Every finding on record at St Joseph's Home AL & NC, Inc

Based on interview and record review, it was determined that the facility failed to complete a death Minimum Data Set (MDS), an assessment tool, as required for 1 of 1 system selected for residents with MDS record over 120 days reviewed (Resident #22), and was evidenced by the following: On 4/2/25 at 9:45 AM, the surveyor reviewed the system selected MDS record over 120 days which revealed Resident #22 was overdue for a MDS assessment. A review of Resident #22's medical record (MR) revealed that the resident had a death in the facility on 1/17/25. A review of the resident's MDS assessments revealed the last MDS completed was a quarterly assessment dated [DATE]. The was no assessment for the resident's death. On 4/3/25 at 12:08 PM, the surveyor interviewed the MDS Coordinator, who confirmed Resident #22 had a death in the facility on 1/17/25, and there was no completed MDS assessment for the death. The MDS Coordinator stated the facility had seven days after the resident's death to complete the assessment and an additional fourteen days to transmit it. The MDS Coordinator stated that the resident's assessment was missed. On 4/3/25 at 12:28 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who confirmed that Resident #22's MDS should have been completed and then transmitted within 14 days. The LNHA could not speak to why the MDS was missed. On 4/7/25 at 10:27 AM, the Director of Nursing (DON), in the presence of the survey team, acknowledged that the completion and transmission of the death in facility MDS for Resident #22 was missed in error. A review of the facility's MDS Assessments policy dated revised January 2025, did not include MDS timing. A review of the facility's MDS Comprehensive policy dated revised 4/3/25, did not include MDS timing. NJAC 8:39 - 11.1

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 02/03/23 10:57 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. In the spice cabinet, an opened and undated package of gluten free pasta was stored on a shelf. The surveyor observed a second opened and undated package of gluten free pasta wrapped in plastic stored on a shelf. When interviewed, the FSD stated the packages of gluten free pasta should have been dated when opened. The surveyor further observed signage posted on the door of the spice cabinet that indicated all items must have an open date on them. 2. In the walk-in refrigerator, a bin containing raw chicken and chicken blood was stored on a slant on top of second pan containing raw chicken. The surveyor further observed that some of the chicken blood had spilled onto the floor of the walk-in refrigerator. When interviewed, the FSD stated the bin containing the raw chicken should not have been stored on a slant and that she would get the blood on the floor cleaned up. 3. In the walk-in refrigerator, an unopened box containing 50 chocolate Mighty Shakes (MS), dated 01/16/23, was stored on a multitiered shelf. When interviewed, FSD stated the date on the box was the receiving date and not the pull date. The FSD added that the box may have been pulled last Thursday. 4. Two bins containing plastic lids were stored on a shelf. The plastic lids were open and exposed. When interviewed, the FSD stated the lids were not supposed to be in the bin and that they should be stored in plastic and in a drawer. 5. The surveyor observed that the mixer was covered in plastic. The FSD stated the mixer had been cleaned and sanitized. Upon inspection, the surveyor observed white chunky unknown substance on the edging of the pot. When interviewed, the FDS stated that it should not be stored in that manner and removed the pot to be cleaned. Review of the facility's Labeling and Dating Food Items and Shelf Life, revised 05/01/2019, indicated that All food items must be covered, labeled, dated, and properly stored for a length of time to keep the food safe. The policy revealed that food items would be labeled with the open date once opened for use. The policy further revealed, under dry storage, that any opened products should be placed in seamless plastic, glass containers with tight-fitting lids, or Ziploc bags. Review of the facility's Food Receiving and Storage policy, revised July 2014, revealed that uncooked and raw animal products would be stored separately in drip-proof containers. NJAC 8:38-17.2 (g)

Based on interview, record review and review of other pertinent facility documentation it was determined that the facility failed to notify the resident and/or the resident's representative in writing of the reason for transfer or discharge to the hospital and also send a copy to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 residents reviewed for hospitalization , Residents #17 and Resident #24. This deficient practice was evidenced by the following: According to the Admission Record (AR) Resident #17 was admitted to the facility with the diagnoses which included but was not limited to hypertension, depression, and age-related physical disability. The surveyor reviewed the unplanned discharge Minimum Data Set (MDS-an assessment that facilitates a resident care) dated 11/08/2022, which indicated that the resident was discharged to the hospital. The surveyor reviewed the New Jersey Universal Transfer form (NJUTF) dated 11/08/2022, which indicated that Resident #17 was discharged to the hospital for a right leg wound. The surveyor also reviewed the physician's order dated 11/08/2022, that the resident was to be sent to the hospital's emergency room for evaluation of a right leg wound. The facilities hospitalization Tracking Record (HTR) indicated that Resident #17 was discharged to the hospital on 11/08/2022 and returned on 11/13/2022. The HTR also indicated that the residents responsible party (RP) was notified by phone and not letter. The surveyor could not find any documentation in the resident's medical record that the RP or Office of the State Long-Term Care Ombudsman was notified about the resident's transfer to the hospital on 11/08/2022. 38679 The surveyor reviewed the medical records of Resident #24. Review of the AR reflected that the resident was admitted to the facility with diagnoses which included but was not limited to dementia, heart failure, and pneumonia. Review of the NJUTF, dated 01/01/23, indicated the resident was transferred to the hospital. Review of Resident #24's Progress Notes revealed a 01/01/23 Nursing Notes that indicated the physician requested for the resident to be transferred to the hospital. Review of the MDS dated [DATE], indicated the resident had a discharge assessment with return anticipated. Review of the facility's HTR indicated that Resident #24 was discharged on [DATE] and revealed under the Date of Letter Send to POA [power of attorney] section that the representative was notified by phone. Review of Resident #24's medical record did not include a notification letter to the Office of the State Long-Term Care Ombudsman of the transfer to the hospital. On 02/09/23 at 12:32, the surveyors interviewed the Administrator who confirmed that the facility did not inform the Office of the State Long-Term Care Ombudsman or the RP in writing regarding Resident #17 and Resident #24's unplanned discharges to the hospital. The Administrator explained that the process for notifying the Ombudsman and RP regarding the written notice for discharge was not yet explained to the new Social Worker, (SW) so the SW did not know that it was her responsibility to complete the notifications in writing of discharge to the Ombudsman and RP. NJAC 8:39-5.3; 5.4

Based on interview and review of the medical record and other facility documentation, it was determined that the facility failed to provide a bed-hold and return policy to a resident representative. This deficient practice was identified for Resident #17 and #24, 2 of 2 residents reviewed for transfer and was evidenced by the following: 1.) According to the Admission Record (AR) Resident #17 was admitted to the facility with diagnoses which included but were not limited to hypertension, depression, and age-related physical disability. The surveyor reviewed the unplanned discharge Minimum Data Set (MDS-an assessment that facilitates a resident care) dated 11/08/2022, which indicated that the resident was discharged to the hospital with return to the facility anticipated. The surveyor reviewed the New Jersey Universal Transfer form (NJUTF) dated 11/08/2022, which indicated that Resident #17 was discharged to the hospital for a right leg wound. Review of Resident #17's medical record did not include a notification letter to the residents and/or their representatives with the facility's notice of bed-hold policy. 38679 2. The surveyor reviewed the medical records of Resident #24. Review of the AR reflected that the resident was admitted to the facility with diagnoses which included but not limited to dementia, heart failure, and pneumonia. Review of the NJUTF dated 01/01/23, indicated the resident was transferred to the hospital. Review of Resident #24's Progress Notes revealed a 01/01/23 Nursing Notes that indicated the physician requested for the resident to be transferred to the hospital. Review of the MDS dated [DATE], indicated the resident had a discharge assessment with return anticipated. Review of Resident #24's medical record did not include a notification letter to the residents and/or their representatives with the facility's notice of bed-hold policy. On 02/09/23 at 12:32, the surveyors interviewed the Administrator who confirmed that the facility did not inform the RP in writing regarding the facility's notice of bed-hold policy. The Administrator explained that the process for notifying the RP regarding the bed hold policy in writing was not yet explained to the new Social Worker (SW) so the SW did not know that it was her responsibility to complete the notifications of bed hold to the RP. NJAC 8:39-5.3

Based on observation, interview, medical record review, and review of other facility documentation, the survey team determined that the facility failed to implement mitigation strategies to prevent the transmission of COVID-19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) by not having placed a resident (Resident #2), who was exposed to another resident that tested positive for COVID-19, on Transmission Based Precautions (TBP) and by not having implemented source control measures (use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing) which occurred on 1 of 2 units toured. This deficient practice placed 15 of 21 residents on the first-floor unit at risk for COVID-19 infection during a COVID-19 Focused Infection Control survey on 1/19/22. The facility's failure to implement TBP and source control measures for Resident #2 to prevent the spread of Covid-19 posed the likelihood of serious and immediate threat to the safety and wellbeing of all non-ill residents (residents who were negative for Covid-19). This situation resulted in an Immediate Jeopardy (IJ) situation that began on 1/18/22 when the facility was notified of the confirmed Covid positive for Resident #1. The facility Administration was notified of the IJ on 1/19/22 at 2:50 PM. The immediacy was removed on 1/19/22 at 9:35 PM, based on an acceptable Removal Plan implemented by the facility and verified by the surveyors during an onsite revisit survey conducted on 1/21/22. The deficient practice is evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, with an updated date of 9/10/21, included the following: Source Control and Physical Distancing Measures; Refer to Interim Infection Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic for details regarding source control and physical distancing measures recommended for vaccinated and unvaccinated HCP and residents. Testing; Create a Plan for Testing Residents and HCP for [CONDITION(S)]-CoV-2. Asymptomatic HCP with a higher-risk exposure and residents with close contact with someone with [CONDITION(S)]-CoV-2 infection, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV-2 infection. In these situations, testing is recommended immediately (but not earlier than 2 days after the exposure) and, if negative, again 5-7 days after the exposure. Criteria for use of post-exposure prophylaxis are described elsewhere: Manage Residents with Close Contact. Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. Fully vaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should wear source control and be tested as described in the testing section. Fully vaccinated residents and residents with [CONDITION(S)]-CoV-2 infection in the last 90 days do not need to be quarantined, restricted to their room, or cared for by HCP using the full PPE recommended for the care of a resident with [CONDITION(S)]-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with [CONDITION(S)]-CoV-2 infection, or the facility is directed to do so by the jurisdiction's public health authority. Additional potential exceptions are described here [Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic]; New Infection in Healthcare Personnel or Resident. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. Respond to a Newly Identified [CONDITION(S)]-CoV-2-infected HCP or Resident. Because of the risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any HCP or a nursing home-onset [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak. The approach to an outbreak investigation should take into consideration whether the facility has the experience and resources to perform individual contact tracing, the vaccination acceptance rates of staff and residents, whether the index case is a healthcare worker or resident, whether there are other individuals with suspected or confirmed [CONDITION(S)]-CoV-2 infection identified at the same time as the index resident, and the extent of potential exposures identified during the evaluation of the index resident. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-level or group-level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. Fully vaccinated residents and HCP: In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of quarantine for fully vaccinated residents and work restriction of fully vaccinated HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. Definitions: Source Control: Use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Reference: CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, with an updated date of 9/10/21, included the following: 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 Pandemic . Implement Source Control Measures. Source control refers to the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control and physical distancing (when physical distancing is feasible and will not interfere with the provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have; Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with [CONDITION(S)]-CoV-2 infection for 14 days after their exposure, including those residing or working in areas of a healthcare facility experiencing [CONDITION(S)]-CoV-2 transmission (i.e., outbreak); and for those moderate to severe immunocompromised. Reference: New Jersey Department of Health (NJDOH) Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities, with an updated date of 11/17/21, included the following: COVID-19 has had a major impact on healthcare facilities, especially in the post-acute care setting. COVID-19 has a broad clinical presentation, long incubation period, and is transmissible through asymptomatic or pre-symptomatic infected people, including patients/residents and healthcare personnel (HCP). Therefore, cohorting using traditional symptom-based screening alone should be avoided. When necessary, cohorting should be done with caution, given the risk of asymptomatic or pre-symptomatic infection. Cohorting is most effective when resources permit rapid identification, isolation, and dedicated HCP and equipment per cohort. Please note that this document is intended to help guide decisions in consultation with the clinical team and facility-specific resources. However, fully vaccinated patients/residents identified as close contacts* should continue to follow the Centers for Disease Control and Prevention (CDC) infection prevention and control measures, including wearing well-fitting source control, getting tested as described above, and monitoring for symptoms for 14 days after exposure. Additionally, healthcare facilities should continue to follow the infection prevention and control recommendations for unvaccinated individuals when caring for fully vaccinated individuals with moderate to severe immunocompromise due to a medical condition or receiving immunosuppressive medications or treatments. This includes using transmission-based precautions for those who have had close contact with someone with [CONDITION(S)]-CoV-2 infection. Do patients/residents who are fully vaccinated require quarantine? In general, the current updated CDC guidance does not require quarantine for asymptomatic fully-vaccinated individuals. However, there are circumstances when quarantine may be considered: Patient/resident is moderate to severely immunocompromised; If the previous diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Fully vaccinated asymptomatic close contacts should continue to follow CDC infection prevention and control measures, including wearing well-fitting source control, getting tested , and monitoring for COVID-19 symptoms. Reference: NJDOH Outbreak Management Checklist for COVID-19 in Nursing Homes and other Post-Acute Care Settings, with an updated date of 12/17/21, included the following: Note: Public health authorities may recommend the use of full COVID-19 PPE, regardless of the presence of symptoms, when uncontrolled transmission is identified, with strong consideration for inclusion of fully vaccinated patients/residents. A facility-wide or group-level approach, including full COVID-19, recommended PPE, may be considered if all potential close contacts cannot be identified or managed with contact tracing or when contact tracing fails to halt transmission. Note: Resident should continue to wear well-fitting source control, practice physical distancing, and monitor for symptoms for 14 days from the last exposure to the [CONDITION(S)]-CoV-2 positive individual, even if they test negative. Note: Source control and physical distancing (when physical distancing is feasible and will not interfere with the provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have: not been fully vaccinated; or suspected or confirmed [CONDITION(S)]-CoV-2 infection or other respiratory infection; or had close contact (patients/residents and visitors) or a higher-risk exposure (staff) with someone with [CONDITION(S)]-CoV-2 infection for 14 days after their exposure, including those residing or working in areas of a healthcare facility experiencing [CONDITION(S)]-CoV-2 transmission; or moderate to severe immunocompromise; or otherwise had source control and physical distancing recommended by public health authorities. Reference: CDC's Strategies for Optimizing the Supply of N95 Respirators with an updated date of 9/16/21 included the following: Conventional Capacity Strategies (should be incorporated into everyday practices). Source Control; Everyone entering the healthcare facility should practice source control. Source control refers to the use of well-fitting cloth face coverings, facemasks, or respirators to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. Additional information about source control is available in the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. On 1/19/22 at 8:55 AM, the survey team entered the facility. Surveyor #1 observed a sign posted at the entrance doorway that read: Residents 42. COVID 19. At 9:20 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) stated that the facility was currently in a COVID-19 outbreak (an increase in cases of the virus in time or place that is greater than expected). She stated the facility census was 40 residents and that currently, 7 of the residents had COVID-19. She then noted that the facility had two residents in the hospital for COVID-19 related reasons and that the facility had one death from COVID-19 [during this outbreak]. At 9:40 AM, Surveyor #1 toured one wing of the first-floor unit. Surveyor #1 observed ten resident rooms (room [ROOM NUMBER]-room [ROOM NUMBER]) on that wing of the first-floor unit. Surveyor #1 observed one of the rooms (room [ROOM NUMBER]) had a sign posted on the door, which indicated that the resident was a PUI (person under investigation) and what Personal Protective Equipment (PPE) was required to enter that room. Surveyor #1 also observed three rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) with a sign posted on each of those doors, which indicated that the residents in those rooms had COVID and what PPE was required to enter those room. At 9:42 AM, Surveyor #1 interviewed the Licensed Practical Nurse (LPN) regarding the signage on some of the resident rooms. The LPN revealed to the surveyor that on 1/18/22, there were two residents in room [ROOM NUMBER] (Resident #1 and Resident #2) and explained that Resident #1 tested positive for COVID-19 during the weekly PCR test (Polymerase Chain Reaction test that requires a lab to perform the test). The LPN added that the roommate (Resident #2), who tested negative for COVID-19 on the weekly PCR test, was moved to room [ROOM NUMBER] with a resident (Resident #3) that the LPN identified also tested negative for COVID-19 on the weekly PCR test on 11/18/22. Surveyor #1 observed that Resident #1's room had a sign on the door which included the following: ATTENTION: Staff must wear the following PPE BEFORE entering COVID-19 rooms: N95 Face shield/goggles Isolation gown Gloves. However, Surveyor #1 did not observe signage posted on Resident #2 and Resident #3's door to indicate that they were on TBP even though Resident #2 was exposed to Resident #1, who tested positive for Covid-19. At 9:45 AM, Surveyor #1 observed (through the open door) a Certified Nursing Assistant (CNA) inside Resident #2/Resident #3's room. The CNA wore an N95 mask and a face shield. The CNA did not have a gown or gloves on. Surveyor #1 then asked the LPN, who was in the hallway outside of Resident #2/Resident #3's room, if a gown or gloves were needed to enter Resident #2/Resident #3's room. The LPN stated no gown or gloves were required. She added that gloves would be used for care. She further indicated that a gown and gloves were needed to enter rooms that were COVID-19 positive or PUI. At approximately 9:45 AM, Surveyor #2 interviewed the LNHA and the Director of Nursing (DON) during the entrance conference. The LNHA stated that the current COVID-19 outbreak had started with a staff member that tested positive for COVID-19 on 12/24/21 and that the first resident had tested positive on 12/29/21. She then stated that the facility was still in an outbreak and that the latest date of a COVID-19 positive test result for a staff member and a resident was 1/18/22. At 9:47 AM, Surveyor #1 interviewed the CNA. The CNA confirmed that she was not wearing a gown or gloves while in Resident #2/Resident #3's room. She stated that she did not have to put on anything additional to enter their room. She then added that she would put on a gown and gloves to go into a room that had someone who was positive for COVID-19 or was considered a PUI. The CNA also confirmed that Resident #2 was transferred from Resident #1's room after Resident #1 tested positive for COVID-19. The CNA also confirmed and acknowledged that Resident #2 (exposed to covid positive roommate) was now in the same room as Resident #3 (who was not exposed to COVID-19). At 9:56 AM, Surveyor #1 observed the CNA exit another room that was not on TBP. The CNA performed hand hygiene with an alcohol-based hand rub. The CNA then donned (put on) a disposable gown and gloves and entered a PUI room. At 10:00 AM, Surveyor #1 interviewed the LPN to obtain more information regarding Resident #1 and Resident #2. The LPN stated that yesterday (1/18/22), the facility received Resident #1's PCR COVID-19 test result, which was positive; The test had been done as part of the weekly testing collected on 1/17/22. Surveyor #1 asked the LPN what had been done with Resident #1's roommate (Resident #2). The LPN stated that Resident #2 was transferred into a room where Resident #3 resided. Surveyor #1 asked the LPN who made the decision to move Resident #2 into Resident #3's room. The LPN replied that the sisters (nuns) had made that decision. Surveyor #1 then asked the LPN why Resident #2 was not put on TBP after exposure to COVID-19. The LPN stated that the facility determines isolation (TBP) by testing for COVID-19. The LPN further stated that she did not know the reason why Resident #2 was not placed on TBP other than Resident #2's PCR COVID-19 test on 1/18/22 was negative. Surveyor #1 then asked the LPN if Resident #2 was exposed to COVID-19 since Resident #2 was the roommate of Resident #1 who tested positive for COVID-19. The LPN stated, I think so. She added that Resident #2 was under observation and checked for signs and symptoms for COVID-19. She also said that she performed a rapid COVID-19 test (an [MEDICATION(S)] test that provides a result in 15 minutes) on Resident #2 earlier today to make sure Resident #2 was still negative for COVID-19. Surveyor #1 then asked the LPN what the process was for a resident exposed to COVID-19; The LPN stated that she would isolate them. At 10:12 AM, Surveyor #2 interviewed the independent contracted Infection Preventionist (ICIP). The ICIP stated that if a resident tested positive for COVID-19 and had a roommate, the positive resident would be moved to the COVID-19 positive unit, and the exposed roommate would isolate in place and considered a PUI. She added that when a resident was a PUI, the facility would post signs to indicate what PPE was necessary, and an isolation cart with the required PPE would be placed outside the room. Surveyor #2 then asked if a resident exposed to COVID-19 should be transferred into a room with a non-exposed resident. The ICIP stated that if a resident was exposed to a COVID-19 positive resident, that the exposed resident should not come in contact with a well, non COVID-19 resident because of potential transmission of the virus. She added that an exposed resident should not be transferred to a well room and that the exposed resident should isolate in place. At approximately 10:15 AM, Surveyor #1, in the presence of Surveyor #2, interviewed the ICIP and asked what the facility process was if a resident becomes positive for COVID-19 and another resident resided in the same room. The ICIP stated that a resident that tested positive for COVID-19 would be moved to the COVID unit and that the roommate would be left in the original room and would become a PUI. She then stated that when COVID-19 started on the first-floor unit, the first resident that had tested positive for COVID-19 was moved to the second-floor unit. She said that, unfortunately, COVID-19 spread through the first-floor unit about a week ago. At 10:28 AM, Surveyor #1 interviewed the DON regarding what was done after the facility received Resident #1's positive COVID-19 test result. The DON stated that on Monday (1/18/22) in the late afternoon, the facility received the weekly PCR COVID-19 test result for Resident #1, which was positive. She further stated that Resident #1 was asymptomatic (did not have any signs or symptoms). She then said that Resident #2's (Resident #1's roommate) weekly PCR COVID-19 test result was negative. The DON stated that the facility then performed a rapid COVID-19 [MEDICATION(S)] test on Resident #1 and Resident #2. She then stated that the rapid COVID-19 [MEDICATION(S)] test result for Resident #1 was positive, and the result for Resident #2 was negative. The DON stated that it was decided to leave Resident #1 in their room and not move them to the COVID-19 unit on the second floor because the resident did not want to move. The DON stated that she, the LNHA, the ICIP, and two other staff members discussed and decided where to transfer Resident #2. She added that changes for the residents were hard on the residents. The DON stated that they chose to transfer Resident #2 into Resident #3's room because there was an open bed in that room, and that room was spacious, with more than six feet between the beds. Surveyor #2 then asked the DON what the facility policy was regarding a resident that is exposed to their COVID-19 positive roommate. The DON stated that when a resident tested positive for COVID-19, their roommate was now considered a PUI and put on isolation. She added that basically everyone is on isolation, are fully vaccinated, being monitored and observed. The DON then pointed to a resident seated in a wheelchair and indicated that the resident was Resident #2. Surveyor #1 observed that the resident was seated in a wheelchair next to the nurse's station and had a blue surgical mask positioned under the resident's chin and not covering the resident's mouth or nose. Any staff or visitors entering the building would pass Resident #2 to the elevator to access the second floor. Surveyor #1 did not observe any staff member encouraging Resident #2 to wear the surgical mask correctly over their mouth and nose. At 10:40 AM, Surveyor #1 confirmed with the DON that the resident in the hallway near the nurse's station and not wearing a surgical mask correctly was Resident #2. Surveyor #1 asked the DON why the resident was in the hallway. The DON stated that Resident #2 was at risk for falls. At 11:05 AM, Surveyor #1 observed Resident #2, whose eyes were closed, seated in a wheelchair next to the nurse's station. Surveyor #1 observed that Resident #2 had a blue surgical mask on that was positioned under the resident's chin and not covering the resident's mouth or nose. Surveyor #1 did not observe any staff member encouraging Resident #2 to wear the surgical mask over their mouth and nose. At 11:14 AM, Surveyor #1, in the presence of the survey team, interviewed the facility Infection Preventionist (IP) regarding what the facility policy was if a resident became positive with COVID-19. The IP stated that an asymptomatic resident that tested positive for COVID-19 would isolate in their room. She then said that asymptomatic (to have signs or symptoms) resident that tested positive for COVID-19 would be moved upstairs. Surveyor #1 then asked the IP if an asymptomatic person could transmit COVID-19 to another person. The IP stated that if a person tests positive, they could transmit COVID-19 to another person. Surveyor #1 then asked the IP what would be done for a COVID-19 positive resident's roommate. The IP stated that if the roommate is exposed, the roommate should then be tested . If the result is positive, the resident should be moved upstairs, and if negative, they should be tested again. The IP stated that Resident #1 should have been transferred to the second floor but that Resident #1 did not want to be transferred. She added that the facility moved Resident #2 to another room last night after the resident was tested for COVID-19, and the test result was negative. The IP confirmed that a resident exposed to COVID-19 should be moved to a private room and placed on TBP to prevent spreading the virus. She added that an exposed resident should be considered a PUI, and TBP should be implemented. Surveyor #1 then asked the IP why Resident #2 was transferred into a room with a resident that was well and not exposed to COVID-19 (Resident #3's room). The IP stated that she did not know why the facility transferred Resident #2 into Resident #3's room. She then stated that it should not have happened. She added that staff members could get the virus and transmit it. Surveyor #1 then asked the IP if she had been made aware of the transfer. The IP stated that she was not notified last night and added that the LNHA and the DON had made that decision. Surveyor #1 then asked the IP if a resident exposed to COVID-19 should be outside their room. The IP stated that we could not keep a resident in their room. Surveyor #1 then asked the IP why Resident #2, who was exposed to COVID-19, was in the hallway with their mask on but positioned under their chin. The IP stated that they cannot keep the resident in their room because they would climb out of bed and need to be monitored. The IP added that the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At 11:29 AM, Surveyor #1, in the presence of the survey team, interviewed the DON regarding the decision to transfer Resident #2. The DON stated that Resident #2 was transferred so that Resident #2 would not have any additional exposure to COVID-19 from Resident #1, who was positive for COVID-19. She then added that CDC guidance said that if residents were vaccinated and boosted, they did not have to be placed on TBP. She admitted that the facility did not look at the situation closely and should have transferred Resident #2 into a private room. She then stated that the facility would now place the residents on the first floor on TBP. Surveyor #1 then asked the DON why Resident #2 was outside their room and wore a surgical mask positioned under their chin. Surveyor #1 then asked the DON what the facility's Outbreak Response Plan included for a resident exposed to COVID-19. The IP stated that the resident, exposed to COVID-19, should be a PUI and then admitted that Resident #2 was transferred into the wrong room. At 11:46 AM, Surveyor #1, in the presence of the survey team, interviewed the LNHA regarding what happened after the facility was made aware that Resident #1 tested positive for COVID-19. The LNHA stated that they would meet and brainstorm where to move the covid positive resident and notify the family. She then stated that they had moved the positive residents upstairs and placed them on TBP. She further added that when all the rooms became occupied on the second floor, they started cohorting the Covid-19 positive residents in one area of the first floor. She then confirmed they would have placed exposed roommates of a COVID-19 positive resident with another resident exposed to COVID-19 and placed them both on TBP. The LNHA then admitted that Resident #2 was exposed to their roommate that tested positive for COVID-19 and that Resident #2 should have been placed on TBP. Surveyor #1 then asked the LNHA if a resident exposed to COVID-19 should be in the hallway with their mask positioned under their chin, not properly over their mouth and nose. The LNHA stated that Resident #2 should not be in the hallway with the mask positioned under their chin. At 12:09 PM, Surveyor #1 further observed Resident #2, whose eyes were closed, seated in a wheelchair next to the nurse's station. Surveyor #1 observed that Resident #2 had a blue surgical mask on that was positioned under the resident's chin and not covering the resident's mouth or nose. Surveyor #1 did not observe any staff member encouraging Resident #2 to wear the surgical mask over their mouth and nose. At 12:40 PM, Surveyor #1 observed Resident #2 seated in a wheelchair next to the nurse's station. Surveyor #1 observed Resident #2 eat lunch while wearing the surgical mask positioned under their chin. Surveyor #1 observed another resident seated in a wheelchair approximately ten feet away from Resident #2 in the hallway. The other resident was not wearing a surgical mask. At 12:41 PM, Surveyor #1 interviewed the CNA regarding how to know whether or not a resident was on TBP. The CNA stated that she would get the report in the morning and be told if a resident was COVID-19 positive or PUI and if she needed to put on a gown and gloves to go in the room. She also stated that signs would be posted on the resident's door if the staff needed to put on any PPE before entering the room. Surveyor #1 then asked the CNA what the process was if a resident became positive for COVID-19. The CNA stated that the facility usually separated the resident that tested positive and the roommate and that they both were placed on TBP. Surveyor #1 then asked the CNA why Resident #2 was not on TBP. The CNA replied that Resident #2's COVID-19 test result was negative, so she did not have to wear a gown or gloves. At 12:54 PM, Surveyor #1 observed the CNA, who wore an N95 mask and face shield, take off the clothing protector that Resident #2 wore while the resident ate their lunch. Resident #2 was seated in a wheelchair in the hallway near the nurse's station and still wore the surgical mask positioned under their chin. The CNA then took the meal tray from Resident #2 to the meal cart. Surveyor #1 did not observe the CNA encourage Resident #2 to wear the surgical mask over the resident's mouth and nose. A review of the facility provided line listing for the current COVID -19 outbreak listed a total of 19 staff members and 21 residents that tested positive for COVID-19 and included the following: On 12/24/21: one (1)staff member (date tested COVID-19 positive or symptom onset prior to testing date) On 12/26/21: two (2) staff members On 12/27/21: one (1) staff member On 12/29/21: one (1) resident On 12/30/21: two (2) staff members On 12/31/21: one (1) resident and one (1) staff member On 1/1/22: one (1) resident On 1/2/22: one (1) resident On 1/3/22: three (3) residents On 1/4/22: three (3) residents and two (2) staff members On 1/6/21: two (2) staff members On 1/8/22: nine (9) residents On 1/10/22: one (1) resident and six (6) staff members On 1/17/22: one (1) resident and one (1) staff member Date unavailable: one (1) staff member A review of the facility provided document titled Completed Immunizations included the following regarding the first-floor resident's COVID-19 vaccination status: 21 of 21 residents had both doses of a two-dose COVID-19 vaccination. 20 of 21 residents had an additional booster dose of COVID-19 vaccination. Surveyor #1 reviewed the medical record for Resident #1. The Admission Record face sheet (an admission summary) indicated that Resident #1 had been admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Clinical Report dated 1/18/22 indicated that Resident #1 tested positive for [CONDITION(S)]-Cov-2 (COVID-19). The Interdisciplinary Progress Notes dated 1/18/22 2:25 PM included the following: Lab report received with positive COVID-19 result; Resident is asymptomatic. His/her roommate lab test is negative. Roommate was transferred to negative room. Resident #1 will stay in his/her room on isolation. Surveyor #1 reviewed the medical record for Resident #2. The Admission Record face sheet indicated that Resident #2 had been admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review it was determined that the facility failed to accurately: a.) assess and code residents with contractures (the process in which a muscle becomes shorter and tighter) and b.) document diagnoses, reflected in the Minimum Data Set (MDS) an assessment tool. This deficient practice was identified for 4 of 12 residents reviewed (Residents #1, #18, #43, and #45), and was evidenced by the following: 1. The Admission Record (AR) reflected that Resident # 1 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], indicated that the resident had severe cognitive deficits. The MDS also reflected that the resident required total assistance with activities of daily living (ADL's). The MDS' dated 7/28/18 (quarterly), 10/21/18 (annual), 1/22/19 (quarterly), 4/25/19 (quarterly) all indicated that Resident # 1 had full range of motion (ROM) to his/her bilateral (b/l) lower extremities however the resident's bilateral knees were contracted with impaired ROM. The resident was unable to be interviewed by the surveyor due to severe cognitive impairment. On 6/04/19 at 10:53 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who had been working in the facility for [AGE] years and was providing care for Resident # 1. The CNA stated that the tilt back wheelchair (w/c) the resident was utilizing was a positioning w/c that helped the resident sit up straighter for meals and tilt back for positioning. The CNA also revealed that the resident had contracture's of the bilateral knees on the lower extremities. On 6/04/19 at 11:08 AM, the surveyor interviewed the Registered Nurse (RN) who stated that the resident had contractures of the b/l lower extremities and this is why he/she is in a special chair for positioning. The facility form titled Updated Plan of Progress for Outpatient Rehabilitation dated 9/15/15, indicated that Resident # 1 had flexion contracture's of both knees. On 6/04/19 at 11:30 AM, the surveyor interviewed the Director of Rehabilitation (DOR) who stated that the chair the resident was currently using was a nursing intervention for the contractures of the b/l knees of the lower extremities. On 6/04/19 11:50 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident is using the tilt back w/c without foot rest because when he/she had the foot rest, he/she pushed her legs up, thus further increasing the risk for the lower extremity knee contractures to worsen. On 6/05/19 09:36 AM, the surveyor interviewed the DON and Administrator who confirmed that the functional range of motion area in section G, was coded incurrectly on the MDS dated [DATE], 10/21/18, 1/22/19, 4/25/19, and that they should have indicated that the resident had decreased ROM of the b/l lower extremities. We will do modifications to the MDS assessments so that they will be accurate. 2. The AR indicated that Resident #18 was admitted to the facility 3/1/17, with the medical [DIAGNOSES REDACTED]. The MDS dated [DATE], reflected that the resident was cognitively intact and required total care with all aspects of activities of daily living (ADLs). The quarterly MDS's dated 6/12/18, 9/11/18, 12/10/18, and an annual MDS dated [DATE], reflected that the resident had no impairment with functional range of motion (ROM ) on either side of the upper body and hands, however, both hands are contracted and have decreased ROM. On 6/03/19 at 09:28 AM, the surveyor observed Resident # 18 resting in bed and his/her b/l hands visible on top of the blankets. The surveyor observed that the resident's fingers on both hands were deformed and contracted. The resident was interviewed at this time and stated that the nursing staff put his/her hand rolls in during the day because he/she could not move some fingers. The hand rolls were observed in place in both the resident's hands. The resident added that he/she had contractures of some of the fingers on both hands for about a year. On 6/04/19 at 10:35 AM, the surveyor interviewed the primary care CNA #2 who stated the Resident #18 required total assistance with ADL's because both of her legs were very weak and his/her hands were contracted which impaired his/her ability to care for himself/herself . The CNA added that the resident wears hand rolls during the day to prevent both of the hand from becoming further contracted. On 6/04/19 at 10:48 AM, the surveyor interviewed the RN who stated that Resident #18 had contractures of the bilateral hands for quite a while but that she was not sure exactly for how long. The facility form titled, Plan of treatment for Outpatient Rehabilitation dated 3/20/19 reflected that Resident # 18 had an OT referral for contracture management of the left and right hands and indicated that the resident had contractures to all digits of the left hand and the right hand only had 50% of functional use. The rehabilitation form titled, Updated Plan of Progress for Outpatient Rehabilitation dated 4/11/18, reflected that Resident #18 had only 50% of functional use of the left hand. The rehabilitation daily treatment record dated 5/9/18, reflected an Occupational Therapy (OT) note indicating that Resident #18 had a contracture of the left hand on the 4th and 5th fingers. The OT care plan dated 3/20/19, indicated that the resident had decreased functional use of both hand and was at high risk for further contractures of bilateral hands. On 6/05/19 at 09:32 AM, the surveyor interviewed the DON who stated that the MDS Coordinator must of missed coded the functional range of motion area in section G of the MDS because the resident had decreased range of motion and contractures to both hands for about a year. 3. The AR indicated that Resident #43 was admitted to the facility with the [DIAGNOSES REDACTED]. The MDS dated [DATE] reflected that the resident was cognitively intact. The MDS also reflected that the resident had a [DIAGNOSES REDACTED]. On 6/03/19 at 09:41 AM, the surveyor interviewed Resident #43 who stated that he/she did not have a [DIAGNOSES REDACTED]. I've had Depression in the past but never [MEDICAL CONDITION]. The MDS dated [DATE], 4/2/19, and 4/17/19 all reflected that Resident #43 was cognitively intact and had a [DIAGNOSES REDACTED]. The Medical history and physical examination [REDACTED]. According to the Psychiatry Consult dated 3/29/19, the resident refused to be seen by a psychiatrist. On 6/05/19 at 12:42 PM, the Director of Nursing confirmed that the resident did not have a major mental illness [DIAGNOSES REDACTED]. According to the facility job description, the MDS Coordinator has the responsibility to ensure that the MDS is accurate and are completed according to state and federal regulations and completes accurate coding with information obtained by the medical record review as well as observation and interview with facility staff members, residents and family members. The facility policy titled, Resident Assessment Instrument and dated 2010, indicated that the purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. The policy also indicated that the information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/hers highest practical level of functioning. The Policy also indicated that all persons completing any portion of the MDS resident assessment must sign the document to attest to the accuracy of such information. 4. On 6/03/19 at 10:00 AM, the surveyor observed Resident #45 seated in a wheelchair in the hallway with a left splint in place. The attachment site on the splint was unfastened and the resident's hand was clenched closed like a fist. When interviewed, the resident was unable to explain why her hand was not fastened. On 6/04/19 at 01:14 PM, the surveyor observed Resident #45 seated in a wheelchair in the hallway with a left palm guard in place. The palm guard was different than the splint worn on the previous day and had a sheepskin lining. Resident #45 indicated the new splint, was more comfortable. On 6/05/19 at 12:48 PM the surveyor made the same observation of Resident #45's splint in place while in the main dining room. The surveyor reviewed Resident #45's Admission Record, with a readmission date of [DATE], which revealed Resident #45's medical [DIAGNOSES REDACTED]. The surveyor reviewed the quarterly MDS dated [DATE], which revealed Resident #45 had no impairment with the upper extremity. This was also reflected in the quarterly MDS dated [DATE], the quarterly MDS dated [DATE] and the annual MDS dated [DATE]. The surveyor reviewed the (MONTH) 2019 Physicians Order Sheet which revealed the left-hand splint was ordered in (MONTH) of (YEAR). This same order was reflected and signed off by the nurses in Resident #45's Treatment Administration Record. The surveyor reviewed Resident #45's care plan which reflected the resident wore the splint to prevent further left-hand contracture dated back to (YEAR). On 6/06/19 at 09:35 AM, the surveyor interviewed CNA #3 who revealed that Resident #45 has worn a variety of assistive devices for a left-hand contracture over the past four years. On 6/05/19 at 01:11 PM, the surveyor interviewed the LPN who revealed the Resident #45 has worn the brace on and off for the last couple years related to a contracture. The LPN further indicated Resident #45 had the contracture for the last couple of years and was seen by therapy for it. The LPN revealed Resident#45 was recently evaluated by Occupational Therapy (OT) who recommended a trial for a palm guard since Resident #45's fingers were slipping out of it. On 6/05/19 at 01:27 PM, the surveyor interviewed the Physical Therapist (PT), Director of Rehab who confirmed Resident #45 had a left-hand contracture for a few years and has worn an assistive device for the contracture. On 6/05/19 at 01:30 PM, the Director of Nursing (DON) confirmed Resident #45 has had a left-hand contracture and wore a splint. The DON further revealed that the MDS coordinator, who was unavailable for interview during the survey, miscoded it. N.J.A.C 8:39-33.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to properly dispose of medication in 1 of 4 storage areas for a period of 5 months. This deficient practice was identified during inspection of 1 of 4 medication carts as evidenced by the following: On 1/25/2017 at 11:35 a.m., the surveyor inspected the first floor medication cart with the Licensed Practical Nurse (LPN) and observed an unopened box of Duo-Neb solution inside the first floor medication cart. On the same day at 11:40 a.m., the surveyor reviewed the clinical record that revealed that the Duo- Neb Nebulizer solution had been discontinued since August 2016. On 1/25/2017 at 11:45 a.m., the surveyor interviewed the LPN about the discontinued Duo- Neb Nebulizer solution. The LPN agreed that the Duo- Neb Nebulizer solution was discontinued and should have been removed from the medication cart. NJAC 8:39-29.11 (g)

Based on observation and interview it was determined that the facility failed to provide an environment that provided dignity in dining when all residents seated at a table were not assisted with meals in a timely manner. This deficient practice was identified for 2 sampled residents, Resident # 9 and #12 as evidenced by the following: 1. On 1/25/17 12:30 p.m., the surveyor went to the second floor dining room to observe residents being served lunch. The dietary aide delivered the lunch cart at 12:35 p.m. The surveyor observed Resident #12 seated at the table from 12:35 p.m. to 1 p.m., with the lunch tray unopened while another resident at the same table was being assisted with the meals. 2. On 1/25/17 at 12:20 p.m., the surveyor observed Resident #9 seated in the activity room with the lunch tray untouched. Resident #9 sat at the table from 12:35 p.m. to 1: 05 p.m. without being assisted with the lunch tray. Another resident at the same table was being assisted and completed his/her lunch at 1:00 p.m. A review of the clinical records on 1/26/17 at 10:30 a.m., revealed that Resident #12 was confused and totally dependent on staff for all Activities of Daily Living (ADL's ) including meals and Resident #9, the resident assessment tool noted cognitively impaired and totally dependent on staff for all ADL's. On 1/27/17 at 1:15 p.m., the surveyor interviewed the Registered Dietitian (RD) regarding the delay with the meals delivery system. The RD stated that the facility was aware of the delay but did not have a plan yet to assist all residents with the meals in a timely manner. The RD further stated that she had trained several staff members to assist with meals including the receptionist. However, she did not want one staff to feed two residents at once because of the potential for cross-contamination. NAACP 8:39-17.4 (d)

Based on observation, interview and record review, it was determined that the facility failed to serve hot food at temperatures that were acceptable to all the residents. This deficient practice was based on the following: During the group meeting on 1/26/17 at 10:30 a.m. 3 of 6 residents in attendance complained of cold food. Resident # 4 stated, Nine times out of ten the eggs are cold. Later that day, Resident #4 reported to another surveyor, I keep telling them that the eggs are cold. Another resident at the group meeting stated that the hot cereal was served a little cool. A third resident at the group meeting reported that lunch was served lukewarm. At 12:09 p.m. on 1/26/17 the surveyor interviewed the Food Service Director (FSD) who stated that he didn't check test trays anymore. We were wasting food. He said that he conducted monthly menu committee meetings and there were no issues raised regarding food temperature. The surveyor reviewed the minutes for the last 4 months and could not find any indication that the residents voiced concerns before over the food temperature. On 1/26/17 at 12:34 p.m. the surveyor requested that 2 test trays be sent to the second floor. The trays arrived on the floor in an enclosed food truck at 12:35 p.m. The last resident was served at 12:50 p.m. in the second floor dining room. At that time, the surveyor used the calibrated thermometer in the presence of the consulting dietitian to record the following temperatures: Pureed vegetables: 129.1 degrees Fahrenheit (F) Mashed potatoes: 129 degrees F Whole carrots: 121 degrees F French fries: 122 degrees F Note: The pureed and regular chicken on these test trays were served at 136.8 degrees F and 137.3 degrees F, respectively, which were in an acceptable range for hot food. On 1/27/17 at 7:40 a.m., the surveyor went to the first floor to observe the meals delivery system and monitor the food temperature. The dietary aide delivered the breakfast tray at 7:40 a.m. The last resident received the breakfast tray from the cart at 7:55 a.m. Using a calibrated thermometer in the presence of a Certified Nursing Assistant, the surveyor recorded the following temperatures: Scrambled eggs: 96.8 degrees F Farina: 126.9 degrees F On 1/27/17 at 8:12 a.m. the surveyor interviewed Resident #7 who was eating breakfast in bed. This resident had attended the group meeting the day before and had no complaints about food temperatures at that time. However, the resident stated that he/she usually ate breakfast in the main dining room and reported to the surveyor that the eggs are never hot. The resident at that time described the temperature of the hot cereal as So-so. NJAC 8:39-17.4 (e)

Based on observation, interview, and record review, it was determined that the facility failed to properly store a scoop used for the Thick It ( a substance used to thicken food and liquids for residents on mechanically altered diets.) This deficient practice was identified during inspection of the first floor medication room as evidenced by the following: On 1/25/2017 at 11:30 a.m., the surveyor noted two cans of Thick It powder inside the first floor medication room. The LPN opened the first container. The surveyor observed that the can was half full and the entire scoop was immersed in the powder. The second container was also half full, and the surveyor observed the entire scoop in the powder. Anyone using the powder would need to place their fingers in the powder to reach the scoop. During an interview on 1/25/16 at 12:30 p.m., the LPN stated that the scoop should have been stored in a plastic bag, not in the Thick it powder, to prevent contamination. During a conference on 1/27/17 at 11:45 a.m. , the Administrative staff agreed that the scoop should not have been stored in the container. NJAC 8:36-18-3 (7)

Based on observation, interview and record review it was determined that the facility failed to implement care plan interventions while providing care to Resident #12. This deficient practice was identified for 1 of 13 residents reviewed as evidenced by: During the initial tour on 4/7/15 at 9:30 a.m. the unit nurse told the surveyor that Resident #12 was confused and required the assistance of two staff for all care needs. The surveyor observed the resident in a low bed with padding on the headboard. The surveyor reviewed Resident #12's medical record on 4/9/15. According to a nurse's note, written on 10/5/14, the Certified Nurse Aide (CNA) reported to the nurse that while providing morning care to the resident she noticed a bruise and swelling to the top of the resident's head. An investigation into the injury of unknown origin was initiated. At that time, the resident had a care plan for "Self Care Deficit" that included that the resident required the assistance of two staff for "AM and PM care," turning and positioning, bathing, dressing and grooming, incontinence care and transfers. According to the investigation, the CNA who provided PM care to the resident on 10/4/14 did not call for assistance while caring for the resident. The CNA provided incontinence care and repositioned the resident in bed without assistance. The conclusion of the investigation was that the CNA did not follow the resident's care plan while providing PM care and as a result the resident sustained [REDACTED]. Refer F323 NJAC 8:39-11.2(f)

Based on observation, interview and record review it was determined that the facility failed to provide care in a safe manner for Resident #12. This deficient practice was identified for 1 of 9 residents reviewed as evidenced by: During the initial tour on 4/7/15 at 9:30 a.m. the unit nurse told the surveyor that Resident #12 was confused and totally dependent on staff for all care needs. The surveyor observed the resident in a low bed with padding on the headboard. The surveyor reviewed Resident #12's medical record on 4/9/15. The resident had a care plan for "Self Care Deficit," initiated on 6/8/14, which included two staff assistance with "AM and PM care," incontinent care, dressing, grooming, turning, positioning and transfers. According to a nurse's note, written on 10/5/14, during morning care the Certified Nurse Aide (CNA) reported to the nurse that the resident was noted to have a "bruise and swelling" on the top of the head. The cause of the injury was unknown. The physician was notified and an order was received for an X-ray of the skull. The X-ray was done on 10/5 and was negative for fracture. On 4/9 the surveyor reviewed the "Skin Tear/Bruising Investigation" which was initiated by the facility on 10/5/14 to determine possible causes for the injury. According to the investigation, the CNA who provided evening care to the resident on 10/4/14 did not call for assistance. The CNA "washed" the resident, provided incontinence care and bed positioning without the assistance of a second staff member. The conclusion of the investigation was that the lack of two staff assistance with PM care were possible causative factors of the bruise/swelling to the resident's head. At that time the resident's care plan was undated to include "cushion and sheepskin to head of bed." The surveyor interviewed the Director of Nurses (DON) on 4/9 at 9 a.m. The DON confirmed that the CNA provided care to Resident #12 "alone" and further stated that "she should have had two people." The DON stated that during care the resident may have "hit head on headboard." Refer F282 NJAC 8:39-27.1(a)

Based on record review and interview, it was determined that the facility failed to document sequencing and/or consistent parameters for the use of an [MEDICATION NAME] for a period of 8 months for 1 resident, Resident #4, and 26 months for 1 resident, Resident #6; failed to provide documented evidence that a medication had been administered to 1 resident, Resident #7; and failed to provide indication for the use of PRN (as needed) medications for 2 residents, Resident #6 and #3. This deficient practice was identified in 5 of 13 residents reviewed for adherence to professional standards of practice and was evidenced by the following: 1. On 4/26/12 at 10 a.m., the surveyor reviewed the Physician order [REDACTED]. An order, dated 5/26/10, indicated to administer liquid [MEDICATION NAME] via a gastrostomy tube (GT) for a total of 650milligrams (mg) every 4 hours PRN "for pain" and/or "temp greater than 100." Another order, dated 6/2/11, indicated to administer an [MEDICATION NAME] 650 mg suppository "per rectum" every 4 hours PRN "for pain" and/or "temp greater than 101." During an interview on 4/26/12 at 2:15 p.m., the Director of Nursing (DON) stated that Resident #4 had a history of [REDACTED]. The DON acknowledged that there was no documented evidence of sequencing of which medication route should be used based on the resident's condition. The facility did not provide information to explain the discrepency in the temperature parameters for the use of Tylenol for Resident #4. 2. On 4/26/12 at 11 a.m., the surveyor reviewed the medical record for Resident #6. The 4/2012 POS included the following ongoing physician orders: Tylenol 650 mg every 4 hours as needed for pain and Tylenol 650 mg every 4 hours as needed for a temperature greater than 100 degrees, each by mouth and both initiated on 2/24/10. Additional orders, both initiated 2/26/10, included Tylenol 650 mg rectal suppository every 4 hours as needed for pain and Tylenol 650 mg rectal suppository as needed for a temperature greater than 100 degrees. The physician's orders [REDACTED]. 3. The surveyor reviewed Resident #7's medical record on 4/25/12. The resident had a physician order [REDACTED]. According to the March 2012 Medication Administration Record (MAR) the medication was scheduled to be administered on 3/3 and 3/27. The 3/27 dose was not signed as administered on the MAR. On 4/26 at 11 a.m. the surveyor interviewed the nurse who was on duty on 3/27. The nurse told the surveyor that the medication was administered but she "forgot" to sign the MAR. The nurse provided evidence that 1 dose of the medication was provided by the pharmacy and another dose of the medication was ordered after the 3/27 administration. 4. The surveyor reviewed Resident #1's medical record on 4/26/12. The resident was readmitted from the hospital on [DATE] with a physician order [REDACTED]. On 4/5/12 a physician order [REDACTED]. suppository twice daily as needed. Neither of the as needed physician orders [REDACTED]. 5. The surveyor reviewed Resident #3's medical record on 4/25/12. The resident had a physician order, dated 4/13/12, for [MEDICATION NAME] 0.25 mg. every 6 hours as needed. The physician order [REDACTED]. NJAC8:39-11.2(b) 8:39-29.2(d)

Based on observation, interview and record review, it was determined that the facility failed to follow proper handwashing protocol during treatment observation for Residents # 1 and #4; during medication administration observation for Residents #14,#5 and #15; and during the kitchen tour observation. The facility also failed to follow proper infection control protocol while handling soiled linen for Resident #4. These deficient practices were evident for for 5 of 13 residents reviewed and for Residents #14 and #15 who were referred to but not reviewed as evidenced by the following: 1. On 4/26/12 at 9:40 a.m. the surveyor observed the unit nurse provide a treatment to an open area on Resident #1's left ankle. After completing the treatment the nurse washed her hands. The nurse applied soap to dry hands and rubbed them together, then rinsed. The soap did not lather when applied to dry hands. 2. On 4/26/12 at 8:50 a.m., the surveyor observed 2 Certified Nursing Assistants (CNA) performing hand washing before and after assisting the Licensed Practical Nurse (LPN) during a wound dressing change for Resident #4. Both CNAs completed washing their hands and then used their clean hands to pump the manual paper towel dispenser handle for additional towels to turn off the water faucet. 3. On 4/26/12 at 7:53 a.m. the surveyor observed the unit nurse administer medication to Resident #14. After administering the medication the nurse washed her hands. After applying the soap the nurse washed her hands the entire time under running water. 4. On 4/26/12 at 8:15 a.m. the surveyor observed the unit nurse administer medication to Resident #5. After administering the medication the nurse washed her hands. After washing and drying her hands, the nurse used clean hands to pump the manual paper towel dispenser for a towel to turn off the faucet. 5. On 4/26/12 at 8:25 a.m. the surveyor observed the unit nurse administer medication to Resident #15. After administering the medication the nurse washed her hands. After washing and drying her hands the nurse used clean hands to pump the manual paper towel dispenser for a towel to turn off the faucet. 6. On 4/26/12 at 9:35 a.m. in the facility kitchen, a Food Service Worker (FSW) who was not wearing gloves placed a soiled sheet pan into the wash compartment of the 3 compartment pot sink. The FSW proceeded to empty clean sanitized dishes from the clean end table of the dish machine without handwashing and putting on clean gloves. The Food Service Director (FSD), who observed the cross contamination, instructed the FSW to wash her hands. The FSW proceeded to the wash compartment of the 3 compartment pot sink where she washed her hands instead of the designated hand washing sink. On 4/30 at 11:15 a.m. the surveyor reviewed the facility policy for handwashing in the presence of the Director of Nurses. The policy included to wet hands before applying soap and to rub hands "atleast 20 seconds" before rinsing under running water. The DON confirmed that clean hands should not be used to dispense towels from the towel dispenser after handwashing. 7. On 4/26/12 at 8:50 a.m., the surveyor observed 2 CNAs providing incontinence care for Resident #4. The surveyor observed that, after removing the soiled cloth bed pad, it had been placed, unbagged, on the lower shelf of a suction machine storage cart next to the resident's bed. The surveyor then observed the LPN clean the resident's gastrostomy tube (GT) insertion site using a wet washcloth, which was then placed on top of the bed pad on the shelf. NJAC 8:39-19.4(a) 8:39-19.4(a)1

Based on observation and interview, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner. This deficient practice was evidenced by the following: On 6/27/11 from 9:50 a.m. to 11:10 a.m., the following was observed by the surveyor in the kitchen, in the presence of the Food Service Director (FSD): 1. The dish machine, which required a hot water temperature for adequate sanitization, specified a minimum wash temperature of 150 degrees and a final rinse water temperature of 180 degrees or greater. Breakfast clean-up had been completed and the machine tanks were emptied. The surveyor asked the FSD for the dish machine temperature logs. The FSD gave the surveyor an "Ecolab Dish Machine Temperature Chart" (EDMTC) which contained temperature strips used to indicate if the dish machine water was hot enough for adequate sanitization (a final plate temperature of 160 or greater). When reviewed with the FSD, there was no documented evidence the dish machine temperature had been checked prior to the breakfast clean-up that morning. The FSD stated the facility only ran a test strip through the dish machine when the silverware was washed and the time when it was checked varied. If a test strip failed to indicate that the hot water was adequate, the facility would notify a repair company. Documentation on the EDMTC revealed temperature strips were utilized for 69 out of 120 meals, served between 5/16/11 lunch to 6/25/11 breakfast. In addition, the dish machine final plate temperature strips failed to reach a temperature to indicate adequate sanitization for 39 of the 69 meals that the water temperatures were checked. The FSD stated he was unaware that the dish machine temperature had failed to reach temperature. There was no evidence of a system in place to ensure the dish machine reached water temperatures for wash and rinse according to the manufacturer's specifications and final plate temperatures for adequate sanitization at the beginning of meal clean ups. 2. The FSD identified the dedicated hand washing sink as the sink built in to the counter top adjacent to the coffee maker. The surveyor washed her hands. The trash at the handwashing sink had a lid on it. When the surveyor asked where to discard the paper towels used to dry her hands, the FSD stated he just lifted the trash can lid with a paper towel after washing his hands. 3. The FSD rinsed out a coffee pot in the hand washing sink and filled the coffee pot with water. The FSD stated he was going to use the water to make coffee. 4. A Food Service Worker (FSW) was observed washing her hands at the hand washing sink. The FSW used friction under the running water for 5 seconds, turned the faucets off with her wet hands and lifted the trash can lid with the paper towel. 5. Water splashed onto the adjacent counter top during handwashing. Stacked trays with mugs, identified as clean, were stored on the adjacent counter and within splashing distance of the hand washing sink. 6. A food processor and a blender was observed on a table top abutting the soiled side of the 3 compartment sink. The FSD stated that the wash and rinse compartments were used to wash and rinse dirty pots and pans. 7. Multiple spray bottles of chemical cleaning agents were stored on a wall mounted shelf above the soiled end of the 3 compartment sink and in close proximity to the adjacent table with the food processor and blender. Two of five of the spray bottles were not labeled. 8. A cook was observed cooking instant mash potatoes on the steam table. When brought to the attention of the FSD, he stated they have always used the steamtable to cook mashed potatoes because the pan was to heavy for the cook too carry it. 9. The scoop for the ice machine was stored in an unsealed Ziploc bag that was sticky to touch, on top of the ice machine. 10. In the walk-in refrigerator, a sheet pan which contained a multi-gallon container of pickles and a bin with packages of raw poultry was observed on the bottom shelf. The cook entered the refrigerator and placed a pan of cooked pork adjacent to the raw poultry on the bottom shelf. 11. In the walk-in refrigerator, 5 containers of a nutritional supplement which had a 14 day shelf life once thawed, were not labeled with a "use by date." 12. In the walk-in refrigerator, a package of sliced ham was dated 6/26. The FSD stated the date indicated the date of expiration. NJAC 8:39-17.2(g)