Every finding on record at Trinitas Hospital

Based on observation, interview, record review, and facility policy review, the facility failed to assess a resident for self-administration for 1 of 11 residents (Resident # 35) reviewed for self-administration of medication(s). Findings included: A facility policy titled, Self-Administration of Medications, revised 09/2025, specified, Policy Statement Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. Residents who express the desire the self-administer medications will be assessed to determine ability to self-administer medication. Per the policy, 3. If the nursing assessment completed by the IDCP [interdisciplinary care plan] Team will resident agreement reveals that the resident is able to safely administer medications, a physician's order will be obtained, and the residents care plan will be updated to reflect self-administration of medications. A Resident Face Sheet revealed the facility admitted Resident #35 on 06/02/2026. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of chronic respiratory failure with hypoxia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/08/2026, revealed Resident #35 had a Brief Interview of Mental Status (BIMS) of 12, which indicated the resident had moderate cognitive impairment. Resident #35's active physician orders revealed an order dated 06/02/2026 for milk of magnesia suspension 400 milligrams per 5 milliliters (mL), give 30 mL for constipation at bedtime as needed. There was no order that specified the resident could self-administer medication(s). During an observation on 06/22/2026 at 9:55 AM, Resident #35 sat in a wheelchair in their room and the surveyor noted on top of the resident's bedroom dresser the following medications: a half-empty 26 ounce (oz) bottle of milk of magnesia, a half-empty 6 oz. container of Vicks VapoRub, a half-empty tube of ammonium lactate, a half-empty tube of ketoconazole, and a half-empty bottle of melatonin gummies. During an interview on 06/22/2026 at 10:00 AM, Resident #35 stated they took of the milk of magnesia every day as it helped relieve constipation, and they applied the ketoconazole every day to a sore on the bottom of their left foot. Resident #35 stated they applied the ammonium lactate cream daily to their arms and legs, the Vicks VapoRub was used daily under their nostrils, and the melatonin gummies were used to help them sleep. Resident #35 did not respond when the surveyor asked where they got the over-the-counter medications from. During an interview on 06/22/2026 at 10:17 AM, Licensed Practical Nurse (LPN) #1 stated she had not observed any medications at the resident's bedside. LPN #1 stated the only time medications were allowed in a resident's room was when the resident's physician assessed the resident and wrote a physician's order so the resident could self-administer. LPN #1 stated there were no residents in the facility with a physician's order to self-administer medication During an observation on 06/23/2026 at 10:38 AM, the surveyor entered Resident #35's room and asked permission to look at the contents of the resident's dresser drawer. The resident's dresser drawer included: three boxes of sore throat lozenges, a 26 oz bottle of milk of magnesia, a 6 oz container of Vicks VapoRub, ammonium lactate, ketoconazole, and melatonin gummies. Resident #35 did not respond when the surveyor asked where they got the over-the-counter medications from. During an interview on 06/23/2026 at 10:50 AM, Certified Nursing Assistant (CNA) #3 stated she obtained permission from Resident #35 to observe the items in their drawer. CNA #3 stated she found sore throat lozenges, milk of magnesia, Vicks VapoRub, and a couple of skin creams in the resident's drawer. CNA #3 stated she informed LPN #1 that the resident had medication in their room. During a concurrent observation and interview on 06/23/2026 at 10:56 AM, CNA #2 exited Resident #35's room and reported there were multiple medications, to include melatonin gummies, milk of magnesium, Vicks VapoRub, and skin creams, on the top of the resident's bedroom dresser. CNA #2 stated she was not aware whether residents were permitted to self-administer medications. CNA #2 stated she informed LPN #1 about the medications observed on Resident #35's bedroom dresser. During an interview on 06/24/2026 at 11:07 AM, Nurse Practitioner (NP) #6 stated the process for a resident to self-administer medications required a physician's order to self-administer medication. NP #6 stated the expectation before a resident could self-administer medications was the resident must be assessed by their physician and have a physician order to self-administer medication. NP #6 reviewed Resident #35's medical record and stated Resident #35 was not assessed by their physician to self-administer medications and did not have an order to self-administer medications. During an interview on 06/24/2026 at 11:20 AM, Registered Nurse #7 stated that before a resident was permitted to self-administer medication, a physician's order must be obtained. During an interview on 06/24/2026 at 2:37 PM, the Director of Nursing (DON) stated the facility did not have any residents who self-administered medications. The DON stated the process and expectation for residents to self-administer medication was only when the resident had a physician's order. The DON stated Resident #35 was not assessed and did not have an order to self-administer medications. During an interview on 06/24/2026 at 2:53 PM, the Administrator explained the process and expectation for a resident to self-administer medication included the resident being evaluated by their physician and approved to self-administer medication and have a physician's order to self-administer medication(s). The Administrator stated Resident #35 was not assessed to self-administer medications and did not have an order to self-administer medications. NJAC 8:39-29.2(c)6

Based on observation, interview, record review, and facility policy review, the facility failed to ensure timely repair of a resident's wheelchair for 1 resident (Resident #77) out of 2 sampled residents reviewed for accommodation of resident needs.Findings include: A facility policy titled, Maintenance Services & Work Order Policy, revised 01/2026, revealed, Maintenance services is provided to all areas of the building/facility, grounds, & equipment. Policy Interpretation & Implementation 1. Maintenance Department is responsible for maintaining the physical integrity of the facility, grounds, & maintenance/repairs of resident equipment in a safe & operable manner always. A Resident Face Sheet revealed the facility admitted Resident #77 on 06/11/2004. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis, cerebral infarction, difficulty walking, and muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/2026, revealed Resident #77 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident used a walker and wheelchair. During a concurrent interview and observation on 06/22/2026 at 10:36 AM, Resident #77 stated the right brake on their wheelchair was stuck in the locked position. The surveyor noted the right brake on the resident's wheelchair was stuck in the locked position, which prevented the right wheel of the wheelchair from moving. Resident #77 stated they informed staff that their brake on their wheelchair was locked and they were not able to disengage the right hand brake on their wheelchair. During a follow-up interview on 06/23/2026 at 11:32 AM, Resident #77 stated the right brake on their wheelchair was stuck in the locked position. During an interview on 06/23/2026 at 2:28 PM, Certified Nursing Assistant (CNA) #11 stated if a maintenance concern was identified in a resident's room, she would notify the nurse so the maintenance department could be contacted. CNA #11 stated she was aware that Resident #77's wheelchair brake was stuck, and she knew about the concern approximately two weeks prior. CNA #11 stated she informed a nurse of the concern but was not able to state which the name of the nurse. During an interview on 06/23/2026 at 3:17 PM, the Regional Plant Operator (RPO) stated staff should enter in a work order related to resident equipment in the facility maintenance software. The RPO stated he was not able to locate a work order related to Resident #77's wheelchair. During an interview on 06/25/2026 at 9:00 AM, the Director of Nursing stated if a resident's wheelchair was not functioning properly, she would expect the nursing staff to notify the maintenance department to ensure the resident's wheelchair was fixed if a concern was identified and enter a work order into the facility maintenance software. During an interview on 06/25/2026 at 9:06 AM, the Administrator stated he expected a concern related to a resident's wheelchair to be addressed right away. NJAC 8:39-4.1(a)11

Based on observation, interview, and facility policy review, the facility failed to ensure medications found in 1 of 5 medication carts (5th floor Side B) were disposed of per the facility policy.Findings included: A facility policy titled, Discarding and Destroying Medications, revised 02/2026, indicated, Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. The policy specified, 6. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substances with other solid waster following the steps below: a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. c. Dispose with solid waste in the presence of two witnesses. Witnesses will be a charge nurse releasing custody of narcotic from narcotic storage and Nurse Supervisor, DON or ADON. d. Document the disposal on the medication disposition record. e. Include the signature(s) of at least two witnesses. During a concurrent interview and observation of the 5th Floor Side B medication cart on 06/24/2026 at 11:35 AM, the surveyor noted a gray specimen cup labeled Non-narcotic meds - disposable cups, which held 21 tablets of varying size, shape, and color. The Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 evaluated the contents of the specimen cup and stated the medications were not labeled and were not resident-specific. The DON stated the medications did not meet facility expectations for proper storage. LPN #1 stated the medications were intended for disposal and should not have been stored in the medication cart. Both the DON and LPN #1 walked away with the specimen cup of pills, and the DON stated they were on their way to dispose of the medications per the facility policy. During an interview on 06/24/2026 at 3:16 PM, LPN #1 stated the medications in the specimen cup were most likely intended for disposal by the previous nurse, LPN #13. LPN #1 stated medications were required to be labeled with resident identification, expiration date, and date opened. LPN #1 stated medications should not be stored in an unlabeled container within the medication cart. Per LPN #1, the facility's drug disposal policy should be followed to prevent contamination and potential spread of infection. During an interview on 06/24/2026 at 6:01 PM, the Pharmacy Consultant (PC) stated the variety of medications that were stored in the specimen cup within the medication cart should have been discarded immediately. The PC stated medications awaiting disposal should not be kept in the medication cart. During an interview on 06/25/2026 at 8:13 AM, LPN #13 stated when she cleaned the medication cart, loose medications were collected and placed into a specimen cup with the intent to dispose of them using the designated disposal system. LPN #13 stated she placed the specimen cup in the medication cart with the intent to dispose of the medication, but was called away to handle another matter. During an interview on 06/25/2026 at 8:28 AM, the Infection Preventionist stated medications should be disposed of immediately and should not be accumulated or stored in a medication cart. During an interview on 06/25/2026 at 8:38 AM, the DON stated medications that required disposal must be discarded immediately and not stored in the medication cart. The DON stated medications must be properly stored and labeled to avoid improper handling and contamination. During an interview on 06/25/2026 at 8:45 AM, the Administrator stated staff were expected to dispose of medications using appropriate disposal materials, and medications intended for disposal were not allowed to stay in the medication cart. The Administrator stated staff were expected to follow facility protocol for medication storage and disposal. NJAC 8:39-29.4

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) during the provision of care for 1 (Resident #6) of 3 sampled residents reviewed for infection control.Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 01/2026, revealed, To minimize the transmission of germs transferring from residents to staff hands and clothing, staff will wear gown and gloves when providing care to residents that require significant physical contact and are at high risk of acquiring or spreading Multidrug Resistance Organisms (MDRO). Definition: Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that requires staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading MRDO. The policy specified, b. Residents with an indwelling medical device including central venous catheter, urinary catheter, feeding tube, tracheostomy/ventilator regardless of their MDRO status. A Resident Face Sheet revealed the facility admitted Resident #6 on 05/21/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of obstructive and reflux uropathy, benign prostatic hyperplasia, and retention of urine. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2026, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required substantial/maximal assistance with toileting and had an indwelling catheter. Resident #6's Care Plan included a problem statement initiated 06/16/2026, that indicated the resident had an indwelling catheter and was on enhanced barrier precautions (EBP). Interventions directed staff to follow EBP per facility policy during catheter care (initiated 06/16/2026). Resident #6's General Administration History for the timeframe 06/01/2026 - 06/24/2-26, revealed the transcription of an order dated 06/22/2026, for enhanced barrier precautions in place for suprapubic catheter, every shift. During an observation of catheter care for Resident #6 on 06/24/2026 at 10:16 AM, Licensed Practical Nurse (LPN) #8 performed hand hygiene and gathered supplies for catheter care out of the treatment cart and entered Resident #6's room. Signage was observed outside of Resident #6's room that indicated the resident was on EBP. LPN #8 explained the procedure to Resident #6, set up supplies for catheter care, performed hand hygiene, put on clean gloves, and began performing catheter care for Resident #6. LPN #8 did not put on a gown prior to conducting catheter care on Resident #6. During an interview on 06/24/2026 at 10:27 AM, LPN #8 stated that EBP was implemented for residents with a wound or a tube, such as an indwelling catheter. LPN #8 stated staff were to put on a gown and gloves when they performed catheter care. LPN #8 stated she did not put on a gown prior to starting catheter care for Resident #6 because she forgot to put one on. During an interview on 06/24/2026 at 2:20 PM, the Nurse Manager (NM) stated when nursing staff provided wound care, incontinence care, or catheter care, they must put on a gown and gloves. The NM stated she would expect staff to follow the posted signage by the resident's door related to EBP. During an interview on 06/24/2026 at 3:39 PM, the Infection Preventionist (IP) stated a resident with any type of opening, such as a wound, an indwelling catheter, or a tracheostomy, was at increased risk for infection and would be on EBP. The IP stated that when performing any type of direct care for a resident on EBP, she would expect staff to put on a gown and gloves. The IP stated she would expect staff to follow the posted signage next to the resident's door and refer to the signage if they had any questions. During an interview on 06/25/2026 at 8:55 AM, the Director of Nursing (DON) stated EBP was used for residents with any type of opening, such as a wound, indwelling catheter, or gastrostomy tube. The DON stated EBP would be implemented when performing direct care, such as hygiene, wound care, gastrostomy tube feeding, and catheter care. The DON stated she would expect staff to put on a gown and gloves when performing care for residents on EBP. During an interview on 06/25/2026 at 8:59 AM, the Administrator stated he would expect nursing staff to follow the facility's infection control protocols. NJAC 8:39-19.4

Based on observation and interviews, it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. The deficient practice was identified on 3 of 3 units. This deficient practice was evidenced by the following: During the Resident Council Meeting on 01/15/2025 at 10:00 AM, five of five alert and oriented residents said they were not aware of the location of the State Survey results and that the facility had not spoken to them about the results. During a tour of each unit, the surveyor had to ask at the nurse's station where the State survey results binder was kept. The surveyor was told by the unit secretary or nurse that was at the desk at each unit that it was located behind the nurse's station. The surveyor was also told at each unit that if the residents asked for it, they could see it. On the 4 South unit the Registered Nurse (RN) could not locate the binder when asked. The RN said, I know it's here somewhere. There were no posted signs to direct resident's, families, and the public to the location of the survey results. These binders were not accessible to residents or visitors without asking staff. During an interview with the surveyor on 01/15/2025 at 10:34 AM, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) said that the survey results are located on the unit behind the desk. The DON then said the residents were allowed to go behind the nurse's station and ask or get look at the results if there was someone behind the desk to help them. When asked if they considered if the results binder was readily accessible to the residents or public, the LNHA stated, No. The facility was unable to produce a policy in reference to the State of New Jersey inspection results. NJAC 8:39-9.4(b)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for 2 of 3 units (South and North Units). This deficient practice was evidenced by the following: On 01/12/2025 at 10:28 AM, Surveyor #1 observed the baseboard trim in room [ROOM NUMBER] detached from the wall on the North Unit. On 01/13/2025 at 10:35 AM, Surveyor #1 observed water stains on the ceiling tiles in the shower room on the North Nursing Unit. On 01/13/2025 at 10:43 AM, Surveyor #1 observed the shower room on the North Nursing Unit, which including a portable commode, three commode buckets, a commode lid, and a non-stick food placement mat placed on a chair in the corner. During an interview with Surveyor #1 on 01/15/2025 at 9:58 AM, the Maintenance Director (MD) said that water stains could indicate condensation or a leak and if wet ceiling tiles are observed, an investigation is conducted, followed by the replacement of ceiling tiles as needed. During an interview with Surveyor #1 on 01/15/2025 at 10:14 AM, the Assistant Housekeeping Director (AHD), said that shower rooms are cleaned regularly and as needed. Housekeeping does not handle residents' personal items, emphasizing that they do not touch any private belongings. During an interview with Surveyor #1 on 01/15/2025 at 11:40 AM, the Director of Nursing (DON) said that nursing staff shares the responsibility of cleaning the shower rooms, and while they remove residents ' personal items, housekeeping conducts a thorough cleaning afterward. A review of the dated facility policy 03/2024, titled, Homelike Environment, revealed, The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Those characteristics include cleanliness and order. 43936 2.) On 01/12/2025 at 10:04 AM during the initial tour of the fourth floor, Surveyor # 2 observed Resident # 84's room. At that time, the surveyor observed brown stains on the wall near the bed and on a feeding pump located on a pole in the room. The garbage receptacle had no bag in it. The bedside table adjacent to the bed was observed to have dried stains on it. On 01/14/2025 at 10:37 AM, Surveyor # 2 observed Resident # 84's room. At that time, the surveyor observed that the garbage receptacle had no bag in it. The room also emanated a strong odor of fecal matter. On 01/15/2025 at 11:35 AM during an interview with the surveyor, the Director of Nursing (DON) replied, Daily. Housekeeping is twenty-four seven but lesser on evenings and overnights. when the surveyor asked how often resident rooms are cleaned. The DON explained that cleaning entails the garbage, floors, dusting, bedside tables, and the garbage. 45209 3.) On 1/14/25 at 9:58 AM while touring the fifth floor, surveyor #3 observed large area of brown splatter residue on the wall to the right of Resident #52's bed behind their intravenous pole and dresser. Surveyor #3 also observed brown residue on the intravenous pole. On 1/14/25 at 10:08 AM, surveyor #3 interviewed Certified Nursing Assistant (CNA #1) who reported that all of nursing is responsible to ensure the resident's rooms are clean. When asked who would make sure that the resident's medical equipment remained clean CNA #1 responded, the nurse. On the same date at 10:48 AM, surveyor #3 interviewed Licensed Practical Nurse (LPN #1) acknowledged the large area of brown residue behind the intravenous pole and dresser. LPN #1 stated that the room is their home and it should not have brown splatter on the wall. On the same date at 11:06 AM, surveyor #3 interviewed Unit Manager Registered Nurse (UMRN# 1) who stated that the brown residue appeared to be enteral formula. UMRN #1 confirmed that the wall should not be that condition and it should have been identified by nursing or housekeeping. When asked why the wall should not look like that UMRN# 1 responded, because this is their home and we should keep it clean. On 1/16/25 at 9:59 AM, surveyor #3, interviewed the Assistant Director of Facilities who acknowledged the brown residue on Resident #52's wall and that it should have been identified by housekeeping. On 1/16/25 at 10:04 AM, surveyor #3, interviewed the Assistant Director of Environmental Services, in the presence of the Operations Manager, who confirmed that the brown residue on Resident #52's wall should have identified and should not present in that condition. On 1/16/25 at 11:35 AM, surveyor #3, interviewed the Director of Nursing, in the presence of the Licensed Nursing Home Administrator (LNHA) acknowledged brown residue on Resident #52's wall should have been cleaned to ensure homelike environment. N.J.A.C. 8:39-31.3(a) N.J.A.C. 8:39-31.4 (a)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to use appropriate infection control practices, such as hand hygiene and Personal Protective Equipment (PPE) when providing care and other high-contact care activities to 3 of 3 residents (Resident #23, #52, #84) reviewed under the Infection Control Task. The deficient practices were evidenced by the following: 1. On 1/14/2025 at 10:24 AM, surveyor #1 observed Licensed Practical Nurse (LPN#1) perform tracheostomy (a small surgical opening that is made through the front of the neck into the windpipe) care, which was identified as requiring aseptic techniques (a set of practices that prevent the spread of infection) on Resident #52 and observed the following: At 10:31 AM, following Resident #52's assessment by LPN #1 it was determined that that deep suctioning was required to clear their airway due to excessive secretions. LPN #1 removed her disposable gloves and applied sterile gloves without performing hand sanitation. Upon completion of suctioning, LPN #1 removed the sterile gloves and washed their hands with soap and water lathering under the flow of running water for fifteen seconds. At 10:39 AM, LPN #1 proceeded to apply sterile gloves in order to change Resident #52's tracheostomy inner cannula (the inner portion of the trachestomy tube which can help prevent airway obstruction). While applying the right glove, LPN#1 grabbed the thumb of the glove with the ungloved left hand which broke the sterility of the right glove. During the inner cannula change at 10:41 AM, LPN #1 recognized that she did not have the correct cannula. With sterile gloves applied, LPN #1 retrieved the proper supplies, opened the package, and continued with the change which resulted in a break of aseptic techniques. At 10:46 AM, following the inner cannula change, LPN #1 removed the sterile gloves and changed to disposable gloves without hand sanitization. At 10:51 AM, surveyor #1 interviewed LPN #1 who confirmed that handwashing was not completed for the required 15-20 seconds that there should have been hand sanitizing between glove changes. LPN #1 also acknowledged that she broke aseptic techniques and the sterility of the gloves when she touched the thumb of the right glove and when she gathered supplies in the room with the gloves on. During an interview with another surveyor on 1/15/2025 at 10:00 AM , the Infection Preventionist (IP) confirmed that hand hygiene is essential between glove changes to prevent cross contamination. During an interview with surveyor #1 on 1/16/2025 at 11:35 AM, the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) acknowledged that hand sanitation should be completed between glove changes, the hand washing length, and break in sterile technique. A review of facility policy titled, Tracheostomy Care, Revised 12/24, under section General Guidelines included: 1. Aseptic technique must be used: c. during tracheostomy tube changes, either reusable or disposable [ .] 2. [ .] Sterile Gloves must be used during aseptic procedures . A review of facility policy titled, Handwashing/Hand Hygiene, Revised 3/24, under section Policy Interpretation and Implementation included: 5. Employees must wash their hands for at least 20 seconds using antimicrobial or non-microbial soap and water ( .) 6. In most situations, the preferred method of hand hygiene is with and alcohol-based hand rub. If hands are not visibly soiled use and alcohol based rub containing 60-95% ethanol or isopropanol for the following situations ( .)b. before donning sterile gloves; ( .) j. after removing gloves. 43936 2.) On 01/13/2025 at 11:28 AM while outside of Resident # 84's room, Surveyor # 2 observed Registered Nurse (RN) # 1 in the room. RN # 1 was disconnecting the feeding tube (External tube inserted into the stomach to provide nutritional formula) that was connected to Resident # 84 from the nutritional formula hanging on a pole. RN # 1 was wearing gloves but not a disposable gown. At that time, Surveyor # 1 also observed a sign outside the doorway that was titled, Enhanced Barrier Precautions Everyone Must: The sign revealed that providers and staff must wear gloves and a gown for the following High-Contact Resident Care Activities. The sign revealed a list including Device care or use: central line, urinary catheter, feeding tube . A review of Resident # 84's Active Orders revealed an order for, Formula hang flush bag of 150,L [milliliter] ever 6 hours X 20 hours to run with feeding. Special Instructions: [Brand name redacted] at 50 mL/hour X 20 hours. Up at 2 PM and Down at 10 AM or when total volume of 1000 mL infused. Hang flush bag at 150 mL every 6 hours X 20 hours to run with feeding. Twice a day start feeing at 02:00 PM, Remove feeing 10:00 AM. A review of Resident # 84's Electronic Medical Record (EMR) revealed an order to clean a wound to left foot with normal saline solution and apply aquacel, wrap with gauze daily. A review of Resident # 84's Care Plan revealed a focus for, Impaired skin integrity, presence of: wounds : Stage III wound to sacral area. 9/11/2024 ulcer to left dorsal foot. On 1/13/2025 at 11:30 AM, Surveyor # 2 observed the sign outside the doorway of Resident # 84's room that was titled, Enhanced Barrier Precautions Everyone Must: The sign revealed that providers and staff must wear gloves and a gown for the following High-Contact Resident Care Activities. The sign revealed a list including Wound Care: any skin opening requiring a dressing. On the same date at 11:33 AM, Surveyor # 2 observed Registered Nurse (RN) # 1 with assistance from Certified Nurses Aide (CNA) # 1 perform wound care on Resident # 84. At that time, CNA # 1 did not don a gown while in the room. During the wound care at approximately 11:43 AM, RN # 1 removed the soiled dressing from Resident # 84's left foot. At that time, RN # 1 removed the disposable gloves and applied a new pair of gloves. RN # 1 did not perform any hand hygiene between changing gloves. At approximately 11:46 AM, after irrigating the wound, RN # 1 removed the disposable gloves and applied a new pair of gloves. RN # 1 did not perform any hand hygiene between changing gloves. Lastly, RN # 1 applied a gauze wrap to Resident # 84's left foot. At that time, RN # 1 removed the disposable gloves. RN # 1 did not perform and hand hygiene after removing the gloves. RN # 1 and CNA # 1 then proceeded to lift and position Resident # 84 in their bed. CNA # 1 did not wear a gown throughout the entire observation of wound care. At approximately 11:50 AM during an interview with Surveyor # 2, RN # 1 said CNA # 1 should have worn a gown in the room. RN # 1 said that he washed his hands before wound care and didn't use alcohol-based hand rub between glove changes. On 1/15/2025 at 10:20 AM during an interview with Surveyor # 2, the Infection Preventionist confirmed that staff should be performing hand hygiene between glove changes clarifying it is important to prevent transmission. On 1/15/2025 at 11:35 AM during an interview with the Director of Nursing (DON), Surveyor # 1 asked when a nurse is disconnecting a completed formula feeding for a resident with a feeding tube, should the nurse be wearing a gown if they are on Enhanced Barrier Precautions? The DON replied, yes. The surveyor then asked why would that be important. The DON replied, Because there is an opening an it could possibly transfer possible infection. During the same interview with Surveyor # 2, the Director of Nursing (DON) replied, Yes when the surveyor asked should a nurse perform hand hygiene between glove changes during wound care. The DON said it is important for infection control. A review of the facility policy titled, Handwashing/hang hygiene with a revised date of 3/24 revealed, Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: k. Before and after changing a dressing .e. Before handling clean or soiled dressing, gauze pad, etc., j. After removing gloves. 38680 3.) Surveyor #3 observed a sign for enhanced barrier precautions (EBP) to the right of the door outside Resident #23's room. The sign reflected that everyone must clean hands, including before and when leaving room. Providers and staff must also wear gloves and gown for the following high contact resident care activities: dressing, bathing, providing hygiene, changing linens, changing briefs and device care. On 01/12/2025 at 10:21 AM, Surveyor #3 observed Resident #23 receiving care. Certified Nurses Aide (CNA) #2 was observed performing direct care on this resident wearing a mask and gloves. CNA #2 was not wearing a gown. When asked if she should be wearing a gown the CNA responded, oh yeah. On 01/14/2025 at 11:18 AM, Surveyor #3 observed Registered Nurse #2 at Resident #23's bedside adjusting the oxygen tubing. RN #2 was observed wearing gloves and no gown. When asked at that time if she should be wearing a gown, RN #2 responded yes. A review of the medical record reflected that Resident #23 had diagnosis which included dysphagia (a problem swallowing). A review of the quarterly minimum data set, an assessment tool, dated 11/12/2024 reflected that Resident # 23 had long and short-term memory deficits. It reflected that Resident # 23 utilized a feeding tube for nutrition. During an interview on 01/15/2025 at 10:22 AM, the infection preventionist said that when a resident is on EBP a gown should be utilized when providing care and adjusting Oxygen tubing. A review of the policy titled Enhanced Barrier Precautions with an effective date of 04/05/2024 reflected that all residents with medical devices including feeding tubes require gloves and gowns to be worn during high contact resident care. NJAC 8:39 19.4(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide privacy for a resident during hygienic care. Specifically, the bedroom and bathroom doors were not closed, exposing the resident's upper body. This deficiency was noted for 1 out of 20 residents (Resident # 38) reviewed. This deficient practice was evidenced by the following: On 01/13/2025 at 10:19 AM, the surveyor observed Resident # 38 in the bathroom sitting on the toilet, with the wheelchair positioned in front of the resident while getting dressed. The door was open, exposing the resident's upper body. During an interview with the surveyor on 01/13/2025 at 10:39 AM, the Licensed Practical Nurse #1 (LPN #1) said that she was uncertain whether the bedroom and bathroom doors should remain open during the time the resident was getting dressed. During an interview with the surveyor on 01/15/2025 at 11:40 AM, the Director of Nursing (DON) said that the bedroom and bathroom doors should have been closed while the resident was getting dressed. A review of a facility policy dated 03/2024 titled, Quality of Life -Dignity, revealed, Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. N.J.A.C. 8:39-4.1(a)(16)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to keep the call device system within reach for a resident who was dependent on staff. This deficiency was identified for 1 out of 1 resident (Resident # 32) reviewed for Accommodation of Needs. This deficient practice was evidenced by the following: On 01/13/2025 at 10:01 AM, the surveyor reviewed the electronic medical records (EMR) for Resident #32. The EMR revealed that he/she had a diagnoses of but not limited to Dementia and Alzheimer's Disease (cognitive disease). A review of the significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/20/2024 indicated that Resident #32 had severe cognitive impairment and was dependent in both self-care and mobility. On 01/13/2025 at 9:59 AM, the surveyor observed the resident in the bedroom, seated in a geriatric recliner chair (a large, padded chair designed to assist those with limited mobility) next to the right side of the bed. The call device was out of reach, hanging from the oxygen system connected to the wall on the left side of the bed. On 01/14/2025 at 10:58 AM, the surveyor observed the resident in the bedroom, seated in a geriatric chair next to the right side of the bed. The call device was out of reach, hanging from the oxygen system connected to the wall on the left side of the bed. During an interview with the surveyor on 01/15/2025 at 11:40 AM, the Director of Nursing (DON) said that the resident needs access to a call device and acknowledged that it is not appropriate for him/her to be without one. The DON indicated that she would reassess the situation and seek an appropriate solution. A review of a facility policy dated 03/2024 titled, Call System, revealed, The facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities. If a resident is physically incapable of actuating a call system, the resident shall be physically housed in a resident room close enough to the nursing station to allow for line-of-sight supervision at a frequency identified by a through individualized nursing assessment. N.J.A.C. 8:39-27.1 (a)

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set death in facility tracking record in accordance with federal guidelines. This deficient practice was identified for 1 of 2 residents reviewed for resident assessment (Resident #58). This deficient practice was evidenced by: On [DATE] at 12:07 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. On [DATE] at 12:07 PM, the surveyor reviewed Resident #58's electronic medical record. The record revealed that the resident expired on [DATE]. The electronic health record reflected that there was no death in facility tracking record completed for the resident's death date of [DATE]. On [DATE] at 12:13 PM, the surveyor interviewed the MDS Coordinator. The MDS Coordinator confirmed that the death in facility tracking record was not completed or transmitted for Resident #58. She stated it should have been completed by [DATE]. A MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. The surveyor reviewed the facility's policy entitled MDS Completion and Submission Timeframes with a revised date of [DATE]. The policy revealed that the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. NJAC 8:,d+[DATE].2

Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care plan to address an elopement alarm for 1 of 23 residents (Resident #59) reviewed. The deficient practice was evidenced by the following: On 01/12/25 at 10:00 AM, the surveyor observed Resident #59 in the room with an elopement alarm on the left ankle. The surveyor reviewed Resident #59's medical record which reflected that the resident had diagnoses which included muscle weakness and anxiety. A review of the physician orders for Resident # 59 reflected an order dated 09/10/21 for the resident to have a wanderguard. The minimum data set, an assessment tool, dated 11/8/24 Q MDS reflected that Resident #59 used an elopement alarm used daily. The surveyor reviewed the resident's care plans which revealed there was no care plan developed to address the elopement alarm which was initiated on 09/10/2021. On 01/15/25 at 10:53 AM, the surveyor interviewed the Nurse Manager who said the elopement alarm should be included in the care plan. The nurse manager and surveyor reviewed the care plans of Resident #59 together. She confirmed that there was no care plan addressing the elopement alarm. A review of the policy titled, Care Plans-Comprehensive, with a revised date of January 1, 2025 reflected 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. It further reflected 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to transmit a Minimum Data Set (MDS) - Annual and Quarterly Reporting Assessment in accordance with federal guidelines. This deficient practice was identified for 13 of 13 residents reviewed for resident assessment (Resident #43, #44, #23, #5, #51, #53, #49, #20, #1, #26, #16, #65, #64). This deficient practice was evidenced by: On 8/25/23 at 11:30 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. A MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2019) under Non-Comprehensive Assessments and Entry and Discharge Reporting, page 2-32 MDS must be transmitted (submitted and accepted into the QIES (Quality Improvement and Evaluation System) ASAP system) electronically no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days). Further review of the RAI (Resident Assessment Instrument) Manual under Comprehensive Assessments, page 2-20 MDS must be transmitted (submitted and accepted into the QIES ASAP system) electronically no later than 14 calendar days after the care plan completion date (V0200C2 + 14 calendar days). 1.) Resident #43 was observed to have a Quarterly MDS completion date of 7/1/23 and was due to be transmitted no later than 7/29/23. The Quarterly MDS was not transmitted until 8/23/23. 2.) Resident #44 was observed to have a Quarterly MDS completion date of 7/5/23 and was due to be transmitted no later than 8/2/23. The Quarterly MDS was not transmitted until 8/24/23. 3.) Resident #23 was observed to have a Quarterly MDS completion date of 7/5/23 and was due to be transmitted no later than 8/2/23. The Quarterly MDS was not transmitted until 8/24/23. 4.) Resident #5 was observed to have a Quarterly MDS completion date of 7/3/23 and was due to be transmitted no later than 7/31/23. The Quarterly MDS was not transmitted until 8/23/23. 5.) Resident #51 was observed to have a Quarterly MDS completion date of 7/4/23 and was due to be transmitted no later than 8/1/23. The Quarterly MDS was not transmitted until 8/24/23. 6.) Resident #53 was observed to have a Quarterly MDS completion date of 7/17/23 and was due to be transmitted no later than 8/14/23. The Quarterly MDS was not transmitted until 8/25/23. 7.) Resident #49 was observed to have an Annual MDS completion date of 7/14/23 and was due to be transmitted no later than 8/18/23. The Annual MDS was not transmitted until 8/24/23. 8.) Resident #20 was observed to have a Quarterly MDS completion date of 7/21/23 and was due to be transmitted no later than 8/18/23. The Quarterly MDS was not transmitted until 8/23/23. 9.) Resident #1 was observed to have an Annual MDS completion date of 7/5/23 and was due to be transmitted no later than 8/8/23. The Annual MDS was not transmitted until 8/23/23. 10.) Resident #26 was observed to have a Quarterly MDS completion date of 7/10/23 and was due to be transmitted no later than 8/7/23. The Quarterly MDS was not transmitted until 8/25/23. 11.) Resident #16 was observed to have a Quarterly MDS completion date of 7/14/23 and was due to be transmitted no later than 8/11/23. The Quarterly MDS was not transmitted until 8/25/23. 12.) Resident #65 was observed to have a Quarterly MDS completion date of 7/12/23 and was due to be transmitted no later than 8/9/23. The Quarterly MDS was not transmitted until 8/25/23. 13.) Resident #64 was observed to have an Annual MDS completion date of 7/12/23 and was due to be transmitted no later than 8/16/23. The Annual MDS was not transmitted until 8/25/23. On 8/25/23 at 1:04 PM, the surveyor interviewed the facility's Registered Nurse (RN) MDS Coordinator who was responsible for completing and transmitting the MDS assessments who acknowledge that the above MDS assessments were transmitted late. No further information was provided. On 8/30/23 at 12:19 PM, the surveyor discussed the above concern with the facility's Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). No further information was provided. NJAC 8:39-11.2

Based on observation, interview, and record review, it was determined that the facility failed to accurately code resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for one 1 of 18 residents, (Resident #3) reviewed for accurate coding of MDS. This deficient practice was evidenced by the following: On 8/24/23 at 9:54 AM, Resident #3 was observed sitting on wheelchair in hallway, able to wheel self around unit. The Resident responded to the surveyor appropriately when spoken to stating that they were ok and had no issues with care. The Resident refused to continue the interview. The surveyor reviewed the resident's hybrid medical chart which included review of paper as well as computerized medical chart. A review of Resident #3's Face Sheet (a one-page summary of important information about the resident) documented the resident's diagnosis which included but was not limited to COVID 19, Urinary Tract Infection, Chronic Obstructive Pulmonary disease, Asthma with exacerbation, Type 2 Diabetes Mellitus, Schizophrenia, Depression, Essential hypertension. A review of the Progress Note dated 6/9/23 documented, Resident AAO (Awake, Alert, Oriented) x 3 stable. Resident called for help, found lying on the floor by the bedside facing up stated I fell from the bed while sleeping. Assessment done no apparent injury, denies pain. Message left for Doctor, informed family member. A review of the Progress Note dated 6/18/23 documented, At approximately 8:42 AM this writer heard loud noise in dayroom, writer ran into dayroom, upon assessment resident lying on floor in supine position, awake with confusion, slurred speech no active bleeding noted, this writer called 911 immediately. Upon assessment Blood Pressure 167/86, Pulse 97, 98% oxygen Saturation on room air, Temperature 97.3 Fahrenheit, complaining of stomach pain, denies head/neck pain. Noted resident trying to move arms and head, Re-educated resident to stay still and not move body. Resident complaining of nausea, started to vomit, resident log rolled with 2 assist to side with neck/head stabilized, airway kept clear. Emergency Medical Service arrived on scene, left with resident at 9:06 AM. Further review of the Progress Note dated 7/8/23 documented, Around 1:00 AM Resident roommate reported that resident was on the floor. Resident was assisted back to bed with 3 person assist, stated I fell when I was trying to sit on the chair. Assessment done no apparent injury, no bruise noted, complained of discomfort on their back Tylenol 650 milligrams given with effective. Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 8/4/23, indicated that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 10. This score established that Resident #3 had a moderately impaired cognition. A review of Resident #3's MDS dated [DATE], Section J1800 - Any Falls Since Admission/Entry or Reentry or Prior Assessment coded as 0, indicating that the resident had no falls since their last Annual Assessment of 5/5/23. The documentation in the MDS contradicted the resident's history of falls based on the Progress Notes dated on 6/9/23, 6/18/23, and 7/8/23. On 8/28/23 at 10:41 AM, the surveyor along with MDS Coordinator reviewed the Quarterly assessment dated [DATE] which documented 0 under J1800, indicating no falls occurred since last assessment of 5/5/23. Further review of the Progress Notes dated 6/9/23, 6/18/23, and 7/8/23 with the MDS Coordinator, revealed that Resident #3 had a fall on 6/9/23 with no injury, a fall on 6/18/23 with no injury, and a fall on 7/8/23 with injury. The MDS Coordinator stated, she missed coding the falls. No further information was provided. On 8/30/23 at 12:19 PM, the survey team met with Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the concern above. No further information was provided. NJAC 8:39-33.2(d)

C # NJ 843 Based on interview and review of medical records including facility surveillance camera footage for 9/4/22 and 9/5/22, it was determined that 2 of 3 facility staff (Licensed Practical Nurse [LPN #1] and Registered Nurse [RN #1]) on the 4th floor South unit, failed to ensure that medications which could cause significant harm if ingested, were stored, secured, in locked compartments and inaccessible to high-risk residents with wandering behaviors. The facility also failed to follow their policies Administering Medications, Medication Storage, and General Medication Administration Guidelines of Oral Preparations. This deficient practice was identified for 1 of 3 sampled residents (Resident #1). On 9/9/2022, the surveyors reviewed in the presence of Administrative staff , the incident that occurred on 9/5/22 that was captured on the surveillance camera (SC). It showed that RN #1 (worked 11 pm - 7 am shift) left her medication cart unlocked and unattended from 12:01 am to 5:23 am. As a result, Resident #1 accessed the unlocked medication drawers and took a bottle of liquid medication from the medication cart. Resident #1 was found lethargic at 6:15 am, and an empty bottle of [MEDICATION(S)] liquid medication that belonged to Resident #2 (another Resident) was found in the room. At 6:45 am, the Resident was transferred to Acute Hospital (AH) by 911 emergency services and admitted for [MEDICATION(S)] Drug Overdose, also known as (aka) [MEDICATION(S)]. This incident of RN #1 leaving an unlocked and unattended medication cart that was accessed by Resident #1 who was known for wandering behaviors resulted in an Immediate Jeopardy (IJ) situation. There was a total of 19 residents on the 4th Floor South and 2 of 19 residents including Residents #1 with wandering behaviors. The Administrator was notified of the IJ situation on 9/9/22 at 6:45 pm. The IJ situation ran from 9/4/22 at 8:45 am to 9/9/22 at 6:15 pm. An acceptable removal plan was received on 9/12/22 at 4:00 pm. The survey team noted on the same day (9/12/22) that the removal plan has been implemented based on observations, interviews, and record review. This includes removing and terminating the employment of both RN #1 and LPN #1, facility wide inservices about but not limited to: policies on medication administration and storage as it relates to safety awareness associated with residents with Dementia (i.e., keeping medication carts lock at all times) initiated on 9/6/22, monitoring of Resident #1 every half hour and medication cart was audited on 9/7/22, 9/11/22 and 9/12/22, there were no missing medications. Therefore, the non-compliance remained on 9/12/22 as a level D for no actual harm with potential for minimal harm that is not Immediate Jeopardy. This deficient practice is evidenced by the following: The Facility Reportable Event (FRE) reported to the New Jersey Department of Health (NJ DOH) on 9/6/22, showed that on 9/5/22 at 6:15 am, Resident #1 was found in his/her room lethargic with an empty bottle of [MEDICATION(S)] medication (belonged to Resident #2) in the room. Resident #1 was sent to the AH on 9/5/22 for further evaluation. 1. According to the Resident Face Sheet (RFS), Resident #1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS), an assessment tool dated 8/20/22, showed that Resident #1's cognitive status was moderately impaired, ambulatory, and required limited assistance from staff for Activities of Daily Living (ADL) The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note (PN) and Universal Transfer form dated 9/5/22 indicated that Resident #1 was transferred to AH due to consumption of [MEDICATION(S)] liquid medication and the Resident was admitted for [MEDICATION(S)] Drug Overdose. The AH medical record showed that Resident #1 was admitted on [DATE] to the emergency room for [MEDICATION(S)] Overdose and Encepalopathy (damage or disease that affects the brain that can lead to an altered mental state) with initial [MEDICATION(S)] level of 354 (therapeutic range= 50-100 UG/ML [microgram/milliliter]). The Poison Control was consulted, and the Resident was placed on neurocheck and telemetry monitoring in the hospital. On 9/7/22 at 2:45 pm, Resident #1 was readmitted to the Facility from AH. 2. According to the RFS, Resident #2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS), an assessment tool dated 6/23/22, showed that Resident #2's cognitive status was severely impaired and dependent to staff for Activities of Daily Living (ADL) Resident #2's POR showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The full bottle of [MEDICATION(S)] liquid contained 437 ml. The facility pharmacy provided the Omnicare Drug Information on 9/9/22 for the [MEDICATION(S)] medication which showed that the medication is used to treat [CONDITION(S)] disorders, mental/mood disorders (such as [CONDITION(S)]), and to prevent migraine headaches. Furthermore, the [MEDICATION(S)] bottle for Resident #2 showed a warning label may cause drowsiness, may cause dizziness. The facility's Surveillance Camera Contracted Company provided the footage on 9/9/22 at 3:15 pm to the surveyors and Administration which showed the following: On 9/4/22, from 8:55 am to 1:37 pm, LPN #1, (worked 7 am -3 pm shift) left the 4th floor South (4S) medication cart unlocked and unattended in the hallway outside the dining room where staff and residents passed by. The 4S medication cart contained but not limited to insulins, syringes/lancets, over the counter and prescribed medications in liquid and tablet forms and controlled medications (in locked box). On 9/4/22 at 11:56 am, Resident #1 came out of his/her room and approached the unlocked and unattended 4S medication cart. From 11:58 am to 11:59 am, the Resident slowly opened and closed all the drawers from top to bottom while touching some of the medications. The SC showed no staff members were around to stop Resident #1 from opening the medication cart. At 12:01 pm, the Resident left the medication cart; at 12:02 pm, LPN #1 returned to the same medication cart then continued her medication pass. Further review of the SC showed that on 9/5/22, RN #1 (worked 11 pm - 7 am shift) left her 4S medication cart unlocked and unattended from 12:01 am to 5:23 am. Resident #1 approached the 4S medication cart during these time as follows: At 12:01 am and 12:50 am, the Resident came out of the room, approached the 4S medication cart and opened and closed all the drawers from top to bottom and touched some of the medications. Then the Resident walked away from the medication cart towards his/her room. At 12:55 am, Resident #1 returned to the medication cart, opened, and closed 4 drawers on the left side of the cart from top to bottom then reopened the 3rd drawer, removed a liquid medication bottle, closed the drawer, and took the bottle with him/her to his/her room. At 6:00 am, the staff (Certified Nurse Assistant and RN) were in and out of the Resident's room; RN #1 was seen holding a medication bottle rushing in and out of Resident #1's room. At 6:39 am, Resident #1 was picked up by 911 medical services and transported to the AH. During a telephone interview with RN#1 on 9/9/22 at 2:00 pm, she stated that the medication cart should be kept closed and locked at all times. RN #1 denied that she left her medication cart unlocked and unattended. The surveyor attempted to conduct an interview with LPN #1 on 9/9/22 at 2:15 pm; However, she was not available. During review of the SC on 9/9/22 from 3:15 to 6:00 pm with the Administrator and the Assistant Director of Nursing (ADON), they acknowledged that LPN #1 and RN #1 should have not left the 4S medication cart unlocked and unattended. The nurses are expected to always lock their medication carts. They explained that if the medication cart was kept locked, the Resident would not have accessed to the liquid [MEDICATION(S)]. They could not give the exact amount of how much medication was left in the bottle before it was taken from the medication cart. During a follow-up interview with Administration and the staff on 9/12/22 from 9:00 am to 12:00 pm, they stated that Resident #1 was too weak to come out of the room and ambulate since he/she had returned from the hospital on 9/7/22; however, on 9/12/22, the staff observed that the Resident was ambulating in the room. Therefore, beginning on 9/12/22 they put Resident #1 on every half hour monitoring for his/her whereabouts to ensure safety. According to the facility policy titled Administering Medications dated 1/1/14, under Policy Interpretation and Implementation indicated that .16. During administration, the medication cart will be kept closed and locked when out of sight of the medication nurse. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by . According to the facility policy titled Medication Storage revised dated 3/2010, under Policy indicated that .D. Drugs shall be stored in an orderly manner to cabinets, drawers, or carts of sufficient size to include treatment items, shall be stored in a locked cabinet or room, inaccessible to residents and visitors . According to the facility policy titled General Medication Administration Guidelines of Oral Preparations (including [MEDICATION(S)], Sublingual, Liquid Preparation) revised on 3/2017, under Procedure indicated that medication cart is locked when not in used and when not in view of the medication nurse . According to the facility policy titled Storage of Medications, undated, under Policy Interpretation and Implementation indicated that .2. The nursing staff shall be responsible for maintaining medication storage .in a clean, safe, and sanitary manner. 7. Compartments (including, but not limited to, drawer, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts .shall not be left unattended if open or otherwise potentially available to others . N.J.A.C. 8:39-29.4(h)

C #: NJ 311 Based on interviews, record review and review of other pertinent facility documents on 6/15/22 and 6/16/22, it was determined that the facility failed to honor a resident's meal preferences for 2 of 8 residents (Residents #1, and #2) reviewed for meal preferences. This deficient practice was evidenced by the following: On 6/15/22 at 10:00 am, the lunch menu for residents showed but not limited to the following: roast garlic pork with gravy and egg salad sandwich. 1. Resident #1 was admitted to the facility on [DATE] with diagnosis that included but was not limited to: Essential Hypertension. The Minimum Data Set (MDS), an assessment tool dated 4/24/22 showed that the Resident was moderately impaired and required assistance in feeding. The Nutritional Assessment (NA) dated 4/25/22, documented by Registered Dietician (RD) under food preferences . showed No Pork. The General Information Details (GID) from the Food Service Director (FSD) and the Unit census notes showed that the Resident should not be given pork for all meals. 2. Resident #2 was admitted to the facility on [DATE] with diagnosis that included but was not limited to: Essential Hypertension. The MDS for Resident #2 dated 6/15/22 showed that the Resident was cognitively intact and required set up during meals. The NA dated 12/9/20 documented by the RD showed that the Resident dislikes pork. The GID and the Unit census notes showed that the Resident should not be given pork for all meals. The Registered Nurse (RN #1) and the Certified Nursing Assistant (CNA #1) were interviewed on 6/15/22 from 12:47 pm to 2:00 pm. They stated that the food was served in a disposable aluminum take away container with cardboard cover. Each container did not have a resident's name; however, it was labeled with a type of diet (regular or puree)and preferences such as no pork. CNA #1 revealed that Residents #1 and #2 had pork for lunch because she served their lunch trays. RN #1 confirmed that Resident #1 had pork for lunch because she fed Resident #1. When asked if they were aware that the Residents should not be given pork; they have no answer. Resident #2 was interviewed on 6/15/22 at 3:30 pm in the presence of the Activity Aide (AA), the Resident stated that he/she was served pork for lunch; however the Resident did not eat the pork and only ate potatoes and corn. Resident #2 stated that he/she dislikes the pork. Resident #3 was interviewed on 6/16/22 at 9:30 am. The Resident stated that he/she had not been served pork/beef during meals because the Resident had to remind the staff that he/she does not eat pork/beef. However, during the first few days of admission the Resident was served food that contained pork/beef. The policy titled, Resident Food Preferences . revised 1/2021, under policies showed ,,,Residents are served meals .and comply with food preferences . NJAC 8:39-17.4(a)(1)

Based on observation, interview and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On [DATE] at 09:49 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and the Executive Chef (EC) and observed the following: 1. In the production area, there was one bag of kaiser rolls with no identification on the bag, no opened or use by dates. 2. In the prep fridge #16, there were five small individually wrapped styrofoam plates in clear plastic that contained tomato and lettuce dated use by [DATE]. The FSD removed them and discarded them in the garbage. There was one metal bin with individually wrapped cut onion, cut cucumber, lettuce, cut carrots, and shredded cabbage with no identification, no prepared on date or use by date. The FSD stated, these are fresh, if they are visibly not good then we throw them out. 3. In the dry storage entryway, there was an unsealed bag of 12 hamburger rolls with an orange sticker marked use by ,d+[DATE], the bag was marked with an expiration date [DATE]. The FSD removed the bag. 4. In the dry storage room, there was a box of pumpkin seeds with an internal open to air plastic bag with seeds visible. There was no label, no opened by or use by date. The FSD removed the bag. There was a large plastic bin that contained one open bag of egg noodles that had no opened on or use by date. The FSD stated it, should be discarded and threw the pasta away. On a metal shelf, in the canned storage area, there were three dented 105 ounce (oz) cans of fruit cocktail, one dented 6 pound (lb) 8 oz can of sweet/sour red cabbage and one dented 6 lb 2 oz can of sliced jalapenos. The EC removed the cans and placed them in the dented can section. There was a large plastic bin containing tan crumbles with no identification, no label, no use by date or expiration. The EC stated that they were bread crumbs then removed the bin and stated it was going in the trash. The FSD acknowledged there was no label on the bin as required. 5. In freezer #4, there was one box of chicken tenders breast strips with the inner plastic bag unsealed and the meat was exposed. The EC stated it should have been sealed and removed the box. There was one metal tin with a sticker labeled corned beef and dated ,d+[DATE], good through ,d+[DATE] with unsealed clear plastic wrap and the meat was exposed. The EC acknowledged it should not be like that and removed the bin. 6. The meat slicer had tan and white debris. The EC acknowledged the debris should not be there and that the cleaning process was done after use with a disposable cloth and sanitizer while wearing gloves and cut gloves. The EC acknowledged it should have been covered and that the slicer gets cleaned after each use. The EC stated that cleaning records were not kept. 7. In the kosher freezer, there were two boxes of individually wrapped baked fish dinners with no sticker when they were received or opened, no dates on the individual meals. There were 6 boxes of individually wrapped baked fish dinners with a received sticker dated ,d+[DATE]. There were 2 boxes of fillet of sole with a received sticker dated ,d+[DATE]. The FSD stated that it should have a good through date and a date of arrival and that it is good for 3 months frozen. The FSD informed the EC to toss it. 8. In the freezer, there was a large sheet pan with no identification, that had a sticker dated ,d+[DATE] and good through ,d+[DATE] with clear plastic wrap that covered half the pan and left half exposed. The EC identified it as white cake and stated it should be good for three months and acknowledged he will toss that. There was a metal bin with no identification that had a sticker dated ,d+[DATE] and good through ,d+[DATE]. The bin had clear plastic wrap that was unsealed with the patties visible. The EC identified it as beef and stated he will throw it out. The EC acknowledged the pan should have had clear wrap and foil covering it. 9. In refrigerator #3, there was an opened bag of green beans, no identification, no open date, no use by date, no label. 10. In refrigerator #2, there was one bag of tortilla wraps opened with cling wrap covering it. There was a sticker dated ,d+[DATE] good through ,d+[DATE] with a [DATE] printed expiration date on the bag. There were three unopened bags of tortilla wraps with a [DATE] printed expiration date on the bag. The FSD threw the wraps into the garbage. There was a whole defrosted wrapped pork loin with no sticker, no pull date or use by date. When asked when the pork loin was pulled the EC stated Good question, it came in on Monday. It should have a sticker that says the date it came in and an expiration date. There was a metal tray with 6 defrosted individually wrapped packages of meat sitting in a cloudy liquid with no identification, no sticker, no pull date or use by date. The EC identified them as turkey breasts and stated they are, not good, they are garbage. The EC removed them from the refrigerator then acknowledged it should have had the name of the product, the date it was pulled, an expiration date and the employee initials on an orange [NAME] label and that it should have been covered. 11. In freezer #10, there was one box of Jamaican meat patties with a received by sticker dated [DATE] with no opened date. The plastic inner bag was opened with the meat patties visible. The FSD acknowledged it should be covered and removed the box. There was one box of vegetarian sausage patties with a received by sticker dated ,d+[DATE] with no opened date. The plastic inner bag was opened with the sausage patties visible. The FSD stated, we will not serve them, probably discard them and the box was removed. On [DATE] at 10:31 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and the Executive Chef (EC) and observed the following: 1. In refrigerator #3, there were two 5 lb sealed bags of carrots with an orange sticker with a ,d+[DATE] expiration date and manufacturer marked best if used by ,d+[DATE]. The FSD stated they are throwing them in the garbage and removed the bags. 2. The meat slicer had white debris on the blade. The EC acknowledged the debris and stated they need to clean and sanitize the slicer and that the process is posted on the wall in the area. The EC further stated a visual inspection tells if it is clean between uses and that they used to cover it when it was clean. 3. On the spice rack, there was one bottle of Sriracha sauce opened with no opened date, received on date or use by date. There was one bottle of ReaLemon opened with no opened date, received on date or use by date. The FSD disposed of the bottles in the garbage. During an interview with the EC at that time, the EC stated responsibility for the rotation process and that expiration dates are checked at that time. The EC also stated that supervisors are also tasked with checking coolers daily and no record of delivery is kept. The EC stated that when there is a delivery on Tuesday and Friday that the storeroom staff puts the deliveries away and it is their responsibility to mark it. The EC stated it is everyone's responsibility to put an orange sticker marked with the item product name, the date in, the good through date, and the staff member's initials. During an interview with the surveyor on [DATE] at 12:05 PM, the FSD stated that whoever receives the shipment, primarily the chef, is responsible for labeling the items. The FSD stated it was important to have labels so the food is served fresh and not contaminated or spoiled, and that it is a nourishing state for the residents because some may be nutritionally compromised. During an interview with the surveyor on [DATE] at 12:15 PM, the EC stated that he is the one that usually checked the stock and labeled the food. The EC stated it was important because you want to use the older food before the newer food and you don't want to serve expired food because freshness matters. Review of the facility's policy #B003, Food and Supply Storage with a revision date of ,d+[DATE], revealed: Policies. All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Most, but not all, products contain an expiration date. The words sell by, best-by, enjoy-by or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use-by, sell-by, best-by, or enjoy-by date should be discarded. Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label, or use the Medvantage/Freshdate or other approved labeling system. Products are good through the close of business on the date noted on the label. Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. Frozen storage: Wrap food tightly to prevent cross contamination. Food prepared in-house, and then stored frozen should be kept no longer than 3 months. Commercially produced foods may be held frozen until the manufacturer's expiration date, or for 3 months if no expiration date on the package. Once the packaging around the food has been opened, food must be used within 3 months. Review of the facility's policy #B003, Freezer storage life of foods, dated ,d+[DATE], revealed Use manufacturer's expiration date for products, BUT DO NOT EXCEED 1 YEAR. If there is no expiration date on the package, add the time listed here to the date the food is received. If a case of food is partially used, and the remaining food is exposed to the air (ex: 20# case of frozen vegetables), re-label when product is opened, to use within 3 months. Food item: prepared manufactured entrees, Unopened: +3 months. Review of the facility's policy #B003, Refrigerated storage life of foods, dated ,d+[DATE], revealed Use manufacturer's expiration date for products before they are opened. If there is no expiration date on the package, add the time listed here to the date the food is received. Add the time in the opened column to the date when the food is prepared or opened. Label when product is opened. The time listed is added to today's date. Food item: Meat/Prepared Entrees/Soups, raw meat (frozen: to thaw in refrigerator), Opened: +4 days from frozen to prepared. Raw meat (refrigerated) except top round in cryovac, Opened: poultry:+2 days; beef and pork:+3 days. Fruit, Vegetables and Desserts, cut fresh fruit and vegetables, prepared on-site, Opened: +3 days. Bags of processed produce (diced onion, etc.), Opened: no manufacturer's date: use +3 days of delivery, with manufacturer's date: use +3 days of opening, or by the manufacturer's date, whichever is sooner. Review of the facility's policy #B003, Dry storage life of foods, dated ,d+[DATE], revealed Use manufacturer's expiration date for product storage. If there is no expiration date on the package, add the time listed here to the date the food is received. The time listed is added to today's date. Expiration/use by dates are guidelines; discard products where the quality is deemed unacceptable. Food item: Seasonings, ketchup, BBQ, Tabasco, steak, mustard, horseradish, garlic in oil, Room temperature storage: +1 year unopened; +2 months opened-refrigerate. Breads, bagels, English muffins, bread, rolls, tortillas, Room temperature storage: if no expiration date: +3 days after delivery Review of the facility's policy B002, Receiving, with a revision date of ,d+[DATE], revealed Procedures: Director/Designated Associate: Date foods prior to placing in storage areas, per Policy B003. Review of the facility's undated Daily Master Cleaning Matrix, revealed Equipment/Area/Task/Comments, Cooks: All small equipment i.e., robot coupe, buffalo chopper, blender, slicer, needs to be cleaned. Free of debris and stains. Daily. NJAC 8:39 17.2(g)

Based on observation, interview, and review of records, it was determined that the facility failed a.) to practice appropriate hand hygiene for 1 of 5 staff, and b.) appropriately place the housekeeping carts when cleaning resident rooms for 2 of 4 units in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/2020 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. 1. On 2/8/21 at 10:39 AM, the Registered Nurse/Unit Manager (RN/UM) informed the surveyor that the 4th floor South and North were the Long Term Care (LTC) non-COVID units. At 10:44 AM, the surveyor toured the 4th floor South unit and observed Housekeeper#1 (HK#1) enter a resident room with her cleaning cart. HK#1 performed handwashing in the same room for 29 seconds. HK#1 did not wet hand before applying soap, lathered her hands under the stream of running water, and immediately wiped the sink area with the same paper towel that she used for drying her hands. The surveyor interviewed HK#1 concerning her handwashing and cart placement. She stated that she scrubbed her hands under the stream of running water because that was how she had been taught by the Housekeeping Supervisor. She could not answer as to why she brought the housekeeping cart into the resident's room. 2. On 2/8/21 at 10:56 AM, the surveyor toured the 4th floor North unit and observed HK#2 cleaning a resident's room with her cleaning cart inside the room. HK#2 told the surveyor she did not want her cleaning cart to be out of her sight when cleaning, that was why she had the cleaning cart inside the resident's room. At that time, the RN/UM informed HK#2 that the cart should not be inside the resident's room for infection control. At 11:47 AM, the Assistant Director for Environmental Services (ADES) in the presence of the Operations Manager for Environmental Services (OMES) informed the surveyors that staff should wet hands before applying soap and not to wipe the sink after drying hands because it will contaminate their hands. He further stated that the cleaning carts should be left outside the resident's room when housekeeping staff is cleaning due to safety issues. At 12:56 PM, the Assistant Director of Nursing (ADON) who was also the Infection Preventionist Nurse informed the surveyors that the proper way of performing handwashing was the staff should wet their hands before applying soap, ladder or scrub with friction for at least 20 seconds away from the water, rinse under water, dry hands with a paper towel, and turn off the faucet with a clean paper towel. The ADON further stated that cleaning carts should not be brought inside the resident's room for infection control. A review of the facility Hand Hygiene Policy provided by the ADES with a review date of 10/19 included Technique for handwashing: wet your hands with clean, running water and apply soap. Lather your hands by rubbing together with the soap. Scrub your hands for at least 20 seconds. Rinse your hands well under clean running water. Dry your hands using a clean paper towel. Use paper towel to turn off faucet. A review of the undated facility 10 Steps Patient Room Cleaning Policy that was provided by the ADES did not include information about where to place the housekeeping cart when staff cleaning the room. At 1:09 PM, the surveyors discussed the above concerns with the LNHA, DON, and ADON. No additional information was provided by the facility. NJAC 8:39-19.4 (a) (1)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to adhere to current infection control guidelines to prevent the possible spread of COVID-19 during a COVID-19 focused survey which included: a) improper donning/doffing of personal protective equipment b) failure to perform hand hygiene after glove removal c) failure to provide direct care staff with N-95 respirator masks for newly admitted /readmitted residents who required transmission based precautions for 14 days to monitor for signs and symptoms of COVID-19. This deficient practice was identified on 1 of 4 Nursing units, (5 South) and for 1 of 1 resident reviewed for transmission based precautions (Resident #4), and was evidenced by the following: 1. On 11/18/20 at 1:03 PM, the surveyor observed a physician who wore examination gloves as he walked down the hall from the nurse's station to Resident #4's room. The door of the resident's room was ajar and the resident was observed wearing a surgical mask while seated in a chair at the bedside. There was a Personal Protective Equipment (PPE) (garments or equipment used to protect the body from injury or infection) caddy on the outside of the door which contained examination gloves. There were two blue disposable isolation gowns that were hung on either side of the caddy. The Physician removed one of the isolation gowns and began to put it on before he was stopped by the Registered Nurse (RN) who handed him an isolation gown that was sealed in clear plastic for his use. The physician then hung the gown back up on the door and donned (applied) the gown that was provided for his use. The door of the room remained ajar and the surveyor observed the Physician examine Resident #4. He then removed his gloves and threw them in the trash can located within the resident's room. He came out into the hallway and doffed (removed) the isolation gown and disposed of it in a trash can that was affixed to the RN's medication cart. The physician failed to utilize the alcohol based hand rub (ABHR) from the dispensers that were affixed to the walls in the corridor at regular intervals outside of the resident's room. The surveyor observed the Physician as he walked down the hall and entered the nurse's station. He spoke with the Nurse Manager (NM) briefly, before he proceeded to remove a pen from his pocket and reached for Resident #4's chart where began to document. The surveyor observed the physician utilize ABHR from a dispenser that was affixed to the wall in the nurse's station before he walked out into the hallway. When interviewed, the Physician stated that Resident #4 was on contact isolation for bacteremia (presence of bacteria in the blood stream) and a staph infection (infection caused by bacteria on the skin). The Physician stated that he normally wore the gown that hung on the door when he visited the facility. He stated that it was disposable and shouldn't have been there as the staff must have reused it. The Physician stated that he obtained gloves and placed them on the counter at the nurse's station while he wrote notes before he saw Resident #4. He stated that obviously he did not write notes with gloves on. He further stated that he didn't think that the gloves could become contaminated after being placed on the counter as the facility must have cleaned it. The Physician stated that there were normally bins to dispose of PPE located outside of the resident's rooms who were on transmission based precautions. He stated that he didn't see it, so he placed the soiled gown in the garbage can located on the side of the medication cart. He further stated that since the gown was placed inside the garbage there was no chance of contamination of the medication cart. The physician stated that he looked for hand sanitizer after he removed his gloves but didn't see it. He stated that there may be a possibility of contamination since he didn't perform hand hygiene after he removed his PPE and entered the nurse's station to document. He further stated that the facility should have had something readily available to perform hand hygiene. At 1:21 PM, the surveyor interviewed the Nurse Manager (NM) who stated that the Physician should have received education and training on COVID-19 as he visited the unit weekly. She stated that Resident #4 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The NM stated that the Physician was required to wear a surgical mask and face shield and should have donned gloves and a gown immediately before he entered the resident's room. She further stated that gloves were available in the PPE caddy affixed to Resident #4's door and it was not appropriate for the physician to wear gloves into the room that he obtained elsewhere. The NM stated that the doctor should not have attempted to wear one of the gowns that hung on the Resident #4's door as they belonged to the nursing staff to wear throughout the day within the resident's room. The NM looked inside of the PPE caddy and stated that there were no more disposable isolation gowns inside of the PPE caddy but the nursing staff could have refilled it upon request. The NM stated that the physician was required to donn all PPE prior to entering the room and doff all PPE prior to leaving the room. She stated that hand hygiene should have been performed immediately after PPE was removed. The NM stated that it was not appropriate for the physician to dispose of his soiled isolation gown outside of the resident's room in the medication cart waste basket as now the entire exterior portion of the medication cart was considered contaminated and needed to be disinfected. The NM further stated that nurse's station and resident's chart were also considered contaminated and were required to be disinfected. At 1:53 PM, the surveyor interviewed the Director of Nursing (DON) who was responsible for infection control at the facility, who stated that the physician should not have walked around in gloves and was required to obtain them directly from the isolation caddy located on the outside of the resident's door prior to entry. She stated that the physician should not have attempted to wear the gown that hung on the resident's door as it belonged to nursing. She stated that the doctor should have instead asked nursing for an isolation gown. The DON stated that it was totally wrong of the physician to doff his gown after he came out of Resident #4's room into the hallway and disposed of it in the trash can affixed to the medication cart because now it was considered contaminated and needed to be disinfected. She further stated that he should have utilized the ABHR that was affixed to the wall outside of the resident's room in the hall to perform hand hygiene to reduce the potential to spread infection. The surveyor reviewed the facility policy, Standard Precautions & Isolation Precautions (formulated 09/19/20), which revealed the following: Purpose: To protect patients, employees, and visitors from communicable diseases that are transmitted by blood, bodily fluids, and respiratory droplets. To provide a guide to hospital staff, which protects patients and personnel, from contact with blood and body fluids from any known or unknown source of infection. Wear gloves when touching .contaminated items. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces .and perform hand hygiene immediately to avoid transfer of microorganisms to other patients or environment. Remove soiled gown as promptly as possible, and perform hand hygiene to avoid transfer of microorganisms to other patients or environments. Contact Precautions: In addition to Standard Precautions, use Contact Precautions for specified patients, known or suspected to be infected or colonized with epidemiologically important organisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when performing care activities that requires touching the patient's dry skin) or indirect contact (touching) with environmental surfaces or patient care items in the patient's environment. .Wear gown and gloves when entering the room. Remove gloves and gown before leaving the patient's environment and perform hand hygiene. After glove and gown removal and hand hygiene, ensure that hands or clothing do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments. The surveyor reviewed the Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) (06/20), which revealed the following: Hand Hygiene Guidance: Health care personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical conditions: Immediately before touching a resident. .After touching the resident or the residents' immediate environment .Immediately after glove removal. Hand hygiene using Alcohol Based Hand Sanitizer (ABHS) before and after all patient contact, contact with infectious material and before and after removal of PPE, including gloves. 2. On 11/18/20 at 9:06 AM, the surveyor interviewed the Director of Nursing (DON), the primary person responsible for Infection Control, who stated that the 5 South Nursing Unit was designated for newly admitted and readmitted residents who were placed on quarantine in a private room on transmission based precautions (TBP)/isolation for 14 days to monitor for the presence of COVID-19. She stated that all staff were required to wear full PPE when they entered the residents' room, which included: gown, gloves, surgical mask and face shield. The DON specified that an N-95 Mask (facepiece respirator, that filters at least 95% of airborne particles) was not required to enter the rooms of residents who were on TBP. The DON stated that residents were tested for COVID-19 at the hospital prior to admission to the facility and were tested again upon admission. She stated that once the resident was determined to be negative they were monitored every shift for 14 days for signs and symptoms and no further testing was conducted unless the residents were symptomatic. The DON stated that no residents had tested positive for COVID-19 at the facility since March 2020. At 10:07 AM, the surveyor interviewed the 4 North/4 South Registered Nurse Unit Manager (RN/UM) who stated that when staff worked on the quarantine unit they were required to wear a surgical mask, face shield, gown and gloves. She further stated that an N-95 mask was only required if an aerosol generating procedure such as a nebulizer (a device that produced a fine spray of medication for inhalation) was performed for residents on quarantine. At 10:15 AM, the surveyor interviewed Housekeeper (HK) #1, who stated that housekeeping cleaned resident rooms once daily and a surgical mask, face shield, gown and gloves were required to be worn. HK #1 further stated that no N-95 masks were used unless there was an aerosol generating procedure used for residents on quarantine. At 11:11 AM, the surveyor interviewed the Administrator who stated that staff were required to wear a surgical mask and face shield when they entered rooms of residents on TBP for 14 day quarantine to rule out COVID-19. She further stated that an N-95 mask was only required if the nurse administered an aerosol-generating procedure such as a nebulizer, and believed that this protocol was captured within the facility Outbreak Response Plan. At 11:56 AM, the DON showed the surveyor the facility PPE inventory. There was one full 20 count box of N-95 Masks and an opened 20 count box contained within the DON's office. She stated that she worked at the facility for one year and there were no issues with PPE shortages during the previous outbreak. She further stated that there was no problem with obtaining additional quantities of PPE because they were able to get it from the hospital that they were affiliated with right away if necessary. At 12:20 PM, the surveyor interviewed the Environmental Services Assistant Director who stated that his staff were required to wear a surgical mask, face shield, gown and gloves when they entered a room of a resident who was on TBC for 14 day observation or were considered a Person Under Investigation (PUI) for COVID-19. He stated that the rooms were identified by a yellow sign. He further stated that a red sign indicated that resident was positive for COVID-19. At 12:45 PM, the surveyor observed Housekeeper #2 who wore a surgical mask and face shield in the hallway on the 5 South Nursing Unit. When interviewed, she stated that she was assigned to the unit and was required to donn a face shield, surgical mask, gown and gloves before entering a room that was marked by a yellow (quarantine) or red sign (COVID-19). She further stated that she cleaned her face shield with disinfectant wipes after she exited the room. The surveyor observed that there were no red signs on the unit. At 12:55 PM, the surveyor observed the Registered Nurse (RN) who was assigned to 5 South Nursing Unit. She wore a surgical mask and a face shield while in the hallway. When interviewed, she stated that N-95 masks were worn when aerosol generating procedures such as nebulizer treatments were administered previously and further stated that she wasn't required to wear an N-95 mask anymore because they had no COVID at the facility. The RN stated that full PPE (surgical mask, face shield, gown and gloves) were required to enter the room of a resident who was on quarantine for 14 days and the room was marked by a yellow sign as a reminder. On 11/19/20 at 11:39 AM, during a post-survey phone interview, the Administrator stated that both Webinars and the State told her that they were required to wear a surgical mask and a face shield when care was rendered to a resident on TBC or 14 day quarantine, not an N-95 mask. The DON stated that the facility had not routinely worn N-95 masks on the 5 South Nursing Unit since the Pandemic in March 2020. The Administrator stated that the facility had never experienced a shortage of N-95 masks. She stated that they had more than enough supplies. She stated that nursing was only required to wear an N-95 mask if they cared for a COVID-19 positive resident or for residents on 14 day quarantine who required aerosol generating procedures or nebulizer treatments. The Administrator further stated that this protocol was obtained from guidelines that were issued during the initial pandemic in March 2020. The DON stated that the facility was able to obtain N-95 masks from the hospital immediately if needed. She further stated that they were following the hospital guidance for N-95 usage as outlined in their policy. The DON stated that residents who were on 14 day quarantine were on both droplet and contact precautions and a surgical mask, face shield, gown and gloves were required to enter those resident rooms. The Administrator provided the surveyor with a copy of the signage posted outside of resident rooms on 5 South which informed staff to do the following before they entered a room with a Yellow Circle on the door: All admitted /readmitted Resident (sic.) are monitored closely X 14 days. Resident will be tested for COVID Use of Surgical Mask/Face Shield/Gown, Gloves might be on some sort of precautions such as [MEDICAL CONDITION], C-AUIRS,[MEDICAL CONDITION], VRE, ESBL, MDRO ETC. (Check with nurse) V/S Q shift & COVID Screening The surveyor reviewed the facility, Outbreak Response Plan: Brother Bonaventure Extended Care (undated) which revealed the following: .Appropriate PPE provided as needed. All staff and vendors that enter the facility must wear a surgical mask at all times (Universal Masking). The surveyor reviewed the policy, Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) (06/20), which revealed the following: Personal Protective Equipment and Supplies: Staff will use appropriate PPE when they are interacting with residents, to the extent PPE is available and per CDC guidance on conservation of PPE. For the duration of the state of emergency, all facility personnel should wear a facemask while they are in the facility. *Follow specific state guidance. It is recommended that an N95 or surgical mask is to be used. Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE. If COVID-19 transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 [DIAGNOSES REDACTED]. The surveyor reviewed the facility grid titled, PPE Guidelines for COVID-19 Patients (03/25/20), which revealed the following: RN/LPN, Nursing Assistants, TECHS: Providing care for patients under investigation (PUI) or COVID-19 patients Type of Personal Protective Equipment (PPE): Gloves, gown, surgical mask,and face shield.***An N-95 respirator with face shield is needed during any aerosolizing procedures such as, but not limited to aerosol-generating procedures for PUI or COVID-19 patients . NJAC 8:39-19.4

Based on observation, interview and record review, it was determined that the facility failed to ensure: a.) a medication (Linzess) used to treat irritable bowel syndrome with constipation was administered in accordance with manufacturer's specifications from 5/13/19 until surveyor inquiry 6/17/19, for 1 of 5 residents (Resident #55) reviewed for unnecessary medications, and b.) that medications ([MEDICATION NAME] and [MEDICATION NAME] Patch) were obtained in a timely manner and administered in accordance with professional standards of practice. This deficient practice was identified for 2 of 25 residents reviewed for medication management, (Resident #55 and Resident #37). The evidence was as follows: 1. On 6/13/19 at 9:15 AM, the surveyor attempted to interview Resident #55. The resident was observed in bed with eyes closed and did not respond to the surveyor. On 6/13/19 at 9:30 AM, the surveyor interviewed the Registered Nurse (RN) who stated that the resident spoke another language, was confused and not always clear with speech. On 6/13/19 at 10:09 AM, the surveyor reviewed the medical record for Resident #55. A review of the annual Minimum Data Set (MDS) (an assessment tool) dated 4/15/19, reflected that the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected that the resident had a Brief Interview of Mental Status (BIMS) score of eight (8) out of 15 which indicated a moderately intact cognition with some forgetfulness. A review of the Physician's Orders (PO) revealed an order dated 5/13/19 for Linzess 290 micrograms (MCG), one capsule by mouth every evening in empty stomach for a [DIAGNOSES REDACTED]. In addition a handwritten time of 4:00 PM was noted. A review of the (MONTH) 2019 Medication Administration Record (MAR) also revealed a PO dated 5/13/19 for Linzess 290 MCG, one capsule by mouth every evening in empty stomach for a [DIAGNOSES REDACTED]. In addition, the cautionary warning indicated to administer on an empty stomach 30 minutes before breakfast. The time of administration on the MAR was 4:00 PM. A review of the Consultant Pharmacist (CP) Progress Notes dated 10/9/18, had a recommendation for the Linzess to be administered on an empty stomach. In addition, another recommendation dated 5/9/19, questioning whether medications were being administered through a gastrostomy tube (GTUBE) (a tube inserted in the stomach used to provide nutrition) or by mouth. On 6/13/19 at 11:32 AM, the surveyor with the RN reviewed the (MONTH) 2019 Medication Administration Record (MAR) for Resident #55. The RN stated that Linzess was being administered at 4:00 PM. The RN added that the resident was previously being administered medications through a GTUBE which was changed to administering medications by mouth. The RN thought the resident was changed to medications being administered by mouth last month. The RN added that she did not administer the 4:00 PM medications, but thought the time was appropriate because that would be an empty stomach. On 6/17/19 at 9:20 AM, the surveyor with the RN Nurse Manager (NM), reviewed the PO and MAR for Resident #55. The NM stated that the [DIAGNOSES REDACTED]. The NM also stated that she thought the Linzess was being administered at 4:00 PM because that was a time Resident #55 had an empty stomach and thought the Consultant Pharmacist had made the recommendation. The NM stated that the resident was administered medications by mouth. The NM was unsure of the manufacturer's specifications for Linzess. On 6/17/19 at 9:42 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who said that she was familiar with the resident. The CNA stated, that the resident required total care and was unaware of any issues regarding constipation. The CNA added that there were bowel and bladder records that all CNA's were responsible for completing. Further review of the (MONTH) and (MONTH) 2019 resident's Activities of Daily Living (ADL) Flow Record, revealed that the resident was incontinent with respect to bowel movements, and the total number of voids (emptying of bowels) per day were being monitored. There were consistent voiding of bowels noted. On 6/18/19 at 9:47 AM, the surveyor interviewed the NM who stated that she had called the provider pharmacy in reference to the administration of Linzess. The NM was informed that the Linzess was suppose to be administered on an empty stomach, in the morning and before breakfast in order to be effective. The NM also stated, that the cautionary was on the MAR, but the order indicated to be administered in the evening. The NM added that the PO was clarified to reflect the [DIAGNOSES REDACTED]. On 6/18/19 at 11:09 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone regarding the administration of Linzess. The CP stated that Linzess should be administered on an empty stomach in the morning before breakfast. The CP added, that the resident was being administered medications through a GTUBE and thought that was the reason for a 4:00 PM administration time. The CP also stated, that the 4:00 PM administration time was appropriate for the Linzess when being administered through the GTUBE, because that would be on an empty stomach based on the feeding times. The CP added, that when the medications were changed to being administered by mouth, the Linzess should have been changed to being administered on an empty stomach before breakfast. The CP added that the NM does not administer the medications and thought the usual medication nurse was no longer working full time. The CP added, that she would usually speak to the medication nurses regarding the administration times on the MAR. On 6/18/19 at 1:22 PM, the survey team met with the Administrator and Director of Nursing (DON). The DON stated that she would review the PO for the resident. On 6/19/19 at 9:04 AM, the survey team met with the Administrator and DON. The DON stated that the NM had reviewed the Linzess with the provider pharmacy and the Linzess administration time was changed. The DON stated that the physician's orders and administration time for Linzess was not clarified when the resident was changed from medication administration through the GTUBE to by mouth. A review of the facility policy provided by the DON for General Medication Administration Guidelines of Oral Preparations revised on (MONTH) (YEAR), revealed that medications are administered as prescribed in accordance with standard nursing principles and practices and according to cautionary statements. In addition, the time of administration for medications will be adjusted according to the cautionary statement and the time adjustment will be noted with an order. A review of the manufacturer's specifications for Linzess indicated that Linzess is to be administered on an empty stomach, at least 30 minutes prior to the first meal of the day. 2. On 6/13/19 at 9:30 AM, the surveyor interviewed the RN with respect to Resident #55's behaviors. The RN stated that the resident had [MEDICAL CONDITION] and behaviors of frequently yelling out and could become combative. The RN added, that the behaviors were recorded and monitored on a Behavior Monitoring Flow Record in the MAR. The RN stated that the resident had been on an as needed (PRN) medication for anxiety which was recently changed to routine [MEDICATION NAME] ([MEDICATION NAME]). On 6/13/19 at 10:09 AM, the surveyor reviewed the medical records for Resident #55. A review of the Physician's Orders (PO) revealed an order dated 5/31/19 for the PRN [MEDICATION NAME] to be discontinued and to start [MEDICATION NAME] 0.25 milligrams (MG) by mouth twice a day (BID) on Monday. A review of the (MONTH) 2019 Medication Administration Record (MAR) indicated that the PRN [MEDICATION NAME] was discontinued on 6/3/19. In addition, the MAR revealed a handwritten PO for [MEDICATION NAME] 0.25 MG by mouth BID, start 6/3/19 for a [DIAGNOSES REDACTED]. 5 PM doses for 6/4 and 6/5 had no initials indicated. On 6/13/19 at 11:32 AM, the surveyor with the RN reviewed the (MONTH) 2019 MAR. The RN stated that she had not worked on 6/3/19 but when a medication was circled it meant the medication was not administered and there should be a reason written on the MAR and/or, a nursing note. The RN added that the MAR did not have a reason indicated. The RN then stated that a blank could mean that the nurse forgot to sign or the medication was not administered. The RN added that when [MEDICATION NAME] was administered to the resident the Controlled Medication Utilization Record (CMUR) would indicate the removal of the dose at that time of administration. The RN added that behaviors for the resident were monitored on a Behavior Monitoring Flow Record. A review of the resident's CMUR for the [MEDICATION NAME] 0.25 MG tablets date as received on 6/4/19, indicated that the first tablet was removed on 6/4/19 at 9 AM. There were no entries of removal for 6/4/19 at 5 PM and 6/5/19 at 5 PM. A review of the resident's Behavior Monitoring Flow Record did not indicate any observation of behaviors on 6/3, 6/4 and 6/5. On 6/17/19 at 9:20 AM, the surveyor with the RN Nurse Manager (NM) reviewed the PO and MAR for Resident #55. The NM stated that a monthly behavior summary was done for (MONTH) but could not locate the (MONTH) behavior summary. The NM also stated that the psychiatric nurse practitioner had recommended on 5/31/19 to restart routine [MEDICATION NAME] after reviewing the PRN use of [MEDICATION NAME]. The NM was unaware that there was an issue with [MEDICATION NAME] being started. On 6/17/19 at 9:42 AM, the surveyor interviewed the certified nursing assistant (CNA) who stated that she was familiar with the resident. The CNA stated that the resident did yell out and seemed anxious at times, but thought the resident had improved. On 6/18/19 at 9:47 AM, the surveyor interviewed the NM who stated that there should be documentation when a resident does not receive a medication. The NM stated that the nurses should call the physician and clarify an order if they were not able to administer a medication because it was not available. The NM added that there was no documentation referring to the missed doses of [MEDICATION NAME]. On 6/18/19 at 11:09 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that the nurses should call the physician if a resident has not received a medication for whatever reason. The CP added, that the physician may want to order another medication that was available or change the order. On 6/18/19 at 1:22 PM, the survey team met with the Administrator and Director of Nursing (DON). The DON stated that she would review when the [MEDICATION NAME] was ordered. The DON added that there was [MEDICATION NAME] available in the electronic back up supply machine. On 6/19/19 at 9:27 AM, the survey team met with the Administrator and DON. The DON provided a summary dated 6/18/19 which indicated that the resident had not received the [MEDICATION NAME] doses on 6/3 at 9 AM and 5 PM, 6/4 at 5 PM and 6/5 at 5 PM. The DON stated that she spoke with both nurses responsible for omitting the administration of the [MEDICATION NAME] on 6/3. Both nurses stated that the [MEDICATION NAME] was not administrated because it was not available in the medication cart. The DON added, that the physician was not made aware, and that neither nurse thought to use the electronic back up supply machine. In addition, the DON stated that the nurses on 6/4 and 6/5 omitted the doses. The DON stated that the nurses involved were agency and per diem nurses, and that disciplinary action was taken. A review of the facility policy provided by the DON for General Medication Administration Guidelines of Oral Preparations revised on (MONTH) (YEAR) revealed that medications are administered as prescribed in accordance with standard nursing principles and practices. In addition, the policy indicates to check the electronic back up supply machine or have the physician change the medication or medication time if the pharmacy cannot provide the medication. 3. On 6/12/19 at 9:33 AM, the surveyor observed Resident #37 laying on the bed with oxygen. A review of the Face sheet (an admission summary), indicated that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set ((MDS) dated [DATE], indicated that the Brief Interview for Mental Status (BIMS) was 15, which indicated the resident's cognition was intact. A review of the (MONTH) 2019 Physician's Order Form (POF) revealed an order dated 4/25/19 for [MEDICATION NAME] 25 mcg/HR (micrograms per hour), apply one patch every 72 hours for chronic pain. A review of the (MONTH) 2019 (Medication Administration Record) MAR reflected the above physician order for [REDACTED]. Further review of the MAR, showed that the [MEDICATION NAME] was not applied or administered according to the physician order on the following dates: 6/3/19 and 6/17/19. On 6/3/19 the nurse signed and circled the MAR, for the [MEDICATION NAME], which meant that the medication was not administered. The nurse documented on the back of the (MONTH) 2019 MAR that the [MEDICATION NAME] 25 mcg patch was not given because the medication was not available. There was no documented evidence why the [MEDICATION NAME] wasn't administered on 6/17/19. On 6/19/19 at 9:04 AM, the surveyors met with the Administrator and the Director of Nursing (DON) and the above discussed the above concerns. On that same day at 9:49 AM, the resident informed and showed the surveyor the [MEDICATION NAME] which was applied to his/her right upper arm and dated 6/18/19. Resident #37 stated that the patch was being replaced routinely, but not every day, and wasn't sure when the patch should be changed because he/she relied on the nurses. The resident denied that he/she was in pain. On 6/19/19 at 9:52 AM, Registered Nurse#1 (RN#1) informed the surveyor that she was the nurse who applied the [MEDICATION NAME] on 6/18/19 because the 11-7 nurse on 6/17/19 forgot to apply the patch. RN #1 stated that she reported the incident of omitted [MEDICATION NAME] to the Assistant Director of Nursing (ADON) on 6/18/19. RN#1 indicated that the resident had no complaints of pain upon assessment on 6/18/19. On that same day at 10:07 AM, the Registered Nurse/Unit Manager (RN/UM) informed the survey team that on 6/3/19 the [MEDICATION NAME] was not available. The RN/UM had no answer as to why the [MEDICATION NAME] was not administered on 6/4/19. Review of the [MEDICATION NAME] declining sheet indicated the medication was delivered from the pharmacy on 6/4/19. RN#1 stated that the [MEDICATION NAME] was administered on 6/5/17. She further stated, there was no reason not to administer the [MEDICATION NAME] on 6/17/19 because the medication was available. On 6/19/19 at 11:36 AM, the ADON informed the survey team that it was RN#2, a per diem nurse, who omitted the [MEDICATION NAME] on 6/17/19. The ADON added, that it was RN#3, an agency nurse, who did not administer the medication on 6/3/19. On that same day at 12:47 PM, RN#3 informed the survey team that on 6/3/19 the [MEDICATION NAME] was not available. She stated that she found the prescription (Rx) for the [MEDICATION NAME] was filed in the medical record of the resident when she called the physician for an Rx. She further stated that the physician indicated that he had written the prescription a few days earlier because he knew that resident needed a refill of the medication. RN#3 further stated that she faxed the Rx to the pharmacy on 6/3/19. On 6/19/19 at 1:06 PM, RN#2 informed the surveyor that she overlooked the order for [MEDICATION NAME] of 6/17/19 and was sorry that she did not administer the medication according to the physician's order. RN #2 further stated that the resident was not in pain at that time. A review of the [MEDICATION NAME] prescription and copies of the facsimile to the pharmacy provided by the Administrator, revealed that the prescription was written and signed by the physician on 5/27/19 and was faxed to the pharmacy on 6/3/19 as shown on the facsimile. A review of the General Medication Administration Guidelines Policy provided by the DON with a revised date of 3/17, reflected that Medications are administered according to physician orders. NJAC 8:39-29.2(d), 29.7(c)(d)

Based on observation, interview and record review, it was determined that the facility failed to clarify an allergy for 1 of 25 residents (Resident #37) in accordance with professional nursing standards; and, failed to ensure that a Licensed Practical Nurse (LPN) had the specific competencies and skill sets necessary to care for 1 of 22 residents, (Resident # 103) observed during a wound care treatment. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) On 6/12/19 at 9:33 PM, the surveyor observed Resident #37 laying on the bed with oxygen. A review of Resident #37's Face sheet (an admission summary), indicated that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set (MDS), dated [DATE], indicated that the Brief Interview for Mental Status (BIMS) was 15 on a scale of 1 out of 15, which indicated the resident's cognition was intact. The 4/5/19 MDS indicated the resident received opioid, a medication that acts on the nervous system to relieve pain. Further review of the medical record revealed the following allergies [REDACTED]. A review of the (MONTH) 2019 physician's orders [REDACTED]. Further review of the POF indicated a physician order [REDACTED]. A review of the (MONTH) 2019 (Medication Administration Record) MAR indicated [REDACTED] On 6/13/19 at 9:26 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM had no answer as to why the resident was on [MEDICATION NAME] and [MEDICATION NAME] when the resident had an allergy to Opioids. She stated that she would get back to the surveyor. On 6/13/19 at 10:00 AM, the resident informed the surveyors that he/she was not sure what pain medication he/she was allergic to. Resident #37 further stated that the current pain medications helped to relieve pain and denied any kind of an allergic reaction. On 6/13/19 at 11:57 AM, the surveyor interviewed the RN/UM who informed the surveyor that the Opioid allergy was from the hospital medical records dated 8/18/17, and documented in the History and Physical. The RN/UM stated that the standard of practice was that the nurse should have followed up with the physician and clarified the opioid allergy when the [MEDICATION NAME] and [MEDICATION NAME] were ordered. She further stated, that there was no documented evidence that the nurse had clarified the listed allergy when the two pain medications were ordered. On that same day and time, the RN/UM indicated that the allergy was clarified after surveyor's inquiry. She further stated that the physician ordered to continue the [MEDICATION NAME] and [MEDICATION NAME] because the resident had no allergic reaction. On 6/17/19 at 11:09 AM, the surveyor conducted a telephone interview with the facility's Consultant Pharmacist (CP) who informed the surveyor that she was aware of the opioid allergy. She said she was aware of the physician orders [REDACTED]. The CP said she questioned a nurse who informed her that it was approved by the physician. The CP could not recall the name of the nurse. The CP further stated that she did not indicate the opioid allergy in the monthly medication regimen review (MMR) but that she had personal notes in her computer that she used as a guide and resource. On 6/17/19 at 12:53 PM, the surveyors met with the Administrator and the Director of Nursing (DON) and informed them about the above observations and concerns. On 6/18/19 at 8:25 AM, the surveyor conducted a telephone interview with the physician who informed the surveyor that the resident had an allergy to [MEDICATION NAME] which was exhibited by itchiness. He indicated that Resident #37 was on [MEDICATION NAME] before and there was no allergic reaction exhibited, that was why he ordered the pharmacist to dispense the [MEDICATION NAME] on 4/25/19, and to continue with [MEDICATION NAME]. The physician stated, that it was only yesterday that the facility had contacted him regarding the clarification of the opioid allergy. On 6/18/17 at 1:23 PM, the DON in the presence of the Administrator and the survey team, acknowledged that the facility should have clarified the opioid allergy. The DON further stated the resident's physician was notified after the surveyor's inquiry and that the physician wanted to continue with the [MEDICATION NAME] every 72 hours and [MEDICATION NAME]. A review of the allergies [REDACTED].#5 that Advise resident's physician of stated allergies [REDACTED].>2.) On 6/13/19 at 10:30 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound treatment to Resident #103's right heel. The LPN did not follow acceptable standards of nursing practice and failed to follow the Facility's Wound Treatment Policy and Procedure. The surveyor discussed the breaks in technique with the LPN. The surveyor reviewed the medical record which reflected Resident #103 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS)dated 6/4/19, an assessment tool, indicated that the resident had a Brief Interview for Mental Status (BIMS) of 13 which indicated that Resident #103 was cognitively intact. Review of the facility's Wound policy and procedure instructed to always use clean technique during wound care to prevent infection; clear the top of over bed table and sanitize with disinfecting solution; open a plastic bag to line the table; disinfect scissors or any multiple-use equipment; remove soiled dressing and place in opened plastic bag, apply medication and or primary dressing according to manufacturer's direction, care plan, and physician orders, dispose all used supplies, place in a bag before putting in the treatment cart trash; remove bags and discard in the medical waste bin (red bin) in the dirty utility room. On 6/18/19 at 1:26 PM, the survey team met with the Administrator and Director of Nursing (DON) and discussed the above observations and concerns. The surveyor requested the LPN's wound performance competency. On 6/19/19 at 9:17 AM, the survey team met with the Administrator, DON and ADON and again, requested the wound performance competency for the LPN. The DON and ADON both stated that there was no wound treatment competency for the LPN as he had not received wound treatment training. On 6/19/19 at 12:12 PM, the Administrator stated that the LPN should not have been doing the wound treatment for [REDACTED]. No further documentation was provided by the facility. NJAC 8:39-11.2 (b); 27.1 (a)

Based on observation, interview, and record review it was determined that the facility 1) failed to provide the necessary supervision to prevent a resident from sustaining injury while receiving a physician ordered treatment and 2) failed to properly secure hazardous substances stored on nursing units where confused ambulatory residents resided. The deficient practices were identified for 1, Resident #2, of 4 residents reviewed for accident/hazards and on 2 of 4 nursing units inspected. The lack of adequate supervision while receiving a physician ordered treatment resulted in Resident #2 sustaining a second degree burn which required treatment. The following evidenced these deficient practices: 1. The surveyor observed Resident #2 during the 10/24/11 initial unit tour at 9:45 a.m. The resident was in bed watching television. The unit nurse told the surveyor the resident had burned his fingers while receiving physical therapy. The surveyor reviewed the medical record on 10/24/11 at 12:00 p.m. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 9/13/11 physical therapy evaluation indicated the resident had generalized weakness and deficits in bilateral upper and lower extremities, the skin was intact and sensation was within functional limits. The medical record contained a 9/20/11 physiatrist order for "heat on hands." A 9/23/11 interdisciplinary progress note (12:20 p.m.) indicated the resident sustained [REDACTED]. Resident c/o feeling sore." A 9/23/11 physician's orders [REDACTED]. A subsequent order was obtained from the physician on 9/28/11 for Silvadene Creme application to the right hand middle finger following the opening of the blister. The surveyor reviewed the medical record and treatment administration record (TAR) to locate initial and subsequent wound assessments for the 2 finger blisters. Two unit nurses confirmed on 10/25/11 at 1 p.m. that, with the exception of noting a closed or opened blister, no description or measurement of the wounds was on the medical record or the TAR. The following day at 9 a.m. the unit nurse stated to the surveyor that the wound care specialist brought in documentation to the unit on 10/25/11 at 2 p.m. The wound specialist told the unit nurse she had wound care flow sheets in her possession for 10/11/11. The wound specialist assessed the 2 fingers on 10/25/11. The right index finger had healed. The right middle finger measured 1 x 1 x 0.1 centimeters and was 100% necrotic. The facility's wound assessment policy and procedure (6/05) instructs nursing staff to document "size, shape, location, color, tissue type, drainage, odor," etc. and "document wound assessment and dressing change (if applicable) on the flow sheet and on the TAR (Treatment Administration Record)." The surveyor reviewed the "summary of investigation" written on 9/26/11 regarding the 9/23/11 treatment, which was the 7 th in the series of treatments. The therapist stated 10 layers of towels were placed between the resident's hands and hot packs. The resident was checked after 5 minutes with no problems or resident complaints. After an additional 5 minutes the resident complained that the pack was hot. Four additional layers of towels were added after checking the resident's skin integrity. No redness or irritation was noted. The treatment was completed 5 minutes later. The resident was noted to have blistering and redness to the right index and middle fingers. The facility's rehabilitation services Hydrocollator packs policy and procedure (undated) indicated "wrap Hydrocollator packs so that a minimum of 12 to 16 layers of towels separate the patient from the pack." The therapist was in-serviced by the rehabilitation manager on 9/23/11 regarding the correct application of hot packs. The surveyor interviewed the resident on 10/25/11 at 10:35 a.m. in his room. The resident was assessed to be alert and oriented to person, place and time on assessments done on 1/2/11 and 8/27/11 using the brief interview for mental status (BIMS). He scored 15 of 15. The resident stated "on a Friday I got a heat treatment for [REDACTED]. Seven to eight minutes went by and I said 'it's getting hot'. They did not check my hand and added 1 more towel. I said 'it's too hot '. I was not checked and they added 1 more towel. The time was up for treatment. I saw a blister on my finger tip. . . The blister ruptured when I was repositioning myself in bed (5 days later, 9/28/11)." There are discrepancies in the statement obtained from the resident around the time of the incident and what the resident told the surveyor 1 month later. The surveyor interviewed the therapist in the presence of the rehabilitation manager on 10/25/11 at 11:15 a.m. in the rehabilitation department. The therapist stated 5 towels (10 layers) were placed over the hot pack, the hands were placed over the towels. Five towels (10 layers) were placed over the resident's hands and another hot pack was placed on top. The therapist said after the first 5 minutes, skin integrity was checked and the resident offered no complaints. After another 5 minutes the resident said his hands felt hot. Two more layers of towels were added. The treatment was completed after 15 minutes. At that time the redness and blistering was observed on the right pointer and middle fingers. The nurse was notified. The survey team spoke with the Director of Nursing (DON) and the Administrator on 10/27/11 at 1:00 p.m. regarding the resident's blistered fingers resulting from the application of hot packs. The DON and Administrator replied the following day at 10:30 a.m. The Administrator stated the resident was not required to be constantly monitored. He continued that the therapist did the right thing by feeling the pack herself (this was not in the investigational report or interview). After the treatment finished she saw the redness and irritation and reported it immediately to the nurse. The DON stated the facility does not measure burns. She further stated the wounds were treated initially with ice and subsequently, when the blisters opened, were treated with Silvadene and then Santyl. She confirmed the wound care flow sheets should have been on the medical record or Treatment Administration Record, not in the possession of the hospital wound care specialist. The DON further stated in the future the facility's wound nurse would manage resident's wounds along with the medical director. If the hospital wound specialist was needed, she would be consulted. 2. The surveyor toured the 4 South nursing unit on 10/24/11 at 9:20 a.m. The Janitor ' s closet was unlocked and contained a bottle of floor cleanser, a spray can of wall cleaner, a box of pine scented absorbent granules, and a wall mounted dispenser containing disinfectant cleaner and deodorizer. At 9:35 a.m. the surveyor observed a staff person enter the closet, come out and close the door without locking it. The surveyor toured the 4 North nursing unit on 10/24/11 at 9:30 a.m. The Soiled Utility room door was ajar. The room contained a utility cart filled with plastic bags of soiled laundry and 3 plastic bags of soiled laundry on the floor. A confused, ambulatory resident (Resident # 4) was walking up and down the length of the 4 North hallway. NJAC 8:39-27.1(a); 31.4(a)