelines; d) single-use gowns were doffed in accordance with U.S. CDC guidelines; e) the appropriate transmission-based precaution signs were posted outside rooms/cohort areas for residents under investigation for COVID-19; and, f) access to a handwashing station or alcohol-based hand gel upon exit of the COVID-19 positive cohort unit. This deficient practice was identified on 2 of 3 units/cohort groups (Levin 1/COVID-19 positive and Goldfarb 1/persons under investigation unit) during the COVID-19 focused infection control survey conducted on 12/18/20. The evidence was as follows: 1. According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 7/15/20, included guidelines for collection of diagnostic respiratory specimens. It included, When collecting diagnostic respiratory specimens (e.g., nasopharyngeal or nasal swab) the following should occur: HCP (Healthcare Personnel) in the room should wear an N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown. Further, according to the manufacturer instructions for the (brand redacted) COVID-19 Ag Card for rapid [MEDICATION NAME] testing for COVID-19 revised 12/2/20 included instructions to Wear appropriate personal protective equipment and gloves when running each test and handling patient specimens. It further indicated that All operators using your product must be appropriately trained in performing and interpreting the results of your product, use appropriate personal protective equipment when handling this kit, and use your product in accordance with the authorized labeling. On 12/18/20 at 8:30 AM, two surveyors entered the facility through the main entrance. After performing hand hygiene, the Receptionist obtained a temperature check for COVID-19 and a screening for other signs and symptoms of COVID-19. The Receptionist then cleared the surveyors to enter the conference room for rapid [MEDICATION NAME] testing for COVID-19. At 8:40 AM, a Licensed Practical Nurse /Charge Nurse (LPN/C) entered the conference room wearing a blue single-use surgical mask. The LPN/C stated that she would perform the rapid [MEDICATION NAME] testing for the surveyors, and she prepared the rapid testing cards. The LPN/C did not don a gown, eye protection, or a respirator mask. The LPN/C donned a pair of gloves, and while wearing her surgical mask, she tested the first surveyor using a nasal swab, placed it on the testing card for reading, and set a timer for 15 minutes. She then doffed her gloves, performed hand hygiene with an alcohol-based hand gel (ABHG), and donned a new pair of gloves for testing the second surveyor. At 8:45 AM, the LPN/C tested the second surveyor using a nasal swab, and the LPN/C was only wearing a surgical mask and gloves as a form of personal protective equipment (PPE) during the COVID-19 testing. At approximately 9:00 AM, the surveyors interviewed the LPN/C, who confirmed she was only wearing the surgical mask and gloves during the COVID-19 testing for the surveyors. She acknowledged that when testing for COVID-19, it was appropriate to wear full PPE, including eye protection, a gown, and a respirator mask to protect herself in the event of an asymptomatic positive result. At 10:25 AM, the surveyors interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP), who confirmed the facility followed U.S. CDC guidelines for COVID-19 infection prevention and control. She stated that when conducting COVID-19 tests for either residents or staff, full PPE should be worn, including eye protection (face shield or goggles), a respirator mask, and a gown. She stated that full PPE was always worn when testing residents and staff but couldn't speak to why the LPN/C did not wear it during COVID-19 testing with the surveyors. The surveyor reviewed the facility's Outbreak Response Plan revised 5/19/20, which included the COVID-19 testing plan and procedures, their Testing Policy revised 10/2020, and COVID-19 Cohort and PPE policy updated 7/2020. The policies provided did not address the necessary PPE to be used and worn by the staff responsible for performing COVID-19 testing for residents, staff, contractors, volunteers, or visitors. At approximately 3:00 PM, the surveyors reviewed the findings with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the ADON/IP; No additional information was provided. 2. According to the U.S. CDC guidelines, Responding to Coronavirus (COVID-19) in Nursing Homes updated 4/30/20 included, Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. All recommended COVID-19 PPE (personal protective equipment) should be worn during care of residents under observation, which includes the use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Further, according to the U.S. CDC guidelines, Preparing for COVID-19 in Nursing Homes, updated 11/20/20, included If extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility, and these residents are not known to have any co-infections (e.g., Clostridioides difficle (infectious diarrhea)). On 12/18/20 at 9:15 AM, two surveyors interviewed the ADON/IP, who stated that the facility currently had an outbreak of COVID-19. There were three residents with current active COVID-19 infections residing on the COVID-19 positive cohort unit located on Levin 1. She stated that one of the three residents was transferred to the facility COVID-19 positive. The surveyor inquired if the facility had any residents under investigation for COVID-19. The ADON/IP stated that there were no residents under investigation for COVID-19 because the facility performed daily COVID-19 testing for residents and all staff. She said that because of the facility-wide daily testing, the facility had a new admission cohort in which newly admitted residents are on transmission-based precautions for 14 days. She stated that the newly admitted residents were tested in the hospital as negative for COVID-19, then upon admission to the facility, they are tested again for COVID-19. The surveyor asked what PPE staff were to be wearing when in the Cohort/new admission cohort area on Goldfarb 1, and the ADON/IP continued that staff wears a long-sleeve gown, gloves, and an N95 respirator mask. She stated that eye protection if needed could be worn if providing wound care. She continued that some staff have safety goggles if they do wound care. The surveyor requested clarification regarding what form of transmission-based precautions the facility used for the Cohort/new admission residents. The ADON/IP stated further that, We don't use droplet precautions unless there are symptoms because the facility was conducting daily COVID-19 testing. She added that because the newly admitted residents are not experiencing symptoms, the PPE use for that unit was just cautionary. The ADON/IP stated that in the Cohort/new admission area on Goldfarb 1 (G1), Certified Nursing Aides (CNA's) must don (put on) and doff (take off) PPE between caring for each individual resident and that the licensed Nurses could continuously wear the same gown between each newly admitted resident, unless it was visibly soiled or if they were going into a resident room where the resident had a co-infection such as infectious diarrhea. She stated that the CNA's had to switch out their PPE between every resident room because they provide more intimate care than the nurses do. She said that because of this practice, the surveyors should be seeing licensed nurses wearing long-sleeve gowns in the hallways of G1, and meanwhile, CNA's would have to doff the PPE before exiting the resident rooms. The ADON/IP stated that the new admissions were not considered persons under investigation (PUI) for COVID-19 because the residents were monitored for signs and symptoms of COVID-19 every four hours and due to the facility's frequent testing strategies. She stated that COVID-19 Polymerase Chain Reaction (PCR) tests (a diagnostic test that determines if an individual is infected with [MEDICAL CONDITION] by analyzing a sample to see if it contains genetic material) and results would take between 24-48 hours before they were posted for the facility to view. At 10:55 AM, the surveyor toured the PPE inventory/ stockpile with the Licensed Nursing Home Administrator (LNHA), which included multiple large boxes of new face shields and goggles available for use. At 11:20 AM, the surveyor toured Goldfarb 1, the Cohort/new admission hallways designated for 14-day observation. The surveyor observed three hallways that had newly admitted residents in the last 14 days. In front of the entrance to each of three hallways was a small cabinet stacked with washable long-sleeve gowns and disposable long-sleeve gowns. Adjacent to the gown cabinet was another storage bin with gloves and disinfectant wipes. Alongside the PPE storage bins was a covered stepper can marked for used washable gowns stored in the hallways. There were signs posted upon entry to the unit from the U.S. CDC that indicated Stop and Contact Precautions. The sign indicated to Put on gloves before room entry. Put on gown before room entry. Discard gloves before room exit. Discard gown before room exit. In red led letters, it specified, Do not wear the same gown and gloves for the care of more than one person. There were no postings on the unit for droplet or otherwise airborne precautions and the need to wear eye protection and a respirator mask upon entering a resident room. There were no transmission-based precaution signs posted on any of the resident rooms except three resident rooms that also specified Contact Precautions. At 11:20 AM, the surveyor observed a Certified Nursing Aide (CNA #1) inside the room of Resident # 1 inside the Cohort/new admission unit. The door was opened, and CNA #1 was wearing a respirator mask and gloves, squatting and positioned at the level of the bed emptying urine into a urinal from a large drainage bag. Resident #1 was observed to be in bed with his/her eyes closed. CNA #1 was not wearing a gown or eye protection (i.e., face shield/goggles) inside the resident's room. The surveyor observed CNA #1 empty the filled urinal into the toilet and stored the urinal. He then removed his gloves and discarded them in a small trash can at the resident's room's exit. CNA #1 then exited the room without performing hand hygiene. At that time, CNA #1 stated to the surveyor that he was supposed to be wearing a gown and a face shield while in the resident's room, adding that I forgot. The CNA #1 subsequently walked over to the PPE storage bin at the front end of the hallway and donned a new gown and his face shield without performing hand hygiene. At approximately 11:25 AM, the surveyor interviewed CNA #1, who stated that he worked at the facility for approximately six months. He added that he had been in-serviced to wear a gown, face shield, a respirator mask, and gloves when inside the resident rooms on his assignment, including the private room of Resident #1. He stated that Resident #1 had an indwelling urinary catheter that he was emptying when the surveyor observed him. He continued that the resident was on transmission-based precautions because he/she was newly admitted to the facility less than 14 days and had tested negative for COVID-19. CNA #1 noted that the resident was showing no signs or symptoms of [MEDICAL CONDITION]. CNA #1 stated that he believed that he was allowed to share gowns between residents but that the face shield had to be disinfected with a disinfectant wipe after use. He acknowledged that a face shield was used to protect his eyes from splashes, including via the spontaneous coughing or sneezing of a resident. The surveyor asked CNA #1 about hand hygiene and when that gets performed, and the CNA #1 replied that it was supposed to be done between contact with every resident and after removing gloves or other PPE. The surveyor asked if he had performed hand hygiene after emptying the urine from the drainage bag and before applying his new gown and face shield. CNA #1 acknowledged he had not yet done it. At that time, the surveyor observed CNA #1 access an ABHG pump from the top of the PPE storage bin in the hallway and performed hand hygiene. After the interview, the surveyor observed the CNA #1 walk over to an unsampled resident in the Cohort/new admission unit wearing the respirator mask, gown, and face shield and propelled him/her in a wheelchair to their private room. At 11:35 AM, the surveyor attempted to interview Resident #1 in his/her room, but the resident could not be interviewed. A review of the Face Sheet (an admission summary) for Resident #1 reflected that the resident was admitted to the facility on [DATE]. A review of a COVID-19 PCR test conducted on 12/9/20 reflected that the resident was negative for COVID-19, and a follow-up COVID-19 PCR test conducted on 12/15/20 reflected that the results were still pending. At approximately 11:40 AM, the surveyor observed two Certified Nursing Aides (CNA #2 and CNA #3) exit the room of an unsampled resident on the Cohort/new admission unit. Both CNA's were wearing washable gowns, gloves, face shields, and N95 respirator masks. The surveyor observed the CNA's exit, the resident room and doff their gown, and face shields in the hallway. The CNAs opened the clean gown cabinet in the hallway and removed an alcohol-based hand wipe with 62% alcohol, and began rubbing their hands with it. They then disinfected their face shields with an EPA (Environmental Protection Agency)-registered disinfectant wipe and waited for it to dry. At that time, the surveyor interviewed the CNA's. CNA #2 stated that she had to doff her PPE (gown, gloves, and face shield) between every resident room and that she doffed it in the entrance of the hallway where the PPE changing station was located. She stated that CNA's were not allowed to share gowns between residents in the new admission cohort area but couldn't speak to what nurses had to do. She stated that she was trained to wear a face shield to protect her eyes and face from the droplets associated with COVID-19. She added that the residents were tested for COVID-19 and tested negative, but she still wore the PPE as a protective measure. At 12:00 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who was assigned the Cohort/new admission area. LPN #1 stated that she had an orientee with her, LPN #2, who was learning from her. The surveyor asked LPN #1 about the Contact Precautions sign outside the Cohort/new admission area. The LPN stated that the signs were just used as a reminder that these residents were on transmission-based precautions because they are new admissions. She said that only one resident on the unit had a co-infection (C.Diff/infectious diarrhea), requiring contact precautions. She stated that she had to wear a gown from room to room because all the residents were newly admitted in the last 14 days, and it was to prevent any spread of COVID-19. The surveyor asked how COVID-19 was spread, and she stated that it could be spread through contact and droplet. The surveyor asked what PPE was to be worn for Droplet Precautions, and she said that she had to wear an N95 respirator mask, a gown, and gloves at this facility. She stated that a face shield or eye protection was not necessary if the eyeglasses were worn. The surveyor asked the LPN #1 about the Contact Precautions signs posted on the entrance to the Cohort/new admission unit, and why it was not specified as Droplet Precautions if the staff had to also wear an N95, and the LPN #1 stated that it was just used as a reminder. She acknowledged that the signs did not indicate the need for a face shield or eye protection and noted that eye protection was optional because the unit's residents had tested negative for COVID-19. LPN #1 acknowledged that the CNA's should at least be wearing a gown when in the resident room, and that CNA's are to change the gown between each resident room, but that the nurses can move throughout the unit and wear the same gown between caring for the different residents, except the resident who had infectious diarrhea, which required a new gown to be used and discarded aftercare. She stated that hand hygiene was to be done after doffing PPE and between contact with residents using soap and water or an ABHG located throughout the units and at the PPE storage bins. At 12:20 PM, the surveyor interviewed the ADON/IP, who confirmed the Contact Precautions signs were in place to act as a reminder for staff to know to wear a gown and gloves. She stated, they don't need to be on droplet precautions, and it stems from a place of dignity and rights for the residents. The surveyor discussed the U.S. CDC guidelines on COVID-19 in Nursing Homes with the ADON/IP. At 3:00 PM, the surveyor interviewed the ADON/IP, who acknowledged that CNA #1 should have performed hand hygiene immediately after removing the gloves and before donning the new clean PPE. The ADON/IP confirmed that the facility was to be using Droplet Precautions for the newly admitted residents. Furthermore, the signage for Contact Precautions did not address the need to wear the respirator mask and eye protection. The ADON/IP also acknowledged the CDC guidelines regarding PPE use for newly admitted residents in the last 14 days and regarding doffing PPE before exiting the resident room and not in the hallways. A review of an in-service record for Hand Hygiene and competency dated 11/6/20 reflected that all facility staff had been trained on proper hand hygiene with a hand hygiene competency evaluation. A review of the Handwashing policy effective 1/2019 included, All employees shall wash their hands with soap and water for 20 seconds or use other effective hand sanitation techniques before and after contact with residents, before and after performing any procedure, and after using the toilet. A review of the facility's Droplet Precautions policy effective 2019 included to Use droplet precautions for residents known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a resident who is coughing, sneezing or talking. The policy included that staff should Use personal protective equipment appropriately. Don mask upon entry into the resident room or space. The policy did not specifically address the use of eye protection (i.e face shield or goggles.) A review of the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers about Hand Hygiene and COVID-19, updated 5/17/2020 included, CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. 3. On 12/18/20 at approximately 11:40 AM, the surveyor observed a Licensed Practical Nurse (LPN #1) exit a resident room in the middle-3 hallway of the Cohort/new admission area wearing a respirator mask and a washable long-sleeve gown. She was wearing standard eyeglasses without protective features, goggles, or a face shield. She was returned to the medication cart with her orientee (LPN #2), who was also wearing a washable long-sleeve gown, and he was observed to be wearing proper eye protection/goggles. The surveyor observed LPN #1 store the medication cart in the hallway. While wearing the PPE, LPN #1 and LPN #2 proceeded to walk down the hallway of residents admitted for longer than 14 days, which were considered non-ill, non-exposed to COVID-19 cohort. The LPN #1 obtained keys for a treatment cart and proceeded down the very end of the hallway where the parked treatment cart was positioned. She then accessed the treatment cart designated for the non-ill, non-exposed cohort. While wearing the same PPE, she opened two drawers from the treatment cart to obtain items, including 4x4 wound dressings supplies. The LPN #1 and #2 then proceeded to walk back down the non-ill, non-exposed cohort hallway. LPN #1 stated that she was going to do a treatment for [REDACTED]. The surveyor then observed the two LPN's enter the room of Resident #4. The LPN's were wearing the same PPE between the resident rooms, and LPN #1 did not don appropriate eye protection in accordance with U.S. CDC guidelines. At 12:00 PM, the surveyor observed the LPN #1 and LPN #2 doff their PPE in the (1136-1148) Cohort/new admission area at the cohort entrance hallway and proceeded to go to the nourishment room to perform hand hygiene at the sink. The surveyor interviewed the LPN #1 who was assigned the Cohort/new admission area and stated that she was allowed to share gowns between residents that were newly admitted to the facility in the Cohort unit, but that the CNA's could not share gowns because they provided care that was closer in contact, than the nurses. She stated that staff did not have to wear face shields or eye protection if they wore eyeglasses because eyeglasses would protect the eyes from any droplets. LPN #2 stated that he wore the eye protection/goggles at work to protect his eyes from pathogens due to the COVID-19 pandemic. At 3:00 PM, the surveyor interviewed the ADON/IP in the presence of a second surveyor, regarding the eye protection for staff and the wearing of the same gowns between the Cohort/new admission area and the LPN's walking down the non-ill, non-exposed hallways in the same gowns. The ADON/IP acknowledged that the LPN's should have obtained the supplies from the clean utility room and should have doffed their PPE, perform hand hygiene then access the area. According to the U.S. CDC guidelines for the National Institute for Occupational Safety and Health (NIOSH) for Eye Safety in Infection Control, reviewed 7/23/13 included, Workers should understand that regular prescription eyeglasses and contact lenses are not considered eye protection. It further had, Eye protection provides a barrier to infectious materials entering the eye and is often used in conjunction with other personal protective equipment (PPE) such as gloves, gowns, masks or respirators. 4. On 12/18/20 at approximately 12:35 PM, the surveyor walked to the Levin 1 unit/COVID-19 Positive cohort unit. Upon approaching the COVID-19 positive unit, the surveyor observed closed double doors, and there was no ABHG accessible upon entry to the unit. There was no sign to indicate that the Levin 1 (L1) unit was the COVID-19 positive unit and what precautions or PPE was necessary to enter. The surveyor opened the double doors and observed a PPE changing station/vestibule area separated by a plastic barrier. The surveyor observed a large trash can with a lid that can be accessed by stepping on a pedal full of used PPE, including hazmat-type gowns and a face shield. There was also a storage cart with wheels with PPE supplies, including face shields/goggles, surgical masks, gloves, shoe protectors, and disinfectant wipes. There was no alcohol-based hand gel located in the PPE changing area. The surveyor used her own ABHG and donned full PPE. A Certified Nursing Aide (CNA #4) was wearing full PPE, and he informed the surveyor that a gown, gloves, eye protection, and an N95 mask were needed to enter L1. The surveyor and CNA #4 accessed the COVID-19 unit and walked down the long-vacant hallway perpendicular to the hallway where the three residents who tested positive for COVID-19 resided. The surveyor observed several ABHG wall dispensers secured to the wall in the long-vacant hallway; There was no ABHG solution in the observed dispensers for the entire hallway. The surveyor observed ABHG pumps at the nurses' station on the COVID-19 positive unit. At 12:40 PM, the surveyor interviewed CNA #4 regarding the lack of ABHG leading into the COVID-19 unit and in the PPE changing area. CNA #4 stated that he does not leave the unit from where the surveyor entered. CNA #4 said when he leaves the unit, he exits through a door that leads to the outside, and so, he stated he would not have known that there was no ABHG in the area. He confirmed there were no ABHG solutions pre-filled on the wall dispensers leading up to the perpendicular COVID-19 hallway either. Then CNA #4 stated that he thought there was a hand sink in one of the vacant rooms leading up to the COVID-19 hallway; CNA #4 looked at the rooms adjacent to the changing area, and the doors were secured closed. CNA #4 acknowledged that if staff had to re-enter the COVID-19 area after doffing PPE to perform hand hygiene, it could pose a risk of transmission. He confirmed that ABHG should be located in the PPE changing area. At 12:45 PM, the surveyor interviewed the LPN/C, who stated that there was plenty of ABHG at the nurses' station and a pump in each resident room. The surveyor asked if there was ABHG in the PPE changing area of the COVID-19 unit at any point today, and she stated that she thought there was some, but someone must have taken it. The LPN/C confirmed there was no ABHG where PPE was donned and doffed for the COVID-19 positive unit. She confirmed that the trash can was filled with used PPE, which indicated that staff had used that area to remove PPE and exit to the lobby area. She was unable to speak further to the accessibility of ABHG for donning and doffing PPE within the PPE changing area. At approximately 12:55 PM, the surveyor doffed her PPE in the PPE changing area, used her own ABHG to perform hand hygiene, and exited the COVID-19 unit. At 3:00 PM, the surveyor interviewed the ADON/IP, who confirmed that an ABHG pump should be accessible within the PPE changing area of the COVID-19 unit so that staff can do appropriate hand hygiene. A review of the facility's COVID-19 Cohort and PPE policy updated 7/2020 included procedures for the COVID-19 positive cohort, including that PPE is stored in the side entrance vestibule. Still, it did not address the accessibility of ABHG in the PPE changing area or throughout the COVID-19 positive cohort unit. According to the U.S. CDC guidelines, Preparing for COVID-19 in Nursing Homes, updated 11/20/20, included, Put alcohol-based hand sanitizer with 60-95% alcohol in every resident room (ideally both inside and outside of the room) and other resident care and common areas (e.g., outside dining hall, in therapy gym). Unless hands are visibly soiled, an alcohol-based hand sanitizer is preferred over soap and water in most clinical situations. NJAC 8:39-19.4 (a)

Based on observation, interview, and record review, it was determined that the facility failed to: a.) accurately account for and administer an anti-anxiety medication in accordance with a physician's order; b.) waste a controlled drug in accordance with accepted standards of practice, c.) obtain a lab in accordance with physician's order for the therapeutic management of an anticoagulant, and d.) accurately account for and document for a dosage of an anticoagulant medication, [MEDICATION(S)]. This deficient practice was identified for 3 of 15 residents reviewed for medication management (Resident #189, #298, and #303). The evidence was as follows: 1. On [DATE] at 12:10 PM, the surveyor observed Resident #189 seated in a wheelchair by the nurse's station. The resident was asking the Licensed Practical Nurse/Unit Manager (LPN/UM) where he/she was and why he/she was here. The surveyor attempted to interview the resident but the resident was unable to respond appropriately to the surveyor. The surveyor reviewed the medical record for Resident #189. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included restlessness and agitation, major depressive disorder, dementia, altered mental status, and anxiety disorder. A review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 4 out of 15, which indicated severely impaired cognition. A further review of the MDS, indicated that the resident received [CONDITION(S)] medications on 7 out of the last 7 days during the look-back period. A review of the resident's individualized, comprehensive care plan dated [DATE], reflected a care concern that the resident had inappropriate behaviors which included agitation, wanting to go home, pacing to the point of exhaustion, and asking staff what he/she was still doing here? Interventions included to provide non-pharmacological interventions; to redirect the resident; to use calm slow approaches; to assess personal needs; to monitor and document behaviors; and to administer medications as ordered. A review of the Physician Order (PO) reflected an order dated [DATE] for [MEDICATION(S)] (a controlled drug used to manage anxiety) 0.25 milligram (mg) tablet. The order specified to administer one tablet by mouth daily at bedtime for anxiety. A review of the electronic Medication Administration Record (eMAR) for [DATE] was signed to reflect that on [DATE] the resident refused the [MEDICATION(S)] 0.25 mg. A review of the Individual Patient Controlled Substance Administration Record (CDAR) for [MEDICATION(S)] 0.25 mg tablets was dated as having received 30 tablets on [DATE]. The CDAR reflected that the 30th tablet was signed out of inventory on [DATE] at 9:00 PM by LPN #1. There was no evidence the dose was wasted by another nurse. A review of another CDAR for [MEDICATION(S)] 0.25 mg tablets was dated as having received 14 tablets on [DATE] for Resident #189 reflected that another tablet (#13) was signed out of inventory on the same day on [DATE] at 9:50 PM by LPN #1. There was no evidence the dose was wasted by another nurse. A review of the electronic Nurses Notes (eNN) reflected that the resident was hospitalized from [DATE] to [DATE]. On [DATE] at 10:32 PM, an eNN written by the Registered Nurse /Supervisor (RN/S) indicated that the resident was readmitted to the facility that evening. That LPN #1 reported that the resident had a combative episode with the nurse and the Certified Nursing Aide #1 (CNA). A call was placed to the resident's Physician who ordered a one time dose of an [MEDICATION(S)] gel (anti-anxiety medication) 0.5 mg, which was subsequently administered to the resident by LPN #1. A further review of the eNN included a note dated [DATE] at 12:12 AM written by LPN #1 which indicated that on [DATE] the resident refused to stay in bed and became combative with CNA #1. The resident refused all medications and the LPN #1 informed the RN/S. The note included that the RN/S called the Physician who ordered the one time dose of [MEDICATION(S)] 0.5 mg gel which was administered to the resident. A review of the [DATE] eMAR reflected that the resident received [MEDICATION(S)] gel 0.5 mg on [DATE] at 10:03 PM. The nursing notes written by both the RN/S and the LPN #1 for [DATE] did not specify where the [MEDICATION(S)] gel dose was obtained from on [DATE] as the resident did not have [MEDICATION(S)] gel in current stock/inventory and there was no CDAR for the [MEDICATION(S)] gel. A review of the back-up Narcotic Stock List reflected that the system had not contained a back-up supply of [MEDICATION(S)] gel. On [DATE] at 11:41 AM, the surveyor conducted a phone interview with the LPN #1. The LPN stated that she worked the 3:00 PM to 11:00 PM shift, and that Resident #189 was one of her residents. The LPN stated that the resident had behaviors that included verbalizations to go home and wandering around the unit. The LPN continued that on [DATE], CNA #1 reported to her that the resident was aggressive with him and scratched him. The LPN informed the RN/S who called the Physician and the Physician ordered [MEDICATION(S)]. The LPN #1 could not recall if the Physician had ordered [MEDICATION(S)] gel or a tablet, and for that reason, could not speak to where the dose came from. On [DATE] at 9:44 AM, the surveyor attempted to conduct a phone interview with the RN/S, who did not return the surveyor's call. At 10:30 AM, the surveyor interviewed the Registered Nurse/Charge Nurse (RN/CN) who stated that when a physician ordered a one time dose of medication, the nurse entered the order into the computer and faxed the order to the pharmacy. If the medication was in the facility's electronic backup stock, the nurse obtained the medication from the system and documented the removal of the medication from the machine. The RN/CN informed the surveyor that if a controlled drug was signed out of inventory by a nurse, but the resident refused to take the medication, the medication was wasted (process of disposing medications). The RN/CN stated that one nurse would disposed of the medication and it would be witnessed by another licensed nurse. After it was witnessed as wasted, they both would signed the CDAR sheet next to that medication writing the word wasted next to it. If medication was discontinued, two nurses wasted the remaining inventory of the medication, then signed the CDAR indicating the medication was discontinued and wasted accordingly. The original drug control sheet was placed in the resident's chart, and a copy of the sheet was given to the Director of Nursing (DON). The RN/CN stated that she was unfamiliar with Resident #189 since he/she no longer resided on the unit. She further stated that the resident's regular medication nurse was out on leave. At 10:41 AM, the surveyor observed the [NAME] 2 unit's controlled drug record book with LPN #2. The surveyor reviewed a controlled drug sheet for 30 tablets of [MEDICATION(S)] 1 mg dated as received on [DATE]. The record indicated that on [DATE] at 4:34 PM, one tablet of [MEDICATION(S)] 1 mg was wasted by two nurses. The sheet further reflected that [MEDICATION(S)] 1 mg was removed from active inventory on [DATE], [DATE], and [DATE] for administration to Resident #189. At 11:03 AM, the surveyor was informed by the Unit Manager (UM) of [NAME] 1 that the backup medication machine had not contained [MEDICATION(S)] gel, since the medication required refrigeration for proper storage. At 11:23 AM, the surveyor interviewed the DON in the presence of the Licensed Nursing Home Administrator (LNHA). The DON stated that the controlled drug sheet was kept on the resident's chart and that he kept a copy of the controlled drug sheet in his binder once the medication was discontinued. The surveyor requested a copy of the CDAR for the [MEDICATION(S)] gel. The DON continued that if a controlled drug was refused by a resident after the drug was signed out of inventory, then the drug was wasted. Two nurses destroyed the medication in the drug buster and then both nurses signed on the controlled drug sheet that the medication was wasted. The surveyor reviewed the two controlled drug sheets for [MEDICATION(S)] 0.25 mg where two [MEDICATION(S)] tablets were removed from inventory on [DATE]. The DON stated he would look into that. The surveyor continued to review the medical record for an order for as needed (PRN) [MEDICATION(S)] tablets. A review of the Physicians Orders reflected a PO dated [DATE] for [MEDICATION(S)] 1 mg tablet administered by mouth every eight hours PRN for restlessness and anxiety. This PO was discontinued on [DATE]. A review of the [DATE] eMAR reflected that the resident had no order for [MEDICATION(S)] 1 mg tablet after [DATE]. A review of the [DATE] eMAR, reflected that [MEDICATION(S)] 1 mg was reordered on [DATE] for [MEDICATION(S)] 1 mg tablet administered every eight hours PRN for agitation until [DATE]. On [DATE] at 12:37 PM, the surveyor conducted a phone interview with the facility's Consultant Pharmacist (CP). The CP stated that any medication that was discontinued would be removed from active inventory and disposed of in accordance with the facility's policy. He added that medication that was discontinued should not be used to administer to the resident. At 1:02 PM, the surveyor interviewed the Registered Pharmacist from the facility's pharmacy provider who stated that [MEDICATION(S)] gel was not supplied in the back-up medication machine. The pharmacy would deliver the medication, including a facility's emergency order. On [DATE] at 10:59 AM, the surveyor interviewed the LPN/UM stated that when medication was discontinued it would be taken from inventory and placed in a box to return to the pharmacy. If the medication was a controlled drug two nurses had to waste the drug in the drug buster sign in the CDAR that the drug was wasted. The controlled drug sheet was placed in the resident's chart and the DON received a copy of the sheet. The LPN/UM stated that discontinued medication would not be used. At 1:26 PM, the LNHA in the presence of the DON and the survey team, stated that the two [MEDICATION(S)] 0.25 mg tablets removed from inventory on [DATE] were both refused by the resident and wasted. The medication was wasted by LPN #1 and the RN/S, who both had not signed that the medication was wasted on the controlled drug sheet. The LNHA stated that the facility was crazy that night so the nurses forgot to sign for the wasting of the medication. The LNHA continued that he spoke with the RN/S who informed him that the [MEDICATION(S)] gel administered on [DATE] was taken from Resident #303's [MEDICATION(S)] gel supply. The LNHA stated that it was not protocol to borrow medication from another resident, but in the nurse's mind, she felt that she was doing the right thing. The facility received emergency medication from the pharmacy, but the medication would take a few hours to arrive at the facility. On [DATE] at approximately 12:40 PM, the LNHA in the presence of the DON and survey team stated that he could not speak to why the [MEDICATION(S)] 1 mg tablets delivered on [DATE] were not removed from active inventory when the PO was discontinued on [DATE]. The LNHA stated that the facility did not keep medication once it was discontinued. The LNHA acknowledged the facility had an issue with the accounting of controlled drugs and that he would have to further investigate what happened. A review of the facility's Managing Controlled Substances updated 2019 included discontinued controlled medications will be collected and sent to the DON office and follow facility practices. Discontinued controlled medications will be destroyed by two nurses and disposed of in the drug buster receptacle. The policy also included the DON or designee will monitor weekly destruction of controlled medications and audit weekly all declining inventory. 2. On [DATE] at 1:46 PM, the LNHA in the presence of the DON and the survey team stated that on [DATE], Resident #189 received [MEDICATION(S)] gel 0.5 mg from the supply of Resident #303, who has since expired. The LNHA stated that at the time the [MEDICATION(S)] gel was borrowed from Resident #303 to administer to Resident #189, Resident #303 was still an active resident in the building. The LNHA provided the surveyor a copy of the CDAR for Resident #303 which revealed the following: A review of the CDAR for [MEDICATION(S)] 0.5 mg per 1 milliliter (mL) dated as received [DATE], indicated that on [DATE] [MEDICATION(S)] gel syringe #26 was wasted. On the back of the controlled drug sheet was a note which indicted syringe #26 was administered to Resident #189. (There was no evidence written within the CDAR that indicated how a wasted medication was also able to be administered to Resident #189). The surveyor continued to review the medical record for Resident #303. A review of the Face Sheet reflected that the resident was admitted to the facility with diagnoses which included anxiety disorder, dementia, depressive disorder, and mood disorder. A review of the most recent quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 5 out of 15 which indicated a severely impaired cognition. A review of the resident's individualized, comprehensive care plan included a concern dated [DATE] for end stage Alzheimer's disease with interventions that included to promote psychosocial spiritual comfort; to provide hospice services; and to apply [MEDICATION(S)] gel for anxiety. The care plan included that the resident was also on hospice end of life services. A review of the eMAR for [DATE] indicated a PO dated [DATE] for [MEDICATION(S)] gel 0.5 mg. The order specified to apply two applications [syringes] topically to equal 1 mg of [MEDICATION(S)] at 6:00 AM, 2:00 PM, and 10:00 PM. The eMAR was signed to reflect that nine routine doses were administered from [DATE] at 2:00 PM until [DATE] at 6:00 AM, for a total of 1 mg of [MEDICATION(S)] (2 syringes) each shift. A review of the corresponding CDAR for the [MEDICATION(S)] gel 0.5 mg revealed that only one syringe (0.5 mg instead of 1 mg) was signed as removed from inventory on [DATE] at 10:00 PM, [DATE] at 3 AM (removed from inventory ,d+[DATE] hours before the dose was due), [DATE] at 6:00 AM and 2:00 PM, and [DATE] at 6:00 AM. A review of the eNN from [DATE] through [DATE] did not reflect documented evidence as to why only 0.5 mg was removed from inventory and administered. The eNN also had did not reflect documented evidence as to why the [MEDICATION(S)] gel was removed from inventory at 3:00 AM on [DATE], three hours early when the PO was timed to be administered for 6:00 AM. There was no documented evidence within the eNN that the resident exhibited increased anxiety or agitation during this time in which only one [MEDICATION(S)] gel (0.5 mg) removed from inventory when two [MEDICATION(S)] gels (1 mg) were ordered to be administered. A further review of the [DATE] eMAR reflected a PO dated [DATE] for a different concentration of [MEDICATION(S)] gel, 0.5 mg/0.5 mL (instead of 0.5 mg/1 mL) to apply topically at 6:00 AM, 2:00 PM, and 10:00 PM. The order specified that 1 mL equaled 1 mg. The eMAR was signed to reflect that the resident had received the [MEDICATION(S)] 0.5 mg/0.5 mL for a total of seven routine doses from [DATE] at 2:00 PM until the PO was discontinued on [DATE] at 2:00 PM. However, a review of the corresponding CDAR revealed that the nurses signed out of inventory an [MEDICATION(S)] gel 0.5 mg/1 mL which was a differing concentration than what was ordered by the physician. There was no evidence that the facility had [MEDICATION(S)] gel 0.5 mg/0.5 mL in active inventory. The CDAR reflected that the nurses removed one gel of 0.5 mg/1 mL from inventory on those dates. (This reflected that the resident only got 0.5 mg instead of 1 mg in accordance with the physician order.) A review of the eNN from [DATE] through [DATE] did not reflect documented evidence as to why the resident was receiving a differing dose than what was ordered by the physician. The eNN reflected that the resident did not exhibit increased target behaviors or an adverse outcome from receiving the inadequate dose of [MEDICATION(S)] gel. A review of the Hospice Symptom Management Recommendation dated [DATE] indicated a new recommendation to increase the frequency of the [MEDICATION(S)] gel. The recommendation included, [MEDICATION(S)] gel 1 mg to be administered every six hours for restlessness and agitation. A review of the [DATE] eMAR reflected a PO dated [DATE] to administer [MEDICATION(S)] gel 1 mg four times a day to be applied topically at 12:00 AM, 6 :00 AM, 12:00 PM, and 6:00 PM. The eMAR reflected that the resident was administered 13 doses from [DATE] at 6 PM through [DATE] at 6 PM without refusals. A review of CDAR for [MEDICATION(S)] gel 0.5 mg/1 mL dated as received on [DATE], indicated that on [DATE] at 6:00 AM, only one 0.5 mg syringe of [MEDICATION(S)] gel was signed out of inventory instead of 1 mg. There was no evidence from the CDAR that [MEDICATION(S)] gels were removed from inventory to correspond with the dose signed as administered on [DATE] at 12:00 AM. A review of the controlled drug sheet for [MEDICATION(S)] gel 1 mg/1 mL dated received on [DATE], indicated that on [DATE] at 6:00 AM, no [MEDICATION(S)] gel was removed from inventory to correspond with the dose signed as administered on [DATE] at 6 AM. A review of the eNN from [DATE] through [DATE], provided no additional information regarding the [MEDICATION(S)] gel dosage and administration. There was no documented evidence that the resident exhibited increased target behaviors or an adverse outcome as a result of the incorrect dosages administered. On [DATE] at 2:13 PM, the surveyor informed the LNHA and the DON in the presence of the survey team the concerns regarding the dosage of [MEDICATION(S)] gel that the resident received. The LNHA and DON were unable to speak to or provide documented evidence as to why there were discrepancies for the accountability of the [MEDICATION(S)] gel for Resident #303, and when there was [MEDICATION(S)] gel available for administration to Resident #303. At this time, the LNHA acknowledged that the facility needed to look into how controlled drugs were being given and wasted. He acknowledged narcotics get signed as wasted after the medication was witnessed as wasted. He confirmed if staff were following that standard of practice, there couldn't be a way for a medication to be signed as wasted, but yet also be available for administration to another resident for sharing purposes. He was unable to speak to how that could happen for the [MEDICATION(S)] gel removed from Resident #303's inventory to administer to Resident #189 on [DATE]. The LNHA acknowledged the surveyors findings. A review of the facility's Medication Administration policy updated 2019, included to administer medications as ordered. 3. On [DATE] at 11:50 AM, the surveyor observed Resident #298 sitting on the seat of a rollator in his/her room. The resident agreed to be interviewed by the surveyor. At that time, the resident stated that he/she knows his/her medication regimen well and takes nine pills. The resident stated that the anticoagulant, [MEDICATION(S)], was not provided in the medicine cup, and the nurse told him/her it wasn't available. The surveyor asked the resident if the anticoagulant medication was ordered by the physician to be on hold during that time, and the resident indicated, not that he/she was aware of. The surveyor reviewed the medical record for Resident #298. A review of the Face Sheet reflected the resident was recently admitted to the facility with diagnoses which included, cerebral infarction (stroke) due to an unspecified occlusion or stenosis (hardening) of the bilateral vertebral arteries and [CONDITION(S)]. The surveyor attempted to review the admission MDS, but the resident was admitted to the facility less than 14 days. A review of the resident's Interdisciplinary Plan of Care dated [DATE] included that the resident was at risk for injury including bleeding related to the potential for bruising due to the use of an anticoagulant medication, [MEDICATION(S)]. Interventions included to review the medication regimen. The surveyor conducted a medication reconciliation for the anticoagulant medication [MEDICATION(S)]. A review of the lab Test Results, reflected the resident had an International Normalized Ratio (INR), (a blood test typically used to determine if one's coagulation is within therapeutic levels while on [MEDICATION(S)]), of 1.88. There was a note on the lab that specified the resident was to be given [MEDICATION(S)] 6 milligrams (mg), for three days and repeat an INR test on [DATE]. A review of the eMAR for [DATE] and [DATE] reflected a physician's order dated [DATE] for the [MEDICATION(S)] 6 mg by mouth daily at 6 PM. The eMAR's reflected that the resident was administered [MEDICATION(S)] 6 mg on [DATE], [DATE] and [DATE]. A review of the INR test results collected on [DATE], reflected that the resident had an elevated INR result of 4.3. A note on the lab indicated MD aware, Hold [MEDICATION(S)] ,d+[DATE] - ,d+[DATE]. Recheck PT/INR on ,d+[DATE] Saturday. The lab was signed on [DATE] at 4 PM. A review of the electronic Skilled Nurses Notes dated [DATE] at 11:55 PM reflected a note that resident was alert and oriented to person, place and time. The note included that labs came back for patient .INR, informed doctor, received orders to hold [MEDICATION(S)] for the next two days and redraw . INR on Saturday [DATE]. A review of the eMAR for [DATE] reflected that the [MEDICATION(S)] was held on ,d+[DATE] and ,d+[DATE] in accordance with the physician order. In addition, the eMAR reflected a physician's order (PO) dated [DATE] for INR blood work to be drawn tomorrow [DATE] in the morning. Please contact [Primary Physician's name redacted] with results to determine what dosage of [MEDICATION(S)] to give to patient tomorrow evening!! The eMAR was entered into the system as being plotted every day and every shift. The nurses were signing every shift on ,d+[DATE] at 9 PM, ,d+[DATE] at 5 AM, 1 PM and 9 PM that the labs were to be done on [DATE]. A review of the resident's lab blood tests, did not reflect evidence of an INR lab collected on [DATE] in accordance with the physician's order. A review of the facility's Daily Lab Log dated [DATE] did not reflect evidence of the name of Resident #298 for communication that lab was to be collected for the resident. A review of the lab receipt book did not reflect evidence of a lab receipt slip for [DATE] for Resident #298. A review of a Skilled Nurses Notes dated [DATE] and timed at 1:34 AM reflected that the nurse received an order from an unnamed physician for [MEDICATION(S)] 3 mg and draw a PT/INR tomorrow, the note included that medication administered as ordered. The Skilled Nursing Notes did not address the PT/INR labs ordered on [DATE] with evidence of results or why the results were unable to be obtained. The note did not include what physician ordered the [MEDICATION(S)] 3 mg or where the [MEDICATION(S)] 3 mg for administration was obtained. A review of the eMAR for [DATE] reflected a physician's order dated [DATE] for [MEDICATION(S)] 3 mg by mouth from [DATE] at 9 PM due to a cerebral infarction. The eMAR a blank space on [DATE] and an x at 9 PM on [DATE] indicating not addressed. There was no evidence within the eMAR for the accountability for the [MEDICATION(S)] 3 mg on [DATE]. On [DATE] at 10:31 AM, the surveyor interviewed the Unit Clerk. The Unit Clerk stated the facility had two lab companies, one that comes at 4 AM on weekdays, and the hospital-based lab company would be utilized for residents who had lab orders to be obtained on weekends. The surveyor inquired about her involvement in the process for lab orders. The Unit Clerk stated that all lab orders get written in a communication Log book, and a lab slip would be filled out by the nurse for what labs were to be obtained. She further added that all receipts for labs for the month were kept in a binder for lab receipts. The surveyor asked specifically about labs ordered on [DATE] for Resident #228. The Unit Clerk confirmed the resident's name was not in the communication log book for either lab companies, and there was no lab receipt in the book for Resident #298 on [DATE]. She reviewed the book to see if the receipt was filed in the wrong date, and the Unit Clerk was unable to locate a lab receipt dated [DATE]. The Unit Clerk printed out a lab dated as collected on ,d+[DATE] that had been scanned into the resident's electronic medical record. On [DATE] at 10:51 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated all PT/INR labs were performed by the lab company who sends a phlebotomist in the middle of the night. She confirmed PT/INR labs were done by a phlebotomist and were not done using a PT/INR monitoring device. The surveyor asked the LPN regarding labs ordered on [DATE] for Resident #298. The LPN reviewed the communication Log for the lab companies and the Lab receipt book and confirmed there was no evidence that the resident's name made it to the lab communication log and no evidence that a lab slip had been filed out for the resident dated [DATE]. The LPN was unable to show the surveyor evidence of lab results and/or evidence within the eMAR for accountability for the [MEDICATION(S)] 3 mg on [DATE]. She stated that residents on [MEDICATION(S)] get PT/INR labs tested regularly and the frequency of those tests vary between residents. She stated the surveyor would have to talk to the LPN/Unit Manager (LPN/UM) regarding what happened, as this was her first day assigned to care for Resident #298. At 10:58 AM, the surveyor interviewed the LPN/UM who stated that the resident was admitted to the facility on both [MEDICATION(S)] and an injectable anticoagulant during a therapeutic bridge to maintain the resident's coagulation due to a recent stroke. The LPN/UM stated the injectable anticoagulant was discontinued within a day or two by the physician and the resident remained on just the medication, [MEDICATION(S)]. She added that the resident's therapeutic INR goal range was to be maintained between results of 2 to 3. The LPN/UM stated the process for labs, that all labs orders get documented and placed into the eMAR system using a physician's order. She stated that the day it is ordered, the nurse documents in the eMAR for that day plotted on the eMAR that the labs were obtained and reviewed with the attending physician for further orders for a [MEDICATION(S)] dose or hold schedule. She confirmed there was no evidence within the eMAR for the accountability for [MEDICATION(S)] 3 mg on [DATE]. She acknowledged that the labs ordered for [DATE], the nurses were signing on ,d+[DATE] and ,d+[DATE] on multiple shifts for the labs and could not speak to what they were signing in the eMAR for next to the order for the lab. The LPN/UM also reviewed the Lab communication book and the Lab receipt book and was unable to provide documented evidence that the resident had labs obtained on [DATE]. The surveyor asked the LPN/UM why the resident did not have labs drawn on [DATE] when there was an order, and she could not speak to it. The LPN/UM stated that there was a progress note dated [DATE] that indicated the Physician had ordered [MEDICATION(S)] 3 mg on [DATE] and that it was given to the resident. She could not speak to what INR lab result that order was based on. The surveyor asked where the [MEDICATION(S)] 3 mg was obtained from, and the LPN/UM stated that the facility had an electronic dispensing device for back-up medications/supplies, and that [MEDICATION(S)] doses were kept in back-up. She stated there were 1 mg tablets and 2 mg tablets of [MEDICATION(S)] available in back-up. The surveyor inquired about evidence that [MEDICATION(S)] 3 mg was removed from back-up for Resident #298 on [DATE]. The LPN/UM stated she would have to get back to the surveyor. At 11:35 AM, the surveyor conducted a phone interview with a Registered Pharmacist (RPh) from the facility's Pharmacy Provider. The RPh stated that they sent three tablets of [MEDICATION(S)] 6 mg each based on a physician order dated [DATE] to administer [MEDICATION(S)] 6 mg one tablet for three days. The RPh stated that they only sent three tablets of 6 mg each which would have lasted them for three days. The RPh further added a [MEDICATION(S)] order was received from the facility on [DATE] at 11:18 PM to be filled for [MEDICATION(S)] 3 mg. The RPh stated that the order was not filled until [DATE] when the next delivery was due. The RPh stated that seven tablets of [MEDICATION(S)] 3 mg were sent to the facility on [DATE]. On [DATE] at 2:34 PM, the surveyor interviewed the Physician who was covering for the Attending Physician on the weekend of [DATE], in the presence of another surveyor. The Physician pulled up the resident's electronic medical record to reference for the interview. The Physician stated that the resident had a stroke with a vascular blockage, requiring [MEDICATION(S)] for anticoagulation. The Physician stated that the INR goal was to be at a therapeutic level of between 2 and 3, and that the INR had been slightly elevated on [DATE]. He added that the the Primary Physician had ordered to hold the [MEDICATION(S)] for two days on ,d+[DATE] and ,d+[DATE] and recheck the labs on [DATE]. The Physician stated he had ordered for the [MEDICATION(S)] 3 mg on [DATE]. The surveyor asked if he recalled what the INR result was or what he based his dosage on, and the Physician stated that he could not recall what the results were, but that the nurse wouldn't call him if they didn't have results to give. He further added that I wouldn't go three days without giving it [[MEDICATION(S)]], adding that it would be out of the body's system in three days. He stated that a lab was collected on [DATE] and the result was sub-therapeutic so he increased the dose further on [DATE]. He confirmed he could not find the lab dated [DATE], but stated there was no adverse outcome. On [DATE] at 2:22 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team, who stated that the [MEDICATION(S)] 6 mg was scored and he believed that the nurse administered a half of a tablet from the resident's inventory. He stated that there were no [MEDICATION(S)] dosages removed from the back-up supply to be administered to Resident #298 on [DATE]. The surveyor asked if all three of the 6 mg tablets of [MEDICATION(S)] had been administered on ,d+[DATE], ,d+[DATE] and ,d+[DATE], and the Pharmacy Provider only sent three tablets, how there would be a fourth, 6 mg tablet to cut in half to make 3 mg on [DATE]? The LNHA could not answer the surveyor and acknowledged again it was not removed from the back up supply. The LNHA was unable to provide the surveyor documented evidence as to where the [MEDICATION(S)] 3 mg came from for administration on [DATE], documented evidence that the lab was performed on [DATE] in accordance with physician orders and evidence in the eMAR that it was signed as administered on [DATE] in accordance with professional standards of practice. A review of the facility's Obtaining Lab Orders policy updated 2020, included that the staff will process test requisition and arrange for the test; nursing staff will inform resident/family member of test ordered by the physician; nurse will communicate to the ordering physician test results and will document any new orders. NJAC 8:,d+[DATE].1,2,5,7

Based on observation, interview, and record review, it was determined that the facility failed to ensure: a.) non-pharmacological interventions were attempted prior to the administration of an anti-anxiety medication, and b.) specific target behaviors were monitored and evaluated after the administration of two controlled drugs used to treat anxiety, as needed. This deficient practice was identified for 1 of 6 residents reviewed for unnecessary medications (Resident #189), and was evidenced by the following: On 1/9/2020 at 12:10 PM, the surveyor observed Resident #189 sitting in a wheelchair by the nurse's station. The resident was asking the Licensed Practical Nurse/Unit Manager (LPN/UM) where he/she was and why he/she was here. The surveyor attempted to speak to the resident, but the resident was unable to respond appropriately to the surveyor. The surveyor reviewed the medical record for Resident #189. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included restlessness and agitation, major depressive disorder, dementia, altered mental status, and anxiety disorder. A review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/19/19 reflected that the resident had a brief interview for mental status (BIMS) score of 4 out of 15, which indicated severely impaired cognition. A further review of the MDS, indicated that the resident had no behaviors and received [CONDITION(S)] medications on 7 out of the last 7 days during the look back period. A review of the resident's individualized, comprehensive care plan dated 11/19/19 included a care concern of the resident that had inappropriate behaviors which included agitation, wanting to go home, pacing to the point of exhaustion, and asking staff what I am doing here? Interventions included to provide non-pharmacological interventions; to redirect resident; to use calm slow approaches; to assess personal needs; to monitor and document behaviors; and to administer medications as ordered. A review of the Physician Orders (PO) indicated a one time order dated 12/17/19 for [MEDICATION(S)] gel (anti-anxiety medication) 0.5 milligrams (mg). The order was discontinued on 1/1/2020. A review of the corresponding December 2019 electronic Medication Administration Record (eMAR) reflected that resident received the [MEDICATION(S)] gel on 12/25/19 at 9:00 AM and 12/26/19 at 8:53 AM. A review of the controlled drug accountability record (CDAR) for the [MEDICATION(S)] gel had a received date of 12/20/19. There was no evidence within the CDAR that [MEDICATION(S)] gel was signed out of the inventory on 12/25/19 to correspond with the eMAR at 9 AM. A further review of the CDAR reflected that one [MEDICATION(S)] gel was signed out of inventory on 12/26/19 at an illegible early morning time. There was no evidence within the eMAR that the resident received a dose in the early morning hours. Another dose was signed out on 12/26/19 at 9:00 AM, this corresponded with the eMAR for December 2020. A review of the electronic Nurses Notes (eNN) reflected that the last note entered on 12/25/19 was at 7:36 AM which indicated that the resident went to bed at 6:00 AM with no agitation or behaviors voiced. There was no note corresponding to the administration of the [MEDICATION(S)] gel at 9:00 AM, including the resident's exhibited target behavior, non-pharmacological interventions attempted and the resident's response, and the monitoring/effectiveness of the treatment of the [MEDICATION(S)] gel. A further review of the eNN dated 12/26/19 at 3:11 AM, reflected that the resident was experiencing behaviors and non-pharmacological interventions were tried and failed so [MEDICATION(S)] gel was administered effectively at 2:45 AM. This administration was not reflected in the eMAR. There was no eNN that corresponded to the [MEDICATION(S)] gel administered on 12/26/19 at 8:53 AM. A review of the January 2020 eMAR reflected a PO dated 1/1/2020 for [MEDICATION(S)] gel 0.5 mg. The order specified to apply one application topically every eight hours as-needed (PRN) for anxiety. The eMAR reflected that the resident received [MEDICATION(S)] gel on 1/5/2020 at 4:29 PM. A review of the eNN had not reflected a note on the administration of the [MEDICATION(S)] gel on 1/5/2020 at 4:29 PM, including the resident's exhibited target behavior, non-pharmacological interventions attempted and the resident's response, and the monitoring/effectiveness of the treatment of the [MEDICATION(S)] gel. On 1/13/2020 from 12:31 PM to 12:37 PM and 1/14/2020 from 9:48 AM to 9:58 AM, the surveyor observed the locked medication storage refrigerator on all four resident units. There was no [MEDICATION(S)] gel in storage. On 1/14/2020 at 10:30 AM, the surveyor interviewed the Registered Nurse (RN) who stated that she was currently the Charge Nurse (CN), since the previous UM left last month. The RN/CN stated that if a resident was on a controlled drug that was discontinued, the controlled drug sheet was placed in the resident's medical chart and a copy was given to the Director of Nursing (DON). The RN/CN stated that she was not familiar with Resident #189 who no longer resided on that unit. The RN/CN further stated that the resident's nurse at the time was currently on a leave of absence. At 11:23 AM, the surveyor interviewed the DON in the presence of the Licensed Nursing Home Administrator (LNHA). The DON stated that the controlled drug sheet was kept on the resident's chart when the inventory was zero or the medication was discontinued. The surveyor reviewed the December 2019 eMAR with the DON which indicated that [MEDICATION(S)] gel was administered with a corresponding PO dated 12/17/19 for [MEDICATION(S)] gel to apply one time for anxiety. The surveyor requested additional information at this time for the administration of all [MEDICATION(S)] gels the resident received after 12/17/19. The surveyor continued to review the resident's medical record and noted that the resident had order for the anti-anxiety medication, [MEDICATION(S)], in tablet form. A review of the January 2020 eMAR reflected an order dated 1/10/2020 for [MEDICATION(S)] 1 mg tablet. The order specified to administer one tablet every eight hours PRN for restlessness and agitation until 1/24/2020. The eMAR was signed to reflect that the resident had received the [MEDICATION(S)] 1 mg tablet on 1/10/2020 at 4:08 PM. A review of the eNN reflected no documentation on 1/10/2020, including the resident's exhibited target behavior, non-pharmacological interventions attempted and the resident's response, and the monitoring/effectiveness of the [MEDICATION(S)] tablet. On 1/15/2020 at 9:15 AM, the surveyor interviewed the facility's provider Pharmacy's Compliance Officer/Pharmacist who stated that the pharmacy received a controlled substance order for Resident #189 on 12/18/19. The pharmacy delivered 30 - 0.5 mg [MEDICATION(S)] gel syringes to the facility on [DATE]. The Compliance Officer/Pharmacist emailed a copy of that order to the surveyor. At 10:26 AM, the surveyor interviewed the resident's LPN who stated that the resident at times became agitated and verbalized wanting to go home. The resident tried to get out of his/her wheelchair, which was not safe. The resident's target behaviors included exit seeking behaviors, wandering, wanting to go home, crying, restlessness, threatening behaviors, and anxiety, and that the resident had a PRN anti-anxiety medication when he/she exhibited those target behaviors. The LPN stated that since the resident had been on this unit, the resident had not refused medications with her. At 10:59 AM, the surveyor interviewed the UM/LPN who stated that the resident had behaviors, but most of the time it was related to confusion because the resident would ask why he/she was at the facility. The resident would also ask for their family member. The UM/LPN stated that any resident who received [CONDITION(S)] medications, the nurses would monitor their target behaviors each shift. If the resident was on a PRN [CONDITION(S)] medication, the nurse would first offer a non-pharmacological intervention such as offering a snack, toileting, or re-directing. If that had not worked, then the nurse administered the PRN medication as prescribed. The nurse then documented in the eNN what behaviors had occurred, the non-pharmacological interventions attempted, and if the non-pharmacological interventions were ineffectiveness. and then document effectiveness of the medication administered. On 1/15/2020 at 1:26 PM, the surveyor interviewed the LNHA in the presence of the DON and the survey team who stated that the doctor ordered 30 syringes of [MEDICATION(S)] gel on 12/18/19 for the resident. The nurse who transcribed the order on the eMAR transcribed the order incorrectly. The LNHA further stated that the resident had received the doses in question from that inventory. The LNHA had not provided the controlled drug sheet at this time. The surveyor at this time again requested the [MEDICATION(S)] gel controlled sheet as well as additional information regarding the [MEDICATION(S)] gel administered on 12/25/19, 12/26/19, and 1/5/2020. The surveyor also requested additional information regarding the [MEDICATION(S)] tablet administered on 1/10/2020. On 1/16/2020 at 12:27 PM, the surveyor interviewed the LNHA in the presence of the DON and the survey team who stated that the [MEDICATION(S)] tablet was administered to the resident on 1/10/2020 for screaming and agitation and that the nurse had not entered a progress note until surveyor inquiry. The LNHA further stated that he couldn't speak to the resident's target behaviors and nonpharmacological interventions attempted prior to administering the [MEDICATION(S)] gel. The expectations for administering an as-needed [CONDITION(S)] medications was to assess behaviors, offer non-pharmacological drug interventions, if not effective then administer the medication, and follow-up with the resident to determine if the medication was effective. The nurse would need to document all the information in the eNN. The LNHA was unable to provide documented evidence of the nurse's notes to warrant the use of the [MEDICATION(S)] Gel on 12/25/19 at 9:00 AM, 12/26/19 at 8:53 AM, and 1/5/2020 at 4:29 PM, and for the [MEDICATION(S)] tablet on 1/10/2020 at 4:08 PM. The surveyor reviewed the facility's Managing Problem Behavior policy updated 2019, which included to document episodes of behaviors and non-pharmacological interventions rendered prior to administering a [CONDITION(S)] medication. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) the accountability for pressure-relieving suspension heel boots before and after the development of a facility-acquired full thickness pressure ulcer to the left heel, b.) a wound treatment was initiated for three days, c.) the Wound Consultant's recommendations for a wound treatment were addressed, d.) the use of compression stockings were followed in accordance with physician orders, e.) a dietary consult addressed the resident's most recent [MEDICATION(S)]/protein levels prior to recommending the discontinuation of a protein supplement, and f.) ensure the re-assessment for pressure ulcer risk was completed after the resident developed the full-thickness pressure ulcer to the left heel for the same resident. This deficient practice was identified for 1 of 4 residents reviewed with a facility acquired-pressure ulcer (Resident #117) and was evidenced by the following: On 01/15/19 at 11:04 AM, the surveyor observed Resident #117 sitting in a wheelchair in his/her room. The resident's legs were in a dependent position in the wheelchair, and he/she was wearing yellow non-skid socks. The surveyor could see the resident's bare skin above the sock line. The surveyor noted that the resident had a slightly swollen left leg, as compared to the right leg, and there were no TED (compression) stockings on the resident at that time. The surveyor interviewed the resident who stated that he/she had been a resident at the facility for a little while, and that his/her left heel busted open about a week ago, and he/she was not sure if a podiatrist or physician had looked at it yet. The resident stated that he/she had chronic pain to the bilateral legs due to the repetitive-motion tasks from his/her history of employment. The surveyor reviewed the medical record for Resident #117. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/08/18 reflected that the resident had a brief interview for mental status (BIMS) score of 7 out of 15, indicating a moderately impaired cognition level. The assessment reflected that the resident did not exhibit behaviors of rejecting care that would interfere with treatment goals in the last seven day look-back period. The resident required an extensive one-person assistance with bed mobility and transfers and that he/she was admitted with one, stage II pressure ulcer (partial thickness tissue loss). (There was no evidence that the resident had a pressure ulcer upon admission in the Admission Nursing History and Assessment, the individualized Comprehensive Care Plan, admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the undated and unsigned Admission Nursing History and Assessment form reflected that Resident #117 was admitted to the facility on [DATE] at 05:30 PM and was accompanied by two Emergency Medical Transport (EMT) staff. The assessment reflected that the resident was alert and oriented to self only and had intact skin to the bilateral heels upon admission with a left buttock skin tear that measured 0.5 centimeters (cm) x 0.5 cm. The assessment did not reflect evidence that the resident was admitted with a pressure ulcer. A review of the admission Physician Order's Form (POF) dated 11/02/18 reflected physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Braden Scale-for Predicting Pressure Sore Risk assessment dated upon admission 11/01/18 reflected the resident was at a mild risk for developing a pressure ulcer. The assessment had a total score of 15 out of a possible 23 (a score of 15-18 reflects mild risk for developing a pressure ulcer). A review of the resident's individualized, Interdisciplinary Plan of Care dated 11/01/18 reflected that the resident was at risk for pressure ulcers due to a decrease in mobility. The Care Plan reflected that the resident had a left buttock skin tear upon admission. The goal indicated that skin will remain intact for the next 90 days, and interventions included to assess skin condition with daily Activities of Daily Living (ADL) care and report any abnormalities, turn and reposition every two hours while in bed, shift positions when out of bed, dietary consult, lubricate heels, utilize heel pads/heels up using pillows to elevate the heels, perform a skin assessment weekly and obtain labs as ordered. A review of the Interdisciplinary Care Plan (IDCP) Meeting notes dated 11/02/18 reflected that the resident was alert and oriented x 2-3 with forgetfulness. Incontinent of bowel and bladder. Skin breakdown present at left buttock upon admit with treatment and preventative measures in place. The plan was for the resident to return home following a short term rehab stay. The IDCP notes did not address the type of skin breakdown or wound the resident had on the left buttock. A review of a Routine Chemistry blood laboratory report with a collection date of 11/03/18 at 12:05 (AM/PM not specified) reflected the resident had a low [MEDICATION(S)] (a protein released by the liver) level of 2.8 grams per deciliter (g/dl) (normal range indicated 3.5 to 5.5 g/dl); and a total protein level of 6.3 (normal range indicated 6.0-8.0 g/dl) Handwritten on the lab result was the Attending Physician (MD) signature with instructions dated 11/05/18 to start a liquid protein supplement, Prostat 30 milliliters (ml) by mouth twice a day. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses were signing that they were administering a dose at 10 AM and 10 PM daily. A review of the initial Admission Nutrition assessment dated [DATE] reflected that the resident had dementia, history of [CONDITION(S)], pneumonia, high blood pressure and [CONDITION(S)]. According to her assessment, the resident had a basic metabolic profile labs drawn on 11/09/18 which indicated a normal blood sugar level, kidney function tests and lab results for sodium, potassium and calcium documented. The space for an [MEDICATION(S)] level was blank. The Registered Dietician (RD) documented that the resident had no meal intake issues, and did not have increased or decreased protein needs. She indicated that the resident received a multivitamin with minerals daily, and that he/she had a skin tear to the left buttock. The RD made an estimated daily protein requirement based on the resident's weight of 157 pounds (71 kilograms) (kg). The daily protein estimated requirement reflected 92 based on a 1.3 g/kg assessment, so the RD recommended to discontinue the Prosource supplement. (The RD assessment did not reflect the resident's low [MEDICATION(S)] level drawn on 11/05/18, nor did it address the resident's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the POF dated 11/13/18 reflected a telephone order to discontinue the Prosource twice a day in accordance with the RD recommendation. The order was subsequently discontinued in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of follow up blood laboratory results collected on 11/21/18 at 07:05 AM reflected that the resident had a reduced low total protein result of 5.4 g/dl (normal indicated 5.7 - 8.2 g/dl) and a continued low [MEDICATION(S)] level of 3.0 g/dl. The labs were signed by the MD on 11/21/18. A review of an initial Podiatry Consult dated 11/09/18 reflected that the resident had dry scaling skin to the bilateral feet, which may ulcerate. The assessment reflected that the resident had thin skin texture and cool extremities with decreased skin turgor and elasticity and pitting [CONDITION(S)] (swelling) to both lower extremities. The section used to address if the resident had ulcers, indicated none. A review of the Braden Scale-For Predicting Pressure Sore Risk assessment reflected that the resident had two more risk assessments conducted on 11/07/18 and 11/14/18 with unchanged numeric results and still reflected that the resident was at mild risk for skin breakdown. There was a 4th assessment to be completed on 11/21/18, but the assessment was blank for that date. A review of the TAR for November 2018 reflected weekly skin assessments and Braden Scale assessment for 3 PM to 11 PM shift plotted to be performed on Saturdays on 11/03, 11/10, 11/17 and 11/24. The TAR was blank and not signed on 11/10, 11/17 and 11/24. (These dates did not correspond with the dates on the Braden Scale-For Predicting Pressure Sore Risk). A review of the resident's Interdisciplinary Comprehensive Plan of Care updated on 11/21/18 reflected that the skin tear to the left buttock and incontinence-associated [CONDITION(S)] (moisture rash) present upon admission had healed. A review of the POF for November 2018 reflected that on 11/21/18 the treatment orders for the Incontinence associated [CONDITION(S)] had been discontinued and prophylactic barrier cream was implemented. A review of the Daily Skilled Nurses Notes for 11/21 and 11/24, 11/25, 11/26, reflected that the resident's skin was not intact but there was no corresponding note to address what areas of the body had non-intact skin. It did not address where on the body the non-intact skin was, and if there was a new finding. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence the order had been clarified to reflect when the suspension heel boots were to be worn. A review of the TAR for December 2018 reflected the corresponding physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was plotted to have each shift sign that the heel suspension boots were in place during the 11 PM to 7 AM shift, 7 AM to 3 PM shift and the 3 PM to 11 PM shift. The TAR reflected that the nurses were not consistently signing for the application of the suspension heel boots as there were blanks on the TAR for the following dates and shifts: During the 11 PM to 7 AM shift, there were blanks on 12/08, 12/18, 12/19, 12/23, 12/25, and 12/29. During the 7 AM to 3 PM shift, there were blanks on 12/12, 12/20, and 12/23. During the 3 PM to 11 PM shift, there were blanks on 12/19, 12/20, 12/21, 12/22, 12/24, 12/25, 12/26, 12/28, 12/29, and 12/30. A review of a follow-up Podiatry consult dated 12/24/18 reflected the resident had dry scaling skin to bilateral feet which may ulcerate; swelling to the bilateral lower extremities, which may ulcerate; and pain in the back of the foot, heel, bunion and toes. The consult indicated that the resident currently had no ulcers. The Podiatrist recommended an ace bandage for compression which may be beneficial and to utilize heel suspension boot when in bed. A review of the Daily Skilled Nurses Notes dated 01/01/19 and 1/02/19 for the 7 AM to 3 PM shift reflected that there was no evidence of skin breakdown. The spaces designated for the nurses to document for the 3 PM to 11 PM shift and 11 PM to 7 AM shift were blank. A review of a Wound Care Notes dated 01/02/19 reflected that the resident was noted to have a new Stage III pressure ulcer (full thickness tissue loss, but bone/tendon are not exposed) to the left heel. A review of the wound consult Visit Report dated 01/02/19 and documented by the Advanced Practice Nurse/Wound Consultant (APN/WC) reflected that the left heel wound was a stage III pressure ulcer with a moderate amount of serous (clear) drainage and 20% moist black eschar (dead tissue), and the size was 2.5 centimeters (cm) x 5 cm x 0.2 cm. The APN/WC recommended to apply a medicated ointment Santyl (a [MEDICATION(S)] agent) and calcium alginate (an antimicrobial absorbent dressing), and abdominal (ABD) pad and wrap the wound with kling on a daily basis. A review of the resident's individualized Interdisciplinary Comprehensive Plan of Care updated on 01/02/19 reflected that the resident developed a stage III pressure ulcer to the left heel. There was no documented evidence for a Braden Scale Pressure Ulcer Risk assessment dated upon identification of the new stage III pressure ulcer to determine the resident's new pressure ulcer risk. A review of the POF for January 2019 did not reflect evidence of a new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Daily Skilled Nurses Notes dated 01/02/19 indicated the resident's skin condition was intact for the 7 AM to 3 PM shift, and the nurse(s) for the subsequent shifts on 01/02/19 did not address the resident's skin condition in the notes. The Daily Skilled Nurses Notes dated 01/03/19 and 01/04/19 during the 7 AM to 3 PM shift reflected that the resident's skin was intact. There was no evidence that the 3 PM to 11 PM shift or the 11 PM to 7 AM shift addressed the resident's skin condition. (This did not correspond with the APN/WC note dated 01/02/19 in which a stage III pressure ulcer was identified to the left heel. Further review of a subsequent Daily Skilled Nurses Note dated 01/05/18 reflected the nurse found a new open area to the left heel and no odor noted. The nurse documented that the wound measured 3 cm x 2 cm and that family were made aware and new treatment was ordered and in progress. A review of the POF for January 2019 reflected that the nurse called the Attending Physician and received an order dated 01/05/19 to clean the left heel wound with NSS and apply a [MEDICATION(S)] agent, [MEDICATION(S)] gel to the wound, apply an ABD pad and wrap it with kling daily. A review of the TAR for January 2019 did not reflect evidence that a treatment to the left heel pressure ulcer was implemented until three days after the stage III pressure ulcer was initially identified on 01/02/19 with the first treatment to the left heel implemented on the 3 PM - 11 PM shift on 01/05/19. The TAR reflected that the nurses were signing for the [MEDICATION(S)] each shift and this did not correspond with the APN/WC recommendations made on 01/02/19. Further review of the TAR reflected a typed order dated 11/30/18 to Apply suspension foam or air boots to offload heels bilateral to prevent pressure ulcers. The order did not specify when the heel boots were to be applied, it was not plotted for a specific time in the TAR, and there was no signing for the accountability for the suspension heel boots for the month of January 2019. A review of the Attending Physician's progress notes dated 01/02/19, 01/04/19, 01/05/19, 01/08/19, and 01/18/19 reflected that the resident was examined and that his/her skin was warm and dry with no events reported. There was no documented evidence from the resident's Attending Physician that addressed his/her new stage III pressure ulcer to the left heel and/or evidence that it was examined by the the Attending Physician. A review of a follow-up APN/WC Visit Report dated 01/09/19 reflected that the left heel pressure ulcer was not healed and there was no change in wound progress. The measurement reflected 3 cm x 4.3 cm x 0.1 cm, with a moderate amount of serous drainage. The note reflected that the Wound is stable in size today with 100 % granulation, with center dark discoloration noted . The note indicated that the APN/WC debrided (removed the dead tissue) biofilm from the wound without complications. The note indicated a Heel boot needed The APN/WC further indicated to continue the current treatment to Apply Santyl, Calcium Alginate, ABD and kling daily. A review of the Wound Care Notes dated 01/09/19 at 08:50 AM reflected that the resident was seen by the wound team for follow up for the left heel, heel boot to left lower extremity, and continue same treatment order. A Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a third APN/WC Visit Report dated 01/16/19 reflected that the resident's left heel pressure ulcer had not changed and the wound measured 3 cm x 4 cm x 0.2 cm with a moderate amount of serous drainage noted. The note reflected that the wound was stable in size with 50% black eschar noted, and was debrided without complications. The APN/WC recommended to continue with the Santyl. calcium alginate, ABD pad and kling daily and that a heel boot was needed. A review of the Wound Care Notes dated 01/16/19 reflected that the resident was seen by the wound team and tolerated wound care well, and that the team will continue to monitor. The notes did not address the discrepancy between the resident's current treatment orders and the recommendations made by the APN/WC on 01/02/18, 01/09/19 and 01/16/19. A review of a follow-up Nutrition assessment dated [DATE] which was 15 days after the identification of the stage III facility-acquired pressure ulcer to the left heel, with worsened skin condition to the left heel, at which time the RD indicated that she initiated a dietary care plan. The RD recommended to change the resident's diet to a regular thin liquid diet, add 4 oz of Resource 2.0 nutritional supplement four times per day with medication pass, start Vitamin C x 30 days and Zinc for 14 days to promote wound healing, and recommended labs of a complete metabolic profile (CMP), zinc level and a pre-[MEDICATION(S)] level. On 01/18/19 at approximately 11:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to do the treatments for the residents on the unit that day. The LPN was outside the resident's room with the treatment cart and she stated that Resident #117 was easy-going and she was about to do his/her wound treatment to the left heel. She stated that it was a newer wound but could not speak to when it developed. At that time, the surveyor observed Resident #117 sitting on the edge of the bed facing the window and wearing a hospital gown that was coming off the right shoulder. The surveyor observed two black suspension heel boots in the resident's room, one was on the floor next to his/her bed and the other was on the seat of the wheelchair facing the window. The resident's old wound dressing was on the floor. The resident was not wearing TED compression stockings on either leg, and his/her left leg was slightly swollen. The LPN stated that the resident removed the dressing for her already and the LPN showed the surveyor the old dressing which revealed scant dried drainage on the abdominal (ABD) pad. The LPN asked the resident if he/she had any pain and the resident indicated No. The LPN proceeded to prepare the resident's area for the wound treatment. The LPN squeezed a medicated ointment, [MEDICATION(S)] (a [MEDICATION(S)] agent) into a medication cup and opened a new bottle of normal saline and placed it into a medication cup. She retrieved a 4 x 4 gauze pads, and ABD pad and kling. Upon cleaning and prepping the resident's bedside table, she placed a clean field liner over the bedside table, and placed the treatment supplies on the liner. While the resident was still sitting up in the dependent position, the LPN reached behind the resident's leg and began to clean the left heel with the normal saline and 4 x 4 gauze pads, without visualizing the wound. She did not ask and/or assist the resident to lay back for better visualization of the wound. As the LPN prepared to apply the [MEDICATION(S)] using a gauze pad to the wound, the surveyor inquired how she would assess the wound, as the wound was not in visual field of the surveyor or the LPN. The LPN stated that she could not see the wound but that she had a mirror and could show the surveyor what the wound looked like using the mirror. She then went to the treatment cart, cleaned a large flat-head mirror and placed it behind the resident's ankle to visualize the left heel wound. The surveyor observed the resident's left heel had a full thickness wound that extended from the base of the heel length-wise and had granulating (healing) tissue around the edges with a blackened center. The LPN stated to the surveyor that there was a scant amount of slough (yellow-colored, dead tissue) around the outer lower base of the wound, and that there were no signs of infection. She stated that the resident liked to sit in the dependent position during wound dressing changes, and acknowledged the wound was not visible when the resident was in that position. Without using the mirror, the LPN then placed the [MEDICATION(S)] onto a gauze pad, and rubbed the gauze over the back of the left heel, discarded the gauze and placed an ABD pad over the wound bed, and wrapped it with kling. The LPN signed and dated a piece of tape that she used to secure the kling to the resident's leg. She did not apply the TED compression stockings to the resident's legs and/or the suspension heel booties, and the LPN then discarded the supplies, washed her hands and went to the treatment cart to sign the Treatment Administration Record (TAR). The resident remained sitting up on the edge of the bed with the legs dependent. The LPN opened the TAR for January 2019 for Resident #117 and signed for a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor saw there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN did not apply the TED stockings and did not sign in the TAR for the TED compression stockings to be applied at 10:00 AM. The surveyor further noted in the TAR that there was a typed order dated 11/30/18 to Apply suspension foam or air boots to offload heels bilateral to prevent pressure ulcers. The order was not plotted to reflect a time of application of the heel boots and there was no accountability for application of the suspension heel boots for the month of January 2019. In addition the order was not clarified to reflect when the heel boots were to be applied and/or if they were to be in place continuously or only during certain times of the day. At 11:30 AM, the surveyor interviewed the LPN after she signed in the TAR for the wound dressing change. The surveyor asked what she does to protect the resident's heels, and she stated that the wound dressings get changed daily and that the resident was monitored by the weekly wound team. She stated that therapy handled all equipment related orders and that the resident did not have any active orders for heel boots. She stated that therapy handled all that. The surveyor pointed to the order on the TAR dated 11/30/18 to Apply suspension foam or air boots to offload heels bilateral to prevent pressure ulcers, and the LPN stated she would have to look at the resident's chart because the order on the TAR was very generic and it was more of an FYI [For Your Information] order. She stated that nurses did not need to sign for FYI orders. She stated that the resident did not have an active order to apply suspension heel boots during her shift. At 11:33 AM, the LPN pushed the treatment cart down the hallway and stationed it outside another resident's room to prepare her next treatment. The suspension heel boots were not applied and the LPN left the resident's room with the heel boot still on the floor and the other one on the seat of the wheelchair. The resident remained sitting up on the edge of the bed, with his/her feet dependent resting on the floor. The resident was not wearing the TED compression stockings. On the same day 01/18/19 at 01:00 PM, the surveyor interviewed the Certified Nursing Aide (CNA) assigned to care for Resident #117. The CNA could not speak to the resident's cognitive status but stated that he/she was able to follow commands. She stated that the resident was incontinent at times but that she had just taken him/her to use the bathroom. She stated that she assists the resident in getting him/her dressed, apply barrier cream to the buttocks and prop the legs up on a pillow when in bed. She stated that she puts the resident's brown slippers on his/her feet even though they do not fit around the left heel. The CNA was unsure about TED stockings and/or suspension boots. The CNA stated the only shoes she applies on the resident were the brown slippers he/she was wearing right now. At 01:05 PM, the resident was sitting up in a wheelchair without evidence of TED compression stockings. The resident was wearing yellow non-skid socks with a pair of brown slippers over them. On 01/22/18 at 09:58 AM, the surveyor interviewed the treatment LPN a second time who reviewed the TAR together. The resident's TAR reflected that the order for the application of the TED stockings was not signed for at 10:00 AM on 01/18/19. The LPN stated that she forgot to sign for the application of the TED stockings in the TAR on 01/18/18. She could not speak to if she applied them on 01/18/19. She confirmed she did not apply them during the wound treatment with the surveyor on 01/18/19. She stated that she was supposed to sign immediately after applying them. The surveyor attempted to interview the LPN further regarding the resident's wound, and the LPN stated she cannot speak to anything regarding the resident's wound and that the surveyor would need to speak to the Assistant Director of Nursing who goes on the wound rounds with the APN/WC. On 01/22/19 at approximately 10:00 AM, the surveyor was provided a copy of an Incident Report form dated 01/02/19 at 07:30 AM. The report was completed by the Assistant Director of Nursing (ADON) and reflected that she was informed by nursing staff that the resident had a wound to the left heel. The wound was a stage III pressure ulcer that measured 2.5 centimeters (cm) x 5 cm x 0.2 cm. The investigative report reflected an area to review potential medical factors, and the ADON indicated impaired mobility. Environmental factors reflected a list of possible environmental factors that may have led to the incident, and instructions indicated to circle the correct response for each item when applicable. There was no environmental factors circled. Under Immediate Measures taken to prevent recurrence, it reflected wound care consult rounding today, will be seen . elevate bilateral lower extremities. A review of the Pressure Ulcer Investigation Form attached to the Incident Report dated 01/02/19 reflected that the last skin breakdown risk assessment was done on 11/21/18 and reflected a mild risk for developing a pressure ulcer. The area for the risk factors for the development of pressure ulcers was blank, the section to review labs and weights related to malnutrition/dehydration as a possible contributing factor to the development of the wound was blank, and the section indicating if lab values were unavailable, assess for clinical signs, that section for review was left blank as well. The subsequent section on the form indicated A determination that a pressure ulcer was unavoidable may be made if the resident is terminally ill, comatose, or semi-comatose and life sustaining measures have been withdrawn, or if treatment is limited by advance directive or resident or family wishes. Check and explain below: There was no explanation on the investigation report. The outcome of the investigation reflected that the resident had impaired mobility who required assistance of one person for Activities of Daily Living (ADL), transfers and repositioning. The resident is known to have bilateral lower extremity [CONDITION(S)]. On 12/03/18 the resident was seen by the Attending Physician with orders for an X-ray to the bilateral feet which showed vascular calcification and advanced osteo-arthritis to bilateral first metatarsal-phalangeal joint. Resident was on supplements, heel boots and dietician consult as needed. Attached to the Pressure Ulcer Investigation dated 01/02/19 were three written statements by the staff that identified the wound on 01/02/19. The Certified Nursing Aide (CNA) wrote that the resident had finished breakfast that day and that I was helping resident with AM [morning] care, I noticed blood on the sheet, when I checked [his/her] heel, it was red. I called the nurse and she came immediately to check. The Charge Nurse/LPN statement dated 01/02/19 reflected that she was called by the primary nurse and the CNA that a wound had developed on the left heel and that it had eschar. The statement reflected that the primary Attending Physician and responsible party were notified, and a wound consult was initiated. The third statement was written by the ADON who conducted the investigation. The statement reflected that she was informed by nursing staff that the resident had an open area to the left heel and when reviewed with wound team it was noted to be a stage III pressure ulcer and that the resident denied discomfort to the heel. There were no statements from the Primary Nurse, and/or statements from previous shifts from direct care staff. The investigative report did not address if neglect had been ruled out as a possible cause for the development of a stage III pressure ulcer. In addition, the investigative report did not reflect an investigation into why the CNA found blood on the sheet when the resident had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The investigative report reflected that the ADON completed the report, and that she also signed as the supervising nurse. There was no evidence that the investigative report was reviewed by the Administrator and/or Director of Nursing. On 01/22/19 at 10:07 AM, the surveyor interviewed the ADON. The ADON stated that she completed an investigation to the left heel stage III pressure ulcer wound that was identified on 01/02/19. She stated that she and the wound team round once a week on Wednesdays on all the units. She stated that the APN/WC shows her what the wound looks like and she assists with the supplies, and the APN/WC makes recommendations and that the APN/WC was responsible for writing the orders in the resident charts. She added that she doesn't review the APN/WC visit reports for one or more days due to the volume that the APN/WC has to see in the building. The ADON and surveyor reviewed the chart together for Resident #117 and the ADON could not speak to the timing, acc