Every finding on record at Skilled Nursing at Pine Village

Based on observation and interview it was determined that the facility failed to ensure the kitchen and remote food service pantry were maintained in a clean and sanitary manner to prevent the spread of potential infection and food borne illness. The deficient practice was evidenced by the following:On 08/25/2025 at 8:59 AM, the surveyor toured the food service pantry with a Dietary Aide (DA) who stated the meals were brought up to the pantry from the main kitchen, and served via the pantry. The DA confirmed the dish machine located in the pantry was also utilized to wash the lunch and dinner dishes. The surveyor observed the following:The walls and ceilings were soiled with various colored debris and stained throughout.The cutting board, attached to the steam table was visibly stained and grooved. The DA moved the steam table away from the wall and the area behind the steam table was soiled with various crumb type debris.The plastic wrap container was soiled with grease type marks.The metal shelves underneath the counter contained three containers that held lids and containers. The shelves had visible debris on them, and the containers were visibly soiled with various debris on the outside. The dish machine drain area had debris in the drain and small flies were flying around with debris including paper and a pink wipe were crumbled up on the floor. The vent hood over the dish machine was visibly soiled with dust like debris surrounding the opening of the vent as well as inside the vent. A pink cleaning wipe was rolled up on the floor.The reach in refrigerator had blackened debris inside the gasket.Steak type knives with wood handles were in the knife rack and the handles were visibly worn.A garbage can was visibly soiled on the exterior of the canThe white wall vent behind the plate warmer was visibly soiled with blackened debrisThe surveyor then entered the main kitchen at 9:24 AM and observed the following in the presence of the District Dining Manager (DM) and Director of Dining (DOD):The large walk in refrigerator had dust like debris above both fans and blackened areas with debris in both of the vents of the fans, and debris in the corner of the wall where the wall meets the ceiling.The sprinkler head on the walk in refrigerator ceiling had blackened debris. The DM confirmed the observations and the DOD stated the vents were cleaned quarterly. The ice scoop was uncovered and on a wall next to the ice machine.The ceiling vents throughout the main kitchen had visible dust like debris and darkened areas inside the vents. The DM stated, the kitchen staff were responsible to clean up until 6 feet high on the wall and not the ceiling vents. Dust like debris was observed on the wall throughout various areas on the kitchen ceiling tiles.Two stainless steel hood filters above the stove had blackened areas of debris and a nozzle over the area that dispensed a fire protection agent appeared embedded with a grease like substance. The dry storage room contained metal racks with embedded dust like debris and dust like debris was under the food storage racks. The observations were confirmed by the DM.The fryer oil was black and dark and the DM stated, it needed to be changed. Visible debris was on the floor under the fryer.The knife rack by the food preparation area was soiled with debris and the metal shelf in the same area had visible crumb like debris.The vent area was visibly soiled with debris. Under the vent area where uncovered utensils that were hanging, in that area a cob web was observed and was pulled down by the DM.The can opener insert had blackened debris on it.NJAC 8:39-17.2(g)

Based on interview and record review it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) for 1 of 3 residents reviewed for accident and incidents (Resident #22).This deficient practice was evidenced by the following:Refer to F610 On 8/25/25 at 9:30 AM, the surveyor observed Resident #22 in bed. When the surveyor inquired regarding their care, Resident #22 informed the surveyor that they had an accident with the lift machine and their Representative would be able to elaborate on the incident later. On 8/26/25 at 10:30 AM, the surveyor observed a visitor at Resident #22's bedside, the visitor informed the surveyor that two weeks ago, the resident had reported to them pain to the left shoulder after an incident that occurred during transfer with the Sit to Stand lift (STS) (a device used to transfer patients from one seated surface to another) in the bathroom. The visitor further stated that they had reported the incident to the Unit Manager. The surveyor reviewed the medical record for Resident #22. The admission Face sheet reflected that Resident #22 had diagnoses which included but were not limited to; Parkinson's disease without dyskinesia (involuntary movements of the body), heart failure, repeated falls, syncope (fainting) and collapse. A review of the admission Minimum Data Set (MDS), an assessment tool dated 7/31/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9/15 indicative of moderately impaired cognition. Resident #22 also required total assistance from staff for care. A review of Section GG of the MDS which addressed Functional Status reflected that Resident #22 was totally dependent on staff for transfers and required two-person assistance to transfer from the bed to a wheelchair. A review of the Comprehensive Care Plan initiated 7/22/25, revealed that Resident #22 had a Focus for transfer initiated 7/22/25. The goal reflected that Resident #22 would need assistance to transfer. Interventions/Tasks included, I will need a Hoyer lift for transfer assistance x 2 . Initiated 07/24/25. A review of the Accident/Incident Report, completed by the Licensed Practical Nurse (LPN#1), dated 8/14/25 and timed 18:40 PM,(6:40 PM), indicated that Resident #22's resident representative (RR) had requested to speak with the nurse related to something that happened in the room. RR reported that during the transfer in the bathroom, [Resident #22's] arm got hurt and would like LPN #1 to come to the room to see the resident. LPN #1 went to the room and Resident #22 reported that their left shoulder got hurt during the transfer with the STS lift in the bathroom. The Certified Nursing Assistant (CNA#1) who cared for Resident #22 was questioned regarding the above concerns, and she confirmed that during the STS transfer in the bathroom, the STS locked up in the mid air transfer, resulting in [both legs] buckling with lift belt sliding up toward the chest area. The physician was notified and ordered an X-ray of the left shoulder to rule out fracture. The X-ray results dated 8/14/25, indicated the following: There is a fracture at the junction of the middle and distal thirds of the clavicle.Conclusion: There is a fracture in the left clavicle which appears fairly recent. A review of the undated summary provided by the Director of Nursing (DON) did not include documentation that the New Jersey Department of Health (NJDOH) was notified of the injury of unknown origin. The X-ray report dated 8/14/25 showed a fracture of the left shoulder. A review of the Interdisciplinary notes written by the DON concluded the following, Based on the resident's history the Interdisciplinary Team (IDT) felt that the incident did not result in the fracture but exacerbated a chronic problem with the resident's left shoulder area. On 8/29/25 at 11:30 AM, the survey team asked if the incident had been reported to the New Jersey Department of Health ( NJDOH). The Licensed Nursing Home Administrator (LNHA) stated that she did not report the incident. The information that was provided by the DON did not indicate that the resident sustained an injury of unknown origin at the facility. The DON informed the survey team that the incident was not reported as the facility concluded that the fracture did not happen during the transfer, and provided no additional details. The surveyor reviewed the undated facility policy, Section G which addressed Injuries of Unknown Origin which indicated the following: An injury should be classified as an injury of unknown source when both of the following conditions are met:The source of the injury was not observed by any person or the source of the injury could not be explained by the resident.The injury is suspicious because of the extent of the injury or the location of the injury.Injuries of unknown origin should be reported immediately as soon as possible, but ought not to exceed 24 hours after discovery of the incident. If an incident or allegation is considered reportable, the Administrator or designee will make an initial ( immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within five working days. INJAC 8:39-9.4(f)

Based on interview, record review, and review of pertinent documents, it was determined that the facility failed to ensure a thorough and complete investigation was conducted, and documented for an injury of unknown origin to ensure a) when a resident reported they were hurt during a mechanical lift transfer while in the bathroom, experienced pain, and b) was diagnosed with a left clavicle fracture, to determine the root cause and implement interventions to prevent recurrence. This deficient practice occurred for 1 of 3 residents reviewed for accidents and incidents (Resident #22) and was evidenced by the following: On 8/25/25 at 9:30 AM, the surveyor observed Resident #22 in bed. When surveyor inquired regarding the resident's care, Resident # 22 informed the surveyor that they had an accident with the lift machine and their Representative (RR) would be able to elaborate on the incident later. On 8/26/25 at 10:30 AM, the surveyor observed the RR at the bedside, who then informed the surveyor that two weeks ago, Resident # 22 reported pain to their left shoulder and informed them of an incident that had occurred during the transfer with the sit to stand lift (STS- a mechanical lift used to assist with transfers) while in the bathroom. RR further stated that they then reported the incident that Resident #22 reported to the Unit Manager (Licensed Practical Nurse- LPN #1). The surveyor reviewed the medical record for Resident #22. The admission Face sheet reflected that Resident #22 had diagnoses which included, but were not limited to; Parkinson's disease without dyskinesia (involuntary muscle movement), heart failure, repeated falls, syncope (fainting) and collapse. A review of the admission Minimum Data Set (MDS), an assessment tool dated 7/31/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9/15 indicative of moderately impaired cognition. Resident #22 also required total assistance from staff for care. A review of Section GG of the MDS which addressed Functional Status reflected that Resident #22 was totally dependent for transfers, and required two-person assistance to transfer from the bed to wheelchair. A review of the Comprehensive Care Plan initiated 7/22/25, revealed that Resident #22 had a Focus for transfer initiated 7/22/25. The goal reflected that Resident #22 will need assistance to transfer. Interventions/Tasks included, I will need a Hoyer (a mechanical lift type that was different from a STS) lift for transfer assistance x 2 (2 -persons). Initiated 07/24/25. A review of the Facility's Accident/Incident Report, completed by LPN #1, dated 8/14/25 and timed 18:40 PM (6:40 PM), indicated under Incident Description: that Resident #22's RR, requested to speak with the nurse related to something that happened in the room. RR reported that during the transfer in the bathroom, [R 22's] arm got hurt and would like the nurse to come to the room to see the resident. The nurse went to the room and Resident #22, who was lying in bed with both arms across chest and stated their left shoulder got hurt during the STS mechanical transfer in the bathroom. The Certified Nursing Assistant (CNA #1) who cared for Resident # 22 was questioned regarding the above concerns, and she confirmed that during the STS transfer in the bathroom, the mechanical lift locked up in midair transfer, resulting in resident bilateral legs buckling with lift belt sliding up toward the chest area. yhe document did not identify how the resident was then transferred to bed, or by whom. Resident Description: My shoulder hurts. Was the incident witnessed: no. Immediate Action Taken: Description: Assessment of resident who is in bed, rom [range of motion] lue [left upper extremities], palpitation of lue/shoulder area, resident interview, staff interview, call to telehealth medical doctor. Order for left shoulder Xray obtained. Notification to maintenance for battery/charger heck on mechanical lifts. Injury Type: no injuries observed at time of incident. There was no documented assessment completed by a registered nurse. Predisposing environmental factors: Medical Equipment was checked. The Agencies/People Notified: 8/14/25 18:10- Physician Telehealth. An X-ray of the left shoulder to rule out fracture. The X-ray results 8/19/25, comparison: 8/14/25, indicated the following: There is a fracture at the junction of the middle and distal thirds of the left clavicle (bone from shoulder to neck) . Conclusion: There is a fracture in the left clavicle which appears fairly recent. The incident report provided by the Director of Nursing (DON) did not include statements from all staff involved with the incident. The causal factor was not identified. On 8/28/25 at 8:00 AM, the Director of Nursing (DON) provided a questionnaire filled by the Certified Nursing Assistant (CNA #1) who cared for the Resident on 8/14/25 during the 3:00 PM- 11:00 PM shift. There were no statements from the 7:00 AM-3:00 PM shift. CNA #1 used the STS Lift to transport and transfer Resident #22 alone from the bed to the bathroom. The facility was not aware that the STS Lift was being used for transport device. An interview with CNA #1 revealed that she was not asked to write a statement, she was provided with a questionnaire to complete.On 8/28/25 at 9:08 AM, the DON provided a statement from CNA #2. However, CNA #2 was not involved with the transfer.On 08/29/25 at 9:25 AM, the surveyor, in the presence of the survey team, interviewed CNA #1 about the incident with Resident #22. CNA #1 stated the RR requested that the STS and take the resident to the bathroom. CNA #1 stated she asked LPN #1, the Unit Manager for the shift, for clarification since there was a bedside commode next to Resident #22's bed (a chair type toilet) and LPN #1 then told her that per the Care Plan for Resident #22, CNA #1 had to use the STS to take Resident #22 from the recliner to the bathroom. And according to CNA #1's assignment sheet for Resident #22 they were identified as requiring a STS with one person assist. CNA #1 stated it was not the first time she used the STS by herself. When asked if she had been trained to use the STS, she stated, no. CNA #1 stated, she always thought it was one person for a STS, and two people were required for Hoyer lift. CNA #1 stated she had access to the Care Plan, but the assignment had the transfer status and CNA #1 went with that, and what LPN #1 instructed her to do. CNA #1 stated, when she was transferring Resident #22 to the toilet, and lowering them, the mechanical lift locked, and when it locked it bounced, and [Resident #22] buckled. Then, the buckle part that was around their waist went up to their chest and hurt their shoulder, and Resident #22 cannot turn in the bed, and is a big [gender redacted], and I've been saying they should be 2 persons assist. CNA #1 stated that CNA #3 came when I called for help and stated that Resident #22 cried out, stating ouch, ouch. When asked who assessed Resident #22? CNA #1 could not recall, and stated she reported what happened to the nurse immediately and LPN #1 gave both her and CNA #3 a questionnaire to fill out, and CNA #3 no longer worked at the facility. CNA #1 stated she was not asked specifically what happened or to document it. When asked if she was educated, to provide a return demonstration with the STS, she stated, no.On 08/29/25 at 11:10 AM, a follow-up interview with CNA #1 was conducted and the survey team asked if a nurse was present and assessed the resident. CNA #1 stated, the Registered Nurse (RN #1) did not assess Resident #22 after the fall and she did not come into the bathroom to assess the resident.On 8/29/25 at 11:30 AM, the DON confirmed that the investigation was not complete. When inquired regarding a statement from CNA #3, the DON stated that she attempted on 8/28/25 (14 days later) to reach CNA#3 but he would not answer the call.On 08/29/2025 at 1:29 PM, the survey team met with DON and the Director of Regional Services and shared the above, and the facility stated the STS was for transfer, not transport, and confirmed they were not aware that CNA #1 used the STS for transport. There was no Root Cause Analysis. There were no interviews available from CNA #3 and all of the staff who worked during the 3:00 PM-11:00 PM shift according to the documentation reviewed. The DON was unable to provide interviews or documented statements from all staff that were present during the incident.The surveyor reviewed the facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property) under procedure the following were documented:The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. The investigation will include:Who was involved.Residents' statement.Resident's roommate statements.Involved staff and witness statements.A description of the resident's behavior and environment at the time of the incident.Injuries present including a resident assessment.Observation of resident and staff behaviors during the investigation.Environmental considerations.All staff must cooperate during the investigation to assure the resident is fully protected.NJAC 8:39-4.1(a)5

Based on observation, interview, and record review, it was determined that the facility failed to: a.) ensure wound care was done in accordance with professional standards of practice, and b) staff were trained and followed infection control measures during wound care to prevent potential infection. This deficient practice was identified for 1 of 2 residents reviewed with pressure ulcers (Resident # 2) and was evidenced by the following: On 8/25/25 at 7:58 AM, the surveyor inquired about Resident#2's wound and the nurse confirmed that Resident #2 was admitted with a stage 3 sacral pressure ulcer. The surveyor informed the LPN that she would observe the wound care on the next day. On 8/26/25 at 11:15 AM, the surveyor observed the following wound care provided by the Licensed Practical Nurse (LPN):-The LPN entered the room to provide wound care to Resident #2 sacral wound. The LPN performed hand hygiene (HH) with soap and water, then returned to the treatment cart to collect the items needed for the wound care. -At 11:30 AM, the surveyor observed the LPN placed all the items needed on the resident's bedside table. The LPN positioned the resident to the left side to expose the area to be treated. The LPN removed and disposed of the soiled dressing in the plastic bag. The LPN did not remove her gloves, or perform HH. -The surveyor [NAME] observed the LPN cleanse the resident's sacral wound with the wound cleanser, patted the wound dry, and then without first performing HH, used the same gloves to pack the wound. The LPN then covered the wound with the absorbent dressing and ordered and repositioned the resident to the dorsal area. The LPN then, without first performing HH, used the same gloves hand to apply Vitamin A&D ointment to the resident's feet. The LPN then removed her gloves, washed her hands, and put on another pair of gloves and informed the surveyor that she had to change Resident #2's colostomy bag. The surveyor reviewed Resident #2's electronic medical record. The admission Face Sheet reflected that Resident # 2 had diagnoses which included but were not limited to; Type 2 diabetes mellitus, pressure ulcer of right hip (stage 3), and unstageable pressure ulcer of sacral region.A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/5/25 reflected that the resident was at high risk for developing pressure ulcers and had an unstageable pressure ulcer to the sacral area.The Comprehensive Care Plan initiated 7/30/25 had a focus for pressure ulcers on the sacrum, coccyx, ischium, distal plantar foot, left and right heel. The interventions included to assess and document status of wound perimeter, wound bed and healing progress. Administer treatments as ordered and monitor effectiveness. Report improvements and declines to the physician.A review of the Physician's Orders sheet (POS) for August 2025, reflected an order dated 8/26/25 for the sacral wound to be cleansed with Acetic Acid 0.25%. Apply calcium alginate and cover with silicone dressing during the day shift for ulcer. On 8/26/25 at 12:30 PM, the surveyor requested the facility wound care policy for review. On 8/26/25 at 1:48 PM, the Director of Nursing provided the clean dressing change procedure guide dated 6/13/25. The following were noted:Policy:It is the policy of this facility to provide wound care in a manner to decrease the potential for infection and/ or cross-contamination. Physician's orders will specify type of dressing and frequency of changes.Policy Explanation and Compliance Guidelines:4. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application.Place only supplies to be used per wound on the clean field at one time.Wash hands and put on gloves.Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sitesLoose the tape and remove the existing dressing.Remove gloves, Discard into appropriate receptacle.Wash hands and put on clean gloves.Cleanse the wound as ordered.Wash hands an put on clean gloves. Apply topical ointment and dressed the wound as ordered. On 8/26/25 at 2:15 PM, the surveyor reviewed the Clean Dressing Change procedure guide with the LPN in the presence of the survey team. The LPN confirmed that she did not change her gloves as indicated in the policy. The LPN stated also that she was not aware of the facility procedure guide for clean dressing change.NJAC 8:39-27.1 (e)

Based on observation, interview and document review, it was determined that the facility failed to ensure infection surveillance was implemented during a Covid-19 outbreak to limit the spread of a virus and prevent the spread of potential infections ensuring that a.) staff performed hand hygiene prior to serving meals and b.) residents were provided with opportunities to wash their hands prior to dining. This deficient practice was evidenced by the following: During the initial tour of the facility on 8/24/25 at 8:00 PM, the surveyor observed signage posted at the entrance door for all to wear a mask prior to entering the facility. The receptionist informed the team that the facility was in an outbreak of Covid19.On 8/25/25 at 11:21 AM, the surveyor met with the Infection Preventionist (IP), who confirmed the facility was in a Covid-19 outbreak which started on 7/16/25. The IP confirmed that the outbreak included 11 residents and 9 staff members who tested positive for COVID-19. The IP stated that the outbreak will be completed on 8/28/25 if no other cases were identified.The surveyor requested the facility's line listing for review which revealed 11 residents and 9 staff members had been identified. According to the document provided, the outbreak began on 7/16/25 with one staff member. The staff was symptomatic at work and presented with the following symptoms: fever, chills, and body ache. The staff member tested at the facility and was confirmed positive for COVID-19 infection.On 8/26/25 at 9:30 AM, the surveyor again requested from the IP to identify the measures that were put in place following the onset. The IP informed the surveyor that she had been on vacation at the time and the Director of Nursing (DON) would have the documents requested.On 8/28/25 at 10:30 AM, the surveyor met with the IP to request the surveillance monitoring of symptoms for three residents (Resident #20, Resident #45 and Resident #49) who were identified as positive for COVID-19. The IP stated the monitoring should include vital signs and other symptoms, such as body ache, changes in mental status, cough and gastro-intestinal symptoms, such as diarrhea, nausea and vomiting. The IP was unable to provide any symptom monitoring documents as requested. The surveyor then reviewed the Progress Notes (PN) with the IP who confirmed there was no documentation in the PN that residents had been monitored for symptoms during the COVID-19 outbreak to prevent further spread. On 08/29/2025 9:23 AM 8:10 AM, the survey team interviewed the IP about the outbreak of Covid-19. The surveyor asked what was your evidenced based guidance that the facility used for infection control/surveillance to prevent the spread of Covid-19, and the IP stated, I don't understand, and would find out and provide. Asked what were her roles, and the IP stated that infection control and other jobs as needed, when asked how many hours for IC - 20-30 hours. The IP then stated the employee worked who tested positive for Covid-19, worked and left on 7/16 and went home and tested the following day. The IP then stated, she wasn't working during the outbreak, she was on vacation until 7/28/25 and she was not involved in the outbreak management.On 8/29/25 at 8:20 AM, the surveyor interviewed the Director of Nursing (DON) who stated she became aware of the first staff testing positive on 7/17/25, but did not document it. The next morning 7/18/25 was when she had implemented wearing and told staff to wash hands. When asked about potential exposure of the Covid-19 positive staff to residents, the DON stated there had to be 15 minutes of exposure. When asked if that exposure was at one time or cumulative over multiple small amounts of time, the DON stated I don't know. When the surveyor questioned the DON regarding the testing of potentially exposed residents to the positive staff member the DON stated only after one resident had symptoms and tested positive were residents tested on day 1 day 3 and day 5. The DON further stated this was the first time I dealt with covid in this building.On 8/29/25 at 10:30 AM, during an interview with the DON, she stated there was a discrepancy on the line listing. The DON stated that the initial staff who tested positive had tested at home after their shift and not during work at the facility. However, a review of the staff member's timecard revealed the staff member had been working and then became symptomatic and tested positive for COVID prior to exiting the facility. The DON could not provide any documentation to confirm measures had been implemented from 7/17/25 to 7/20/25 to mitigate the spread of COVID-19. 2. On 8/27/2025 at 8:40 AM, the surveyor observed CNA #1 assisting Resident #20 with their breakfast meal. CNA #1 first donned gloves, adjusted the resident's bed and positioned the resident for the meal. Then using the same gloved hand opened the resident's tray, their drink, peeled their banana and set the other items on their meal tray. The resident was not provided the opportunity to wash their hands prior to eating breakfast. CNA #1 confirmed there was no hand sanitizing cloth on the resident's meal tray. CNA #1 then went to the bathroom and washed her hands under running water for five seconds.On 8/27/25 at 8:50 AM, during an interview with CNA #1, she confirmed that she washed her hands under running water. CNA #1 stated, if you want you can take your hands out of the water you can. The surveyor then asked CNA #1 if she had received an in-service on hand hygiene, she stated sometime this year but could not remember the exact date. On 8/27/25 at 10:10 AM, the surveyor interviewed the DON, in the presence of the LNHA, and inquired whether the facility had a Nurse Educator, both stated they were all responsible for the staff education.3. On 8/28/25 at 8:45 AM, the surveyor observed the meal tray delivery in the dining area. The surveyor observed CNA #2 assist residents to their tables, went to the food cart collected their trays, set up the trays, used the phone to request assistance in the dining room, returned to the food cart to retrieve more trays and failed to sanitize her hands at any time between the tasks. In addition the residents were not provided with opportunities to sanitize their hands prior to their breakfast meal.On 8/28/25 at 11:30 AM, during an interview with CNA #2, she stated residents washed their hands during morning care and confirmed hand sanitizing cloths were not provided on resident's meal trays to sanitize the resident's hands. A review of the facility provided education transcript revealed that CNA #1 and CNA #2 had completed on-line education which included but was not limited to infection control and prevention, as well as hand hygiene. When the surveyor inquired regarding the CNAs' ability to then demonstrate proper handwashing technique, the DON stated that depended on the topic and would not elaborate further. On 8/29/25 at 12:30 PM, the surveyor in the presence of the survey team informed the LNHA and the DON about the above concerns, the DON indicated that they acknowledged the concerns and staff would be re-educated.A review of the facility's outbreak response plan last revised 2/20/24 revealed the following: The Infection Preventionist actively monitors and for new and past outbreaks among residents and team members and documents positive findings ( those with suspected symptoms and positive tests) on the line list. Surveillance activity will be increased to at least daily until the outbreaks ends. Nursing team members will monitor residents every shift for early recognition of infectious disease symptoms. A review of the Infection Preventionist/ Unit Support Nurse Job Description revealed the following under Essential Function: Conducts ongoing surveillance of infection, analyses data, and identifies trends to implement targeted interventions. The facility's policy for hand hygiene last revised 5/2/25 . indicated the following: All team members will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors . alcohol based hand rub . is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. Hand hygiene technique when using soap and water: wet hands with water. Avoid using hot water to prevent drying of skin. Apply to hands the amount of soap recommended by the manufacturer. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Rinse hands with water. Dry thoroughly with a single-use towel. Use clean towel to turn off the faucet .Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, immediately after removing gloves.NJAC 8:39-19.4(e)(m)(n).

Based on observations, interviews, record review, and review of facility documents, the facility failed to provide appropriate catheter care for 1 of 2 residents reviewed for urinary catheter with Urinary (Resident #20). This deficient practice was evidenced as follows: On 8/24/25 at 8:30 PM, the surveyor observed Resident #20 in bed. The residents foley catheter drainage bag was noted to be on the left side of the bed, resting directly on the floor. The foley catheter drainage bag was not in a privacy bag.On 8/24/25 at 9:45 PM, the surveyor observed that the resident's foley catheter drainage bag was in the same position, directly touching the floor and was not in a privacy bag. Same observation verified with another surveyor. A review of Resident #20's admission Record reflected that the resident was admitted with diagnoses which included but were not limited to: depression, chronic kidney disease, and urinary retention with an indwelling (fixed in a person's body for a long period of time) catheter.A review of Resident #20's admission Minimum Data Set (MDS), a tool to facilitate the management of care, dated revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 07 which reflected that he/she was severely cognitively impaired. Normal Score 15. The MDS also reflected that the resident required extensive assistance of 1 to 2 staff for bed mobility, transfers, and toileting. In addition, the MDS reflected that the resident had a suprapubic catheter (thin flexible tube inserted directly into the bladder through a small incision in the lower abdomen to drain urine.) A review of Resident #20's Order Summary Report for August 2025 reflected a physician's order for Urinary Catheter 18 FR 10 balloon one time a day starting on the 3rd and ending on the 3rd every month for foley care change foley q 4 weeks.A review of Resident #20's Care Plan initiated 7/10/2025, reflected an order for supra pubic tube for Neurogenic bladder secondary to Benign Prostatic Hypertrophy (BPH) and Lewy Bodies. The goal was for Resident #20 will show no signs and symptoms of Urinary infection through review date. The interventions included: Change supra pubic tube as per Physician order. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Maintain Enhanced Barrier Precautions as ordered.Resident #83 not to have acute complications due to urinary catheter use. The interventions included to maintain the catheter drainage bag below bladder level, secure the catheter with a securement device, and report signs of a UTI to the physician.On 8/25/25 at 9:15 AM, the surveyor observed the resident seated in a recliner chair at the bedside. A Certified Nursing Assistant (CNA) was at the bedside assisted the resident with the breakfast meal. Upon inquiry, the CNA informed the surveyor that Resident #20 wore a leg bag during the day for ease of therapy. The surveyor went to the resident's bathroom and observed the foley catheter drainage bag stored in a plastic bag hung on the rail in the bathroom. The drainage port was not capped, and visible urine residual was noted in the bag. On 8/25/25 at 9:30 AM the surveyor interviewed the CNA regarding the storage of the foley catheter drainage bag. The CNA stated in the morning she would empty the foley drainage bag, measured the urine, rinsed the bag with water and stored the bag in the bathroom. The surveyor then inquired regarding the cleansing of the port prior to switch the bag. The CNA stated, 10 years ago it was the norm to cleanse the port, but not anymore. The CNA added upon orientation I was not informed to cleanse or cap the port.On 8/25/25 at 10:15 AM, the surveyor interviewed the Infection Control Nurse (IP) regarding the protocol for the storage of the urinary catheter drainage bag. The IP stated she preferred a closed system to prevent infection. However the facility reused the drainage bag and used a leg bag during the day. The IP stated that the CNAs were to cleanse the port before switching the bag, rinse the bag, cap and store in a plastic bag in the bathroom. The surveyor accompanied the IP in the bathroom and observed the foley catheter drainage bag stored in the bathroom with residual urine and the drainage port was not capped. During a second interview with the CNA in the presence of the IP, the CNA stated clearly, I did not know that I have to disinfect the port, I learned something today>On 8/28/25 at 2:15 PM, the surveyor interviewed the Licensed Practical Nurse assigned to Resident #20 regarding the storage of the foley catheter drainage bag. The LPN stated ,that the foley catheter drainage bag should be in a dignity bag for privacy and should not be stored with residual urine.On 8/28/25 at 2:30 PM, the surveyor interviewed CNA #2. She stated that if a resident had a foley catheter drainage bag it should have been in a privacy bag and, it should not touch the floor to avoid contamination.A review of the facility policy Catheter Care, Urinary Catheter Leg Drainage Bags with a revised date of 6/17/25, indicated the following:It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheter are in use. When assisting resident back to bed, Wash hands or use alcohol-based hand rub. Apply clean gloves.Disconnect the leg bag from catheter tubing reconnect to Foley drainage bag. Rinse, replace cap on leg bag connector, and store leg bag in plastic bag in the resident's bedside stand or designated spot in resident's bathroom. Under Infection Control it is stated: Use standard precautions when handling or manipulating the drainage system. Be sure the catheter tubing and drainage bag are kept off the floor. The policy was not being followed. NJAC 8:39-19.4 (a)5

Based on interview, record review, and review of facility documents, it was determined that the facility failed to develop person-centered comprehensive care plans for 2 of 13 residents (Resident #34 and #38) reviewed. This deficient practice was evidenced by the following: 1. According to the Face Sheet, Resident #34 was admitted to the facility with diagnoses which included, but were not limited to, paraplegia (paralysis), pressure ulcer and colostomy. The admission Minimum Data Set (MDS), an assessment tool, dated 03/05/24, indicated that the resident had severe cognitive impairment and required maximum assistance with activities of daily living. The MDS also indicated that the resident received antidepressants, had an indwelling urinary catheter, and a colostomy (an operation that redirects your colon from its normal route, down toward the anus, to a new opening in your abdominal wall). The surveyor reviewed the resident's electronic medical records (EMR) which revealed the following information: The Physician Order Sheet (POS) dated 02/28/24 reflected a physician's order Trazadone 50 milligrams (mg) tablet by mouth, give at hours of sleep for trouble sleeping. The psychiatric consult evaluation and Treat was ordered by the physician on 04/17/24 for Depression was currently pending. On 04/23/24 at 09:49 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that the resident's psychiatric consult was pending, however the resident was on the schedule for the psychiatrist to evaluate the resident for the use of antidepressant medications. The surveyor reviewed the resident's Care Plan (CP) which didn not include the use of antidepressant medication nor related interventions. On 04/23/24 at 01:27 PM, the surveyor interviewed the MDS Coordinator who stated that the initial CP was developed when the resident was admitted to the facility. She explained that by day 14 of admission, the CP was fully developed and updated continuously. She stated that psychotropic medications should be included on the CP due to risk factors of taking the medication and that behaviors associated with depression should be included in a separate CP with interventions to manage behaviors. She stated that the CP was important for goal development and risk factors. She stated that the CP directed resident care was developed by the interdisciplinary team. She continued to add that the family and resident was also involved in care planning process. On 04/24/24 at 08:32 AM, the surveyor interviewed LPN #2 who stated that if a resident was on a psychotropic medication, it should be documented on the CP with interventions to include any behaviors and important for the team members to know that the resident was on this medications and to communicate to the staff how to manage the behaviors according to the interventions. LPN #2 reviewed Resident #34's CP and confirmed that there was no documentation that the resident was on antidepressant medications and there were also no behaviors or interventions documented on the CP. On 04/24/24 at 08:36 AM, the surveyor interviewed the LPN acting Charge Nurse (LPN/CN) who stated that she had been employed in the facility for 6 years. The LPN/CN stated that the registered nurses (RNs) usually update the CP with any resident changes. She stated that the CP was interdisciplinary and was important so the staff knew what type of care the resident wanted and needed. She stated that the CP should include use of antidepressant medication and psychosocial wellbeing. She explained that the interventions should include interventions for depressive symptoms and emotional support and diversional activities and monitor their appetite. She stated that the family should also be involved in CP interventions. She confirmed that a CP was not developed for Resident #34 to include the use of antidepressant medications. 2. The surveyor further reviewed the Resident #34's EMR which revealed the following information: Review of the POS, dated 02/27/24, reflected an order from the physician for a 16 french urinary catheter for retention. Further review of the POS reflected a physician's order for colostomy check every shift and empty as needed. Review of the POS, dated 03/30/24, reflected that the resident required catheter care every shift. The surveyor reviewed the resident's CP which did not include the resident's colostomy or indwelling urinary catheter. On 04/24/24 at 09:49 AM, the surveyor interviewed the interim Director of Nursing (DON) who stated that a CP should have been developed with interventions for the colostomy and the indwelling urinary catheter. The DON stated that a CP was essential to address the resident needs and so that the staff knew what care the resident was to receive. She stated that the staff would be responsible to update that CP to address all the resident's needs and should be comprehensive for all residents. 41260 3. According to the Detailed Summary, Resident #38 had diagnoses which included, but were not limited to, urinary tract infection. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/07/24, included the resident had Brief Interview for Mental Status score of 08, which indicated the resident's cognition was moderately impaired. Further review of the MDS included the resident was frequently incontinent of urine. Review of the admission progress note, dated 02/29/24 at 6:01 PM, included the resident was taught to increase fluid intake due to being on an antibiotic for a urinary tract infection (UTI). Further review of a progress note, dated 02/29/24 at 8:07 PM, included the resident was incontinent of urine. Review of the care plan, dated 03/26/24, did not include the resident was incontinent of urine with a history of UTI nor related interventions. During an interview with the surveyor on 04/24/24 at 9:45 AM, the Certified Nursing Assistant, (CNA), stated that she performed incontinence rounds every two hours or as needed in order to prevent UTIs and skin breakdown. She further stated that Resident #28 wore incontinence briefs for periods of incontinence. During an interview with the surveyor on 04/24/24 at 9:50 AM, the Licensed Practical Nurse (LPN #3) stated incontinent residents were changed twice a shift and as needed to prevent UTIs and skin breakdown. She further stated that the Charge Nurse was responsible for initiating care plans and that it was important for the care plan to be comprehensive for proper care of the resident. During an interview with the surveyor on 04/24/24 at 10:00 AM, the LPN/Charge Nurse (LPN/CN) stated incontinent residents were changed every two hours and as needed. The LPN/CN further stated that the interdisciplinary team initiated the care plan upon admission so staff know how to care for the resident. During an interview with the surveyor on 04/24/24 at 10:07 AM, the Director of Nursing (DON) stated interventions to prevent UTIs included offering fluids. The DON further stated the admission nurse initiated the resident care plans within 24 hours and the comprehensive care plan was completed within 14 days of admission. The DON added that it was important that the resident's care plan was comprehensive because it is available to all those involved in the care of the resident, and, the care plan is an overview of the resident's needs. Review of the facility's Comprehensive Care Plans policy, dated 01/09/24, included, The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment, and, The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. NJAC8:39-11.2 (f)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order for oxygen therapy and develop a care plan for respiratory care. This deficient practice was identified for 1 of 1 resident (Resident #43) reviewed for respiratory care. This deficient practice was evidenced by the following: On 04/22/24 at 07:37 AM, during the initial tour the surveyor observed Resident #43 lying in bed sleeping receiving oxygen (O2) via nasal cannula. On 04/23/24 at 11:01 AM, the surveyor observed Resident #43 lying in bed watching TV. At that time, the surveyor interviewed the resident who stated that she received oxygen three (3) liters/minute (3 L/M) via nasal cannula and that the staff change the tubing but was not sure how often it was changed. The surveyor reviewed the medical record for Resident #43. A review of the Admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease with (acute) exacerbation (COPD- airway blockage with breathing related problems and worsening respiratory symptoms such as shortness of breath -SOB), pneumonia, and dependence on supplemental oxygen. A review of the significant change in status Minimum Data Sheet (MDS), an assessment tool, dated 4/12/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. A further review of the MDS in Section O: Special Treatments, Procedures and Programs reflected the resident received continuous oxygen therapy. A review of the April 2024 physician's orders (PO) did not include any orders for oxygen therapy. A review of the discontinued PO indicated, as of 3/21/24, the following orders were discontinued: -Change and date humidifier bottle every Tuesday night. -Change and date O2 nasal cannula/mask (tubing from humidifier bottle to resident) every Tuesday night. -Oxygen 2 liters/minute (L/M) via nasal cannula continuously; SOB. A review of the individualized Care Plan revealed there was no developed care plan for respiratory care. On 04/23/24 at 01:00 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated they had POs for oxygen to ensure they administered the appropriated amount of oxygen. She further stated they checked every shift to ensure the L/M matched the order. The LPN stated that the tubing was changed during the 11 PM to 7 AM shift and that she never had to change it but believed the tubing was changed every 72 hours. The LPN stated that there were POs in the electronic medical record (EMR) for the tubing to be changed, for how many L/M, and if continuous or PRN (as needed). The LPN emphasized there should be an order for O2 prior to administering to ensure the resident was properly assessed. When asked if respiratory care should be on the care plan, the LPN stated that most of the time it would be on the care plan. She further stated that when she completed her new admissions, she updated the care plan to reflect if the oxygen was continuous, PRN, and how many L/M. The LPN stated that the care plan was important so that staff was aware on how to care for the resident. On 04/23/24 at 01:10 PM, the surveyor interviewed the Registered Nursed (RN) who stated that everyone who received oxygen had an order for it. She further stated that oxygen should also be on the care plan. The RN stated that the Charge Nurse (CN) was responsible for entering the POs in the EMR. She stated that the importance of an order was so it could be administered. The RN emphasized, you can't administer oxygen without an order. She further stated that the order also indicated how many liters the oxygen should be set to and if it was continuous or PRN. The RN stated that the CN or the MDS Coordinator was responsible for updating the care plan. She stated that the care plan tells the resident's plan of care, interventions, and goals for that specific resident. The RN concluded that there should be a PO for oxygen and that it should be on the care plan so everyone knew what to do. On 04/24/24 at 11:29 AM, the surveyor conducted a follow up interview with the RN who showed the surveyor the Low Side Census Nurse's Flow Sheet which indicated Resident #43 was on oxygen. She stated that the flow sheet did not indicate the number of liters because it could change. The RN reviewed the orders in the EMR with the surveyor which revealed that all the oxygen orders were entered as new and to start that day 4/24/24. On 04/24/24 at 11:48 AM, the surveyor interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN) who stated that one of the nurses had just entered the oxygen orders to start today. The LPN/CN stated that she reviewed the PO as well as another nurse, but they could not find any oxygen orders. When asked if there should be orders for oxygen, the LPN/CN stated, absolutely there should be an order for oxygen. She further stated that it was important to have orders, so everyone was aware that the resident was on oxygen. The LPN/CN stated, I'm just disappointed. She explained the resident was sent out to the emergency room in March and was on oxygen then and returned to the facility 04/05/24 on oxygen. She further explained that everything should be checked on the 11 PM to 7 AM shift to ensure that all the orders were entered. Upon further review, the LPN/CN stated that the order did not indicate how many L/M and stated that the order would have to updated to include the number of L/M. On 04/24/24 at 11:56 AM, the LPN/CN and surveyor reviewed the Care plan in the EMR. The LPN/CN stated she did not see anything related to respiratory care. She stated that the care plan told the story of the resident, why they were there, what care should be provided and what they were at risk for. She further stated that all departments such as nursing, dietary, therapy, and activities could update the care plan because everyone was involved in the care. The LPN/CN acknowledged that oxygen should be on the care plan that there should have been POs for oxygen prior to surveyor inquiry. On 04/24/24 at 12:05 PM, the surveyor interviewed the Interim Director of Nursing (DON) who confirmed that the resident did not have any oxygen orders prior to surveyor inquiry. The Interim DON stated, of course the resident should have orders for oxygen. She stated they completed an audit on oxygen and care plans last week. She further stated that the resident slipped through the cracks. She acknowledged the nurses entered the orders today 4/24/24 for changing the oxygen tubing and the continuous oxygen 2 L/M via nasal cannula. She explained it should be in the EMR and the nurses should be signing it off. On 04/24/24 at 12:13 PM, the surveyor continued to interview the Interim DON who stated that a care plan addressed specific problems that the resident may have or the potential problems as well as interventions put into place to resolve those problems. She explained for example Respiratory care is the problem, and the intervention would be oxygen which should be on the care plan. The Interim DON stated that the care plan should be implemented on admission and updated whenever there was a change. The DON acknowledged the orders and care plan should have been updated prior to surveyor inquiry. On 04/26/24 at 09:14 AM, the Licensed Nursing Home Administrator (LNHA) acknowledged in the presence of the Interim DON, the Director of Plant Operations, and the survey team that the care plan and the orders should have been updated prior to surveyor inquiry. A review of the facility's Oxygen Administration policy, dated reviewed 12/23/2019, included, A practitioner's order is required to initiate oxygen, except in an emergency situation, when oxygen therapy is ordered an order will also be entered to change all disposable components weekly. A review of the facility's Comprehensive Care Plans policy dated revised 1/9/24, included, to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing .needs that are identified in the resident's comprehensive assessment. A review of the facility's Care Plans - Updating for Status Change policy dated revised 1/9/24, included, 1. The comprehensive care plan will be reviewed, and revised or updated as necessary, when a resident experiences a status change. 2. C. The care plan will be updated with the new or modified interventions accordingly. F. The Charge Nurse/Nurse designee and, or other team member who updated the care plan will coordinate that all care plan intervention updates are communicated to team members involved in the resident's care. NJAC 8:39- 19.4(a); 27.1(a)

Based on interview and record review, it was determined that the facility failed to evaluate the performance of all Certified Nursing Assistants (CNAs) on an annual basis. This deficient practice occurred with 2 of the 5 CNAs whose personnel records were reviewed and was evidenced by the following: On 04/24/2024 at 10:48 AM, the surveyor reviewed the employee files of 5 randomly selected CNAs which were provided by the facility. The surveyor identified the following: CNA #1 had a hire date of 02/20/19. According to CNA #1's personnel record, the last documented performance appraisal was 05/27/22. There were no annual performance reviews conducted within the past year. CNA #2 had a hire date of 07/26/21. According to CNA #2's personnel record, the last documented performance appraisal was 12/16/22. There were no annual performance reviews conducted within the past year. During an interview with the surveyor on 04/24/24 at 12:05 PM, the Licensed Nursing Home Administrator (LNHA) stated she had been employed at the facility for the last four months. The LNHA stated that performance appraisals should be done annually. The surveyor then showed the LNHA the personnel records of CNA #1 and CNA #2 and confirmed that their performance appraisals were not completed annually. During a follow up interview with the surveyor on 04/25/2024 at 10:02 PM, the LNHA stated that the Director of Nursing (DON) was responsible for performance appraisals and the Human Resource (HR) Manager was responsible to send a list of performance appraisals that were due to the DON. During an interview with the surveyor on 04/25/24 at 10:10 AM, the HR manager stated that the performance appraisals should be completed on the anniversary date of the date of hire. The HR Manager stated he had sent the prior DON several email reminders to complete the performance appraisals. A review of the facility policy titled, Performance Appraisal, undated, indicated that a performance appraisal measures and evaluates an individual team member's performance and accomplishments over a period of time. Typically, supervisors will complete performance appraisals as follows: a) at the end of the orientation period, b) annually, and c) when considering a team member for promotion. The policy further revealed that a performance appraisal system should be on-going, and in no case should evaluations be given less than once a year. NJAC 8:39-43.17(b)

Based on interview and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services, or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing or contracting with individuals or entities that meet either of the following conditions: (i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act. (ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76 (d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes: (1) Within 30 days - (i) A change of ownership; (ii) Any adverse legal action; or (iii) A change in practice location. (2) All other changes in enrollment must be reported within 90 days. On [DATE] at 9:00 AM, the surveyor reviewed the facility's Long-Term Care Facility Application for Medicare and Medicaid (form CMS-671) which reflected under name of facility as Skilled Nursing Home at Pines Village. At that time, the surveyor requested additional information and the Licensed Nursing Home Administrator (LNHA) provided the New Jersey Department of Health (NJDOH) Division of Certificate of Need & Licensing documents which indicated Skilled Nursing at Pines Village; Effective: [DATE]; Expired [DATE], and Issued: [DATE]. The LNHA stated that she knew it used to be named [NAME] Place at the Pines at [NAME] prior to the name change. On [DATE] at 9:52AM, the LNHA stated she started at the facility four (4) months ago and to her knowledge the facility was named Skilled Nursing at Pines Village. She stated in her files she had where an application was submitted but needed to look for the approval letter. At that time, the LNHA provided a letter which indicated the NJDOH confirmed they were in receipt of the documents reflecting [DATE] as the completion date for the final transfer of ownership of [NAME] Place at the Pines at [NAME]. It further included the new facility name was Skilled Nursing at Pines Village and that the transfer of ownership approval was in transaction. The surveyor asked if there was any additional information of the approval from CMS and not just from the NJDOH and the LNHA stated she would continue to look it in her files. On [DATE] at 10:23 AM, the surveyor inquired if the Medicare Enrollment Application for institutional Providers application (form CMS 855A) was completed and submitted and the LNHA stated she would have to find out. On [DATE] at 12:51 PM, the surveyor followed back up with the LNHA who stated that she was still waiting to hear back from the corporate office regarding the licensing. On [DATE] at 09:54 AM, the LNHA confirmed that the CMS 855A application was not submitted. She stated that the business office was in the process of completing it today [DATE]. The LNHA acknowledged that the CMS 855A application should have been done prior to surveyor inquiry. On [DATE] at 09:06 AM, the LNHA provided an email from the business office that the Medicare Enrollment Application was submitted on [DATE]. On [DATE] at 09:14 AM, the LNHA acknowledged in the presence of the Interim Director of Nursing, the Director of Plant Operation, and the survey team that the application should have been completed and received approval from CMS prior to the name change. A review of the facility's Name Change for the Entity policy, dated [DATE], included, Notify the state in which your business operated and any other agencies. File the official name change with the IRS [Internal Revenue Service]. Update permits and licenses with regulatory agencies. NJAC 8:,d+[DATE].1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain ongoing records of communication between the nursing facility and the [CONDITION(S)] center. This deficient practice was identified for 1 of 1 resident (Resident #25) reviewed for [CONDITION(S)] and was evidenced by the following: On 2/3/22 at 10:22 AM, the surveyor interviewed Resident #25 who stated that he/she received [CONDITION(S)] services every week on Monday, Wednesday, and Friday. The surveyor reviewed the medical record for Resident #25. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility in February of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's most recent significant change Minimum Data Set (MDS), an assessment tool dated 12/3/21, reflected a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated a moderately impaired cognition. A further review of the MDS Section O. Special Treatments, Procedures, and Programs; reflected that the resident received [CONDITION(S)] treatments. A review of the resident's individualized care plan initiated on 2/27/21, included a problem for self care deficit related to [CONDITION(S)] with an approach for [CONDITION(S)] Mondays, Wednesdays, and Fridays. On 2/8/22 at 10:19 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the facility's procedure for communication with the [CONDITION(S)] center. The LPN stated that the resident's [CONDITION(S)] book went to and from the [CONDITION(S)] center with the resident on [CONDITION(S)] days. The [CONDITION(S)] center obtained the pre and post [CONDITION(S)] vital signs and weights when the resident arrived at the center and prior to leaving the center. This was documented on the [CONDITION(S)] Communication Flow Sheet along with any new orders or recommendations for the resident that was located in the resident's [CONDITION(S)] communication book. If no communication sheet was completed for that day, the nurse would call the [CONDITION(S)] center to obtain the resident's vital signs, weights, and any new orders or recommendations and documented it in the Nurse's Notes. At this time, the surveyor with the LPN and Unit Secretary reviewed the Resident #25's [CONDITION(S)] communication book which revealed that there were only three [CONDITION(S)] communication flow sheets the month of January (1/5/22, 1/7/22, and 1/10/22). On 2/8/22 at 1:01 PM, the surveyor interviewed the Director of Nursing (DON) regarding the facility's procedure for the [CONDITION(S)] communication flow sheets upon the resident's return to the facility from [CONDITION(S)]. The DON stated that the flow sheets should be used for communication and placed in his/her [CONDITION(S)] book. The DON further stated the vital signs and weights should be documented, and the communication sheets should also be checked for new orders from the [CONDITION(S)] center. The DON confirmed that the resident brought the book each time he/she went to [CONDITION(S)] and returned to the facility. On 2/9/22 at 10:02 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, confirmed that the resident's [CONDITION(S)] communication book was not complete for January. The DON could not speak to how many [CONDITION(S)] flow sheets were missing or how many days the resident went to [CONDITION(S)] in January. On 2/9/22 at 10:43 AM, the surveyor interviewed the 3-11 shift Registered Nurse/Charge Nurse (RN/CN) who stated that one of the nurses would be responsible for checking the resident's [CONDITION(S)] communication flow sheets upon their return to the facility for weights, vital signs, and any new orders. The RN/CN stated that the importance of the communication sheets was to inform the facility about the resident's diet; how the resident responded to [CONDITION(S)]; and any new orders that were recommended. The RN/CN stated that he used to check the communication flow sheets, but because the facility was short staffed, he had not been able to in quite a while. On 2/9/22 at 10:43 AM, the surveyor reviewed with the DON, Resident#25's January 2022 Treatment Report which indicated that the resident received thirteen [CONDITION(S)] treatments in the month of January. A review of the facility's [CONDITION(S)] Resident Care policy dated revised 6/29/19, which included: The facility's staff will communicate via phone or in the communication book any current issue, depending upon the urgency. This communication will help to offer the resident continuum of care and positive outcomes in their wellness . The facility charge nurse/designee will review the communication log pre and post the resident's hemodialysis (HD) treatment. If any logged communication is received from the [CONDITION(S)] center upon the resident's return, the nurse is requested to initial the entry, follow the recommendations or comment if any, and document in the nursing notes, if indicated. NJAC 8:39 - 27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to ensure backup medications were available for use for a newly admitted resident. This deficient practice was identified for 1 of 2 Residents (Resident #36) reviewed for thirty-day new admission and was evidenced by the following: On 2/3/22 at 11:04 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the High side medication cart. Located in the top drawer of the medication cart, was a zip top bag with insulin [MEDICATION(S)] inside. On the label outside of the bag, was Resident #25's printed name that had been scratched out in pen and Resident #36's name had been handwritten in. There was no name on the insulin [MEDICATION(S)] pen located inside the bag. On 2/3/22 at 11:28 AM, the surveyor interviewed the LPN who stated that when insulin pens came in from the pharmacy labeled with the resident's name or as facility backup, they were stored in the medication room refrigerator until they were opened. Then when we needed them, we took them out of the refrigerator and dated them. When the surveyor asked why the bag had Resident #25's name crossed out and Resident # 36's name handwritten on instead, the LPN responded that probably Resident #36 needed insulin and the facility did not have the resident's insulin or a facility backup supply of the insulin, so a nurse used Resident #25's unused backup pen from the refrigerator. She stated that Resident #25's insulin [MEDICATION(S)] had been discontinued so the nurse probably took their unused insulin and used it as backup for Resident #36. The LPN further stated since Resident #36's pen was never opened, it was okay to use that one for Resident #25, but it would never be okay to use another person's opened insulin pen on anyone else because it was contaminated. On 2/3/22 at 11:49 AM, the surveyor re-interviewed the LPN who stated that when a new resident was admitted to the facility, the pharmacy orders were put in the computer and were automatically sent to the pharmacy. She further stated the facility had backup medications to be used right away, if needed, and insulin was one of those medications because we cannot delay medications for a diabetic. The LPN stated the pharmacist reviewed the backup stock medications. The surveyor reviewed the medical record for Resident #36. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility in January of 2022 with diagnoses which included [CONDITION(S)], acute kidney failure, and generalized muscle weakness. A review of the admission Minimum Data Set (MDS), an assessment tool dated 1/16/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated a moderately impaired cognition. A review of the February 2022 Physician Orders (PO) reflected a PO dated 1/10/22, for insulin [MEDICATION(S)] 100 unit/milliliter (unit/mL) subcutaneous pen; 3 units subcutaneous three times a day for Type II diabetes mellitus. A review of the corresponding January 2022 electronic Medication Administration Record (eMAR) reflected that the resident received their first dose of insulin [MEDICATION(S)] on 1/10/22 at 4:30 PM. The surveyor reviewed the medical record for Resident #25. A review of the Face Sheet reflected that the resident was admitted to the facility in February of 2021 with diagnoses which included type II diabetes mellitus, [CONDITION(S)], and heart failure. A review of the January 2022 eMAR, reflected a PO dated 6/11/21 with an end date of 1/25/22, for insulin [MEDICATION(S)] 100 unit/mL subcutaneous pen. On 2/3/22 at 12:33 PM, the surveyor interviewed the Director of Nursing (DON) who stated that it was brought to her attention in the past few days that some nurses were not receiving medications that were refilled from the Provider Pharmacy. The DON stated that she was just beginning to investigate the concern, and that she was unsure if medications were not being received because the nurse was faxing the PO instead of electronically sending the PO to the Provider Pharmacy. When questioned, the DON responded that if the nurse did not have a resident's medication, then the nurse should call the resident's physician to see if the resident could have an alternative medication or to hold that medication dose until it was received. The DON stated that the nurse should not borrow the medication from another resident. At this time, the surveyor showed the DON Resident #36's insulin [MEDICATION(S)] pen and packaging with Resident #25's name crossed out. The DON confirmed that the nurse should not have taken Resident #25's backup insulin pen to use for Resident #36 and would look into it. On 2/3/22 at 1:29 PM, the surveyor interviewed the facility's Provider Pharmacy Representative (PPR) who stated that the facility had both resident specific medications as well as a backup medication supply that was not resident specific. If the facility had a backup supply of a certain medication, the facility could administer the backup supply medication to their resident. The PPR stated that the pharmacy delivered medications to the facility in the afternoon and in the evening. The facility could also receive a STAT order (immediate) that would arrive from the pharmacy to the facility within two hours. The PPR stated that insulin [MEDICATION(S)] should be in the facility's backup supply. On 2/3/22 at 1:43 PM, the surveyor interviewed the Provider Pharmacist (PP) who stated that when the nurse used a facility backup medication, the nurse would either send an electronic order or fax a slip to the pharmacy to replace the medication. The PP stated that Monday through Friday, the pharmacy delivered medications two times a week, and on the weekends, they delivered one time. The facility could also do a STAT order in an emergency which that medication would arrive to the facility within two hours. At this time, the surveyor requested all pharmacy deliveries for Resident #36's insulin [MEDICATION(S)]. On 2/3/22 at 3:33 PM, the surveyor interviewed the facility's Consultant Pharmacist (CP) who stated that a nurse should not borrow medication from one resident to another because it was a safety concern. The CP stated that if the medication was not available at the time of administration, the nurse should call the pharmacy to see when the medication would arrive at the facility and then call the resident's physician to let them know the medication was not currently available to determine what the physician recommended to do. A review of the Provider Pharmacy's Delivery Manifest dated 1/11/22, reflected that Resident #36's insulin [MEDICATION(S)] arrived at the facility on 1/11/22 at 12:27 AM. On 2/4/22 at 11:26 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), informed the survey team that she spoke with the Registered Nurse (RN) who stated that she borrowed Resident #25's unused backup insulin [MEDICATION(S)] pen on 1/10/22 for Resident #36 because the resident was admitted to the facility that day and was due for their 4:30 PM insulin [MEDICATION(S)] dose. The DON acknowledged that even in an emergency, a nurse should never borrow medication from another resident. On 2/4/22 at 12:38 PM, the surveyor observed the resident in their room in bed sitting up and finishing their lunch meal. The resident stated he/she was a diabetic and had to recently been prescribed insulin before meals and at bedtime because their blood glucose had been very high. When the surveyor inquired if the resident had missed any doses of insulin, the resident responded that they had never missed a dose of insulin and had not been told there was any problem obtaining their medications from the pharmacy. A review of the facility provided Medication Administration Guidelines dated revised October 2017, included medications will be administered in a safe and accurate manner. A review of the facility provided Dispensing/Receiving Medications Back Up Insulin policy dated revised 4/8/16, included .the pharmacy will provide an emergency supply of insulin pen(s)/vial(s) in a zip lock bag labeled Emergency Refrigerator Insulin to be on specific nursing units and kept in medication refrigerator until needed .once the pen or vial has been assigned to a specific resident, the nurse will complete an Emergency Refrigerator Insulin Form which pharmacy has affixed to the outside of the refrigerator and will fax to the pharmacy .Emergency Refrigerator Insulin .insulin [MEDICATION(S)] 3 mL pen. A review of the facility provided Dispensing/Receiving Medications policy dated effective November 2010, included policy: the pharmacy will provide the facility with a supply of medications to be used in an emergency situation or until the pharmacy delivery is received .the nurse will document any medication removed or replaced in the backup box by filling out the Backup Log Form located in the backup box log book .the nurse will complete and fax the Backup Box Medication Replacement Form and fax to the pharmacy to receive the replacement medications .the backup box contents will be inventoried monthly for expirations, par levels, and integrity of packaging by the pharmacist consultant, facility, and/or pharmacy representative. NJAC 8:39-29.2(d); 29.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to a.) properly label and date insulin pens once opened and removed from the refrigerator, b.) remove discontinued medication from active inventory, and c.) ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 form) were completed with sufficient detail to enable accurate reconciliation. This deficient practice was identified on 2 of 2 medication carts observed and for 3 of 3 provided DEA forms. The evidence was as follows: 1. On 2/3/22 at 11:04 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1) inspected the High side cart and found six zip top bags each containing one opened and undated insulin pen (medication used to regulate blood sugar). Further inspection of the bags revealed the following: Resident #22's insulin [MEDICATION(S)] pen and [MEDICATION(S)] pen were labeled with the resident's name but not the date the pen was opened. Resident #36's insulin [MEDICATION(S)] and insulin [MEDICATION(S)] pens had no name on the syringes and no date indicating the date the pens had been opened. Resident # 39's insulin [MEDICATION(S)] pen and insulin [MEDICATION(S)] were labeled with the resident's name but not the date the pen was opened. On 2/3/22 at 11:28 AM, the surveyor interviewed LPN #1 who stated when the insulin pens were received from the pharmacy, they were stored in the medication room medication refrigerator until it was needed. When the insulin pen was needed, it was then removed from the refrigerator, and the nurse dated both the pen and the bag with the date opened in case the pen and bag were separated. On 2/3/21 at 12:41 PM, the Director of Nursing (DON) stated when insulin pens were in use, they should be stored in the medication cart in a zip top bag. The pen should have both the resident's name and the date it was opened on it. The surveyor reviewed the above residents' medical records. A review of Resident #36's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #22's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #39's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/3/22 at 3:31 PM, the surveyor interviewed the facility's Consultant Pharmacist (CP) who stated, one of her roles at the facility is to review mediation carts. She stated that she checked for expiration dates on mediations and ensured mediations that required dating were dated. A review of manufacturers recommendations revealed insulin [MEDICATION(S)] and insulin [MEDICATION(S)]'s expiration upon opening or removing from refrigerator was 28 days and [MEDICATION(S)] ([MEDICATION(S)]) pens should be discarded after 30 days. 2. On 2/3/22 at 2:39 PM, the surveyor in the presence of another surveyor and along with LPN #2, reviewed the insulin pens located on the Low side medication cart. Inspection revealed an opened insulin [MEDICATION(S)] pen for Resident #25. Upon further interview, LPN #2 confirmed the insulin [MEDICATION(S)] order had been discontinued on 1/25/21. The surveyor reviewed the medical record for Resident #25. A review of the Admission Record indicated the resident was admitted to the facility in February of 2021 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/3/22 at 3:31 PM, the surveyor interviewed the facility's Consultant Pharmacist (CP) who stated that one of her roles at the facility was to review mediation carts. The CP stated that discontinued medications should be removed from the cart and active inventory. On 2/9/22 at 10:02 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, acknowledged that discontinued medications should not be stored in active inventory. 3. On 2/8/22 at 10:24 AM, the surveyor reviewed the facility's DEA 222 forms which revealed that the facility did not complete the number of packages received or the date the medication was received as instructed to on the reverse of the DEA 222 form. The inaccuracies were as follows: Order Form: # 2118, No number received, No date received. # 2118, No number received, No date received. # 7467, No number received, No date received. On 2/8/22 at 12:49 PM, the surveyor interviewed the DON who stated one of the responsibilities of the DON was to complete the DEA 222 forms. The DON stated she had verified with the provider pharmacy that the facility only ordered narcotics three times. The DON stated she was unaware she had not completed the form as required. Upon review, the DON acknowledged that she had not completed the portion of the form that indicated when she had received narcotic mediations and that she should have filled in the quantity received as well as the date the medication was received. A review of the instructions for submission of the DEA 222 form (August 2011) located on the reverse of the form revealed 2 . (When items are received, the date of receipt and the number of items received must be recorded in the spaces provided on the triplicate copy.) A review of the undated facility provided policy from the provider pharmacy titled Medication Administration guidelines, Insulin Pens, Policy 76.3 a, included: . 2. Insulin pens and multidose vials are labeled with patient name and medication name as follows: If only one pen is being dispensed: A small auxiliary label is placed on the body of the pen indicating resident's name, mediation name, and prescription label. The pen is placed in a zip top bag and the prescription label listing full patient and medication information is placed on the bag . 5. Storage of Insulin . Once opened, insulin pens may be stored in med carts and must be labeled with 'date opened' and using manufacturer recommendation for number of days for room temp storage, discard date. A review of the facility provided policy from the provider pharmacy titled Disposition of Medications, Medication Storage, Policy 7.1 with an effective date of November 2010, included: 8. Medication and treatment carts must only store medications that are currently ordered by the physician. The nurse must remove any medication that has been discontinued. Facility provided policies did not include the completion of the DEA 222 form once the medication was received by the pharmacy. NJAC 8:39-29.7(c); 29.4(h)

Based on observation, interview, and review of pertinent facility records it was determined that the facility failed to implement infection control protocols in a manner that would decrease the possibility of the spread of infection by a.) performing hand hygiene in accordance with the Center for Disease Control and Prevention and facility policy and b.) maintaining a resident's urinary catheter bag off the floor. This was observed with 1 of 3 residents (Resident# 12) reviewed for indwelling urinary catheter and evidenced by the following: 1. On 2/8/22 at 10:41 AM, the surveyor observed the Certified Nurse Aide (CNA) preparing to provide care for Resident #12. The CNA performed hand hygiene, lathering with soap outside the flow of running water for three seconds prior to rinsing with water. At this time, the surveyor interviewed the CNA regarding the facility's policy for hand hygiene. The CNA responded that you wet your hands with water, then lathered your hands with soap applying friction outside the flow of water for ten seconds, then rinsed your hands off with water. The CNA then proceeded to don (put on) gloves and gather bathing supplies for the resident's bed bath. On 2/8/22 at 10:50 AM, the surveyor observed the CNA doff (remove) her gloves and perform hand hygiene. The CNA applied soap to her hands, then without rubbing hands together to apply friction, immediately rinsed the soap under running water, and dried her hands. At this time, the surveyor re-interviewed the CNA regarding the hand hygiene policy and the ten seconds she stated that you lathered your hands with soap applying friction outside the flow of running water. The CNA responded, supposed to be ten seconds, and that's what you're supposed to do. On 2/8/22 at 1:08 PM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team, confirmed that the CNA performed hand hygiene inappropriately. The DON stated that when performing hand hygiene with soap and water, you lathered your hands with soap applying friction outside the flow of running water for twenty seconds prior to rinsing Review of the facility's Hand Hygiene policy dated 11/13/2020 included: Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water . 2. On 2/3/22 at 10:56 AM, during initial tour of the facility, the surveyor observed Resident #12 resting in bed with the indwelling catheter (an urine collection devise) urinary drainage bag without a privacy bag (a covering over the urinary collection bag) lying directly on the floor under the bed. The surveyor reviewed the medical record for Resident #12. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility in November of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the February physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/8/22 at 10:28 AM, the surveyor observed the resident in with the indwelling catheter urinary drainage bag without a privacy bag lying directly on the floor under the bed. On 2/8/22 at 10:28 AM, the surveyor interviewed the CNA regarding catheter care who stated that she usually emptied the urinary drainage bag and reported any concerns observed to the nurses. At this time, the CNA accompanied the surveyor into Resident #12's room and observed the urinary drainage bag lying on the floor. The CNA confirmed that the urinary drainage bag should not be on the floor because it was an infection control issue. On 2/8/22 at 11:04 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #12 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated that if the urinary drainage bag was found on the floor, it should be emptied, and replaced with a new one for infection control purposes. The LPN stated the resident would absolutely be at risk for infection if the collection bag was lying on the floor. On 2/8/22 at 11:15 AM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN) who stated that the urinary drainage bag must be kept off the floor for infection control. On 2/9/22 at 10:02 AM, the DON in the presence of the LNHA and survey team, acknowledged that the urinary catheter bag should not be on the floor. Review of the facility's current undated Policy for Foley Catheter Care did not include infection control practice for catheter maintenance and/or bag placement. NJAC 8:39-19.4

Based on observation, interview and record review it was determined that the facility failed to address the risk of infection to residents during a.) the provision of a wound care treatment for 1 of 1 nurses observed, b.) medication administration for 1 of 2 nurses observed, and c.) sanitization of kitchenware observed for 1 of 1 Dietary Aid. This deficient practice was evidenced by the following: 1. During the initial tour on 10/28/19 at 9:34 AM, the surveyor observed Resident #5 lying on an air mattress (mattress designed to prevent and treat pressure wounds). When interviewed, Resident #5 was confused and unable to provide answers to questions regarding wound care treatments. Review of the annual Minimum Data Set (MDS), an assessment tool used in the management of care, dated 10/02/19, reflected that the resident was severely cognitively impaired, incontinent, required extensive assist of two persons for bed mobility, and had impairment to the upper and lower extremities on both sides. The MDS further revealed that Resident #5 had been identified as being at risk for developing pressure ulcers and had a facility acquired pressure ulcer at that time. The MDS noted that skin and ulcer treatments were in place and included the use of pressure reducing devices on the wheelchair and the bed, pressure ulcer care, and application of ointment/medications. On 10/30/19 at 10:30 AM, the surveyor observed Licensed Practical Nurse (LPN #1) complete the sacral wound dressing change for Resident #5. The surveyor observed LPN #1 don two pairs of gloves prior to starting the wound treatment. LPN #1 cleansed the wound and discard the dirty gauze into the trash. The surveyor observed that LPN #1 did not remove her gloves or perform hand hygiene. LPN #1 then picked up a pair of scissors and wiped them down with an alcohol swab for approximately 10 seconds with the same pair of gloves. The surveyor observed that LPN #1 did not remove her gloves or perform hand hygiene. LPN #1 then cut a piece of silver alginate (an antimicrobial wound dressing used for managing non-infected chronic wounds), inserted the piece of silver alginate into Resident #5's sacral wound, and applied Calmospetine (moisture barrier cream) on the skin around the sacral wound opening while wearing the same pair of gloves. LPN #1 then removed the top pair of gloves and applied an abdominal pad (a highly absorbent dressing that provides padding and protection for large wounds) (ABD dressing) over Resident #5's sacral wound opening. LPN #1 then removed the second pair of gloves and performed hand hygiene. During an interview with the surveyor on 10/30/19 at 10:40 AM, LPN #1 stated she dons two pair of gloves so she could apply the clean dressing. LPN #1 further stated that sometimes the ointment gets on her gloves, so she removes the top pair of gloves before she applies the ABD dressing. During an interview with the surveyor on 11/01/19 at 10:34 AM, in the presence of the Administrator and another surveyor, the Infection Control Nurse (ICN) stated the use of double gloves was not part of their facility practice. The ICN confirmed that nurses were supposed to remove gloves and wash hands after cleansing the wound. During a follow up interview with the surveyor on 11/01/19 at 11:25 AM and in the presence of ICN and another surveyor, LPN #1 stated that hand hygiene was performed prior to starting the wound treatment, after removing the old dressing, and after the treatment was completed. LPN #1 stated she would also perform hand hygiene after cleansing the wound and don a fresh pair of gloves prior to continuing the treatment. LPN #1 further stated that she thought she had performed hand hygiene after cleansing Resident #5's wound. The surveyor reviewed the facility's undated Wound Care Procedure for Major Wounds policy provided by the Director of Nursing (DON.) The policy revealed under the Procedure section to cleanse scissors for 60 seconds of contact with alcohol then wash hands and don clean gloves. The policy further revealed to remove gloves and don clean gloves after cleansing the wound. The surveyor reviewed the facility's undated Procedure for Clean Dressing Technique policy provided by the ICN. The policy reflected to cleanse wound using no-touch technique, remove gloves, perform hand hygiene, and apply clean gloves prior to applying any medication ordered. 2. On 10/30/19 at 8:38 AM, the surveyor observed LPN #2 pour, prepare and administer medications for Resident #20. The surveyor observed LPN #2 wash her hands. LPN #2 turned on the faucet, applied soap to her hands, scrubbed her hands with soap for five seconds, rinsed and dried her hands. At 8:45 AM, the surveyor observed LPN #2 pour, prepare and administer medications for Resident #4. The surveyor observed LPN #2 wash her hands in the same manner, scrubbing her hands with soap for six seconds. At 8:54 AM, the surveyor observed LPN #2 pour, prepare and administer medications for Resident #2. The surveyor observed LPN #2 wash her hands in the same manner, scrubbing her hands with soap for five seconds. During an interview with the surveyor on 10/30/19 at 10:38 AM, LPN #2 stated that the scrub time should be 20 seconds to one minute. During an interview with the surveyor on 10/30/19 at 11:40 AM, the DON stated that she educated staff on handwashing by using a lotion that glows. She stated that staff applied the lotion to their hands. Once the lotion dried, the staff member washed their hands and she inspected their hands with a black light. The DON confirmed that she expected the nurses to use friction and wash their hands for 20 seconds including the front and back of the hands, the nails and wrist area. During an interview with the surveyor on 10/31/19 at 9:38 AM, the ICN stated that the DON usually completed the handwashing education with staff. The ICN confirmed that staff should wash their hands with soap for 30 seconds. The surveyor reviewed the undated facility policy, 5.7 Standard Precautions For All Health Care Workers. The policy revealed that staff should wash their hands with an appropriate antibacterial solution for at least 20 seconds. 3. On 10/30/19 at 1:08 PM, the surveyor observed a Dietary Aid (DA) while he was cleaning the dining room and washing dishes after lunch. The DA wore disposable gloves while he removed soiled dishes, glasses and utensils from the dining room tables. He then wheeled the cart loaded with the soiled dishes into the small satellite kitchen adjacent to the dining room. The surveyor then observed the DA handle dishes that were on the counter and had just been washed in the dish washing machine. The DA did not change gloves or wash his hands in between handling the soiled dishes from the dining room and clean dishes and utensils on the counter in the kitchen. The DA then removed his gloves and donned a clean pair of disposable gloves without washing his hands in between the glove change. When the surveyor questioned the DA concerning the procedure for handling soiled dishware and clean dishes, he stated that he had done it wrong. He then stated that he had only handled a couple of clean items before he changed his gloves. The DA also stated that it was the normal procedure for one person to handle both soiled and clean serviceware while washing dishes in the satellite kitchen. On 10/30/19 at 1:21 PM, the surveyor observed the DA wash more dishes. At that time, when he changed gloves the DA washed his hands after he removed the soiled gloves. The DA wet his hands, applied soap and lathered his hands for five seconds outside of the running water, then rinsed his hands under the water stream. On 10/30/19 at 1:28 PM, the surveyor observed the DA as he continued to wash dishes. When he washed his hands, the DA applied friction outside the water stream for five seconds before rinsing. On 10/31/19 at 9:45 AM, the surveyor interviewed the Food Service Director (FSD) about the dish washing procedure in the satellite kitchen. The FSD stated that the DA was responsible to bring dirty dishes into the kitchen, load up a rack of dishes and then place the rack into the dishwasher. When the cycle ended, they were supposed to change gloves and put the clean dishes away. The procedure was usually performed by one D[NAME] The FSD stated that sometimes the DA would push through two racks of dirty dishes, then change gloves before handling clean serviceware. The FSD also stated that the Dietary Aids were supposed to wash hands in between changing gloves. The surveyor reviewed the Handwashing and Personal Cleanliness Policy, dated 01/27/12, which was provided by the FSD. The policy described the procedure for washing hands as, Wash hands thoroughly with approved antibacterial or antimicrobial hand soap. Pay particular attention to the areas underneath fingernails and between fingers. Wash hands and exposed parts of arms for 20 seconds. Rinse thoroughly with clean water. Dry hands with disposable towels or use an air dryer. The surveyor reviewed the Handwashing In-service provided for Dietary Aids in February, 2019. The in-service addressed the topic, When to Wash Hands. This portion of the program included, Before putting on gloves as a circumstance which required proper handwashing. The surveyor noted that the DA who was observed washing dishes on 10/30/19 attended the handwashing in-service in February. NJAC 8:39 19.4 (a)(c)

Based on observation, interview and record review, it was determined that the facility failed to routinely document the evaluation of the status of the access site for a resident with End Stage [MEDICAL CONDITION] ([MEDICAL CONDITION]: kidney failure) for four months. This deficient practice was identified for 1 of 1 residents, Resident #35, reviewed for [MEDICAL TREATMENT] (a life-sustaining treatment that filters waste and toxins from the blood in people with kidney failure) and was evidenced by the following: During the initial tour of the facility on 10/28/19 at 9:46 AM, the surveyor interviewed Resident #35, who stated that he/she goes out for [MEDICAL TREATMENT] treatments on Monday, Wednesday and Friday. On 10/29/19 at 9:08 AM, the surveyor observed that the resident had an Arteriovenous (AV) Fistula ([MEDICAL TREATMENT]) on the left arm. The surveyor interviewed the resident to ascertain if the facility nurses were monitoring the site. Specifically, the surveyor asked if the nurses were listening to the site with a stethoscope. Resident #35 stated that the nurses didn't use a stethoscope, they just feel it. Review of the face sheet revealed that Resident #35 was originally admitted to the facility on [DATE] and was recently hospitalized from [DATE] to 08/09/19. The resident's admitting [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 08/09/19, revealed that Resident #35's cognitive status was moderately impaired. Review of Resident #35's physician's orders [REDACTED]. Review of the Resident #35's most recent Interdisciplinary Care Plan, dated 08/13/19, included the following intervention for [MEDICAL TREATMENT]: If AV fistula is utilized to administer [MEDICAL TREATMENT], auscultate and palpate area for bruit and thrill every shift and as needed. The procedure of checking the bruit to hear the sound of the AV fistula and palpating the area to feel the vibration (thrill) was a method used for monitoring the condition of the resident's access site for [MEDICAL TREATMENT]. On 10/29/19 at 10:45 AM, the surveyor interviewed the Charge Nurse who stated that she didn't see an order to check bruit and thrill for Resident #35. She added, I'll get an order for [REDACTED].>The Charge Nurse then provided the surveyor with the facility's Protocol for [MEDICAL TREATMENT] Resident Care, which was revised on 06/28/19. The Protocol included the statement, The facility's nurse will follow standard of practice in the daily care of the [MEDICAL TREATMENT] resident. The Process section of this policy included in bold type: LISTEN-for the bruit FEEL for the thrill Document. The Charge Nurse stated, We should be documenting in the IDT (Interdisciplinary) notes. On 10/29/19 at 11:33 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who had just stepped out into the hallway after caring for Resident #35. LPN #1 stated that she had just checked the resident's access site. She stated that she checks for bruit and thrill by feeling with her fingers and listening through her stethoscope. LPN #1 then stated that she normally documents the results in the IDT notes. On 10/29/19 at 11:39 AM, the surveyor interviewed LPN #2 who stated that she often takes care of Resident #35. She stated that she checks for bruit and thrill by listening with a stethoscope and feeling with her fingers. LPN #2 stated, I usually chart in the IDT notes. The surveyor inquired if she would document bruit and thrill anywhere else. LPN #2 replied, If there's a problem, I would chart in the [MEDICAL TREATMENT] communication book but (the resident) hasn't had any problems. Review of Resident #35's [MEDICAL TREATMENT] Communication Book revealed that Resident #35 had not experienced any abnormalities with the AV Fistula. Review of Resident #35's Interdisciplinary Notes from (MONTH) to (MONTH) 2019 revealed the following number of times per month that the nurses documented checking the [MEDICAL TREATMENT] access for bruit and thrill: July 2019: 13 entries August 2019: 6 entries September 2019: 5 entries October: 3 entries. NJAC 8:39-27.1 (a)

COMPLAINT#: NJ 1 Based on interviews, review of the Medical Records (MR), and pertinent facility documents on 9/18/2018, it was determined that the facility failed to separate Residents treated for [REDACTED].#2, Resident #6, Resident #7 and Resident #8). This deficient practice was evidenced by the following: 1. According to the PFS, Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the MDS, an assessment tool dated 8/13/2018, Resident #2 had a BIMS score of 4/15, indicating Resident #2 was severely cognitively impairment. The MDS also indicated that Resident #2 required assistance with all ADLs. A review of Resident #2's physician's orders [REDACTED]. [MEDICATION NAME] Cream 5% -1 tube topical, one time for rash to back and buttocks (possible scabies), dated 9/17/2018. A review of Resident #2''s IDN dated 9/18/2018 at 4:11 a.m., revealed Resident #2 was treated with [MEDICATION NAME] cream for a rash and a few dots was noted to the Resident's upper thighs and abdomen. A review of Resident #2's CP showed Infection Control Precautions with a start date of 9/17/2018 and undated discontinued date under Contact Precautions revealed the following: Gloves with all contact, staff and visitors. Good Handwashing for everyone before leaving room. Gown and gloves for direct caregiver. Bag food tray before leaving room. Housekeeping gloves and gown for deep cleaning. Good hand hygiene and education for Resident. 2. According to the PFS, Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the MDS, an assessment tool dated 7/31/2018, Resident #6 had a BIMS score of 7/15, indicating Resident #6 had severe cognitive impairment. The MDS also indicated that Resident #6 required assistance with all ADLs. A review of Resident #6's IDN dated 9/14/2018 at 3:43 p.m., revealed that a rash was observed to Resident #6 chest area with possible scabies exposure. The IPN further showed that the Doctor was made aware and a new order for [MEDICATION NAME] cream was obtained. A review of Resident #6's physician's orders [REDACTED]. [MEDICATION NAME] 5% cream- unit dose topical daily for Scabies. Apply to neck down to feet at 8:00 p.m. tonight- leave on overnight. Wash off in (am) the morning. A review of the TRW dated 9/2018, showed Resident #6 received the [MEDICATION NAME] cream on 9/14/2018, at 8:00 p.m. A review of Resident #6's CP showed Infection Control Precautions with a start date of 9/14/2018 and a discontinued date of 9/16/2018, under Contact Precautions revealed the following: Gloves with all contact, staff and visitors. Good Handwashing for everyone before leaving room. Gown and gloves for direct caregiver. Bag food tray before leaving room. Housekeeping gloves and gown for deep cleaning. Good hand hygiene and education for Resident. 3. According to the PFS, Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the MDS, an assessment tool dated 5/22/2018, Resident #7 had a BIMS score of 6/15, indicating Resident #7 had severe cognitive impairment. The MDS also indicated that Resident #7 required assistance with all ADLs. A review of a Visit Note from the Dermatologist dated 9/14/2018, revealed under the Impression/Plan #1. Scabies . Under the Plan: Prescription section revealed the following order Skin care: [MEDICATION NAME] cream applied neck down to feet x 8 hours and repeated in 1 week. Expectations: Scabies is an infestation of mites that is very contagious. Household contacts should be treated. Contaminated clothing should be isolated x 72 hours and washed and dried on high heat. Under the Plan: section recommendations were to apply [MEDICATION NAME] 5% Topical cream TP Sig: apply sparingly BID (8:00 a.m., 8:00 p.m.) x 2 weeks to affected areas on arms, chest, hands and thighs then discontinue. A review of Resident #7's physician's orders [REDACTED]. [MEDICATION NAME] 5% cream- unit dose topical daily for Scabies. Apply to neck down to feet at 8:00 p.m. tonight - leave on overnight. Wash off in (am) the morning. A review of the TR dated 9/2018, showed Resident #7 received the [MEDICATION NAME] cream on 9/14/2018 at 8:00 p.m. A review of Resident #7's CP showed Infection Control Precautions with a start date of 9/14/2018 and a discontinued date of 9/16/2018, under Contact Precautions revealed the following: Gloves with all contact, staff and visitors. Good Handwashing for everyone before leaving room. Gown and gloves for direct caregiver. Bag food tray before leaving room. Housekeeping gloves and gown for deep cleaning. Good hand hygiene and education for Resident. 4. According to the PFS, Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the MDS, an assessment tool dated 8/26/2018, Resident #8 had a BIMS score of 3/15, indicating Resident #8 had severe cognitive impairment. The MDS also indicated that Resident #8 required assistance with all ADLs. A review of a Visit Note from the Dermatologist dated 9/14/2018, revealed under the Impression/Plan #1. Scabies .under the Plan: Counseling section revealed the following order Expectations: Scabies is an infestation of mites that is very contagious. Household contacts should be treated. Contaminated clothing should be isolated x 72 hours and washed and dried on high heat Further review of the Visit Note under the Plan: Prescription section recommendation revealed the following [MEDICATION NAME] 5% Topical cream TP Sig: Apply neck down to feet at 8 p.m. tonight-leave on overnight. Wash off in (AM) the morning. Repeat 1 week later (1 refill). A review of Resident #8's physician's orders [REDACTED]. [MEDICATION NAME] 5% cream- unit dose topical daily for Scabies. Apply to neck down to feet at 8:00 p.m. tonight- leave on overnight. Wash off in (am) the morning. A review of the TR dated 9/2018, showed Resident #8 received the [MEDICATION NAME] cream on 9/14/2018, at 8:00 p.m. A review of Resident #8's CP showed Infection Control Precautions with a start date of 9/14/2018 and a discontinued date of 9/16/2018, under Contact Precautions revealed the following: Gloves with all contact, staff and visitors. Good Handwashing for everyone before leaving room. Gown and gloves for direct caregiver. Bag food tray before leaving room. Housekeeping gloves and gown for deep cleaning. Good hand hygiene and education for Resident. A review of a typed Scabies Investigation document dated 9/18/2018, revealed, that on 9/13 upon receiving of notification of diagnosis (Dx), the facility requested appointments for five Residents (Resident #3, Resident #4, Resident #5, Resident #7 and Resident #8) that have had various rashes and unresponsive to various treatments. In addition, the document revealed that the Nurse Practitioner refused to do a skin scraping. The document continued to explained that the Medical Director of the facility was notified and [MEDICATION NAME] treatment was ordered for the five Residents. Further review of the Scabies Investigation document revealed that it was reported that Resident #6 had a rash to the upper chest and was also treated. During an interview with the Licensed Practical Nurse (LPN) / Charge Nurse on 9/18/2018 at 10:35 a.m., the LPN stated that all Residents were treated in their room and were isolated, the rooms were carbolized and gloves and gowns were provided to staff. In addition, the LPN stated that he/she did not think the Residents being treated for [REDACTED]. During an interview with the Registered Nurse / Unit Coordinator (RN #1) on 9/18/2018 at 1:00 p.m., the RN stated that there was a discussion with the Administrator and they wondered if the case was reportable. In addition, the RN stated that both the Administrator and the RN went to the Center for Disease Control and Prevention (CDC) and the local Health Department website but could not find any information on if the outbreak was reportable. Review of a facility's policy titled, Policy for Outbreak Investigation undated, included the following: The infection preventionist will have the authority to implement control measures as appropriate, in coordination with facility administration and medical staff as well as state and local agencies. For example, these control measures may include simple resident or unit isolation or quarantine measures for the entire community meetings. NJAC 8:39-19.4(e)

Based on observation, interview and record review, it was determined that the facility failed to consistently label and date food products and maintain sanitation in a safe and consistent manner. This deficient practice was identified during a tour on 11/19/17 and 11/20/17 in the presence of dietary management staff and was evidenced by the following: On 11/19/17 between 8:50 a.m. and 9:30 a.m., the surveyor toured the kitchen with the Executive Chef and observed the following: 1. A plastic container of pecans in the dry storage area with a label which indicated use by 11/10. 2. In the produce refrigerator, the surveyor observed a large container of iceberg lettuce filled over the capacity of the container on plastic storage shelving. The lettuce was in direct contact with the underside of the shelf above it. 3. In the produce refrigerator, the surveyor observed several one gallon containers of salad dressings and condiments with inconsistent labeling. During an interview, the Executive Chef stated that orange stickers indicated the date the product was received; white labels indicated the date the product was opened; and the manufacturers date indicated the use by date. The surveyor observed the following: An open container of Horseradish labeled as opened on 11/7/17 with no manufacturer's date and no use by date. An open container of Extra Heavy Russian dressing opened 11/12/17 with no manufacturer's date and no use by date. An open container of Creamy Tartar sauce labeled as received on 11/9/17 with no open date and no use by date. An open container of Bleu Cheese Extra Chunky with an opened date of 10/31/17 and a manufacturer's date of 9/7/17. An open container of Lite Ranch dressing with no opened date and a manufacturer's date of 10/16/17. The Executive Chef acknowledged that the manufacturer's dates were earlier than the receive dates and/or opened dates therefore could not be the use by dates. 4. The surveyor observed a staff member test the pot sink using a chemical sanitizer test strip by submerging the strip in the water and moving it back and forth for approximately 10 seconds. He then shook the strip and laid it on the side of the sink for approximately one minute before checking the result. The staff member stated that the results should be between 200 and 400 parts per million (ppm). The Executive Chef and the staff member concurred that the result was 470 ppm. 5. The temperature of the walk-in freezer indicated 8 degrees F. The surveyor observed a heavy frost buildup along the inside edge of the freezer door and an accumulation of frost on the floor inside the freezer. The frozen foods stored in the freezer were hard to the touch. On 11/20/17 between 11 a.m. and 11:30 a.m., the surveyor toured the kitchen with two kitchen managers and observed the following: 1. Four large mini muffin pans heavily soiled with baked-on grease. 2. Three gallon containers of ice cream stored in the reach-in freezer open to air due to ripped and damaged container covers. 3. In the produce fridge, the surveyor observed a gallon container of Extra Heavy Russian dressing labeled as opened on 11/1/17 with no use by date. During an interview, the dietary manager stated that dressings should be used ten days after opening as per the facility policy and all should be labeled with use by dates. 4. Eight half pans and eight full pans were wet-nested on a metal shelf used for clean and dry equipment. On 11/20/17 at 11:20 a.m., the surveyor reviewed the Sanitizer Solution Log for November 2017 which indicated three A.M. readings of 450-460, and one P.M. reading of 500. During an interview on 11/22/17 at 11:10 a.m., the Food Service Director (FSD) stated that opened salad dressings and condiments should be labeled with use by dates. The FSD provided instructions for testing sanitizer levels in the pot sink which indicated to dip the test strip for 10 seconds and to compare against package scale immediately. The required concentration for sanitation was indicated as 150-400. NJAC 8:39-17.2(g)

Based on observation, interview and record review it was determined that the facility failed to follow care plan interventions and communicate the plan of care to all disciplines involved with the resident's care. This deficient practice was identified for 1 of 14 residents reviewed for care plan interventions, Resident #4 and was evidenced by the following: On 11/19/17 at 10:15 a.m., the charge nurse toured the unit with the surveyor and stated that Resident #4 was confused, had a history of [REDACTED]. The surveyor observed the resident in bed with the head of the bed elevated and the resident was resting quietly. On 11/20/17 at 11:35 a.m., the surveyor observed the resident in the Dining room. The resident was awake, alert and was able to feed self with cueing from the staff. On 11/20/17 at 12:30 p.m. the surveyor reviewed the electronic clinical record which revealed that the resident had [DIAGNOSES REDACTED]. According to the Annual and Quarterly Minimum Data Set (MDS), a resident assessment tool, dated 12/17/16 and 9/16/17 respectively, Resident #4 required a 2 person physical assist for transfer. A review of the electronic Interdisciplinary Notes for the period 1/3/17 to 11/21/17 documented that Resident #4 required the extensive assist of two persons with transferring. On 11/21/17 at 9:45 a.m. the surveyor observed the resident in the dayroom in a recliner chair, eyes were closed, Geri-sleeves were observed to both upper extremities. An interview with the Certified Nursing Assistant (CNA) who cared for the resident that day revealed that the resident required total care, was incontinent of bowel and bladder, and had a wound to the left lower extremity. The CNA further acknowledged that the resident was combative with care at times. A review of an Interdisciplinary Notes dated 11/18/17 timed 23:12 revealed that Resident #4 sustained a skin tear to the left outer leg during transfer which measured 10 centimeters (cm) x 4 cm. The resident required 28 steri-strip to close the skin tear and Antibiotic treatment with Reflex for 10 days to prevent infection. A review of an Incident report provided by the facility dated 11/18/17 timed 19:25 p.m. revealed the following: Called to resident's room to visualize new wound. Open skin tear to left outer leg with skin split and pushed to side Further review of the section titled, Investigation/Follow Up revealed that the CNA did not follow the plan of care which indicated that the resident was a two person physical assist for transfers. The CNA used a stand and pivot method during the transfer. On 11/21/17 at 12:00 p.m. the surveyor interviewed the CNA who cared for the resident. She stated that she came in the morning, she got report from the nurse and she would access the resident's care guide on the kiosk. The CNA was able to demonstrate to the surveyor how to access the care guide. According to the care guide Resident #4 required a two person extensive assist with transfers. On 11/21/17 at 12:30 p.m. the surveyor reviewed the electronic care plan which confirmed that the resident was a two person physical assist for transfers. A review of the CNA's statement assigned to the resident during the transfer on 11/18/17 revealed that she did not called for assistance with the transfer. On 11/22/17 at 9:40 a.m. the surveyor interviewed the Hospice aide who provided care to the resident from Monday to Friday on a regular basis. The hospice aide told the surveyor that in the morning she provided care to the resident, and transferred the resident to the recliner chair by herself. The hospice aide further stated that Resident #4 was a one person physical assist for transfer. The hospice aide had Resident #4's care plan on her phone and was able the visually show the care plan to the surveyor. The hospice aide told the surveyor that she had been taking care of the resident since September and was never told that Resident #4 was a two person extensive physical assist for transfers. The facility was made aware of the above concerns on 11/21/17 at 1:30 p.m. On 11/22/17 at 11:50 a.m. in the presence of the Director of Nursing (DON ) the Unit Coordinator confirmed that the CNA failed to follow the care plan. The Unit Coordinator further stated that the care plan for hospice did not reflect the correct mode of transfer for Resident #4. The DON indicated that the CNA would be reeducated prior to return to work and the hospice care plan would be updated. NJAC 8:39-11.2

Based on observation, interviews and record reviews it was determined that the facility failed to date and remove expired medications from the medication refrigerator. The facility also failed to ensure that the medications carts were locked when not in attendance. This deficient practice was identified for 2 of the medication carts and one of the refrigerators inspected following the initial tour of the facility and was evidenced by the following: 1. On 11/19/17 at 9:12 a.m. during the medication pass administration, the nurse left the medication cart unlocked in front of a resident's door to administer medication to the other resident that occupied the bed by the window. The curtain was drawn and the nurse was unable to visually see the cart. The surveyor stood by the cart and called the nurse to inform her that the medication cart was unlocked. On 11/19/17 at 9:55 a.m. during an interview with the nurse she revealed that she was told [AGE] years ago that the medication cart did not have to be locked if positioned by the door. The nurse further stated that she could hear if someone tried to move the cart. 2. On 11/19 17 at 9:30 a.m. the surveyor inspected the unit refrigerator with the Night Unit Manager and the Director of Nursing (DON). The following were noted: One bottle of Humulin 70/30 a type of insulin used to treat diabetes open not dated. One bottle of liquid Ativan ( a medication used to treat anxiety ) received on 7/16/17 with a used by date of 10/11/17. 3. On 11/ 21/17 at 10:15 a.m., the surveyor went to the hallway and observed a medication cart unlocked. The nurse was not in the hallway where she could visually see the medication cart. The surveyor stood by the medication cart until 10:20 a.m. The administrator was in the hallway and observed the same. At 10:20 a.m. the nurse emerged from the next hallway and observed both the surveyor and the administrator next to the medication cart. An interview with the second nurse on 11/21/17 at 11:55 a.m. revealed that the protocol was to lock the medication cart when not in attendance. The nurse told the surveyor that she went to activities to offer a milkshake to a resident and got distracted by another resident. She admitted that she forgot to lock the medication cart. The facility was made aware of the above observations on 11/21/17 at 1:30 p.m. On 11/22/17 at 10:15 a.m. the DON told the team that both the pharmacist and the pharmacy consultant were in the facility for the monthly audit and failed to identify any irregularities. The DON further stated that the policy would be reviewed to ensure that the medication cart should be locked when not in the line of sight instead of line of site. NJAC 8:39 -29.4 (d) (3) (g) (h)