Every finding on record at Village Point

Complaint: 2809139Based on interviews, review of medical records, and review of other pertinent facility documents on 3/30/2026, it was determined that the facility failed to ensure that residents (Resident #2 and Resident #3) were free of significant medication errors. On 3/12/2026, a Nurse Trainee Licensed Practical Nurse, (LPN#1) who was assigned with a preceptor (LPN#3) administered the wrong medications to Resident #2. The resident had no adverse reaction to the wrong medications. LPN #1 was re-educated by staff that same day about medication administration. A second medication error occurred on 3/18/2026 when LPN #1 who was assigned with a preceptor LPN #2 administered wrong medications to Resident #3. This resident had a harmful adverse reaction to the wrong medications and was sent to the Emergency and admitted to the hospital. This deficient practice was identified for 2 of 5 residents (Resident # 2 and Resident #3) reviewed. The facility policy titled: Administering Medication with a revised date of 01/10/2025 was reviewed. The Policy stated that Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director. Under Procedure 3, the policy stated that Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders. Under procedure 7, the policy stated that the individual administering the medication must ensure that the right medication, the right dose, the right time, and right method of administration are verified before medication is administered (e.g., review of the drug label, physician orders, etc.) 14. Medication ordered for a particular resident may not be administered to another resident.According to the Facility Reportable Event (FRE) record dated 3/19/2026, which the facility submitted to the New Jersey Department of Health (NJDOH), the Nurse Trainee (LPN #1) accidentally administered Jardiance 10mg along with Metoprolol succinate 100mg, Protonix 40mg, Areds 4296mcg/90mg/226mg along with Eliquis 2.5mg to Resident #3. Resident #3's physician was notified about the error, the resident's resulting low blood pressure reading of 80/50, and symptoms of hypoxia (low blood oxygen level). The resident was transferred to the emergency room and admitted at the hospital.A review of the facility document titled Clinical Note Report (CNR), dated 3/18/2026 revealed LPN #2 documented that she was assigned as preceptor to newly oriented nurse LPN#1 during the day shift (7:00 AM to 3:00PM). At the time of medication pass, the preceptor was assisting another resident and directly observing medication administration for safety. During this time, the newly oriented nurse (LPN #1) independently administered medications to assigned residents. LPN #2 was not present at bedside at the time LPN #1 inadvertently administered the medications to Resident # 3 that were intended for Resident #1. When LPN #1 told LPN #2 about the medication error, she immediately assessed the resident and notified supervisor. The supervisor notified the physician and family. On 03/18/2026, LPN #1 administered the following medications to Resident #3. Jardiance 100 mg (used to treat diabetes), Metoprolol Succinate 100 mg (used to treat hypertension), Protonix 40 mg (used to treat gastroenteritis), Areds 4296 mcg/90 mg/226 mg (used for vision treatment) and Eliquis 2.5 mg (used as blood thinner). These medications were prescribed for Resident #1.According to the admission Record face sheet, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: muscle weakness, diabetes mellitus, acute respiratory failure and epilepticus. According to the quarterly MDS dated [DATE], Resident #3 had a BIMs score of 13 out of 15, which indicated the resident's cognition intact.A review of Resident #3's Order Summary Report (OSR) active orders dated 03/01/2026 contained the following medication orders:Keppra 500mg 1 tab twice daily for seizure.Metformin 500mg 1tab daily for diabetes.Amiodarone 100mg 1 tab daily for arrhythmia.Lipitor 10mg 1 tab daily for lipids.Methimazole 5mg 1 tab daily for hyperthyroidism.Multivitamin 1 tab daily for supplement.Sitagliptin 100mg 1 tab daily for diabetes.Vitamin D25mcg 1 tab daily for supplement.Metoprolol 25mg 1 tab daily for supplement. According to the admission Record face sheet, Resident #1 was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia, chronic kidney disease, overactive bladder, major depression and presence of a cardiac pacemaker. According to the quarterly Minimum Data Set (MDS), an assessment tool dated 01/25/2026, Resident #1 had a BIMs score of 10 out of 15, which indicated the resident's cognition was moderately impaired.A review of Resident #1's OSR active orders dated 03/01/2026 contained the following medication orders:Lipitor 20mg 1 tablet (tab) daily for HLD.Multivitamin 1 tab daily for supplement.Jardiance 10mg 1 tab daily for diabetes.Synthroid 25mg 1 tab daily for hypothyroidism.Lisinopril 10mg 1 tab daily for hypertension.Norvasc 5mg 1 tab daily for hypertension.Flomax 0.4mg 1 capsule daily for urinary frequency.Aspirin 81mg1 tab daily for coronary artery disease.Melatonin 5mg 1 tab daily for insomnia.Eliquis 2.5mg 1 tab twice daily for A Fib.Metoprolol 100mg 1 tab daily for hypertension.Myrbetriq 25mg 1 tab daily for overactive bladder.Metformin 500mg 1 tab daily for diabetes.PreserVision 4296mcg-226mg-90mg 1 capsule daily.Protonix 40mg 1 tab daily for reflux.Zoloft 100mg 1 tab daily for depression. During a telephone interview with LPN #1 on 03/30/2026 at 10:37 AM, she stated that she was in training (orientation) on 03/12/2026 and 03/18/2026. On 03/12/2026, she went into the room shared by Resident #2 and Resident #4 to administer medications. She asked Resident #2 to state their name. The resident stated Resident #4's name. LPN #1 stated that she did not check Resident #2's identification band to confirm their identity. At this time, Resident #2 was administered Resident 4's medications. On 03/18/2026, LPN #1 stated while she was still on orientation with her preceptor LPN #2, LPN #2 told her to go independently and administer medications to Resident #1. LPN #2 provided the name of the resident (Resident #1) to LPN #1. Resident #1 and Resident #3 are roommates. LPN#1 stated that she administered medications to Resident #3. At this time, the Certified Nursing Assistant (CNA #1) who was in the room assisting Resident #1 asked her if she was going to administer medications to this resident. She stated to the CNA that she administered Resident #1's medications, and she was pointing to Resident #3. The CNA revealed to her at this time that Resident #3 was not Resident #1 [name indicated]. LPN#1 stated at this time she immediately informed LPN #2 about the medication error. LPN #1 stated that she did not follow the facility medication policy. On 03/30/2026 at 9:11 AM, the surveyor interviewed LPN #2, who confirmed she was the preceptor for LPN #1 on 03/18/2026 during the 7:00 AM to 3:00 PM shift. LPN #2 stated that she was in the room with another resident during the time LPN #1 was conducting the medication pass. She instructed LPN #1 to independently administer medications to Resident #1. LPN #1 informed her that she had administered Resident #1's medications to Resident #3. LPN # 2 stated the resident's physician was immediately notified of the medication error. LPN #2 stated, she should have remained with the orientee during medication administration.During interview with the Unit Manager/LPN (UM/LPN) on 03/30/2026 at 11:20 AM, she confirmed that LPN #1 was on orientation and assigned with a preceptor (LPN#3) on 03/12/2026 during the 7:00Am to 3:00PM shift. The UM/LPN stated Resident #2's physician was immediately notified of the medication error. The physician ordered staff to monitor Resident #2. She stated that on 03/12/2026, the facility medication policy was not followed by LPN #1.During interview with Resident #2 on 03/30/2026 at 11:48 AM, the resident stated that on 03/12/2026, LPN #1 came into their room to administer medications. LPN #1 did not check their identification band or their name.The CNR dated 03/12/2026, identified that on 03/12/2026 at approximately 10:00 AM, a medication error occurred. Resident #2 was administered medications that were prescribed for Resident #4. On 03/12/2026 a medication error was noted for Resident #2, who received medications prescribed for Resident #4. The medications administered in error included the following: Farxiga 10 mg (used to treat Diabetes), Protonix 40 mg (used to treat gastroenteritis), and Depakote 125 mg (used to treat mood disorder) The physician was notified and staff continued to monitor Resident #2 for any adverse reaction for the medications that were administered. On 03/30/2026, the Licensed Nursing Home Administrator (LNHA) provided Individual Statement Form (ISF) dated 03/12/2026 which revealed LPN #1 failed to verify Resident #2's name before administering medications. The preceptor LPN #3 In the ISF dated 3/13/2026, included that LPN#1 (trainee) is not safe to pass medications by herself and needs further training on the floor. On 03/30/2026, during interviews with LPN #2 and UM/LPN revealed Resident # 1 on 3/18/2026 and Resident #4 on on 3/12/2026 both received their received their prescribed medications. A review of sample Resident #2 medical record revealed the following: The surveyor reviewed the medical record for Resident #2. According to the admission Record face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: edema, traumatic brain injury, depression, and hypertension According to the quarterly MDS dated [DATE], Resident #2 had a BIMs score of 15 out of 15, which indicated the resident was cognitively intact. A review of Resident #2's OSR active orders dated 03/01/2026 revealed the following medication orders.Flomax 0.4mg 1 cap daily for urinary frequency.Colace 100mg daily for constipation.Centrum Complete 18mg-4400mcg 1 tab daily for supplement.Lexapro 30mg 1-tab daily for depression.Zieta 10mg 1 tab daily for lipids.Lasix 40mg 1 tab daily for edemamedroxyprogesterone 10mg 1 tab daily for hypersexuality.Senna 8.6mg 2 tabs daily for constipation.Colace 100mg 2tab daily for constipation.Potassium ER 20meq 1 tab daily for supplement. According to the admission Record face sheet, Resident #4 was admitted to the facility with diagnoses which included but were not limited to: Diabetes mellitus, muscle weakness, insomnia, and chronic kidney disease. According to the annual MDS dated [DATE], Resident #4 had a BIMs score of 9 out of 15, which indicated the resident's cognition was moderately impaired.A review of Resident #3's OSR active orders dated 03/01/2026 revealed the following medication orders.Metformin 1000mg 1 tab daily for diabetes.Farxiga 10mg 1 tab daily for diabetes.Melatonin 3mg 1 tab at daily for insomnia.Vitamin B12 1 tab daily for supplement.Gabapentin 100mg 2 tabs daily for neuropathy.Protonix 20mg 1 tab daily for reflux.Vitamin D3 25mcg 1 tab daily for supplement.Depakote 125mg 1 tab twice daily for mood.During an interview on 03/30/2026 at 1:12 PM with the Director of Nursing (DON) in the presence of the LNHA, the DON stated new nurses are paired with a preceptor during orientation phase. The DON stated LPN #1 was hired on 02/12/2026. The DON presented the surveyor with LPN #1's Licensed Nurse orientation Checklist that was blank. The facility's failure to ensure that residents were free from significant medication errors placed Resident #2 and Resident #3 and all other residents at risk for serious harm, injury/or death and resulted in an Immediate Jeopardy (IJ) situation. The facility was notified the F 760 IJ and was provided with the IJ template on 03/30/2026 at 5:35 PM.The IJ began on 03/18/2026. The facility submitted an acceptable Removal Plan (RP) on 04/01/2026 at 11:39 AM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice to include: on 03/18/2026 the orientee was immediately removed from providing care to any residents and terminated on 03/31/2026. The Consultant Pharmacist was immediately notified of the incident. On 03/19/2026, the DON/Unit Coordinators/Nursing Supervisors immediately initiated the following: An in-service on 5 Rights and Medication Administration. An audit of all resident photos to ensure proper identification of residents. An audit of all resident wristbands to ensure proper identification of residents. On 03/31/2026 the DON/Designee imitated the following: A mandatory in-service for all licensed Nurses on the following topics: (1) the five rights of medication administration with emphasis on resident identification verification; (2) facility policy for medication administration, including requirements for medication administration record (MAR) photo verification and two -identifier confirmation; (3) preceptor responsibilities and requirement for direct observation during orientee medication passes and never to leave an orientee alone; (4) reporting obligations when a medication error occur; and (5) nurses were re-educated on how to be a preceptor. All nurses who were off duty will be re-educated when they return prior to the start of their shift. As of 04/02/2026, all licensed nurses were observed during medication administration for competency by the DON.The surveyor verified the implementation of the RP during an onsite continuation survey on 4/2/2026 at 12:25 PM. The immediacy was removed as of 04/02/2026 at 12:25PM NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of the facility policy, the facility failed to implement residents' care plans related to a mechanical lift transfer (hoyer) for one of 24 sampled residents (Resident (R) 112). This failure placed the resident at risk of harm due to inappropriate transfers.Findings include:Review of the facility's policy titled, Resident Care Plan, dated 10/2024 revealed, .Specific, individualized steps or approaches that staff will take to assist the resident to achieve goals will be listed. Interventions should be short and concise, easy for all staff to follow and serve as a care guide.Review of R112's Face Sheet located on the Home Page of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included a history of multiple sclerosis (MS-a neurological disorder) and vascular dementia with behavioral disturbances.Review of R112's annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/08/24 revealed R112 had a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R112 was severely cognitively impaired. The MDS also indicated the resident had no upper or lower body range of motion impairment and was totally dependent on one to two staff members for all activities of daily living (ADLs) including transfers.Review of R112's Comprehensive Care Plan, dated 11/02/23 and located in the Care Plan tab of the EMR revealed, .I am at risk for developing skin impairment due to weakness, impaired mobility, and balance, bladder incontinence, pain, multiple sclerosis, and dementia. Interventions included but not limited to: I am a two person assist via Hoyer [mechanical full body] lift, staff will ensure I am being transferred from and to bed via Hoyer with two persons.Review of R112's Facility Investigation, dated 12/23/24 and provided by the facility revealed, [Certified Nurse Aide (CNA) 1's Name] did not use a Hoyer transfer to transfer resident to bed on the 3-11PM shift. This was discovered after interviewing [CNA1's Name] a second time and watching the surveillance footage. This transfer occurred on Saturday 12/21/24 on [the] 3-11PM [shift]. That same day, our investigation revealed that the hospice aide [HCNA] transferred this resident using a Hoyer lift without the assistance of another staff member. Both CNAs are stating that the transfers were without incident. The 11PM to 7AM staff from 12/21/24 to 12/22/24 did not notice any issues during changes that evening. CNA1 was terminated and HCNA was asked not to return to the facility.CNA was asked to review the video footage and her recent statements. CNA1 had reported earlier that she and CNA3 had used the Hoyer lift to transfer the resident to bed between 7-7:30PM. CNA1 reported that no incident occurred. CNA1 then changes her statement too. 'She did not have a Hoyer pad under her this morning. We did Hoyer her [CNA3's Name] and I.' When I asked how they did that [CNA1's Name] changed her statement again. [CNA1] stated, 'She has the Hoyer pad that is removable, and we removed it to use for someone else.' [CNA1] did not answer how they transferred the resident at this time.The video footage timeline was reviewed with [CNA1]. On 12/21/24 at 8:43PM, [CNA1] looks into room [number withheld] and continues down the hall. At 9:05 PM, the Medication Cart and Nurse are at the end of the hall. At 9:08 PM, the Nurse went into the room and left. At 9:52PM, [CNA1] is seen going into the room, placing the dirty linen and garbage bags outside the room. At 9:57 PM [CNA1] is placing linen and garbage into bag. Her phone is in her hand face up. It looks like she is looking at the phone. [CNA1] goes back into the room. At 10:08 PM, [CNA1] placed a blue diaper in the garbage bag. Picks up the dirty linen and garbage and leaves the area.This timeline was reviewed with [CNA1]. Explained to her that I noted her pushing the Hoyer down the hall past [R112's room]. At no time did I see the Hoyer or [CNA3] enter R112's room. I asked [CNA1] again what happened on Saturday, how did you transfer R112 to bed. [CNA1] stated, 'I did not use the Hoyer; I transferred her on my own. Nothing happened.The Facility investigation included that the HCNA was interviewed and verified that she was having difficulty when getting R112 dressed on Saturday 12/21/24. The HCNA was asked how she transferred R112. The HCNA stated, I used the Hoyer lift both days without a second person. I could not find anyone. The HCNA denied having difficulty or incidents related to the transfer.Conclusion: .At this time, on 3 different occasions from 12/21/24 to 12/22/24 the resident's care plan was not followed. Policy and procedures were not followed.During an interview on 07/24/25 at 9:18 AM, the Previous Administrator confirmed that CNA1 was terminated for not following policy and the HCNA was asked not to return to the facility.During an interview on 07/24/25 at 12:27 PM, the HCNA confirmed that she did not use two persons when transferring R112 per the care plan. NJAC 8:39-11.2(e) thru(i)NJAC 8:39-27.1(a)

Based on interview, record review, and review of the facility policy, the facility failed to ensure the medical record was complete and accurate for one resident (Resident (R) 5) out of 24 sampled residents. This failure placed the residents at risk for unmet care needs.Findings include:Review of the facility's policy titled, Charting and Documentation, dated 01/10/25 revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.Review of R5's Face Sheet located on the Home Page of the electronic medical record (EMR) revealed that R5 was admitted to the facility on [DATE] with diagnoses that included right hip fracture with hip replacement.Review of R5's admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/12/25 revealed R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 was cognitively intact.Review of R5's Care Plan, dated 06/06/25 and revised on 07/09/25 revealed, I have the potential for infection and retention due to the use of an indwelling catheter in my bladder, due to urinary retention. Interventions included:a. a. Staff will provide foley catheter care every shift.b. b. Staff will assess me for bladder distention dribbling or feelings of bladder fullness.c. c. Staff will confer with MD regarding the continued need for a catheter.d. d. Staff will maintain a closed, sterile system ensuring that the tubing is free of kinks.e. e. Staff will monitor my urine appearance noting color, amount, and clarity every shift.Review of R5's Physician Order, dated 07/07/25 and located in the resident's EMR under the Orders tab indicated that the Indwelling Urinary Catheter was removed on 07/07/25.Review of R5's Urinalysis Laboratory Report, dated 07/14/25 and located in the hard chart revealed that R5 had an abnormal urinalysis report which indicated per the culture on 07/15/25 that R5 had bacteria in her urine and would require antibiotics.Review of R5's Physician Order, dated 07/17/25 and located in the hard chart revealed, Cipro [an antibiotic] 500 mgs [milligrams] to give twice daily for seven days for a Urinary Tract Infection (UTI).Review of R5's Assessments tab in the EMR showed no documentation as to what symptoms R5 was having or the reason for the Urinalysis test.Review of R5'sSkilled Nursing Documentation, dated 07/18/25 and located in the EMR under the Assessments tab revealed antibiotic was checked however, there was no narrative at the bottom of the page to indicate why R5 was on an antibiotic.During an interview on 07/23/25 at 3:04 PM, the Director of Nursing (DON) stated, I did not find a note [from the nurses] regarding the signs/symptoms of the UTI. It was noted on the 24-hour report that the specimen was obtained. I spoke to [Registered Nurse (RN) 2's Name] who stated that the resident had complained to the doctor about her cloudy urine on the 17th [07/17/25]. The DON was asked if there should be a progress note or change of condition note in the EMR. The DON stated, Yes, there should have been a progress note in the EMR. NJAC 8:39-35.2

Based on observations, interviews, record review and review of facility policy, the facility failed to provide care and services for two residents (Residents (R) 112 and R44) out of 24 sampled residents. The facility failed to ensure R112 had adequate monitoring and timely medical care after the facility identified discoloration and swelling to R112's right leg which was later identified as a closed right tibial fracture. In addition, the facility failed to ensure R44 received medications as ordered by the provider. These failures placed residents at risk for unmet care needs and a diminished quality of life.Findings include:Review of the facility's policy titled, Change of a Resident's Condition, dated 08/01/01 revealed, .To ensure that when a resident has a change of condition, appropriate assessments are performed, documented and that timely notification of the resident's physician and family occurs.All accidents involving the resident which results in injury and has the potential for requiring physician intervention.A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications).A decision to transfer or discharge the resident from the facility. When a change of condition occurs, the licensed nurse will perform an assessment based on the signs and symptoms the resident is experiencing. 1. Review of R112's Face Sheet located on the Home Page of the electronic medical record (EMR) revealed R112 was admitted to the facility on [DATE] with diagnoses that included a history of multiple sclerosis (MS-a neurological disorder) and vascular dementia with behavioral disturbances. Review of R112's annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/08/24 revealed R112 had a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R112 was severely cognitively impaired. The MDS also indicated the resident had no upper or lower body range of motion impairment and was totally dependent on one to two staff members for all activities of daily living (ADLs) including transfers. In addition, R112 was on scheduled pain medications and had indicators of pain which included vocal and facial expressions of pain for one to two days out of the previous five days during the observation period.Review of R112's Change in Condition note dated 12/21/24 at 2:34 PM, completed by Licensed Practical Nurse (LPN) 2 and located in the Assessments tab of the EMR revealed, I was asked by the aide to come and look at bruising on resident's right lower front leg. I observed bruising and swelling in the area. I asked the resident if she had fallen, she replied no. I also noticed the leg had begin [sic] to ooze at the bruising area. I went to evergreen [another unit in the facility] to inform the supervisor to come assess the resident. She was not there; [sic] I then went to Aspen [another unit in the facility] and couldn't find her. I went to [NAME] [another unit in the facility] and spoke with the Nurse there. We called the supervisor on the phone, and she didn't answer. I asked the nurse if she see [sic] her can she please tell her I am looking for her. I was told by the Nurse on 12/23/24 that the supervisor did come to [NAME] and she [was] informed that I was looking for her and that my resident had swelling and bruising and weeping from her Right leg, however, the supervisor never came to Sandlewood [sic] to see me and I then endorsed to the 3-11PM Nurse of my finding.I applied ice to the area for the swelling.Review of R112's EMR and hard chart revealed no documented evidence LPN2 had notified the physician, had done a skin assessment after the identification of the bruising and swelling, or documented if R112 was having pain and what intervention she performed to control her pain.Review of the Facility Investigation [for R112] provided by the Director of Nursing (DON) revealed, Type: Skin Issue.Reported by: [Licensed Practical Nurse (LPN) 1's Name] on 12/22/24 at 3:15 PM.Location: Unknown; Assigned Caregiver: [Certified Nurse Aide (CNA) 1's Name]; Physician notified on 12/22/24 at 3:17 PM.Family notification on 12/22/24 at 3:20 PM.Ambulance called on 12/22/24 at 5:00 PM.Sent to hospital on [DATE] at 9:00 PM.Review of R112's Nurse's Note, dated 12/23/24, completed by LPN1 and located in the Facility Investigation revealed [On 12/22/24] Around 3:15 PM, Day shift nurse reported discoloration on resident's rt [right] lower leg. Upon assessment, noted bluish discoloration on Lt [left] chest wall (4.5 cm [centimeters] x 1.7 cm) and bluish discoloration on rt lower leg (23 cm x 7.5 cm) and edema [swelling] on rt lower leg. Pain was noted when the right lower leg is palpated and with movement. The supervisor assessed the resident's affected area and notified resident's son and hospice nurse. Resident was transferred to [hospital] for RLE [right lower extremity], pain, edema, and bruising.Resident unable to explain due to cognitive impairment.The Conclusion of the Facility Investigation revealed .Team met to discuss the bruise to her left chest wall. Spoke with the hospice aide and she reported that R112 was agitated on Saturday 12/21/24 when getting dressed she was pulling and grabbing at her T-shirt. Aide reports there was a red mark to chest after the incident.At this time R112 is in the hospital for the right lower leg discoloration. Investigation is on-going.R112 returned on 12/24/24 on the 3-11(PM) shift.Investigation was unable to conclude the etiology of the fracture. Resident is non-surgical candidate. Returned with knee brace will follow up with orthopedics. Continues to be a Hoyer lift transfer and Tylenol for pain.Review of the 12/22/24 at 11:02 PM Hospital Records provided by the DON revealed, Chief complaint R leg swelling. On arrival here, the knee and RLE [right lower extremity] are discolored and R knee swollen. ED [Emergency Department] spoke with the facility and they denied any trauma. She is essentially bedbound/wheelchair bound; except for transfers. Patient is comfortable. Imaging here suggests proximal [closer to the center of the body] tibial [shin] fracture.During an interview of 07/24/25 at 8:30 AM, Unit Manager (UM) 1 was asked if she remembered the incident from 12/21/24 and 12/22/24 regarding R112's right leg fracture. UM1 stated, I really do not remember the event. I do remember that on 12/23/24 when she went out to the hospital, she was having pain or a bruise, I think. I remember she (LPN2) had not come looking for me. People came to me and stated that no one came looking for me. UM1 was asked if she made rounds on the Sandalwood unit on Saturday 12/21/24. UM1 stated, I did not make rounds on Sandalwood in the morning but, I did make rounds in the afternoon. I was not made aware that there were any problems.During an interview on 07/24/25 at 9:18 AM, the Previous Administrator was asked why there was a delay in treatment on 12/22/25 from 5:00 PM when the ambulance was called to 9:00 PM before R112 had left in the ambulance. The Previous Administrator stated, I can only guess it was a non-emergent transfer.During an interview on 07/24/25 at 12:27 PM, Hospice CNA (HCNA) was asked about the incident involving R112 on 12/21/24 and 12/22/24. The HCNA stated, I was the aide the morning of the 21st on the 7-3 shift. I usually start at about 6:00 am. Everything was fine. I returned on 12/22/24 at the same time and when I saw [R112's Name], she was all 'tucked in tightly.' I went to get my supplies and her clothes and when I uncovered her and took her gown off, I noticed that the knee was swollen, and the bottom of the foot was bruised. The HCNS further stated, I went to tell the nurse around 7:00AM-7:30 AM about the swelling and the bruise. The nurse left the medication cart, and she followed me to the room. I brought R112 to the dining table for breakfast and I told the nurse she was in pain, and she said she would give her something. I don't know if she did or not as I went on to care for my other residents there.Review of R112's December 2024 Medication Administration Record (MAR) revealed R112 had received, Tylenol 325 mg [milligrams]. Give (2) tablets one time daily before wound care. Dated 11/01/23. Documentation showed that she received this dose of Tylenol as scheduled but the time of the administration is unknown per the EMR. In addition, R112's MAR showed that she had as needed medications for pain which included Morphine and Tylenol, but the MAR indicated that these had not been administered to R112 during the entire month of December.During an interview on 07/24/25 at 2:20 PM, the DON was asked why LPN2 asked not to return to the facility. The DON stated, She was an agency, I think it was not finding the supervisor, but I can't prove it. The DON was asked about the investigation which showed that UM1 did not make rounds on Sandalwood. The DON stated, Yes, she was written up for that as she did not make rounds as she should have. The DON stated LPN2 should have notified R112's physician, completed a documented assessment of R112, and documented them both in the resident's medical record when she became aware of the resident's change in condition.The DON was asked why it took so long for the ambulance to arrive at it four hours since the ambulance was called. The DON stated, I can't answer this. The DON was asked if it was appropriate to wait four hours as there was no documentation in the EMR to indicate the condition of the resident while waiting for the ambulance transfer on 12/22/25. The DON stated, I see what you are saying. The DON was asked if HCNA was interviewed during the investigation. She stated, I think the PA did. There was no documentation to show that the HCNA was interviewed for the investigation.There was no documentation to show after the HCNA informed LPN2 that R112 had bruising to her right leg and swelling or the condition of the resident at the time she was informed. The information was placed on a 24-hour report (in-house report) indicating at 3:15 PM the information was shared (endorsed) to the next shift. There was no documentation in the EMR to show if R112 had pain or the physician was contacted until 3:17 PM. According to the investigation, the ambulance left the facility with R112 at 9:20 PM and arrived at the hospital at 11:02 PM when she was seen by the physician. 2. Review of the facility's policy titled Medication and Treatment Orders, revised 02/06/18, provided by the facility revealed Orders for medications and treatments will be consistent with principles of safe and effective order writing. 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available.Review of R44's quarterly Minimum Data Set (MDS,) with an Assessment Reference Date (ARD) date of 04/25/25, located in the MDS tab of the Electronic Medical Record (EMR) revealed an admission date of 01/14/24. The MDS also revealed the facility assessed R44 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R44 was cognitively intact. The MDS further revealed R44 had diagnosis of hypertension, renal insufficiency, unspecified atrial fibrillation, overactive bladder, and primary hyperparathyroidism.Review R44's Medication Administration Record (MAR), dated January 2025 and located in the resident's EMR under the MAR tab revealed an ordered dated 12/27/24 of ergocalciferol (vitamin D2) 1,250 mcg [microgram] (50,000 unit) capsule (1 capsule) capsule one time weekly starting 12/30/24 for a supplement; and an order dated 01/03/25 and 01/04/25 of potassium citrate-citric acid 1,100 mg [milligram]-334 mg/5ml [milliliter] oral solution (7.5ml), two times daily for supplement. Continued review of the MAR revealed the resident was not administered the ergocalciferol on 01/20/25 and was not administered the potassium citrate-citric acid on 01/24/25. The MAR indicated the medications were .not administered (pharmacy called-med being delivered).Review of R44's Pharmacy Order Details provided by the facility revealed the ergocalciferol was ordered from the pharmacy on 01/20/25, the same day the resident missed the dose of medication due to the facility not having in on hand. The Pharmacy Order Details also revealed the resident's potassium citrate-citric acid was ordered from the pharmacy on 01/21/25; however, the medication was not available at the facility on 01/24/25 and the resident missed the dose of the medication.Review of R44's MAR, dated February 2025 and located in the EMR under the MAR tab revealed an order dated 01/15/24 of pyridoxine (vitamin B6) 100 mg tablet.oral one time daily.for a supplement and an order dated 01/16/24 of Myrbetriq 25 mg tablet, extended release (1 tablet) .extended release 24 HR [hour] oral one time daily for overactive bladder. The MAR revealed the pyridoxine was not administered to the resident on 02/23/25; and the Myrbetriq was not administered to the resident on 02/08/25 nor on 02/09/25. The MAR indicated the medications were .not administered (pharmacy called-med being delivered).Review of R44's Pharmacy Order Details provided by the facility revealed the pyridoxine was ordered from the pharmacy on 02/23/25, the same day the resident missed the dose of medication due to the facility not having in on hand. The Pharmacy Order Details also revealed the resident's Myrbetriq was ordered from the pharmacy on 02/09/25 two days after the facility ran out of the mediation.Review of R44's MAR, dated March 2025 and located in the EMR under the MAR tab revealed the resident was ordered diltiazem ER 120 mg capsule, 24 hr, extended release (1 capsule).oral one time daily. for A-Fib. The MAR indicated the medication was not administered to the resident on 03/09/25 nor on 03/24/25. The MAR also indicated the mediation was .not administered (pharmacy called-med being delivered). Review of R44's Pharmacy Order Details provided by the facility revealed the diltiazem was ordered from the pharmacy on 03/09/25 and 03/24/25, the same days the resident missed the doses of medication due to the facility not having in on hand.Review of R44's MAR, dated May 2025 and located in the EMR under the MAR tab revealed the resident was ordered Cinacalcet (used to regulate mineral imbalances) 60 mg tablet (1 tab) .oral one time daily. for hyperparathyroidism and ergocalciferol (vitamin D2) 1,250 mcg (50,000 unit) capsule (1 capsule) .one time weekly starting.for a supplement. The MAR revealed the Cinacalcet was not administered to the resident on 05/26/25; and the ergocalciferol was not administered to the resident on 05/26/25. The MAR indicated the medications were .not administered (pharmacy called-med being delivered). Review of R44's Pharmacy Order Details provided by the facility revealed the Cinacalcet was ordered from the pharmacy on 05/26/25, the same day the resident missed the dose of medication due to the facility not having in on hand. The Pharmacy Order Details also revealed the resident's ergocalciferol was ordered from the pharmacy on 05/26/25 the same day the resident missed the dose of medication due to the facility not having in on hand.Review of R44's MAR, dated June 2025 and located in the EMR under the MAR tab revealed the resident was ordered diltiazem ER 120 mg capsule, 24 hr, extended release (1 capsule) . oral one time daily.for A-Fib [atrial fibrillation] and Myrbetriq 25 mg tablet, extended release (1 tablet) .oral one time daily.for overactive bladder. The MAR revealed the diltiazem was not administered to the resident on 06/03/25; and the Myrbetriq was not administered to the resident on 06/03/25. The MAR indicated the medications were .not administered (pharmacy called-med being delivered). Review of R44's Pharmacy Order Details provided by the facility revealed the diltiazem was ordered from the pharmacy on 06/03/25, the same day the resident missed the dose of medication due to the facility not having in on hand. The Pharmacy Order Details also revealed the resident's Myrbetriq was ordered from the pharmacy on 06/01/25 the same day the facility did not have the medication on hand for the medication to be administered. The medication was delivered on 06/03/25; however, the medication was not administered to the resident on 06/01/25 nor on 06/03/25.During an observation on 07/21/24 at 12:09 PM, R44 was in her room sitting in her wheelchair, dressed and groomed. R44 was asked if she received her medications timely. R44 responded, some days, not always as her blood pressure and other medications were not given because they run out due to poor planning. R44 stated she was especially concerned about her blood pressure medication and the effect it could have on her blood pressure. R44 stated so far, her blood pressure had been okay. During an interview on 07/23/25 at 4:33 PM, Unit Manager (UM) 1 was asked why R44's January 2025 through June 2025 MARs revealed medications were not administered (pharmacy called- med being delivered) but the nurse initialed the med for that day. UM1 stated the pharmacy was late getting the medication delivered to them, stating for example if they call that day, the pharmacy may not get it until after the dose was due. UM1 stated the nurse should be ordering the medication three to five days ahead of time before running out. UM1 stated they do have a medication machine the nurse could have gotten a backup medication, but it should have been documented on the MAR. During an interview on 07/24/25 at 10:40 AM, the Director of Nursing (DON) was asked how far in advance should staff reorder medications. The DON stated she instructed the staff to reorder them a week in advance. The DON was asked if she was aware some of R44's medications were not administered due to not being reordered timely. The DON stated she was only aware of R44's blood pressure medication because the facility paid for it. However, the DON was not aware of other medications. The DON was asked if she completed audits and she stated she reviewed the pharmacy reports. During a follow up interview on 07/24/25 at 11:08 AM, UM1 was asked about the notes at the end of R44's January through June 2025 MARs that listed medications that were not administered. UM1 reviewed the MARs and stated some of the medications were stock medications and the nurse could have retrieved them from the stock. UM1 was asked if that was the case, why was the medication not administered. UM1 then checked the nurses' names on the MARs and stated the nursing staff that failed to reorder timely or use the stock medications, were agency nurses and they must not have been educated on the process. UM1 asked if the agency nurse was on duty and she stated, No. During an interview on 07/24/25 at 5:24 PM, the Clinical Implementation Analyst (CIA) was asked to run a report for R44's medications listed on the last page of the January 2025 MAR to confirm if they were or were not administered as the nurse had initialed the MAR but also documented a note that stated the medication was not administered. The CIA reviewed the 01/20/25 date for ergocalciferol (vitamin D2) and the 01/04/25 and 01/24/25 dates for potassium citrate-citric acid. These dates were highlighted in red. The CIA stated the red meant the medications were not administered and the nurse's initials did not confirm the medication was given. CIA stated if the other MARs had the same note not administered the date would be red as well for the medications not administered. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure activities of daily living (ADLs) were provided for two of three residents (Residents (R) 2 and R76) reviewed for ADLs out of 24 sampled residents. The facility failed to ensure showers were received per the shower schedule. This failure placed the residents at risk for a diminished quality of life.Findings include: Review of the facility policy titled, Showering the Resident, revised 01/21/25 revealed, A shower will be given to residents as requested or as per the care plan. 1. Review of R2's Face Sheet located on the Home Page of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE]. Review of R2's admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) 06/09/25 revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 was cognitively intact. The MDS also revealed R2 required substantial/maximum assistance with showering. Review of R2's Care Plan, dated 06/03/25 and located in the Care Plan tab of the EMR revealed, I require assistance with care due to right leg weakness, generalized weakness and impaired mobility. Interventions included:a. I will be evaluated and treated by therapy as indicated.b. Staff will assist me with care daily and as needed.c. Staff will encourage me to participate in my care as I can tolerate.The Care Plan contained no further documentation related to bathing/showering or resident preferences. During an interview on 07/22/25 at 9:01 AM, R2 was lying in bed, awake. His beard was unkempt. R2 was asked if he was receiving his showers weekly. R2 stated, I am only getting one shower a week, I think I am to get two. Review of R2's shower sheet documentation dated from 07/01/25 to 07/22/25 and provided by the facility revealed the resident only received three showers. The documentation revealed the resident did not refuse any showers; however, sink was documented 26 times. Review of R2's CNA Care Plan, dated 06/26/25 and provided by the facility revealed R2 was to receive a shower (his preference) on Monday and Thursdays on the 3:00 PM to 11:00 PM shift and required one staff assist with bathing. 2. Review of R76's Face Sheet located on the Home Page of the EMR revealed R76 was admitted to the facility on [DATE] and readmitted [DATE]. Review of R76's admission MDS located in the MDS tab of the EMR with an ARD of 06/27/25 revealed R76 had a BIMS score of 15 out of 15 which indicated R76 was cognitively intact. The MDS also indicated the resident required substantial/maximum assistance with showering. Review of R76's Care Plan, dated 06/23/25 and located in the Care Plan tab of the EMR revealed, I need assistance with care and functional abilities due to weakness and impaired mobility. Interventions included:a. My personal belongings will be within reach at all times.b. Staff will assist me with care daily and as needed.c. Staff will encourage me to participate in my care as I can tolerate.The Care Plan contained no further documentation related showering/bathing or resident preferences. During an interview on 07/21/25 at 10:47 AM, R76 was sitting up in his wheelchair fully dressed. R76 was asked if he was receiving his showers per the facility schedule or his preferences. R76 stated, I have not received but one shower in the last 11 days. Review of R76's CNA Care Plan, dated 07/12/25 and provided by the DON revealed R76 had a preference for showers, they were to be given on Mondays and Thursdays on the 3:00PM to 11:00PM shift and he required one staff member to assist him. Review of R76's Shower Sheet from 07/01/25 to 07/22/25 and provided by the facility revealed that R76 had refused shower assistance two times (the day he went to the hospital 07/01/25 and the day he returned from the hospital 07/11/25) and was administered one shower on 7/15/25 per the documentation. During an interview on 07/23/25 at 11:39 AM, Certified Nurse Aide (CNA) 5 stated, R76 has been here for about 6 weeks. The first two to three weeks he was in a lot of pain, so we did a bed bath. CNA5 was asked what did the word sink mean on the shower sheets. CNA5 stated, I have never heard that terminology before. CNA5 stated that when he worked, he would give R76 a shower. CNA5 was asked when a resident refused a shower, what was the protocol. CNA5 stated, We are to let the nurse know and then reapproach. If they still refuse, I document the shower was refused. During an interview on 07/22/25 at 4:58 PM, The DON stated, There does not seem to be follow-up, by nursing, to ensure showers are being done or documented to show why a shower was not done. The DON was asked what it meant if sink was documented on the shower sheets. The DON stated, A sink is just a clean-up, and is not considered to be a shower.NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) consistently identify, comprehensively assess, implement, and modify interventions for an unplanned significant weight loss of 33.4 pounds (lbs) which was 17.7% in 6 months from 04/06/23 through 10/18/2023, then an additional 8.6 lbs which was (5.25%) in 15 days from 10/18/23 through 11/01/23, b.) implement weekly weights for 4 weeks after a significant weight loss occurred; c.) monitor for effectiveness, and ensure coordination of care among the interdisciplinary team for Resident #23 and d.) obtain a re-weight to verify a significant weight loss, consistently record and monitor meal consumption, and ensure a recommended nutritional supplement was prescribed and provided to the resident prior to surveyor inquiry for Resident #23 and Resident #63. This deficient practice was identified for 2 of 4 residents reviewed for nutrition which resulted in a significant and avoidable weight loss for Resident #23 and Resident #63 and was evidenced by the following: Reference: The Academy of Nutrition and Dietitians, Position of the Academy of Nutrition and Dietitians: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings, dated April 2018. Position Statement It is the position of the Academy of Nutrition and Dietitians that the quality of life and nutritional status of older adults in long-term care, post-acute care, and other settings can be enhanced by individualized nutrition approaches. The Academy advocates that as part of the interprofessional team, registered Dietitian nutritionist assess, evaluate, and recommend appropriate nutrition interventions according to each individual's medical condition, desires, and rights to make health care choices. Nutrition and dietetic technicians, registered assist registered Dietitian nutritionists in the implementation of individualized nutrition care. On 11/13/23 at 10:29 AM, during the initial tour of the facility, the surveyor observed Resident #23 awake and alert, sitting in a wheelchair in the dining room with the activities department. On 11/13/23 at 12:55 PM, the surveyor observed Resident #23, awake and alert, sitting in the dining room eating lunch consisted of pork, rice, and peas. On 11/14/23 at 09:14 AM, the surveyor observed Resident #23 lying in bed with his/her eyes closed. On that same day at 9:21 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that the resident was very sleepy that morning and she had fed the resident in bed which consisted of eggs, toast, coffee, and orange juice. The CNA stated that when the resident was up in his/her chair, he/she could feed his/themselves with set up and supervision. On 11/14/23 at 12:43 PM, the surveyor observed Resident #23, awake and alert, sitting in a wheelchair in the dining area feeding him/herself lunch which consisted of chicken, scalloped potatoes, green beans, and soup. Review of Resident #23's Face Sheet (Admission Record) revealed the resident was admitted with diagnoses which included but were not limited to: dementia, fracture of the right femur, repeated falls, and anxiety disorder. Review of the Electronic Medical Record (EMR) revealed a physicians' order (PO) dated 07/18/23, for a regular diet with thin liquids A review of Resident #23's Vital Sign Report in the EMR revealed the following dates/weights: 04/06/23 weight 195 lbs. (pounds) 04/11/23 weight 195 lbs. 04/18/23 weight 188 lbs. 05/02/23 weight 224 lbs. 05/07/23 weight 187.60 lbs. 07/18/23 weight 179.60 lbs. 09/14/23 weight 165 lbs. 10/18/23 weight 163.80 lbs. 11/01/23 weight 155.20 lbs. There were no further documented follow up weights or re-weights in the EMR. A review of the Registered Dietitian's (RD) Admission Nutritional assessment dated [DATE] at 1:15 PM, reflected that the resident was 195 lbs. on admission. It included that the resident's diet was regular with thin liquids and intake was good and usually consumed greater than 75%. The summary included that Resident #23 was at risk for unintended weight loss related to history of dementia and interventions included to continue weekly weights times 4 then monthly if stable. A review of the RD Quarterly Nutritional Progress Note, dated 07/18/23 at 4:55 PM, revealed that per available weights, Resident #23 had experienced an 8 lb. (4.3)% weight loss x 60 days and 9 lb. (4.8%) weight loss x 90 days. Weight goal at this time was for stabilization. The resident's intake was typically adequate. Will provide additional sandwich with dinner and continue to monitor po intake and encourage as needed. Continue to encourage monthly weights as ordered. A review of the RD Quarterly Nutritional Progress Note, dated 10/18/23 at 5:10 PM, revealed that Resident #23's intake had been fair to adequate. Per weights, the resident had experienced a 1.2 lb.(0.7%) weight loss x 30 days, a significant 15.8 lb. (8.8%) weight loss x 90 days and a significant 31.2 lbs. (16%) weight loss x 180 days. The RD recommended super cereal at breakfast and a supplement with lunch and dinner. Continue with weights as ordered. A review of the RD Significant Weight Change Nutritional Progress Note, dated 11/14/23, reflected a weight history that had been variable. Weights indicated a significant 8.6 lb. (5.3%) weight loss x 30 days, a significant 24.4 lb. (13.6%) weight loss x 90 days, and a significant 33.4 lb. (17.7%) weight loss x 180 days. Recommended a supplement three times a day and weekly weights. Encourage weights as needed/accepted. Continue with liberalized diet. No recent labs noted. This assessment was completed after surveyor inquiry. A review of the April 2023 through November 2023 Physician Orders (PO), Medication Administration records (MARs) and Treatment Administration Records (TARs) did not reveal any documentation of dietary interventions as recommended by the RD in July 2023, October 2023 and November 2023. A review of the Physicians' notes dated April through October 2023, indicated that Resident #23 had no weight change and was generally healthy. A review of the EMR from April 2023 through November 2023, did not reveal any documentation that the physician, family, or the interdisciplinary team was aware of Resident #23's significant weight loss. A review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 04/13/23, reflected a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated the resident's cognition was severely impaired. It further reflected independent with eating with set up assistance, weight of 195 lbs. and no weight loss or gain of 5% or more in the last month or loss or gain of 10% or more in the last 6 months. A review of the Quarterly MDS, dated [DATE], reflected a BIMs score of 3 out of 15 which indicated the resident's cognition was severely impaired. It further reflected independent with eating with set up assistance, no weight measurement was documented, and no weight loss or gain of 5% or more in the last month or loss or gain of 10% or more in the last 6 months. According to the 07/18/23 weight in the EMR, Resident #23's weight was documented as 179.60 lbs. Review of the Quarterly MDS, dated [DATE], reflected a BIMS score of 3 out of 15 which indicated the resident's cognition was severely impaired. It further reflected that the resident needed set up or clean up assistance for the task of eating. The MDS revealed a weight of 164 lbs. and weight loss of 5% or more in the last month or a weight loss of 10% or more in the last 6 months and was not on a prescribed-physician weight-loss regimen. A review of the person-centered comprehensive Care Plan revealed a Nutrition care plan created on 04/10/23, revealed a goal to maintain a weight of approximately 190-200 lbs and interventions included to honor preferences, allow staff to weigh resident and to provide diet as ordered. On 10/18/23, the RD updated the care plan and changed the goal to maintain a weight of 165.4 lbs. in the next 90 days. The updated intervention included for staff to monitor intake and encourage resident as needed/accepted. The Care Plan was not updated to address Resident # 23's significant weight loss and did not include the RD's recommended interventions for the sandwich, supplements, fortified cereal, weekly weights etc. On 11/15/23, the surveyor reviewed the ADL Verification Worksheets, provided by the facility,which revealed that the CNA's failed to consistently document daily the percentage of meals and snack intake for Resident #23 from April 6, 2023 through November 15, 2023. On 11/14/23 at 1:00 PM, the surveyor reviewed the handwritten Dietician Recommendations book from January through November 2023, which revealed a handwritten recommendation dated 11/14/23, for Resident #23 to increase the supplement to three (3) times a day for significant weight loss and to start weekly weights. No other recommendations were written by the RD for Resident #23. On 11/14/23 at 1:02 PM, the surveyor interviewed the CNA who stated that upon admission all residents would be weighed weekly x 4 weeks then monthly thereafter. When inquired regarding the process, the CNA stated that all CNAs would obtain the resident's weights, write them on a piece of paper and give to the nurses who would entered the weights in the EMR. If a resident refused their weights, we would attempted again later, inform the nurse, and the nurse would document the refusal in EMR. On 11/14/23 at 1:08 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that a resident would be weighed the day of admission, weekly x 4 weeks, then monthly. The CNA's and the nurses would assist in obtaining the weights and the nurses would document the weights in the EMR. If the nurses noted any weight loss, the nurse should notify the physician and follow their recommendations. If the RD was consulted, then the RD would give the nurse their recommendations either verbally or written down in the Dietician Recommendation log and then the nurses would call the physician and obtain the order. The LPN further stated that any weight loss more than 2 lbs. weekly or monthly would be considered a significant weight loss. On 11/14/23 at 1:14 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM #1) who stated that upon admission all residents were weighed, then weighed weekly x 4 weeks then monthly thereafter. If a resident had a change in weight, loss or gain, the nurse would reweigh the resident and document the weight in the EMR. If it was a true weight loss or gain, the nurse would then notify the physician and consult the RD then follow their recommendations. The RD would see the residents on admission then quarterly thereafter. The RD would be consulted immediately for any significant weight loss or gain, and an assessment would be completed. A significant weight change would be weight loss or gain of 2 lbs daily or 4-5 lbs monthly. The nurses were supposed to document in the EMR progress notes that the physician was notified of a weight change. The RN/UM #1 stated that the first week of November 2023, she called the physician regarding Resident #23's weight of 155 lbs and consulted the RD. The RN/UM#1 confirmed that she did not document in the EMR that the physician or the RD was notified. On 11/15/23 at 11:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated that all residents are weighed on admission, then weekly x 4 weeks then monthly thereafter. The DON added, that the CNAs would obtain the resident's weights and the nurses would document the weights in the EMR. The nurses should document how the resident was weighed whether it was standing, wheelchair, a lift and what type of scale was used. The DON further stated that if a resident had a weight loss or gain weekly or monthly, I would expect the nurses to reweigh the resident to rule out that nothing was interfering with the discrepancy weight. If it was a true weight change then the nurse would notify the physician who would request a dietary consult. The nurses would then follow the physician and the RD recommendations. There should be a physician's order for any supplements and weekly weights. I would expect the nurses to notify the physician of any weight change of 3 lbs either weekly or monthly. Any significant weight change should be discussed in the morning meeting and reported to the team. If the RD recommended a sandwich, there would not be an order, dietary recommendations would come directly from the kitchen. On 11/15/23 at 11:25 AM, the surveyor interviewed the RD who stated that her role included to oversee all nutritional aspects of the residents on admission, quarterly and as needed. All new admissions would be weighed on the day of admission, then weekly x 4 weeks then monthly thereafter. The CNAs would obtain the weights then the nurses would enter the weights into the EMR. If the nurses saw any change in weight, whether a gain or loss, the nurses would reweigh the resident then notify the physician and the RD. If there was a significant weight change, I would complete an assessment, make recommendations and follow up more frequently such as monthly. The RD further stated I usually don't notify the doctor or family in my note, but any recommendations would be placed in the Dietician Recommendation book and the nurses would notify the physician. Any supplements or weekly weight recommendations would require a physician order,but for dietary recommendations such as fortified cereal or an extra sandwich would be sent to dietary and placed on the meal ticket. The surveyor then reviewed Resident #23's weight loss with the RD. The RD confirmed that in October 2023, quarterly assessment did trigger a significant weight loss and that she did not write the recommendations in the Dietician Recommendations book. Therefore, the supplements and super cereal were never carried over. I think I forgot to put them in the book. The RD further stated that the RN/UM #1 informed her that the resident had a decrease in weight for this month (November 2023) and I completed an assessment yesterday (on 11/14/23, after surveyor inquiry). On 11/15/23 at 11:59 AM, in the presence of the surveyor, the staff obtained and recorded Resident #23's weight at 160 lb. On 11/15/23 at 12:22 PM, the surveyor attempted to contact the attending physician, and was informed by the office that the physician was on vacation. On 11/15/23 at 01:40 PM, the surveyor conducted a telephone interview with the covering physician (MD). The MD stated that if he was aware of a resident's significant weight loss, he would want to identify the causal factor and implement interventions to address the weight loss. The MD further stated that he would expect the nurses to notify the MD if there was a significant weight loss of 5-19%. When asked if he was notified of Resident #23's significant weight loss of 31.2 lbs in the last 6 months. He stated, I do not recall. On 11/16/23 at 11:17 AM, the surveyor reviewed the documented weights in the EMR with the RN/UM #1. The RN UM #1 confirmed that when there was a discrepancy in Resident #23's weights, the nurses should have reweigh the resident and documented the reweighs in the EMR. The RN/UM#1 confirmed that there were no documented weights for the month of June 2023 and August 2023. The RN/UM #1 stated that on 05/07/23, she noticed that the 05/02/23 of 224 lbs was off so she obtained another weight on 05/07/23 of 187.6 lbs which was closer to the residents previous weight. The RN/UM #1 stated that she just put the weights in the EMR, but the RD would monitor the weights. The RN/UM#1 also confirmed that the physician, the family, and the DON were not notified of the significant weight change on 10/18/23. The RN UM #1 stated that she entered the 11/01/23 weight of 155.20 lbs in the EMR. She stated that she had notified the physician and consulted the RD, but did not document in the EMR. The RD did not complete her significant weight change assessment until 11/14/23 (after surveyor inquiry). The RN/UM #1 further stated that the CNAs do not document how the residents were weighed such as standing, wheelchair/or using a lift. The RN/UM #1 further stated if we reweigh the resident, we don't document the reweigh, we only document the correct weight. This was missed, we all missed this. On 11/16/23 at 11:53 AM, the surveyor interviewed the LPN who documented the 09/14/23 weight of 165 lbs. The LPN stated that she does not remember if she notified the RN/UM #1 of the weight change. On 11/16/23 at 1:30 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), DON and RD in the presence of the survey team. The surveyor reviewed the past six (6) months weights and the significant weight loss for Resident #23. The LNHA stated her expectation was that all residents would have maintained their weight. She would have expected if any weight changed, the nurses would notify the physician and the RD, reweigh the resident and document in the EMR. The DON and LNHA confirmed that they were not aware of Resident #23's significant weight loss until the surveyor's inquiry. The RD confirmed that the residents' weights were not monitored and there was not documentation of a weight loss trend. The RD stated that the significant weight loss should have been communicated to the DON, LNHA and the physician. If the resident was uncooperative with the procedure, that should have been documented. The DON and LNHA confirmed that supplement recommendations were not entered onto the MAR or TAR for October 2023 and November 2023 nutritional recommendations. There was no documented evidence in the EMR that Resident # 23 was eating the sandwich or consuming the supplement as recommended by the RD. The RD confirmed that she did not follow up with the resident's weights, the recommendations were not implemented and she did not notify the DON and LNHA of the significant weight loss in October 2023. The DON and LNHA stated that it was a system failure from the whole team. The LNHA and the RD stated, We missed it. 2. On 11/13/23 at 10:24 AM, during the initial tour of the Sandlewood Unit, the surveyor observed Resident #63 lying in bed with his/her eyes closed. The surveyor observed snacks at the bedside. Review of Resident #63's Face Sheet (Admission Record) revealed the resident was admitted with diagnoses which included but were not limited to; wedge compression fracture, chronic pain, major depressive disorder, and schizoaffective disorder. Review of the Electronic Medical Record (EMR) revealed the following physician orders (PO): regular diet with thin liquids dated 12/10/23, a nutritional supplement 2 times a day dated 05/31/23, and Magic Cup 2 times a day dated 09/13/23. Review of the May 2023 through November 2023 MARs and TARs did not reflect the above corresponding physician's orders. A review of Resident #63's Vital Sign Report in the EMR revealed the following dates/weights: 08/09/23 weight 97.60 lbs. (pounds) 09/01/23 weight 91.20 lbs. 09/26/23 weight 92.30 10/01/23 refused. 10/03/23 weight 105 lbs. 11/01/23 other weight 11/06/23 weight 92.20 lbs. There were no further documented follow up weights or re-weights in the EMR. Review of the Quarterly MDS, dated [DATE], revealed that Resident #63 had a BIMs score of 11 which indicated the resident had moderate impaired cognition and had a poor appetite. Section K indicated a height of 62 inches and a weight of 91 lbs and had a loss of 5% or more in the last month or loss of 10% or more in last 6 months. Review of the Nurse Practitioners (NP) note, dated 09/11/23, revealed that Resident #63 had moderate protein-calorie malnutrition, weight of 91.2 lbs. The note further included to restart Remeron for appetite stimulant. The NP documented that the family was notified. Review of the Quarterly Nutritional Progress Note, dated 09/12/23 at 5:30 PM, reflected that Resident #63 intake was variable. Resident #63's current diet was regular with thin liquids and a supplement twice a day. The assessment further revealed that the resident had a significant 7.2 lb (7.3%) weight loss x 30 days. No skin issues or recent labs noted. The resident was receiving a supplement and Remeron (medication used to stimulate appetite) which was reinitiated on 09/12/23. Review of Resident #63's Comprehensive Care Plan for nutrition identified the weight loss and had interventions updated which included the following: I will consume supplements as ordered and I will follow diet as ordered. On 11/16/23 at 10:04 AM, the surveyor interviewed the LPN who stated that Resident #63 preferred to stay in bed, needed assistance with meals. On 11/16/23 at 11:35 AM, the surveyor interviewed the LPN who stated monthly weights were completed the first week of each month and if there was a weight loss or gain, the nurse would reweigh the resident. The surveyor reviewed the documented weights in the EMR with the LPN who stated a reweigh should have been done on 10/03/23 for the discrepancy weight of 105 lbs. On 11/16/23 at 11:58 AM, the surveyor and the RN/UM #1 reviewed the weights documented in the EMR on 10/03/23 as 105 lbs and stated the resident should have been reweigh and documented the weight in the EMR. The RN/UM #1 stated that she documented the weight as an error and the reweigh of 92.8 lbs on 11/14/23. On 11/16/23 at 1:30 PM, the surveyor, in the presence of the survey team, interviewed the DON, LNHA and RD. The DON stated that Resident #63 was not reweigh when there was a discrepancy of the weight on 10/03/23. The RD confirmed there was no follow up from September 2023, when a significant weight loss was identified. The DON stated that the RN/UM #1 should have been overseeing all the weights. The DON and LNHA confirmed that the nutritional supplements ordered were not transcribed onto the MAR and TAR. There was no documented evidence that Resident # 63 received the nutritional recommendations from May 2023 through November 2023. A review of the facility provided, Specialist Dietitian I job description, dated 2019, included but was not limited to; responsible for nutrition screening, assessment, diagnosis, intervention , monitoring, evaluation, and plan of care : communicate effectively with the interdisciplinary team, residents, and families; meal rounds, and evaluate and coordinate nutrition formulary per regulatory guidelines. A review of the facility provided, Resident Weights and Weight Changes policy, revised 11/07/17,reflected that significant weight changes will be reviewed by the DON/designee and referred to the dietician and physician if indicated. A reweigh must be obtained within 48 hours if a weight change meets the following criteria: 1 month- 5% body weight change or 6 months-10 % body weight change. The DON/designee or dietician will assess the weight change and make a notation in the medical record as to the plan of action for the weight change-diet counseling, physician notification, dietician notification, etc. The Dietician recommendations will be recorded in the medical record or on the designated form. The resident care plan will be adjusted to reflect the dietary recommendations. A review of the facility provided, Clinical Nutrition Services policy, revised 01/22, revealed that when recommendations are made which require a physician's order, the Registered Dietician Nutritionist (RDN)will follow up within 7 days to verify a response to the recommendations. The RDN monitors and evaluates the patient's response to care which include any or all of the following: nutrition assessment, meal rounds and or care plan rounds/meeting. The results of monitoring and evaluation are documented in the patient's medical record by the RDN. NJAC 8:39-17.1 (c); 17.2(d)

Based on observation, interview and document review it was determined that the facility failed ensure: a) the kitchen environment and equipment was maintained in a clean and sanitary manner, b) the dish machine was functioning in a manner to ensure proper wash and rinse temperatures were maintained, c) refrigerated resident food storage areas (3 of 4 observed) were maintained in a clean manner and food was appropriately labeled and dated, and d) staff performed appropriate hand hygiene, to limit potential bacteria growth and potential food borne illness. The deficient practice was evidenced by the following: On 11/13/23 at 9:24 AM through 10:07 AM, the surveyor conducted a tour of the kitchen with several staff including the Regional Director of the Food Management Company, Executive Chef, Registered Dietitian (RD) and observed: 1. At 9:26 AM, the dish machine was observed in use and resident meal items, including insulated lids and trays were being washed. The surveyor observed the temperature screen to identify the wash temperatures and the wash temperature blinked 156 degrees Farenheight (F) and then intermittently blinked P2 error and continued to flash back and forth. The surveyor asked the RD what the error message meant, and she stated, she was not sure and then instructed the food service worker (FSW) that she wanted to look into it before they continued washing dishes. The surveyor observed that under the temperature gauge, there was a Manufacturer sticker that revealed the Hot Water Sanitizing Wash Temperature, 150 F and the Hot Water Sanitizing Rinse Temperature was 180 F The surveyor asked the FSW what the blinking error message meant and the FSW stated it was just an error. The surveyor asked the FSW if temperatures of the machine were taken, and he responded yes and then he showed the surveyor the temperature logbook which revealed: Dish machine Temperature Record (High Temperature Machine) November 2023. The Wash Temperature and Final Rinse Temperature area of the form (see date plate on machine) was blank. The form indicated Wash Temp (temperature), Final Rinse Temp and Checked by for Breakfast, Lunch and Dinner. The November 13, 2023, Breakfast indicated Wash temp 120 F, Final Rinse 155 F and initialed by the FSW. At that time, the surveyor also observed that the Lunch and Dinner Wash and Final Rinse Temperatures were also documented with the same temperatures and initialed by the FSW. The surveyor asked the FSW why all three meals had been pre-filled out and the FSW stated because when sometimes when he comes in to work the temperatures are not always documented. Further review of the Final Rinse Temperatures revealed that there were no documented Final Rinse Temperatures from November 1-13, 2023, that met the posted Manufacturer's final rinse temperature of 180 F. At 9:31 AM, the surveyor asked the RD about what the P2 error meant and why the temperatures being pre-filled out for the entire day and the RD stated, I cannot answer that now. 2. At 9:33 AM, the surveyor continued the tour with another Food Service Management Company Representative (FSMC). The surveyor observed the floor area by the ice machine. The floor area on the side of the ice machine and toward the baseboard and under a metal table was very soiled with various colored debris. There was a large green salad [NAME] stored on a lower metal shelf which also was observed by the surveyor and the FSMC to be covered with debris on the lid. The surveyor asked the FSMC if the floor area, including the salad [NAME] was clean and the FSMC stated, no, not cleaned. 3. At 9:38 AM, the surveyor observed white rolling bins stored under a metal table in the kitchen. The area under the table, on the wall adjacent to the table and the baseboard had visible stains and debris. Both bins had debris on the exterior of the bins, and on the top of the lids. One bin contained an opened bag of sugar that which did not contain a use by date. The adjacent white bin was identified as containing flower was also stored in an open bag with debris in the bin next to the bag. The surveyor asked the FSMC about the items in the bins and if the area and bins were clean. The FSMC stated this was not really done properly. 4. The large metal meat slicer was wrapped in plastic and identified as clean by the FSMC. The bag was removed, and debris was observed on the base of the slicer. 5. The surveyor observed the dry storage room and there was various debris on the floor and under the food storage racks. At that time, the EC acknowledged the floor was not clean. 6. The surveyor reviewed a P.M. Cook's Cleaning Checklist provided by the FSMC for November 23, Sunday 11/12 which revealed Mop and Sweep was checked off. The FSMC and RD acknowledged that the floor was not clean. The Checklist also revealed Make sure slicer and mixer is cleaned and covered. 7. Per the surveyor request, the FSMC held up pans that were stored on the clean pan rack. The FSMC, in the presence of the EC, held up 1/3rd deep pans, and 3/5 pans were visibly wet and nested, and 4/5 of the 1/6th pans were visibly wet nested. The FSMC stated the pans are supposed to be air dried. The surveyor observed four coffee pots stored upright and asked the EC to show the surveyor 4/4 coffee pots were stored upright and wet inside and they were removed by the EC. At 9:56 AM the surveyor requested the cleaning policy and equipment policy, and dish machine policy. 8. On 11/13/23 at 10:12 AM, the surveyor toured the Aspen Pantry. The surveyor observed that the interior of the refrigerator was soiled with splatters and debris and observed a labeled sandwich snack. The surveyor asked the Registered Nurse Unit Manager (RNUM) to observe and confirmed the refrigerator was not clean. The RNUM then accompanied the surveyor to observe a pantry and small resident area with a refrigerator on the same unit. The refrigerator had dried on splatters on the shelves. Items including what the RNUM identified as a submarine sandwich with a name and was undated, and an undated food item in a brown paper bag. The surveyor asked how long food could stay, the RNUM stated I think 7 days and although the item had no date, he returned it to the refrigerator. The other item was also undated which he then also returned to the refrigerator and stated, it is supposed to be dated. There were also unlabeled/undated items in plastic bags and the RNUM stated, I will keep it, because they [residents] ask about it. The surveyor then opened the freezer in the presence of the RNUM and observed two pints of ice cream and a box of individual Italian Ices which were stored with multiple blue ice packs that filled the bottom of the freezer and a black and white cloth ice pack. The surveyor asked about what the ice packs were used for. The RNUM stated, the cold packs for the body and when asked if that was okay to store those items with food, the RNUM stated, I don't see any problem with that, that is where we store it. 9. On 11/13/23 at 10:27 AM, the surveyor conducted a tour of the Evergreen Pantry. There were two Food Service Staff (FSS) cleaning dishes in the pantry using an under mount dish machine. The pantry was visibly soiled with debris throughout the floor and on the equipment and the metal tables appeared soiled. The FSS were washing black insulated resident meal items including lids, cups, and containers. The surveyor observed that the dish machine had 117 F as the wash temperature that was on the display. The surveyor watched FSS #1 remove clean dishes with her bare hands and then begin to place dirty dishes on the rack. At that time, the surveyor asked what the temperature of the dish machine should be. The FSS#1 stated she doesn't know and normally doesn't do that. At that time, the surveyor then observed the FSS #1 rinse off her hands under running water in a non-hand washing sink, without using soap and then put a pair of gloves on her hands. The surveyor tried the soap dispenser on the hand washing sink on the opposite side of the FSS #1 and it was not dispensing soap. The FSS #1 then placed the dirty dishes in the dish machine. The surveyor asked the FSS#1 if there was anything that should be done prior to putting gloves on and she stated, wash, and the surveyor asked how that would be completed with no soap dispensing. The FSS#1 stated yes, no soap, I rinsed my hands. On 11/13/23 at 10:39 AM, the surveyor alerted the Licensed Nursing Home Administrator (LNHA) of the concerns regarding the observations. 10. On 11/13/23 at 10:40 AM, the surveyor toured the Sandalwood Pantry in the presence of the Unit Manager Nurse (UMN). The refrigerator that stored resident items including two snack sandwiches, was soiled with splatters and debris. There were two frozen food unlabeled and undated items in the freezer. The UMN confirmed the surveyor's observations and when asked if the refrigerator was clean, the UMN stated, no, I agree with you and then discarded the unlabeled/undated items. On 11/13/23 at 1:45 PM, the surveyor interviewed the LNHA about the condition of the pantries and who was responsible for maintain the cleanliness. The LNHA stated the kitchen was responsible. On 11/14/23 at 11:00 AM, the LNHA provided the surveyor with a Summary of Service form the dish machine service contractor dated 11/13/23 at 5:13 PM. The Description revealed the P2 error was the rinse display temperature probe and temperature was not displaying and the probe was replaced. On 11/15/23 at 9:04 AM, the surveyor interviewed the Food Service Director (FSD) regarding the error code and dish machine service. The FSD stated the temperature sensor was broken and needed to be replaced. The FSD stated the rinse temperature was okay when the technician checked it with an indicator strip. The FSD confirmed he did not have the indicator strips to confirm that the rinse temperature was adequate during the surveyor observations. A review of the Cleaning of Food and Nonfood Contact Surfaces Policy #F013, Date Issues 05/95 revealed: The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil, Nonfood contact surfaces of equipment, such as handles on reach in units, sides of sinks . shall be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris . Dish machine Temperatures Policy #F019, Date Issued 05/95 revealed: Dish machine wash and rinse water should be maintained at temperatures that meet the guidelines established by the Food and Drug Administration . Director Confirms the wash and rinse temperatures listed on the manufacture's data plate on the dish machine. Modify the dish machine temperature record as necessary. High temperature Dish machine- record on dish machine temperature record form. Wash and final rinse temperatures during each period of use. Once a day, run a test strip (160 F strip) through the dish machine to verify the surface temperature of a dish. Attach the used test strip to the Test Strip Results form. The test strip must verify that the surface temperature of the plate reached 160F . The Food Handling Guidelines (HACCP) Policy # B007, Date issues 05/95 revealed that Hands should be scrubbed following appropriate hand washing techniques according to the facility/community policy (e.g., after toilet use, between food preparation tasks, before putting on gloves, etc.). The Area and Equipment Cleaning Policy # F014, Date issues 05/95 revealed: Director: . assigns daily cleaning responsibilities in each position workflow, Management/Supervisory Personnel: Assigns weekly and special cleaning to be completed each day. The Personal Food Storage Policy, revised: 11/22/16 revealed: Food or beverage brought in from outside sources for storage in the facility pantries, or refrigeration units will be monitored by a designated facility staff for food safety. Food Safety for Your Loved Ones. Food or beverages should be labeled and dated to monitor for food safety. NJAC 8:39-17.2 (g)

Based on observation, interview and record review, it was determined that the facility failed to: a. ) adhere to accepted standards of infection control practices for the proper storage of respiratory tubing and mask after use for 3 of 3 residents reviewed for respiratory services (Resident #39, #75 and #149). b.) follow the facility infection control policy to limit the potential spread of infection by failing to perform hand hygiene prior to serving and assisting with resident meal tray preparation and during medication pass administration, and c.) ensure individuals providing services under a contractual arrangement were educated on infection control practices. This deficient practice was observed on 2 of the 4 units (Willow and Evergreen) and was evidenced by the following: 1. During the initial tour of the facility on 11/13/23 at 9:13 AM, the surveyor observed Resident #149 in bed. The surveyor observed a continuous positive air pressure machine (C-PAP ) on the bedside table. The C-PAP Mask including the tubing was noted on the floor underneath the bed. The resident was alert and informed the surveyor that he/she used the C-PAP machine at night while sleeping. The surveyor left the room to continue the tour. While in the hallway, the surveyor observed a staff exiting the room. At 10:45 AM, the surveyor returned to the room and observed the mask and the tubing in the same position on the floor. That same day at 10:15 AM, the surveyor observed a Certified Nursing Assistant (CNA) in the room assisted the resident with care. The CNA picked up the tubing and the mask from the floor and placed them on the bedside table. At 12:30 PM, the surveyor escorted the Registered Nurse Unit Manager (RN/UM) to the room where we all observed the C-PAP Mask lying directly on the bedside table. The mask appeared cloudy. Review of Resident #149's medical record revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; Obstructive Sleep Apnea, need for assistance with personal care, urinary tract infection and depression. The Admission Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care, reflected that Resident #149 scored 15/15 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. Review of the November Order Summary Report reflected Resident #149 had a Physician's Order dated 11/03/23, for C-PAP One Time Daily. Notes: Apply C-PAP at HS (Hour of Sleep), Setting: 10 cm of H2O (water). On 11/13/23 at 11:10 AM, the surveyor escorted the RN UM to the room and both observed the C-PAP mask was sitting directly on top of the C-PAP machine. The mask was stained and cloudy. 2. On 11/13/23 at 10:40 AM, the surveyor entered Resident #39's room and observed a Nebulizer machine was on the bedside table with a mask connected to the Nebulizer set and tubing. Upon inquiry, the resident revealed that he/she used the Nebulizer for respiratory treatment. The nurse would set the treatment and once the treatment was completed, the mask would be placed at the bedside on top of the Nebulizer. The mask was observed to be cloudy with white materials. Review of the admission record reflected that Resident #39 was admitted to the facility with diagnoses which included but were not limited to; Acute Respiratory Failure with hypoxia and other pneumonia and hypertension (HTN). Review of the Minimum Data Set (MDS) dated [DATE], an assessment summary reflected that Resident #39 scored 15/15 on the Brief Interview for Mental Status (BIMS) indicative of intact cognition. Review of the November Order Summary Report revealed that Resident #39 had a Physician's Order for the administration of Albuterol sulfate 2.5 milligrams/3 ml ( 0.083% ) solution for nebulization (1) Vial, Nebulizer (ml) Nebulization six times daily starting 09/27/23. On 11/13/23 at 10:57 AM, the surveyor escorted the RN/UM to the room where we both observed the Nebulizer mask sitting directly on the table. The UM stated that the nurses were to place the mask in a bag after the Nebulizer treatment had been administered. When inquired regarding the rationale for storing the mask in a bag, the UM stated that for infection control purposes, all respiratory masks should have been placed in a bag after being used. 3. On 11/13/23 at 10:27 AM, the surveyor entered Resident #75's room. The surveyor observed a C-PAP machine on the bedside table. The bedside table drawer was partly open exposing the C-PAP mask and tubing inside the drawer along with other objects. The mask was not protected, and the mask was cloudy. A record review of Resident #75 admission record, reflected that Resident #75 was admitted to the facility with diagnoses which included but were not limited to; Obstructive sleep apnea, mild cognitive impairment of uncertain or unknown etiology, Urinary tract infection. Review of the Minimum Data Set (MDS) dated [DATE], reflected that Resident #75 scored 15/15 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. Review of the November Order Summary Report revealed that Resident #75 had the following Physician's Order dated 10/24/23: C-PAP (Continuous Positive Air Pressure) machine one time daily. Notes: Apply C-PAP at (HS) hour of sleep, ( setting: C-PAP auto 5-11 CM (centimeter) H2O (water). Review of the Treatment Administration Record (TAR) revealed that staff had signed for the application of the C-PAP machine at bedtime. An interview with the Registered Nurse Unit Manager (RN/UM) on 11/13/23 at 10:30 AM, revealed that all respiratory masks were to be kept at the bedside secured in a bag. On 11/13/23 at 11:15 AM, the surveyor escorted the RN/UM to the room where we both observed the C-PAP mask inside the resident's drawer along with other residents toiletries, the mask was not protected. On 11/14/23 at 9:30 AM, the surveyor interviewed the RN UM regarding how he addressed the above issues. The RN UM stated he verbally informed the nurses to place the mask in a bag. He could not provide documentation of any in-services education that was done to address the concerns. On 11/15/23 at 10:34 AM, the surveyor interviewed again the RN UM regarding the C-PAP masks and the Nebulizer masks. The RN UM stated that he informed the nurses that after care the masks were to be placed in a bag. The RN UM added that the facility protocol was to place the mask in a bag after use. The RN UM further added that he was not aware if the nurses were educated regarding the storage of respiratory equipment prior to the surveyor's inquiry. The surveyor then inquired regarding Resident #149's mask that was noted on the floor. The RN UM stated that he used alcohol swab to wipe the mask and placed the mask in a bag. On 11/15/23 at 12:25 AM, the surveyor conducted an interview with the Infection Preventionist Registered Nurse (IP/RN) regarding the storage of the respiratory masks after treatment. The IP/RN stated that he had just started the role and was not involved in the process of educating the staff regarding respiratory equipment. He further added that the Respiratory Therapist oversaw the staff's education regarding storage and changing respiratory equipment. The IP/RN stated that the Respiratory Therapist (RP) was responsible for oxygenation and other respiratory supplies. The IP/RN did not have any in-services education for the staff regarding storage of respiratory equipment. On 11/16/23 at 9:50 AM, the surveyor conducted an interview with the Respiratory Therapist (RT), who informed the surveyor that she was a contracting agent. She visited the facility for about four hours every day to provide respiratory services to the residents and was not responsible to educate the staff. The RT further added that if she observed some concerns during her visits, she would address them at that time. The surveyor then inquired regarding the maintenance of oxygenation masks, Nebulizer and C-PAP. The RT added that the staff was responsible to secure the mask in a bag. The RT stated also if a mask was found on the floor, it should be discarded. The resident should know how to clean the C-PAP mask and the staff should inquire regarding how the resident maintained the C-PAP mask at home. On 11/16/23 at 10:04 AM, during an interview with the DON, she confirmed the RP was not responsible to educate the staff. The DON added, it is part of the competency, I will provide it. On 11/17/23 at 11:30 AM, a review of the competency package the DON provided,revealed there was no competency for the C-PAP masks. The Nebulizer competency failed to provide directives to staff regarding the care and storage of the masks. A review of the facility's policy titled, Skilled Nursing Policies and Procedures Oxygen Therapy, dated 6/01/01 and last revised 1/20/21, indicated the following: Tubing and humidifiers are changed at least weekly. These are to be dated and initialed each time they are changed. Oxygen/concentrator tubing and nasal cannula shall be stored in a clean plastic bag when not in use. (The policy was not being followed). 4. On 11/15/23 at 08:45 AM, the surveyor observed the Registered Nurse (RN) administering medications to a resident. The surveyor observed that the nurse did not perform hand hygiene prior to preparing the medications for the resident. The nurse entered the room, administered medications to the resident, then went to the bathroom to wash her hands. The nurse turned on the faucet, wet her hands, lathered her hands, and completed the entire hand hygiene within 10.42 seconds. On 11/15/23 at 10:41 AM, the surveyor interviewed the RN regarding the hand hygiene observed during meds pass. The RN stated, I missed the counting, I am sorry. 5. On 11/13/23 at 11:30 AM, the surveyor observed a facility staff sitting in the middle of the hallway on the carpeted floor. The surveyor observed a resident seated in a wheelchair in the hallway next to the staff. The surveyor also observed a nurse on the medication cart in the same hallway. The surveyor inquired about the staff observed sitting directly on the floor. The nurse replied, I asked myself the same question. The surveyor continued the tour, while in the hallway, the surveyor observed the same staff that was sitting on the floor was now sitting directly in the room and on the unsampled resident's bed. On 11/13/23 at 12:53 PM, the surveyor remained in the hallway and observed the staff exiting the resident's room. During an interview with the staff, she informed the surveyor that she was a student in training with the speech therapist. When inquired regarding being seated on the floor, while interacting with the resident, she added she did not see any issue regarding being seated on the floor, she wanted to be at the resident's eyes level. The surveyor then asked about infection control practices. The student stated that she had been at the facility since September and had not received any in-service education on infection control. On 11/13/23 at 11:57 PM, the surveyor interviewed the Speech Therapist Director (STD) and shared the above concerns. The surveyor asked for the employee orientation file for review. The STD informed the surveyor that she did not have a file for the student and the student was verbally educated regarding infection control practices. On 11/16/23 at 10:30 AM, the STD provided a Self-Study Orientation Packet dated 10/06/23 which included topics on infection prevention and Bloodborne Diseases. No in-service education was provided after the issue was discussed with the facility. 31654 6. On 11/15/23 at 8:04 AM, the surveyor observed the breakfast meal on the [NAME] unit and observed the following: On 11/15/23 at 8:07 AM, an Activity Staff (AS) was observed cutting an unsampled resident's meal tray, then removed soiled tray items into garbage, and without first performing hand hygiene proceeded to take out another resident's meal tray from the food cart. The AS then, without first performing hand hygiene, proceeded to put a straw in an unsampled resident's beverage and opened the resident's syrup for the French toast. Then, the AS removed the soiled tray items into the garbage and, without first performing hand hygiene proceeded to place Resident #87's meal tray in front of them and began cutting up the resident's food. On 11/15/23 at 8:15 AM, the surveyor observed a Certified Nurse Aide (CNA) place a clothing protector on an unsampled resident, then set up the resident's meal tray, and dumped the tray debris in the garbage. Then, without first performing hand hygiene removed another unsampled resident's meal tray from the meal cart, opened the resident's nutrition drink and the straw and placed the straw inside the drink. On 11/15/23 at 8:21 AM, the surveyor interviewed the CNA regarding what is the process when you go from one resident's tray to the other, and the CNA stated, you use wipes. On 11/15/23 at 8:30 AM, the surveyor interviewed the AS regarding if wipes or cleaning hands would be done between setting up the residents. The AS stated, yes, I forgot. On 11/15/23 at 11:13 AM, the surveyor requested and reviewed the facility's policy titled, Handwashing/Hand Hygiene, dated 3/1/17 and last revised 7/18/18. The policy revealed: Purpose: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 1. All personal shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare -associated infections. 7. Use an an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: before preparing or handling medications. Washing Hands: Vigorously lather hands with soap and water and rub together, creating friction to all surfaces, for a minimum of 20 seconds ( or longer ) away from the stream of water. (The procedure was not being followed) NJAC 8:39-19.4 (a)1

Based on interview and document review, it was determined that the facility Quality Assurance Performance Improvement (QAPI) Committee failed to a.) improve quality of life and improve quality of care for residents by not having a system in place to identify residents who sustained significant unplanned weight loss, and b.) ensure the kitchen and associated areas were maintained in a sanitary manner. This deficient practice occurred for 1 of 2 residents (Resident #23) and during observations conducted on 11/13/23 and 11/15/23 and was evidenced by the following: Refer to 692G and 812F On 11/17/23 at 9:25 AM, the surveyor intrviewed the Licensed Nursing Home Administrator (LNHA) regarding the currently active QAPI plans. The LNHA stated the facility was working on reducing falls and psychotropic medications as part of the QAPI program. The surveyor inquired to the LNHA if the identified concerns identified during the survey regarding the significant unplanned weight loss for Resident #23 and the sanitation concerns regarding the Dietary department were identified and part of the QAPI program. The LNHA stated, that is what the missing piece was, we did not looking at the resident weights. The LNHA further stated that the Dietary department did not have a QAPI in place to monitor the cleanliness of the kitchen. On 11/12/23 at 10:29 AM, the surveyor observed Resident #23 on the initial tour of the facility. The resident was then observed at 12:55 PM the same day sitting in the dining area feeding him/herself pork, rice and peas. On 11/14/23 at 9:21 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) and stated that Resident #23 could feed him/herself with some assistance and supervision. The CNA explained that Resident #23 was sleepy this morning and assisted with feeding. The CNA stated that the resident had lost some weight. A review of Resident # 23's Electronic Medical Record (EMR) revealed the following weights: 04/06/23 weight 195 lbs. (pounds) 04/11/23 weight 195 lbs. 04/18/23 weight 188 lbs. 05/02/23 weight 224 lbs. 05/07/23 weight 187.60 lbs. 07/18/23 weight 179.60 lbs. 09/14/23 weight 165 lbs. 10/18/23 weight 163.80 lbs. 11/01/23 weight 155.20 lbs. A review of the Physicians Orders, Medication Administration Record and Treatment Administration Records for April, July, August, September, October, and November 2023 did not reveal any documentation of dietary interventions as recommended by the RD. It was also indicated that Resident #23 had no weight change and was generally healthy according to the Physicians' notes dated for 04/10/23, 04/10/23, 04/14/23, 04/17/23, 04/19/23, 05/01/23, 07/17/23, 09/11/23 and 10/06/23. The Electronic Medical Record (EMR) did not have any supporting documentation that Resident #23's significant weight loss was notified to the doctor, family, or the interdisciplinary team. On 11/15/23 at 11:25 AM, the surveyor interviewed the Registered Dietician (RD) and it was confirmed that Resident #23 did trigger a significant weight loss in October 2023's quarterly assessment and she did not write the recommendation in the Dietician Recommendations book. The RD stated, I think I forgot to put them in the book. The failure to document in the Dietician Recommendation book resulted of Resident #23's not receiving the super cereal and supplements the resident required. On 11/15/23 at 01:40 PM, the surveyor conducted a telephone interview with the covering Medical Doctor (MD) regarding the interventions that are taken for a resident with weight loss. The MD stated that he would expect the nurses to notify him of any resident's significant weight loss of 5-19%. The MD stated once aware of the weight loss, he would determine if it was nutritional or medical reason the resident lost weight. The MD was not aware of Resident #23's significant weight loss of 31.2 lbs. in the last 6 months. The MD stated, I do not recall. On 11/16/23 at 1:30 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and the Registered Dietician (RD) in the presence of the survey team. The DON and the LNHA both confirmed of not being aware of the significant weight loss that Resident #23 had until the surveyor's inquired. The RD stated the weight loss trend was not documented and monitored of Resident #23, therefore it should have been communicated with the DON, LNHA and the doctor. The DON and LNHA stated that it was a system failure from the whole team. The LNHA and the RD stated, We missed it. A review of the facility provided, Clinical Nutrition Services policy, revised 01/22, revealed that when recommendations are made which require a physician's order, the Registered Dietician Nutritionist (RDN) will follow up within 7 days to verify a response to the recommendations. B.) On 11/13/23 at 9:24 AM, the surveyor conducted the initial tour of the kitchen and observed unsanitary conditions that included but were not limited to; the dishwasher was not operating at the optimum rinse temperature of 180 degrees Fahrenheit with the machine reading error code P2 error. The floor area by the ice machine was very soiled and had various colored debris. A large green salad [NAME] stored on a lower metal shelf had debris on the lid. There were two white rolling storage bins, one containing sugar that had no use by date and the other containing flour with debris in it; both bins had visible debris on the outside and lids. The meat slicer was covered with plastic and was identified as clean by the Food Service Manager Cooperate Representative (FSMC); after the cover was removed the surveyor observed debris at the base of the slicer. In the dry storage room various debris was observed on the floor and under the food storage racks. The area that stored the clean pan rack had various size pans and 4/4 coffee pots in upright position that were wet and nesting. On 11/13/23 at 10:12 AM, the surveyor toured the Aspen unit pantry and observed unsanitary conditions that included but were not limited to; the interior of the refrigerator was visibly soiled with dried on splatters and debris and there were food items that were unlabeled and undated. The surveyor observed the freezer that contained two pints of ice cream, a box of individual Italian ices and multiple ice packs that were used for resident care, all in the same area. The Registered Nurse Unit Manager (RNUM) stated, the cold packs were for the body and did not see an issue with storing the resident care ice packs with food items. On 11/13/23 at 10:27 AM, the surveyor conducted a tour of Evergreen unit pantry. The pantry was visibly soiled with debris on the floor, on the equipment and the metal tables. The Food Service Staff (FSS) #1 was observed removing clean dishes with her bare hands, followed by putting dirty dishes on the rack without performing hand hygiene. The surveyor observed the same FSS #1 rinse her hands under running water in a non-hand washing sink without any soap. On 11/13/23 at 10:40 AM, the surveyor toured the Sandalwood unit pantry with the Unit Manager Nurse (UMN). The refrigerator that belonged to the residents was visibly spoiled with splatters and debris. The freezer contained two food items that were unlabeled and undated. The UMN confirmed the refrigerator was not clean and discarded the unlabeled and undated items. On 11/15/23 at 9:04 AM, the surveyor interviewed the Food Service Director (FSD) in reference to the error code of the dishwasher and service. The FSD stated that the temperature sensor was replaced. The FSD stated the technician tested the rinse temperature with the indicator strip and it was okay. The FSD confirmed he did not use a indicator strip to test the rinse temperature during the survey. On 11/17/23 at 9:25 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the currently active QAPI plans. The LNHA stated the facility was working on reducing falls and psychotropic medications as part of the QAPI program. The surveyor inquired to the LNHA if the identified concerns identified during the survey regarding the significant unplanned weight loss for Resident #23 and the sanitation concerns regarding the Dietary department were identified and part of the QAPI program. The LNHA stated, that is what the missing piece was and not looking at the resident weights. The LNHA further stated that the Dietary department did not have a QAPI in place to monitor the cleanliness of the kitchen. It was confirmed the facility did not follow the following policy and procedures: #F013 Cleaning of Food and Nonfood Contact Surfaces; #F019 Dish Machine Temperatures; #F014 The Area and Equipment Cleaning; The Personal Food Storage Policy. NJAC 8:39-33.2(b)(c)6 48422

Based on interview and document review, the facility failed to have the Medical Director (MD) and the Director of Nursing (DON) present for one of four Quality Assurance and Performance Improvement (QAPI) meeting as evidenced by the following: On 11/17/23 at 9:15 AM, the surveyor reviewed the QAPI policy and procedure and requested the sign-in sheets or the last four quarterly QAPI meetings. On 11/20/23 at 9:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with four quarterly sign-in sheets for the each quarter of 2023, which revealed: The First Quarter 2023: January 17, 2023, Quarterly QAPI Team Meeting Signature Log. The sign-in sheet was missing the attendance of the Medical Director (MD) and the Director of Nursing (DON). At that time, the LNHA stated that on January 17, 2023 the MD was on vacation and the DON was not present. The facility provided QAPI plan policy included but was not limited to: The Quality Improvement (QI) Committee consists of the Director of Nursing, the Medical Director, the Administrator, Activity Director, Social Work, Housekeeping Director, Dining Director, Coordinators, Maintenance Supervisor and the Infection Control/Prevention Officer. The QAPI Committee, which includes the Medical Director, meets at least quarterly as is accountable for monitoring the continuous improvement in Quality of Life and Quality of Care. Minutes are recorded and shared with staff verbally. NJAC 8:39-23.1(3)

Based on observation, interview and document review it was determined that the facility failed to serve meals at an appetizing temperature for 1 of 1 resident reviewed for food (Resident #148) and on 1 of 4 resident units (Willow). The deficient practice was evidenced by the following: On 11/13/23 at 10:18 AM, during the initial tour, Resident #148 expressed concerns about the quality of the meals served and the temperature of the meals served. The breakfast meal sat on the bedside table, untouched, during the interview. On 11/15/23 at 8:04 AM, the surveyor observed residents in the [NAME] unit dining room sitting at tables waiting for the breakfast meal. On 11/15/23 at 8:09 AM, a meal cart was brought to the unit and the first tray was served. On 11/15/23 at 8:52 AM, the 2nd to last tray was removed from the cart and the surveyor removed the last tray to review for the test tray. The meal was Regular consistency meal. At 8:56 the Food Service Director (FSD) and the surveyor proceeded to test the food temperatures. The FSD stated that the hot food should be 140 degrees Farenheight (F) or higher and the cold food should be 41 F or below and in the 30s would be preferred. The meal tray contained: a) 4 ounces oatmeal; surveyor and FSD both had 121 F. b) 2- 1/2 pieces of cinnamon French Toast; surveyor- 87 F, FSD- 88 F c) 1/2 Cup Pineapple tidbits; surveyor- 60 F and FSD-61F d) 8 ounces 2% milk; The surveyor observed that the carton felt warm to the touch; surveyor-61 F, FSD 58. The surveyor asked the FSD if that temperature was okay and the FSD stated, it is not okay by any means, I wouldn't want it. The Production, Purchasing and Storage Policy, Date issues 5/95 revealed: Hot holding temperatures; Foods should be held hot for service at a temperature of 140 F or higher. Cold holding temperatures: Foods should be held cold for service at a temperature of 41 F or less. NJAC 8:39-17.4 (a)2

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the physician: a.) addressed a significant weight loss of 8.6 pounds (lb.) (5.3%) x 30 days, a significant 24.4 lb. (13.6%) weight loss x 90 days, and a significant 33.4 lb. (17.7%) weight loss x 180 days, b.) monitored weekly and monthly resident weights, and c.) implemented nutritional interventions in a timely manner for 1 of 4 residents (Resident #23) reviewed for nutrition. The deficient practice was evidenced by the following: Refer F692G On 11/13/23 at 10:29 AM, during the initial tour of the facility, the surveyor observed Resident #23 awake and alert sitting in a wheelchair in the dining room with the activities department. On 11/13/23 at 12:55 PM, the surveyor observed Resident #23, awake and alert, sitting in the dining room eating lunch. On 11/14/23 at 09:14 AM, the surveyor observed Resident #23 lying in bed with his/her eyes closed. At 9:21 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that the resident was very sleepy that morning and she assisted the resident with the breakfast meal which consisted of eggs, toast, coffee, and orange juice. The CNA stated that when the resident was up in his/her chair ,he/she could feed themselves with set up and supervision. The CNA stated that Resident #23 could get agitated and sometimes would throw the food on the floor. The CNA further stated that she usually cared for the resident and noticed a weight change On 11/14/23 at 12:43 PM, the surveyor observed Resident#23, awake and alert, sitting in a wheelchair in dining area eating lunch which consisted of chicken, scalloped potatoes, green beans, and soup. Review of Resident #23's Face Sheet (Admission Record) revealed the resident was admitted with diagnoses which included but were not limited to, dementia, fracture of the right femur, repeated falls, and anxiety disorder. Review of the Electronic Medical Record (EMR) revealed under other orders a physicians' order (PO) for a regular diet with thin liquids dated 07/18/23. No other dietary recommendations were ordered. A review of Resident #23's Vital Sign Report in the EMR revealed the following dates / weights: 04/06/23 weight 195 lbs. (pounds) 04/11/23 weight 195 lbs. 04/18/23 weight 188 lbs. 05/02/23 weight 224 lbs. 05/07/23 weight 187.60 lbs. 07/18/23 weight 179.60 lbs. 09/14/23 weight 165 lbs. 10/18/23 weight 163.80 lbs. 11/01/23 weight 155.20 lbs. There were no further documented follow up weights or re-weights in the EMR. Review of the RD Quarterly Nutritional Progress Note dated 10/18/23 at 5:10 PM, revealed that Resident #23 intake has been fair to adequate. Per weights the resident had experienced 1.2 lb.(0.7%) weight loss x 30 days, a significant 15/8 lb. (8.8%) weight loss x 90 days and a significant 31.2 lbs. (16%) weight loss x 180 days. The RD recommended super cereal at breakfast and a supplement with lunch and dinner. Continue with weights as ordered. Review of the RD Significant Weight Change Nutritional Progress Note dated 11/14/23, reflected a weight history that had been variable. Weights indicate a significant 8.6 lb. (5.3%) weight loss x 30 days, a significant 24.4 lb. (13.6%) weight loss x 90 days, and a significant 33.4 lb. (17.7%) weight loss x 180 days. Recommended a supplement three times a day and weekly weights. Encourage weights as needed/accepted. Continue with liberalized diet. No recent labs noted. This assessment was completed after surveyor inquiry. A review of the Physicians' notes dated 04/10/23, 04/10/23, 04/14/23, 04/17/23, 04/19/23, 05/01/23, 07/17/23, 09/11/23 and 10/06/23 indicated that Resident #23 had no weight change and was generally healthy. A review of the EMR from April 2023 to November 2023 did not reveal any documentation that the doctor, family, or interdisciplinary team was aware of Resident #23's significant weight loss. On 11/16/23 at 1:30 PM, the surveyor interviewed the Registered Dietitian (RD) in the presence of the survey team. During this interview, the RD acknowledged that the resident had a significant weight loss and did not notify the physician On 11/15/23 at 12:22 PM the surveyor attempted to contact the attending physician , but was informed by the office that the physician was on vacation. On 11/15/23 at 01:40 PM , the surveyor conducted a telephone interview with the covering physician. (MD). The MD stated that if he was aware of a resident's significant weight loss, he would want to identify the causal factor for the weight loss and implement interventions to correct the weight loss. The MD further stated that he would expect the nurses to notify the MD if there was a significant weight loss of 5-19%. When asked if he was notified of the Resident #23's significant weight loss of 31.2 lbs. in last 6 months, he stated I do not recall. On 11/17/23 at 11:50 AM, in the presence of the survey team, the LNHA and the DON acknowledged that weekly weights were not consistently recorded, the resident experienced a significant weight loss on 10/18/23 and 11/14/23 and there was no documentation of the doctor being notified. The LNHA and the DON stated that the doctor should be monitoring the residents' weights. A review of the facility policy titled, Resident Weights and Weight Changes policy, revised 11/07/1, reflected that significant weight changes will be reviewed by the DON/designee and referred to the dietician and physician if indicated. A reweigh must be obtained within 48 hours if a weight change meets the following criteria: 1 month- 5% body weight change or 6 months-10 % body weight change. The DON/designee or dietician will assess the weight change and make a notation in the medical record as to the plan of action for the weight change-diet counseling, physician notification, and dietician notification. A review of the facility policy titled Clinical Nutrition Services, revised 01/22, reflected that when recommendations are made that require a physician order, the Registered Dietician Nutritionist( RDN) will follow up within 7 days to verify a physicians response and if no response the RDN will contact the physician to discuss the recommendations made. The (RDN) will communicate all nutrition related problems to other disciplines by was of care plan/ morning meeting (FYI: examples may include but not limited to Interdisciplinary Patient Care Plan, Medical Rounds NJAC 8:39-23.2 (b)

Based on interview, record review and review of pertinent documents it was determined that the facility failed to conduct a thorough investigation for an injury of unknown origin for Resident #87. This Deficient practice was identified for 1 of 5 residents reviewed for accidents and was evidenced by the following: On 11/13/23 at 9:30 AM, the surveyor observed Resident #87 sitting at the table in the common area of the [NAME] unit. The resident was observed with a bandage covering to the right eyebrow and blackish purple discoloration in the surrounding area. On 11/13/23 at 11:18 AM, the surveyor reviewed the Electronic Medical Record (EMR) and reviewed a Physician note dated 10/09/23. The note revealed that Resident #87 fell and sustained a laceration to the right side of forehead and a skin tear to the right forearm. On 11/14/23 at 11:46 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN) about Resident #87's injuries. The LPN #1 stated that the resident went home with the family on Sunday 11/12/23 and came back to the facility with a small cut above the right eyebrow. The LPN #1 stated the nurse that was working on 11/12/23 reported that the resident returned on Monday and the area around the right eye was reddened. On 11/14/23 at 11:49 AM, the surveyor interviewed the Registered Nurse (RN) about Resident #87's injuries. The RN stated that the resident went home on Sunday with [family]. The RN stated the [family] stated that the resident had picked the scab that was from the incident that occurred on 10/9/23. The RN stated that on 11/13/23 the right eye had bruising which and stated that it was not from the incident on 10/9/23. On 11/14/23 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) about Resident #87's injuries. The DON stated the LPN did a risk management report and failed to have a written statement at the time for the incident of the bruise to the right eye that was thought had occurred on 11/12/23. The DON stated that it is important to have a statement immediately to narrow down what happened to the resident. Furthermore, the DON stated a conclusion needed to be apparent to be able to implement intervention to prevent these types of situations from recurring, and to rule out abuse. The DON stated, it should not have happened this way. On 11/14/23 at 1:00 PM, the surveyor interviewed Licensed Practical Nurse #2 (LPN) about Resident #87's injuries. The LPN #2 stated that the Resident returned to the facility on [DATE] at 6:00 PM and the residents family member showed the LPN the scratch above the right eyebrow. The resident's family member said that the resident was pinching at the old scab from 10/9/23 and scratched the scab off causing the discoloration. LPN #2 had observed a small bruise to the right eye and the family member stated that the resident had been rubbing her/his eye. On 11/15/23 at 8:04 AM, the surveyor observed resident #87 in the common area during breakfast on [NAME] unit. The resident was observed with a large black and blue type bruise that surrounded the right eye area and a scab above the right eyebrow. The resident reported to the surveyor I fell , I was wearing socks and slipped. On 11/15/23 at 9:24 AM, the surveyor interviewed the DON and she stated that she was unaware that the resident fell . The surveyor inquired about Resident #87's injury of unknown origin that happened on 11/12/23 to the DON and she stated she did not contain any documentation of interviews with the resident until the surveyors informed the facility of what the resident had stated. The DON stated it is important to start an investigation and do interviews to rule out abuse. The DON stated that the nurse providing care for the resident was aware of the injuries on Sunday 11/12/23 at 5 PM and unfortunately the nurse didn't do what he was supposed to do regarding initiating an investigation. 11/16/23 at 11:22 AM, the DON was interviewed by the survey team and asked if the family was contacted regarding an investigation. The DON stated that on 11/13/23 was when the UM observed the black eye getting darker and the UM reached out to the family who did not respond until 11/14/23. The DON stated the UM typically would complete an investigation but the DON stated she had to get involved because the UM didn't do it properly and confirmed she did not have a documented statement from the family. On 11/20/23 at 8:30 AM, the surveyor reviewed a facility provided policy on Resident Abuse revised on 6/19/23. Section 4 Identification and Reporting of Possible Incidents, part A: Facility staff members received training and orientation regarding the identification of an abused, neglected, or exploited resident. The following guidelines apply included, but not limited to unexplained bruises, repeated falls, reports by the resident of physical abuse, bruising or laceration of lips from force-feeding. Section 5 Investigation of Any Violation Which is Suspected and/or Substantiated, part A of the facility provided policy reads as followed: The nursing supervisor on duty shall IMMEDIATELY report any alleged violations of this prevention policy to Administrator or designee. Section 6 Reporting, Investigation, Response/Protection to any Violation which is Suspected and/or Substantiated, part D and E revealed: D. The Administrator and/or a nursing supervisor will conduct a thorough investigation. The investigation will include, but not be limited to, interviewing the alleged perpetrator, all staff, residents, and visitors who are believed to have knowledge of the event. E. A thorough account of the investigation will be documented. All witnesses will sign their individual statements. All notifications will be noted on the Riskwatch report and Narrative Nurses Notes. NJAC 8:39-27.1(a)

Based on observation, interviews, and review of facility documentation it was determined that the facility failed to a.) properly label, date and store potentially hazardous foods and dry 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 07:53 AM the surveyor toured the kitchen in the presence of the Dietary Aide (DA) and observed the following: 1. The foot pedal trash can at handwashing sink #2 was not lined with a trash bag and both trash and food debris were observed in the can. 2. In the main refrigerator was one rolling metal food prep cart with a tray of individually wrapped plates of pie with no labels and no dates. The DA identified them as apple pie and acknowledged they should have a label and date. 3. In the same refrigerator, on the third shelf of a five tiered metal shelf, there was one opened 5 pound block of American cheese wrapped in clear plastic wrap with no opened or use by date. The DA acknowledged it had no opened date and stated she thought it should be dated. The DA removed the cheese from the refrigerator and set it on a metal table in the kitchen. 4. On the same shelf there was one sealed 1.5 pound package of swiss cheese with a dime sized area of a green substance. The DA acknowledged the green substance and identified it as mold. She removed the cheese from the refrigerator and set it on a metal table in the kitchen. 5. On the same shelf was one opened, unsealed 5 pound bag of mozzarella cheese with the contents exposed to air with no opened or use by date. The DA stated she was unsure if it was properly stored and she threw it in the garbage. 6. In the same refrigerator on a rolling metal food prep cart there was a metal half pan which contained green beans covered with clear plastic wrap with no label or use by date. The DA stated the green beans were made yesterday and only smiled when asked if it should be dated. During an interview at that time, the DA stated it was important to label and date food items so that the residents are not served food that had bacteria or was expired. 7. In the walk-in freezer were two sealed packages each containing 5 light tan meat patties which the DA identified as turkey patties. There were no labels and no use by dates. 8. There was one tied clear bag containing white oblong shaped pieces of bread, which the DA identified as breadsticks, with no label and no opened or use by dates. 9. There was one tied clear bag of light tan oval patties, which the DA could not identify, with no label and no opened or use by dates. 10. There was one tied clear bag of light brown rectangular pieces of meat, which the DA could not identify, with no label and no opened or use by dates. 11. There was one untied clear plastic bag of white stuffed pasta which was open and exposed to air with no label and no opened or use by dates. The DA identified the pasta as manicotti and acknowledged the bag should be sealed and dated. The DA further stated that labeling and dating the food was the responsibility of the staff member who stocked the food. 12. The meat slicer was covered with a dark garbage bag. The DA removed the bag and there was brown debris on the base of the slicer. The DA acknowledged the debris should not be there and stated that once the slicer was used it was cleaned and covered with a bag. 13. The Globe mixer was covered with a dark garbage bag. The DA removed the bag and there was debris in the bowl and on the mixer. The DA acknowledged the debris. 14. There was reddish brown debris on the can opener and reddish brown debris on the base. The DA acknowledged the debris. 15. In the prep freezer #4 there were four pink meat patties wrapped in clear plastic wrap with no label and no opened or use by dates. The DA identified them as hamburgers and was unable to state how old they were. 16. There was one large clear unsealed bag of light brown round objects, which the DA identified as pancakes, with no label and no opened or use by dates. The DA states she was unsure when they were opened. 17. There was one large, tied top, clear bag of bread slices, which the DA identified as French toast, with no label and no opened or use by dates. 18. There was one unsealed twisted brown bag of French fries with no opened or use by date. 19. There was one unsealed clear bag of light brown pieces of meat wrapped in clear plastic wrap, which the DA identified as chicken tenders, with no label and no opened or use by dates. 20. There was one opened unsealed bag of light brown pieces of meat, which the DA identified as chicken tenders, with no label and no opened or use by dates. 21. There was one opened clear bag of oval tan patties wrapped in clear plastic wrap, which the DA identified as hash browns, with no label and no opened or use by dates. 22. There was one unsealed, tied top, clear bag of yellow wedges with no label and no opened or use by dates. 23. There was one large clear sealed bag of light brown meat with white frost, which the DA identified as chicken tenders, with no label and no use by date. 24. There was one open unsealed clear bag of tan breaded rings, which the DA identified as onion rings, with no label and no opened or use by dates. During an interview at that time, the DA acknowledged all of the unlabeled and undated food would be thrown away. At 08:37 AM the Director of Dietary Services (DDS) replaced the DA on the tour of the kitchen with the surveyor. 25. On a shelf under the food prep area there was a large covered container marked food thickener with a styrofoam bowl resting on the thickener in the container. The DDS stated it was used as a scoop and removed the bowl. In the presence of the DDS, the surveyor revisited the refrigerator, freezer, prep refrigerator and freezer, the meat slicer, Globe mixer and can opener to review and discuss findings from earlier in the tour. 26. In the refrigerator, the DDS acknowledged the apple pie tray should have had labels and stated the pies should have been discarded on Saturday. 27. The DDS observed the green substance on the swiss cheese, she stated it would be discarded and stated it could have a pin hole that allowed air to get into package. 28. The DDS acknowledged the American cheese should have an open and use by date. 29. The DDS acknowledged the pan of green beans had no date and stated were from Thursday and that they would be discarded. 30. In the freezer were three six pound pork loins with no dates. The DDS stated she did not know when they came in. During an interview with the surveyor at 08:48 AM, the DDS stated that once the food items are received they should be labeled and dated. She further stated they should be marked when they are opened and when they should be used by. 31. In the cooking area on the unused top convection oven there was a brown sticky substance on both the left and right inner doors. There was black and gray debris inside on the bottom of the oven. The DDS was unable to identify the substance and debris and stated the ovens are cleaned weekly. 32. The foot pedal trash can at handwashing sink #3 was not lined with a trash bag and both trash and food debris were observed in the can. The DDS acknowledged the debris and stated there should be a bag in the can. 33. On a metal rack in the clean pot/pan area were four half [NAME] pans wet nested, two quarter pans wet nested and two steam table pans wet nested. The DDS acknowledged they should not be wet and removed the pans to the dishwashing area. 34. In the dry storage room was one opened bag of croutons wrapped with clear plastic wrap with no opened or use by date. 35. There was one opened bag of linguine wrapped with clear plastic wrap with no opened or use by date. 36. There was one large opened bag of penne pasta with no opened or use by date. The DDS stated that when food items were opened that they should be dated. A review of the facility's policy, General Food Preparation and Handling, with a revision date of [DATE], revealed Procedure: 1.a. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Food Preparation 3.k. The can opener will be cleaned and sanitized daily and/or as needed. Food Service 4.d. Leftovers must be dated, labeled, covered, cooled and stored properly in a refrigerator. Equipment 5.a. All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. A review of the facility's policy, Food Safety and Sanitation, with a revision date of [DATE], revealed 4. Food Storage a. All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored. When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. A review of the facility's policy, Food Storage, with a revision date of [DATE], revealed Policy: .Food will be stored .by methods designed to prevent contamination or cross contamination. Procedure: 5. Scoops must be provided for bulk foods (such as sugar, flour, and thickener). Scoops are not to be stored I food or ice containers, but are kept covered in a protected area near the containers. 6.b. Food should be dated as it is placed on the shelves. c. Food should be dated when the original container or packaging is opened. d. Date marking to indicate the date or day by which a ready-to-eat, time/temperature control for safety food should be used will be visible on all high-risk food. 9. Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. 10. Refrigerated food storage d. Refrigerated foods will be dated and stored upon delivery. g. All foods should be covered, labeled and dated. 11. Frozen Foods: c. Frozen foods will be dated upon delivery. d. All foods should be covered, labeled and dated. A review of the facility's policy, Resource: Sanitation of Dishes/Manual Washing, with a revision date of [DATE], revealed Policy: Dishes and cookware will be cleaned and sanitized after each meal. Procedure: 5. Sink 3: Sanitize 4.Check all dishes to be sure they are clean and dry prior to storing. NJAC 8:,d+[DATE].2(g)

Based on observation, interview, and review of medical records, it was determined that the facility failed to follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was identified for 1 of 23 resident reviewed, Resident #139 and was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, Title 45, Chapter11, 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 task and responsibilities within the framework of case finding, reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. A review of the facility's Admission Record indicated that Resident #139 was admitted to the facility in 10/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission Minimum Data Set (MDS), an assessment tool, dated 11/09/2021, revealed that Resident #139 scored a 14/15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident had intact cognition. Further review revealed that the resident received intravenous (IV) medication. A review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order dated 11/03/2021 to monitor and observe the PICC site every shift, before and after medication administration, and during dressing change three times a daily. A review of the November 2021 Treatment Administration Sheet (TAR) revealed an order dated 11/03/2021 which included to change the PICC line dressing one time a week. The entry was last signed by a nurse on 11/24/2021 as being performed. Further review of the TAR revealed an order dated 11/03/2021 to monitor an observe the PICC line site every shift, before and after administration of medication and during dressing change that was signed every shift by nurses as being performed. On 11/29/21 at 09:23 AM, during the tour of the unit, the surveyor observed Resident #139 in bed with a PICC line in the right upper arm with a clear transparent dressing dated 11/17/21. The resident stated the dressing was done in the hospital and not at the facility. On 11/30/2021 at 11:03 AM, the surveyor observed Resident #139 seated in a wheelchair in his/her room. The resident's PICC line dressing was dated 11/17/2021. When interviewed the resident stated that the PICC was used for antibiotic medication administration that he/she received every day. During an interview with the surveyor on 12/01/2021 at 09:50 AM, the Registered Nurse Unit Manager (RN/UM) stated that she thought PICC line dressings were changed every three days. At that time, the RN/UM showed the surveyor Resident #139's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor brought the RN/UM into Resident #139's room. The RN/UM observed Resident #139's PICC line dressing that was dated 11/17/2021 and she stated that she did not know why it was not changed. During an interview with the surveyor on 12/01/2021 at 10:00 AM, the Registered Nurse (RN) assigned to Resident #139 stated she was in-serviced at the facility on dressing changes and learned how to change PICC line dressings. She stated PICC line dressings were changed by an RN weekly on the 3-11 shift. During an interview with the surveyor on 12/01/2021 at 10:15 AM, the Director of Nursing (DON) stated that she did not know when PICC line dressings were changed and was not aware of the policy. During a follow up interview with the surveyor on 12/01/2021 at 12:06 PM, the DON stated the dressing was supposed to be changed on 11/24/2021. She stated all of the nurses who signed the TAR each shift, should have seen and checked the date on the dressing. During a meeting with the surveyor on 12/01/2021 at 12:51 PM, the Administrator was informed of the findings. A review of the policy labeled Central Venous Catheter Dressing Changes dated 02/06/2020, revealed the dressing should be changed at least every 5-7 days and when wet, soiled or not intact. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and a review of facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a.) follow appropriate isolation precaution protocols for residents maintained on a Transmission-Based Precautions (TBP) unit for Persons under investigation/observation (PUI) from potential exposure (a COVID-19 positive staff member and two COVID-19 positive residents) for 9 of 26 residents; Resident's #1, 2, 3, 4, 5, 6, 7, 8, and 9; b.) ensure staff don (put on) appropriate Personal Protective Equipment (PPE) before entering a PUI room for 2 of 2 PUI units (Sandlewood and Aspen) toured; and, c.) ensure staff visited rooms in the appropriate order of well to ill for 1 of 2 PUI units toured (Aspen Unit) in accordance with the Center for Disease Control (CDC) Guidance and New Jersey Department of Health (NJDOH) Guidance to prevent the spread of COVID-19. This deficient practice was evidenced by the following: Reference: CDC guidelines titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 4/29/21, included the following: Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection .Roommates of residents with [CONDITION(S)]-CoV-2 infection should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents while they are in quarantine (i.e., for the 14 days following the date their roommate was moved to the COVID-19 care unit). Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. Residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure . HCP (Health Care Personnel) should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents .Residents can be transferred out of quarantine if they remain with no fever and without symptoms for 14 days . Residents can be transferred out of quarantine if they remain with no fever and without symptoms for 14 days. Reference: NJDOH guidelines titled, Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities, updated 3/25/21, included the following: Cohorting is only one element of infection prevention and control measures used for outbreak control . b) Cohort 2 - COVID-19 Negative, Exposed: This cohort consists of symptomatic and asymptomatic patients/residents who test negative for COVID-19 with an identified exposure (i.e., close contact) to someone who was positive, regardless of vaccination status. This includes new or readmitted patients/residents who have tested negative and have been identified as a close contact in the past 14 days. Exposed individuals should be quarantined for 14 days from the last exposure, regardless of negative test results or vaccination status. All symptomatic patients/residents in this cohort should be evaluated for causes of their symptoms. Patients/residents who test negative for COVID-19 could be incubating and later test positive. To the best of their ability, facilities should separate symptomatic and asymptomatic patients/residents, ideally having symptomatic housed in private rooms. Even though symptomatic COVID-19 negative patients/residents might not be a threat to transmit COVID-19, they still may have another illness, such as influenza. Asymptomatic patients/residents should be closely monitored for symptom development. Patients/residents who are identified as close contacts should be quarantined for 14 days and initially tested . If testing is negative, the patient/resident should be tested again 5-7 days after exposure. If testing remains negative, patients/residents should complete the remainder of their 14-day quarantine period. Testing at the end of this period could be considered to increase the certainty that the person is not infected . d) Cohort 4 - New or Re-admission Observation: This cohort consists of all new and readmitted patients/residents from the community or other healthcare facilities who are not fully vaccinated. This cohort serves as an observation area where persons remain for 14 days to monitor for symptoms that may be clinically compatible with COVID-19. Testing at the end of this period could be considered to increase the certainty that the person is not infected. Frequently asked questions .What does it mean to dedicate HCP to these cohorts? To the extent possible, the same HCP should be responsible for the care and services provided within individual cohorts. HCP caring for the COVID-19 Positive (Cohort 1) should continue to only care for patients/residents in Cohort 1. All efforts should be made to keep HCP working in their assigned cohort. If staffing resources become strained and CDC staffing mitigation strategies are used to return HCP to work, every effort should be made to prevent exposed HCP from working with Cohort 3 (and Cohort 4, if applicable). Ensure HCP are prioritizing rounding in a well to ill flow to minimize the risk of cross-contamination (i.e., beginning with Standard Precaution care areas and working toward Transmission-Based Precaution, then finally outbreak areas). How do we determine if a patient/resident is a close contact? The index of suspicion for exposure should be low, as COVID-19 has been seen to rapidly progress throughout the post-acute care setting. Potential exposures may include shared HCP or being housed on the same wing/unit with a COVID-19 positive person. Facilities should identify patients/residents cared for by HCP who are COVID-19 positive and staff suspected of having COVID-19. Close contacts should be traced back 48 hours prior to symptom onset or positive test for asymptomatic positive HCP, as the exposed patient/resident may later develop symptoms of COVID-19 or test positive. Patients/residents who are identified as a close contact should be restricted to their room and cared for using all recommended COVID-19 PPE until results of the HCP COVID-19 testing are known. If the HCP is diagnosed with COVID-19, patients/residents should be cared for using all recommended COVID-19 PPE until 14 days after last exposure and tested initially. If testing is negative, the patient/resident should be tested again 5-7 days after exposure. If testing remains negative, patients/residents should continue quarantine for 14 days, regardless of vaccination status. Testing at the end of this period could be considered to increase the certainty that the person is not infected . What should we do about roommates of patients/residents who are symptomatic or COVID-19 positive? . The exposed roommate should be cared for using all recommended COVID-19 PPE until 14 days after last exposure and tested initially. If testing is negative, the patient/resident should be tested again 5-7 days after exposure. If testing remains negative, patients/residents should continue quarantine for 14 days. Testing at the end of this period could be considered to increase the certainty that the person is not infected. If testing is positive, the patient/resident should be isolated and placed in the COVID-19 Positive area (Cohort 1) . What types of precautions should be used in each cohort? Full Transmission-Based Precautions and all recommended COVID-19 PPE should be used for all patients/residents who are: .Close contacts to a suspected or confirmed COVID-19 positive person (e.g., HCP, visitor, roommate). On a wing/unit (or facility-wide), regardless of the presence of symptoms, when transmission is suspected or identified. 1. On 5/26/21 at 8:45 AM, the Assistant Administrator (AA) stated the facility was currently in an outbreak. The outbreak started when an employee, who had worked on the Sandlewood unit, tested COVID-19 positive on 5/18/21; The employee was immediately sent home. The AA then stated that the facility then tested all the residents on the Sandlewood unit on 5/17/21 as a preventative measure, and that Resident #10 and Resident #11 tested COVID-19 positive on 5/19/21. Resident #11 was maintained in a private room. Resident #10 shared a room with Resident #3. The AA further stated that Resident #10 and Resident #11 were transferred to the covid section of the Aspen unit, and that all the residents of the Sandlewood unit were considered PUI and placed on TBP. At 9:45 AM, the surveyor began a tour of the facility's Sandlewood unit. After the surveyor entered the unit, the surveyor observed seven residents (Resident #3, #4, #5, #,6, #7, #8, and #9) seated at separate tables in the dining room. The residents were socially distanced at least six feet apart. Resident #6 had a facemask on that was not covering their nose. Resident #4, Resident #5, and Resident #8 had a facemask under their chin. Resident #7 had a facemask that was hanging from their left ear. Resident #3 and Resident #9 did not have a facemask on. The surveyor then observed two residents (Resident #1 and #2) seated in wheelchairs watching TV in the activity area. Resident #1 and Resident #2 wore facemasks that were under their chin. The surveyor observed the Activities Aid, who wore a KN95 facemask and a face shield, in that area monitoring the residents and then provided them with an activity. At 9:55 AM, the surveyor toured the entire Sandlewood unit and observed that every resident room on the unit had a bin with three drawers that contained PPE, including disposable gowns. The surveyor also observed that every resident room on the unit had a sign posted which included the following: STOP DROPLET PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. ALWAYS WEAR: GLOVES, GOWN, EYE PROTECTION, MASK. Make sure their eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit. At 10:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who was wearing an N95 mask and a face shield. The surveyor asked the LPN why the nine residents who were PUI and TBP were all in the unit's dining room and activity area. The LPN replied that the nine residents were in the day area for safety reasons, that some of the residents were a high fall risk, and some of the residents wandered. The surveyor then asked LPN the reason the unit was considered a PUI unit. The LPN stated that a staff member on the unit tested COVID-19 positive and was not currently working. The LPN then said that Resident #11 tested COVID-19 positive and was in a private room at that time. The LPN stated that Resident #10 tested COVID-19 positive and shared a room with Resident #3 at that time. The LPN then stated that Resident #10 and Resident #11 were transferred to the Aspen unit and that all the residents on the unit were placed on TBP. The LPN then stated that staff need to don PPE, which included gowns and gloves to go in the rooms. She added that the staff always wore an N95 or KN95 mask and eye protection while on the unit. At 10:18 AM, the surveyor observed that Resident #2, observed earlier in the activity area, was seated in the dining room. The surveyor interviewed the Activities Aide, who wore a KN95 mask and face shield, and she confirmed that there were eight residents in the dining room and one resident in the activity area. The surveyor asked the Activities Aide if the residents were in the dining room and activity area every day. The Activities Aide stated that usually more residents would be in the area but that when everyone was placed on isolation (TBP), and that they only bring out residents that are a fall risk. She then stated that they always kept the residents socially distanced. The surveyor then asked the Activities Aide what she would need to do to enter any resident's rooms. The Activities Aide stated that she would don a gown and gloves if she entered a resident's room. At 10:27 AM, the surveyor observed LPN #1 don a gown and gloves and entered a resident's room to administer medications. At 10:40 AM, the surveyor asked the LPN what the vaccination status of the unit was; The LPN responded that 90% of the unit were vaccinated for COVID-19. The surveyor then asked the LPN why the nine PUI residents on TBP were out of their rooms. The LPN replied that only fall-risk residents come out of the rooms and that the residents are socially distanced and monitored, no direct care was provided in that area. She further stated that the residents could not be left alone in their rooms because of the risk of them falling. She then added, we put a mask on them. At 10:49 AM, the surveyor, during an interview asked the AA and DON whether the nine residents were considered PUI and on TBP, were in the dining room and activity area. Both the AA and DON confirmed that nine PUI residents were in the dining room and activity area. The AA stated that the staff keep the residents in that area for safety reasons because of falls. She then said that they try to keep the residents masked if they can tolerate a facemask. The AA further stated that the unit was a PUI unit, and the caregivers were expected to wear PPE, which included a gown and gloves if they were going into the rooms to provide care. The DON noted that the staff in the dining room and activity area wore masks and face shields and that the staff were not giving the residents care. The surveyor then asked the AA and the DON to confirm that Resident #3, who was in a recliner in the dining room without a facemask on, was the roommate of Resident #10 who tested COVID-19 positive on 5/19/21. Both the AA and DON confirmed that Resident #3, who was in the dining room, was Resident #10's roommate. The surveyor requested the vaccination status, COVID-19 testing results, and the fall risk assessments for the nine residents. Resident #3 was fully vaccinated for COVID-19. At 11:42 AM, the surveyor observed that Resident #2, #3, #5, #6, #7, #8, and #9 were still seated at separate tables in the dining room. The residents were socially distanced. The surveyor observed that Resident #4 was walking in the hall near the nurse's station. A Certified Nursing Assistant (CNA) who wore a KN95 face mask with a surgical facemask on top and a face shield assisted Resident #4 back to a seat at a table in the dining room. Resident #1, who was observed earlier in the activity area, was not in the dining room or activity area. At 11:55 AM, the surveyor asked the AA to provide the surveyors with the facility's guidance, which allowed PUI residents and TBP to be out of their rooms. The AA stated that the facility had been in a prior outbreak from March 2020 until April 2021, when they were finally cleared from that outbreak. She then noted that the facility asks their Local Health Department (LHD) for guidance and would provide the surveyors with the documentation. At 1:12 PM, the surveyor reviewed the facility provided documents of the Resident's medical records, which revealed the following: The Fall Risk Assessment included NOTE: Total score above 10 points represents HIGH RISK FOR FALLS. Resident #1: The resident was not vaccinated against COVID-19. The facility documented that the resident had refused the COVID-19 vaccination. The Resident's fall risk assessment score was 8. The resident was not at high risk for falls. The resident had a COVID-19 negative test result on 5/18/21 and 5/20/21. Resident #2: The resident was fully vaccinated against COVID-19. The Resident's fall risk assessment score was 12. The resident was a high risk for falls. The resident had a COVID-19 negative test result on 5/18/21 and 5/20/21. Resident #3: The resident was fully vaccinated against COVID-19. The Resident's fall risk assessment score was 8. The resident was not at high risk for falls. The resident had a COVID-19 negative test result on 5/18/21 and 5/20/21. Resident #4: The resident was not fully vaccinated against COVID-19. The facility documented that the resident had received the first dose of a two-dose COVID-19 vaccination. There was no documentation that the resident received the second dose of the COVID-19 vaccination. The Resident's fall risk assessment score was 16. The resident was a high risk for falls. The resident had a COVID-19 negative test result on 5/18/21 and 5/20/21. Resident #5: The resident was not vaccinated against COVID-19. The facility documented that the resident had refused the COVID-19 vaccination. The Resident's fall risk assessment score was 14. The resident was a high risk for falls. The resident had a COVID-19 negative test result on 5/18/21 and 5/20/21. Resident #6: The resident was not vaccinated against COVID-19. The facility documented that the resident had refused the COVID-19 vaccination. The Resident's fall risk assessment score was 8. The resident was not at high risk for falls. The resident had a COVID-19 negative test result on 5/18/21 and 5/20/21. Resident #7: The resident was fully vaccinated against COVID-19. The Resident's fall risk assessment score was 11. The resident was a high risk for falls. The resident had a COVID-19 negative test result on 5/18/21 and 5/20/21. Resident #8: The resident was fully vaccinated against COVID-19. The Resident's fall risk assessment score was 10. The resident was not at high risk for falls. The resident had a COVID-19 negative test result on 5/18/21 and 5/20/21. Resident #9: The resident was fully vaccinated against COVID-19. The Resident's fall risk assessment score was 10. The resident was not at high risk for falls. The resident had a COVID-19 negative test result on 5/18/21 and 5/20/21. Resident #10: The resident was not vaccinated against COVID-19. The facility documented that the resident had refused the COVID-19 vaccination. The resident had a COVID-19 positive test result collected on 5/19/21 and reported to the facility on [DATE]. At 2:05 PM, the surveyor asked the AA if the LHD had performed any onsite visits of the facility which she stated, No. She then noted that the directive says that residents are encouraged to stay in their rooms. The surveyor asked for a copy of the directive that they were referring to; The surveyor then reviewed the facility provided an email from the LHD dated 5/20/21, which included the following: The I-Number has been added to the survey for the facility. Please see below for the I# issued for the one positive staff. Based on this new positive case, please see the recommendations below: .Restrict indoor visitation, group activities, and communal dining on affected units .Implement Transmission-Based Precautions for resident care on all affected units .You must continue to follow NJDOH guidance for infection prevention . At 2:25 PM, the surveyor asked the AA to confirm that the fall risk assessment score of 11 points and above indicated the resident was a high risk for falls which the AA confirmed. The surveyor then asked the AA to confirm that only four of the nine residents were assessed to be a high risk for falls which the AA confirmed. The AA then stated that there were different reasons for bringing the PUI residents on TBP out of their rooms, including wandering and behaviors. The surveyor asked the facility to provide documentation for why the other five residents that were not a high risk for falls were brought out of their rooms. The AA then provided the surveyors with a previously requested document titled, Outbreak Management Checklist for COVID-19 in Nursing Homes and other Post-Acute Care Settings, dated 8/19/2020, which they highlighted in yellow, the following under Outbreak Intervention. Infection Prevention and Control: Encourage patients/residents to stay in their room or cohort. The document included the following, which was above the sentence the facility highlighted: Stop current communal dining and all group activities such as internal and external group activities (e.g., beauty shop, physical therapy gym sessions, activities). The facility did not provide the surveyors with any additional requested documentation for the reason the residents that were PUI on TBP that were not a high fall risk were brought out of their rooms. On 5/27/21 at 9:04 AM, the surveyor called the LHD and requested to speak to the staff member that had communicated with the facility to ask what guidance they provided to the facility. The person who answered the phone stated that the staff member was not available, and a message was taken, and the surveyor was told that the staff member would return the call later that day. The surveyor never received a return call from the LHD. 2. On 5/26/27 at 10:27 AM, during tour of the Sandlewood unit, the surveyor observed a Certified Nursing Assistant (CNA) enter Resident #12's room wearing a K-N95 mask with a surgical facemask over it and a face shield. The CNA did not don a disposable gown before entering the room. The surveyor observed the CNA go into the room then she took the gloves from the holder on the wall inside the room and put them on, and then closed the door. The surveyor observed that outside Resident #12's room was a three-drawer bin that contained PPE, which included disposable gowns. The surveyor also observed a sign posted outside of Resident #12's room. The sign had the following: STOP DROPLET PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. ALWAYS WEAR: GLOVES, GOWN, EYE PROTECTION, MASK. Make sure their eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit. At 10:29 AM, the surveyor observed the same CNA exit Resident #12's room. The surveyor asked the CNA to confirm that she did not don a disposable gown. The CNA confirmed that she did not don a disposable gown before entering Resident #12's room; The CNA stated that she had answered the call bell and then left the room. The surveyor then asked the CNA why she only donned gloves and did not don a disposable gown. The CNA stated that when residents are on isolation, there is a cart outside, and that they have to don a gown and gloves. She further noted that no one is on isolation on the unit, and she only needed to don gloves. The CNA stated that she was from an agency and worked at the facility for 2 to 3 months but usually is on the Aspen unit. The surveyor asked the CNA how she would know if a resident was on isolation or TBP. The CNA stated that normally the nurse would give her report and tell her if a resident was on isolation. She further noted that no one told her that any resident was on isolation. The surveyor then asked the CNA why the sign outside Resident #12's was posted. The CNA stated that to her knowledge, no one on the unit was on isolation. The CNA further noted that she was aware that on the Aspen unit, the residents were new admissions and that they were on isolation for 14 days and that to enter their room, she needed to don a gown and glove. At 10:40 AM, in the presence of the CNA, the surveyor told LPN that the surveyor observed the CNA enter Resident #12's room without donning a gown. The LPN stated that it was her fault that the CNA did not know that the residents were on isolation. LPN further noted that she should have educated the CNA at the beginning of the shift but that she was busy and did not get the chance. The LPN then educated the CNA that all the residents on the unit were on isolation and that a gown and gloves were required to be worn before entering any resident room on the unit. At 10:51 AM, during the surveyor interview, the AA stated that caregivers were expected to wear full PPE, which included a gown if going into a resident's room to give care on the Sandlewood unit, a PUI unit. At 11:38 AM, the surveyor asked the CNA when she had worked at the facility prior to that day. The CNA stated that she worked the day before on the Aspen unit for half a day. The surveyor asked the CNA if she was informed about the outbreak status of the facility. The CNA stated that even though she worked the day before, no one told her of the outbreak. She further noted that maybe the nurse assumed that she knew about the outbreak on the unit from working on another unit but that she did not know. The CNA then stated that she never saw any of the other staff don a gown all morning when they went into the resident's room on the unit and that she thought that meant that she did not have to. The surveyor interviewed other staff on the Sandalwood unit who spoke to the correct process of donning a gown and gloves prior to entering the resident's rooms on the Sandlewood unit. A review of the education for the CNA revealed the following: PPE in-service, which included Donning/Doffing of gowns dated 4/1/21. Droplet Precautions in-service included Always wear gloves, gown, eye protection and mask dated 4/1/21. Handwashing and Hand Sanitizer Use in-service dated 4/21/21. A review of a PPE competency dated 5/25/21 reflected that the CNA had met all standards of applying and removing PPE. A review of the facility provided policy titled, COVID 19 UNIVERSAL TESTING PLAN, COHORTING PLAN, with a revised date of 10/28/20, included the following: B. Cohort 2: COVID-19 Negative, Exposed: This cohort consists of symptomatic and asymptomatic negative residents/residents who test negative for COVID-19 but had a possible exposure to someone who was positive. Exposed individuals should be quarantined for 14 days from last exposure, regardless of test results 1. All symptomatic COVID-19 residents/residents should be considered exposed but should also be evaluated for other causes of their symptoms. To the best of their ability, LTCFs should separate symptomatic and asymptomatic residents/residents, ideally having one group housed in private rooms. Even though symptomatic COVID-19 negative residents might not be a threat to transmit COVID-19, they still may have another respiratory illness such as influenza. 2. Asymptomatic residents should be closely monitored for symptom development . D. Cohort 4: New or Readmissions This cohort consists of all persons from the community or other healthcare facilities who are newly or readmitted . This cohort serves as an observation area where persons remain for 14 days to monitor for symptoms that may be compatible with COVID-19. Testing at the end of this period could be considered to increase the certainty that the person is not infected The policy did not contain information on how staff, who are not designated to one cohort only, should proceed in what order to care for residents in different cohorts. A review of the facility provided policy title, ISOLATION-CATEGORIES OF TRANSMISSION-BASED PRECAUTIONS, with a revised date of 4/22/20, included the following: PROCEDURE: 1. Transmission-Based Precaution will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection . Droplet Precautions . 5. Resident Transport a. Limit movement of resident from the room to essential purposes only. b. If transport or movement from the room is necessary, place a mask on the infected individual and encourage the resident to follow respiratory hygiene/cough etiquette to minimize dispersal of droplets . d. If the resident can tolerate a mask and control respiratory secretions, some activities outside the room may be acceptable. Review of the facility provided policy title, ISOLATION-INITIATING TRANSMISSION-BASED PRECAUTIONS, with a revised date of 1/9/20, included the following: PURPOSE: Transmission-Based Precautions will be initiated when there is a reason to believe that an elder has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions . PROCEDURE: . 4. Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Preventionist discontinues them, which should occur after pertinent criteria for discontinuation are met. 5. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall: a. Ensure that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the elder's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door and inside the cover of the elder's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room . 3. On 5/26/21 between 9:10 AM to 10 AM, during the entrance conference, the surveyor interviewed the Assistant Licensed Nursing Home Administrator (ALNHA) and Director of Nursing (DON), who noted that the Infection Preventionist was on vacation. Both pointed out that infection control was a team effort and that they could speak to any questions regarding infection control. The DON stated that they were following CDC guidelines and NJDOH guidelines for infection control protocols. At that time, the ALNHA and DON further stated that the facility was currently in an outbreak. The staff was required to wear an N95 respirator and a face shield or goggles and, if preferred, a surgical mask over the N95 throughout the building. The ALNHA and the DON explained that the Aspen unit was considered the sub-acute unit. All new admissions were cohorted on that unit, and the new admissions were reviewed for vaccination status. Further explanation included that if the new admission was vaccinated, the resident was not a PUI and did not require to be quarantined. If the new admission was not vaccinated, the resident was considered a PUI and would have to be quarantined for 14 days. In addition, the ALNHA and DON stated that when entering a PUI room, the requirement was to put on a gown and gloves and remove them before exiting the room. On 5/26/21 at 10:30 AM, the surveyor interviewed the CNA in the hallway of the Aspen unit. The CNA stated that she usually worked on the Aspen unit, where new admissions and some residents were quarantined. The CNA explained that there were colored dots on the outside nameplate of the resident's rooms that indicated if the resident was on quarantine. The CNA further explained that the green dot meant that the resident was vaccinated and not quarantined. The yellow dot meant that the resident was not vaccinated, was quarantined, and had precautions. The red dot meant that the resident was quarantined and was COVID-19 positive. The CNA also explained that the green dot was on the resident's nameplate. The yellow and red dots were placed on a 14 Day Quarantine Standard Precautions form with the resident's name and dates of when the resident was to have precautions starting and ending, and the form was taped to the nameplate of the resident's room. The CNA stated that she was wearing an N95 respirator and a face shield. The CNA also said that she had to put on a gown and gloves before entering a resident's room with a yellow dot to perform care. The CNA added that if she was not performing care and just going in to drop something off, she would not need to put on a gown and gloves but always wore an N95 and face shield. The CNA also stated that for the COVID-positive residents (a separate section of the Aspen unit), she had to put on a gown and gloves every time she entered the resident's room. On 5/26/21 at 10:35 AM, the surveyor observed, from the hallway, the Occupational Therapist (OT) in the room of Resident #13 at the foot of the bed. The OT wore a mask with a surgical mask over and a face shield. The OT was not wearing a gown or gloves. The OT handed the paperwork to the resident and then exited the room. On 5/26/21 between 10:37 to 10:42 AM, the surveyor interviewed the OT, who stated that the 14 Day Quarantine Standard Precautions sign on the door of the resident's room had a yellow dot which meant that the resident was under observation. The OT stated that she was wearing an N9[TRUNCATED]

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow their policy for personal protective equipment (PPE) usage and hand washing. This deficient practice was identified for one staff member on 1 of 4 nursing units during a COVID-19 focused survey and was evidenced by the following: On 06/29/20 at 9:10 AM, during the entrance conference, the Senior Director of Nursing (SDON) stated that the facility cohorted PUI residents who tested positive for COVID-19 resided on the odd hallway of the Aspen Unit; 1 Covid + Resident was a recent Hospital Admission and was housed in a private room. She further noted that asymptomatic residents, recovered or tested negative for COVID-19, were cohorted on the Aspen Unit's even hallway, also housed in private rooms. Both sides had designated staff assigned. The SDON stated that all staff on the Aspen Unit were required to wear Personal Protective Equipment (PPE) (protective garments that protect the body from infection, i.e., gloves, gowns, masks) when they entered the room of a COVID-19 positive resident which included an N-95 mask (particulate filtering respirator), a surgical mask placed over the N-95 mask, and a face shield. She further stated that staff was required to wear both an N-95 mask and gloves when they entered the room of asymptomatic residents on the Aspen Unit. At 12:32 PM, during the facility's initial tour, the surveyor observed the meal pass on the low side of the Aspen Unit. The surveyor observed a Certified Nursing Assistant (CNA) remove a tray from the lunch truck and carry it into Resident #1's room wearing only an N-95 mask and no other PPE. The CNA raised the head of the resident's bed and positioned the bedside table in front of the resident before opening items on the food tray. The CNA then left the resident's room without first performing hand hygiene. At 12:35 PM, the surveyor observed the CNA remove a tray from the lunch truck and carry it into Resident #2's room wearing only an N-95 mask and no other PPE. The CNA moved some of the resident's personal effects on the overbed table before placing the tray on the table. The CNA then obtained a pair of gloves and dropped one of the gloves on the floor. She picked up the glove from the floor and applied it to her right hand. The CNA then placed both of her gloved hands on the overbed table, and then picked up a Styrofoam cup with her right hand from the tray and put it within the resident's reach. The CNA proceeded to remove her gloves and went into the resident's bathroom out of the surveyor's line of sight. At 12:39 PM, the surveyor interviewed the CNA, who stated that she was supposed to donn (put on) gloves before entering Resident #1's room to provide resident care but was not required to wear gloves for meal delivery. She further stated that she should have washed her hands or used hand sanitizer both before and after meal delivery and apologized for not doing so. The CNA stated that she should have applied a new glove when she dropped her glove on the floor in Resident #2's room before provided the resident with assistance with his/her meal tray. She stated that instead, she put on a dirty glove that was considered contaminated. She further noted that it was best practice to change her gloves and wash her hands for 20 seconds after glove removal. At 12:46 PM, the surveyor observed the CNA assist with meal tray distribution on the Aspen Unit's high side. The CNA entered Resident #3's room, wearing only an N-95 mask and no other PPE. She then assisted the resident in moving the overbed table and opened items on the resident's meal tray. The CNA then left the room without first performing hand hygiene. The surveyor observed the CNA access the food truck, and she pulled two trays out slightly to view their contents before she pushed them back inside without removing them. The CNA stated that she only touched plastic items on Resident #3's lunch tray when interviewed. She said that she should have washed her hands or used hand sanitizer before leaving the resident's room and accessing the food truck. She stated that there was a potential that her hands could have been contaminated. She further stated that she should have washed her hands more. The CNA did not utilize the alcohol-based hand rub that was affixed to the wall in the hallway or wash her hands after she was interviewed. At 12:52 PM, the surveyor observed a resident seated in a wheelchair in the hallway prepared for discharge with his/her belongings. The CNA then pushed the resident in his/her wheelchair off the nursing unit without first performing hand hygiene. At 1:00 PM, the surveyor interviewed the Registered Nurse (RN) assigned to the Aspen Unit's odd hallway, who stated that she didn't like to wear gloves during the meal pass and instead preferred to wash her hand for 20 seconds both before and after meal delivery. She stated that the CNA should have applied a new glove after dropping her glove on the floor. She further said that she would call for a new tray because it was now considered contaminated. At 1:22 PM, the surveyor interviewed the Infection Preventionist (IP), who stated that hand hygiene should occur with any resident interaction and was required both before and after PPE application or removal. She further said that she would hope that if a staff member dropped a glove on the floor that they would throw the gloves away, wash their hands and apply a new pair of gloves. The IP stated that the CNA's hands could have contaminated the resident's food tray. The IP stated that because the CNA did not wash her hands after she delivered a meal tray and provided resident assistance before she touched the wheelchair of a resident prepared for discharge from the facility, there was a possibility that the CNA could now possibly spread germs out into the community. At 1:30 PM, the surveyor interviewed the SDON, who stated that all new admissions were placed under suspicion of COVID-19 for 14 days. She stated that residents do not require signage or PPE carts outside of their rooms because they have no past medical history of [REDACTED]. She stated that staff is required to wear a surgical mask, and gloves should be worn in accordance with standard precautions. She further noted that staff was required to wash their hands before they exited the resident's room. The SDON stated that if a staff member dropped a glove on the floor, the glove should be picked up and thrown away, and that staff should wash their hands for 20 seconds outside of the stream of running water. The SDON stated that Resident #1 declined to be tested for COVID-19 before admission and would be tested on Wednesday. She further noted that both Resident #2 and Resident #3 tested negative for COVID-19 before admission, and she provided the surveyor with documented evidence of testing. The surveyor reviewed the CNA's Nursing Assistant Competencies, which revealed that she reviewed the facility Hand Washing Policy on 3/10/20, 6/05/20, and 6/11/20 and reviewed the facility PPE Policy on 06/11/20 and that she met facility expectations on evaluation. The surveyor reviewed the following facility policies which revealed the following: [MEDICAL CONDITION] Respiratory Infection and Outbreak (Revised 03/20/2020), Handwashing/Hand Hygiene: (Revised 07/18/18) and Personal Protective Equipment-Gloves (Effective Date: 03/1/17): [MEDICAL CONDITION] Respiratory Infection and Outbreak: Standard Precautions: 1. During the care of any elder, all staff shall adhere to standard precautions, which are the foundation for preventing transmission of infectious agents in all healthcare settings. 2. Hand hygiene: a. Staff will perform hand hygiene frequently, including before and after all elder contact, contact with potentially infectious material, and before putting on and upon removal of personal protective equipment, including gloves. b. Hand hygiene in healthcare settings will be performed by washing with soap and water or using alcohol-based hand rubs. If hands are visibly soiled, soap and water, not alcohol-based hand rubs, will be used. 3. Gloves: a. Gloves will be worn for any contact with potentially infectious material. b. Gloves will be removed after contact, followed by hand hygiene . Handwashing/Hand Hygiene: .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-microbial) and water for the following situations: Before coming on duty; Before and after contact with residents; .Before donning gloves; .After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; After removing gloves; Hand hygiene is the final step after removing and disposing of personal protective equipment. Washing Hands: 1. Turn the faucet on, . 2. Angle your arms down, holding your hands lower than your elbows. Wet your hands and wrists. 3. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) away from the stream of water. 4. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of the sink. 5. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. 6. Discard towels into the trash . Applying and Removing Gloves: 1. Perform hand hygiene before applying gloves. 2. When applying, remove one glove from the dispensing box one at a time, touching only the top of the cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. NJAC 8:39-19.4

Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards of nursing practice by administering expired insulin medication to a resident. This deficient practice was identified for Resident #35, 1 of 21 residents reviewed for medication and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey included, The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On [DATE] at 10:47 AM, in the presence of a Licensed Practical Nurse (LPN), the surveyor inspected the Even Medication Cart on the Sandlewood Unit. During the inspection, the surveyor observed a [MEDICATION NAME] pen, a disposable pre-filled insulin pen that contained a medication used to control blood sugar (BS), which was stored in a plastic bag on the top drawer of the medication cart. The surveyor observed that the [MEDICATION NAME] pen's label had a handwritten opened date of [DATE]. Above the [DATE] opened date, there was a printed cautionary label to discard unused medication after 28 days of the date the [MEDICATION NAME] pen was opened, which indicated the medication should have been discarded by [DATE]. When interviewed, the LPN inspected the medication cart, in the presence of the surveyor, and stated the [DATE] [MEDICATION NAME] pen was currently being used for Resident #35 and there were no other [MEDICATION NAME] pens stored in the medication cart for the resident. The LPN further stated the resident might have an additional [MEDICATION NAME] pen in the Sandlewood Unit medication room (medication room) refrigerator. The LPN entered the medication room and returned to the medication cart. At which time, the LPN informed the surveyor that she checked the medication room refrigerator, and Resident #35 did not have an additional [MEDICATION NAME] pen stored in the medication room refrigerator. The LPN stated that Resident #35 was due to receive a dose in the evening, and she would call the pharmacy to reorder it. On [DATE] at 10:54 AM, the surveyor inspected the medication room, in the presence of the LPN, and observed no additional [MEDICATION NAME] pen for Resident #35. According to the Face Sheet, Resident #35 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care dated [DATE], revealed that Resident #35 was moderately cognitively impaired and had received insulin injections 7 out of 7 days during the assessment period. Resident #35's (MONTH) 2020 Physician order [REDACTED]. The POS reflected a second physician order, dated [DATE], to administer four units of [MEDICATION NAME] one time daily with the scheduled administration time of 9:00 PM. Resident #35's (MONTH) 2020 Electronic Medication Administration Record [REDACTED]. The (MONTH) 2020 eMAR reflected the nurses administered the expired medication on the following dates: [DATE] at 7:30 AM for a BS of 160; [DATE] at 9:00 PM for a BS of 187; [DATE] at 7:30 AM for a BS of 177; [DATE] at 9:00 PM for a BS of 183; [DATE] at 7:30 AM for a BS of 112; [DATE] at 9:00 PM for a BS of 272; [DATE] at 7:30 AM for a BS of 268. During a follow-up interview with the surveyor on [DATE] at 11:16 AM, the LPN stated Resident #35 received [MEDICATION NAME] twice daily, one dose in the morning, and the other dose at bedtime. The LPN said the resident received seven units of [MEDICATION NAME] in the morning as long as the resident's BS level measured above 100. At which time, the LPN confirmed she administered the expired [DATE] [MEDICATION NAME] pen to Resident #35 that morning. The LPN stated she checked the medication label and dates when administering the insulin. When questioned why the expired medication was administered that morning, the LPN stated that she thought the [MEDICATION NAME] pen expired 31 days after opening. The LPN further stated she spoke with the pharmacist, who confirmed the [MEDICATION NAME] pen was to be discarded 28 days after opening. During an interview with the surveyor on [DATE] at 12:22 PM, the Director of Nursing (DON) stated the nurse was to check the physician order [REDACTED]. The DON said the nurse should check the date on the insulin pen to make sure it was not outdated. The DON further stated there was a guide for nurses in the narcotic book on the medication carts that listed expiration dates for opened medications. The surveyor reviewed the (YEAR) Expiration Dates for Opened Medications sheet, provided by the DON, which revealed to date a [MEDICATION NAME] pen when removed from the refrigerator and to discard the pen after 28 days. Review of the facility's Storage of Medications policy, with the revision date of [DATE], indicated the facility should not use outdated drugs. Review of the facility's Administering Medications policy, with the revision date of [DATE], reflected, Medications that have a specific shelf life as per the manufacture should be dated upon opening and discarded as specified, ie. Insulin . NJAC 8:,[DATE].2(b), 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to minimize the potential spread of infection to residents a.) during wound treatment for 1 of 1 nurses observed during wound treatment observation on 1 of 3 units (Sandlewood Unit), and b.) during medication administration for 1 of 5 nurses observed during medication administration on 1 of 3 units (Aspin Unit). This deficient practice was evidenced by the following: 1. On 02/13/19 at 10:55 AM, the surveyor observed the Sandelwood Unit Licensed Practical Nurse (LPN) complete the sacral wound dressing change for Resident #17. The surveyor observed that the LPN established a clean field, gathered her supplies, provided privacy and began the wound dressing change. The surveyor observed that the LPN donned gloves, removed the dressing to the sacral wound, removed her gloves and placed both the soiled dressing and gloves in the trash. The surveyor further observed that the LPN donned gloves, cleaned the wound, dried the wound with gauze, and then removed her gloves. The surveyor observed that the LPN donned gloves, applied the treatment to the wound and applied the dressing to the wound. At the completion of the wound treatment, the surveyor interviewed the LPN. The LPN stated that her hands were not soiled so she just changed her gloves and did not need to wash her hands. 2. On 02/13/19 at 11:39 AM, the surveyor observed the Aspin Unit Registered Nurse (RN) administer Humalog Insulin (an injectable, fast acting diabetic medication) to Resident #214 who was seated in a wheelchair at the bedside. After administering the medication, the RN discarded the insulin syringe into the sharps container located on the outside of the medication cart and removed her gloves. The RN then wheeled Resident #214 out of the room to lunch, without performing hand hygiene after the administration of the medication and glove removal. The RN stated at that time that she needed to get the resident to lunch. The surveyor reviewed the facility's Handwashing/Hand Hygiene policy with an effective date of 03/01/17. The policy revealed, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy further revealed the staff should wash their hands before donning gloves, before handling clean or soiled dressings, gauze pads, etc., after handling used dressings, contaminated equipment, etc., and after removing gloves. NJAC 8:39-19.4(a), 19.4(n)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a manner intended to prevent the spread of food borne illness. This deficient practice was evidenced by the following: On [DATE] from 8:50 a.m. to 9:25 a.m., the surveyor, who was accompanied by the Executive Chef (EC), observed the following in the kitchen: 1. The surveyor observed the EC with a hat on her head which left hair exposed out of the back of her hat. 2. In a sink located near the cooking area, the surveyor observed a packaged food in a container with water running over the packaged food. The surveyor further observed that the packaged food was not fully submerged in the water. When interviewed, at that time, the EC stated that the packaged food in the container was frozen fish and that the fish was currently being defrosted. 3. The Director of Dining Services (DDS) entered the kitchen, the DDS did not have a hairnet or a beard restraint on. 4. In the dry storage room, a clear plastic container contained a white substance which was uncovered and unlabeled. When interviewed at that time the EC stated that the substance was salt. 5. In the main walk-in refrigerator the surveyor noticed a tray on a push cart. The tray contained multiple cartons of expired fat free milk. When interviewed, at that time, the EC stated the expired cartons of fat free milk should not have been in the walk-in refrigerator. 6. A Food Service Worker was in a prep area chopping vegetables. The FSW had a hat on and her long bangs, reaching passed her eyebrows, were not restrained. When interviewed, at that time, the FSW stated that she was preparing salads. 7. A box holding clear plastic wrap was visibly soiled with an unknown substance. When interviewed, at that time, the EC stated the stains were water and stuff. 8. A FSW entered the kitchen with a hat on her head and her bangs were not restrained. On [DATE], the surveyor interviewed the DDS in the presence of the Administrator and other surveyors. The DDS stated that is was not in their policy to wear beard restraints and that hairnets/hair restraints are worn in food prep areas. The surveyor reviewed the facility's undated Employee Sanitary Practices policy. The policy revealed that all employees shall wear hairs restraints (hairnet, hat) to prevent hair from contacting exposed food. The surveyor reviewed the facility's undated Safe Thawing Practices policy provided by the DDS. The policy reflected to completely submerge the item in clean running water. The surveyor also reviewed that facility's undated Food Storage policy. The policy revealed that all foods would be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. NJAC 8:,[DATE].2(g)