Complaint #: NJ178726 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to sanitize and ensure that the frying pan was cleaned to prevent microbial growth. This deficient practice was evidenced by the following: On 11/14/24 at 11:36 a.m. the surveyor, who was accompanied by the Director of Food Services (DFS), observed in the kitchen, Dietary Aide (DA #2) washed a frying pan, rinsed, and then dipped the frying pan in the sanitizer for less than 3 seconds and removed and placed the frying pan on the side of the sink to drain. During an interview with the Director of Food Services (DFS) at 11:09 a.m., he stated that the sanitizing step should not be missed because it was the most important step, and it killed the bacteria and the germs. During an interview with DA #2 at 11:48 a.m., he stated that the frying pan should be sanitized for 20 seconds and that he did it for less than 20 seconds. DA #2 further stated it was important to disinfect the frying pan so that it does not have any germs, and that if there were germs, it was not good for serving food. During an interview with the DFS at 11:53 a.m., who also observed DS #2 washed the frying pan, he stated that the staff did not let the frying pan sit for the full 20 seconds. DFS stated that staff should have let the frying pan sat for a full 20 seconds and then pull the frying pan out to let it air dry. DFS further stated that it was important for staff to dip the frying pan in the sanitizer for 20 seconds to kill any bacteria or germs to prevent infecting residents. During an interview with Dietary supervisor (DS #1) at 12:08 p.m., he stated that staff should not have dipped the frying pan in the sanitizer taken it out immediately. DS #1 stated that staff should have held or placed the frying pan for at least 20 seconds in the sanitizer to make sure the frying pan was free of germ and bacteria. DS #1 further stated that the sanitizer killed the germs, and that germs could spread and cause sickness to the residents and employees who must consume the food. During an interview with the Infection Preventionist Nurse (IPN) at 2:20 p.m., she stated that if the sanitizing process was not followed as directed by not sanitizing for the length of time, the item was still dirty, could attract pest, was unsanitary, and not fit for cooking in, which could result in people potentially getting sick. Review of undated policy titled Cleaning Dishes - Manual Dishwashing that dishes should be placed in the sanitizing sink and allow to stand according to the manufacturer's guidelines for sanitizer. Review of the Ecolab Smartpower Sanitizer Instruction revealed, EPA-registered sanitizer for pre-cleaned use on hard, non-porous food prep surfaces and ware, kills food borne organisms as listed on product label. Review of the Ecolab Smartpower Sanitizer instructions revealed, Apply SMARTPOWER Sanitizer at proper solution. Expose all surfaces of equipment, ware or utensils to the sanitizing solution for a period of not less than one minute. Air dry. NJAC 8:39 - 17.2 (g)

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Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan to address the anticoagulant medication prescribed for 1 of 3 residents (Resident # 115) reviewed for anticoagulant medications and evidence by the following: On 7/22/24 at 12:54 PM, the surveyor observed Resident #115 in room and the resident stated takes an anticoagulant medication. The surveyor reviewed the Electronic Medical Records for Resident # 115 that revealed the following: According to the admission Record indicated that Resident # 115 was admitted with diagnoses that included Atrial Fibrillation. According to the Physician's Order Summary Sheet, the resident had the following physician's order for by mouth administration of medications: -Apixaban Tablet (a medication which thins the blood and is used to reduce the risk of stroke and heart attack) 2.5 mg 1 tablet by mouth every two days. The surveyor reviewed the resident's care plans and observed that there was no care plan to address the care needs for Resident #115 with an anticoagulant. On 7/25/24 at 11:03 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the Unit Manager completes the care plans and that there should be a care plan in place for this resident who receives anticoagulant medication. The LPN stated that she was not sure why there was no care plan created. On 7/25/24 at 1:16 PM, the surveyor discussed the above concern with the Administrator and Director of Nursing. No additional information was provided. NJAC 8:39-11.2 (e)

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Based on observation, interview and record review, it was determined that the facility failed to ensure that the physician signed and dated monthly medication orders. The deficient practice was identified for 5 of 34 residents reviewed (#2, 84, 115, 32 and 33) and occurred over a 3 month period. The deficient practice was evidenced by the following. 1. A review of the hybrid medical record for Resident # 2 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. 2. A review of the hybrid medical record for Resident # 84 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. 3. A review of the hybrid medical record for Resident # 115 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. 4. A review of the hybrid medical record for Resident #32 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April or June 2024. 5. A review of the hybrid medical record for Resident #33 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. On 7/26/24 at 10:51 AM, the Wing 2 Unit Manager stated to the surveyor that the physicians should sign their monthly orders electronically. On 7/26/24 at 12:49 PM, the surveyor discussed with the Director of Nursing (DON) and the Administrator concerns of physicians not signing their monthly orders. The DON stated the physicians should be signing orders electronically. NJAC 8:39-23.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to assess for complications upon residents' return from the renal dialysis (RD) center for 2 of 5 residents (Resident #55 and Resident #146) reviewed for dialysis care. The deficient practice was evidenced by the following: 1. On 7/22/24 at 11:07, AM the surveyor observed Resident #55 lying in bed with the television on, wearing glasses, call light within reach. The resident stated, I go to dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) M-W-F, but I refused to go today because I don't feel good. I usually get my medication and meal before I leave for dialysis. I have my access on left arm and the nurses checks on this at times. A review of the medical record revealed the following information: The Resident #55 had a diagnosis of but not limited to end stage renal disease (esrd); dependence on renal dialysis. End stage renal disease is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life. A review of the order summary in the electronic health record (EHR) revealed orders for: Dialysis treatment 3 times a week on Mon, Wed, Fri at 10:00am. Pick-up at 9:45am, one time a day every Mon, Wed, Fri; Monitor dialysis access site Left Arm for signs & symptoms of bleeding, infection and pain every shift. Notify provider if abnormal findings and document in progress note every shift; AV (arterial venous) Fistula Left Arm, monitor bruit/thrill every shift, report any abnormal findings to medical doctor (MD). A review of the Quarterly Minimum Data Sheet (MDS), an assessment tool used to facilitate the management of care, dated 5/17/24 reflected the Resident #55 had a brief interview for mental status (BIMS) score of 3 out of 15, indicating the resident had severe impaired cognition. The RD Care Plan initiated on 1/12/24 instructed nursing staff to monitor AV fistula for a bruit, thrill, signs of infection, bleeding, patency, etc. Refer to MD as needed. On 7/24/24 at 12:15 PM, the surveyor interviewed the registered nurse (RN) in Unit 3, who has been working at the facility for 20 years, who stated, Resident #55 was in the hospital a couple of times because resident refused dialysis at least 4x a month and was sent out to hospital due to refusing dialysis. This is resident's typical self, and all the doctors are aware. The resident goes to dialysis M-W-F. A review of the nurses' progress notes for post dialysis access site assessment when resident was agreeable to go to dialysis, revealed inconsistent nursing assessment done from 5/17/2024 through 7/26/24 (two months-18 days total). The missing nursing documentations for post dialysis access site assessment were: 5/17/24; 5/27; 5/31; 6/10; 6/12; 6/14; 6/17; 6/19; 6/24; 6/26; 6/28; 7/3; 7/5; 7/15; 7/17; 7/19; 7/24; and 7/26. 2. On 7/22/24 at 10:20 AM, the surveyor observed Resident #146 lying in bed, appears neat and dressed, call light within reach. The resident stated, I have an access on my left arm for dialysis, I'm supposed to go today. A review of the medical records for Resident #146 revealed diagnosis but not limited to: end stage renal disease and dependence on renal dialysis. The order summary revealed: Continue to monitor Dialysis Access site wound every shift for bleeding; Dialysis treatment 3 times a week on Tu/Th/Sat; L-arm AV Shunt, monitor shunt for s/s of infection, bleeding, bruit/thrill every shift. NO BP ON LEFT ARM, Monitoring Report any abnormal findings to MD; Monitor left arm for signs & symptoms of bleeding, infection and pain every shift every shift ordered 3/6/24. The Quarterly MDS dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. Care plan dated 2/23/24 reflected to monitor AV fistula. A review of the nursing progress notes revealed the resident received renal dialysis on T-TH-Saturdays and then changed to M-W-F on 7/22/24. The surveyor reviewed nurses progress notes for post dialysis access site assessment which revealed inconsistent nursing assessment done from April 2024 through 7/19/24 (three months-32 days total). The nursing progress notes revealed missing documentation for post dialysis access site assessment for the dates of: 4/20/24, 4/23, 4/25, 4/27, 4/30, 5/2, 5/7, 5/11, 5/14, 5/16, 5/18, 5/21, 5/23, 5/25, 5/30, 6/1, 6/4, 6/6, 6/8, 6/13, 6/15, 6/18, 6/22, 6/27, 7/2, 7/4, 7/6, 7/9, 7/11, 7/18, 7/22, and 7/24/24. On 7/24/24 at 2:15 PM, the surveyor interviewed the director of nursing (DON), who has been working in the facility since last October of 2023, in the presence of the Licensed Nursing Home Administration (LNHA) and the survey team regarding the Dialysis Communication Worksheet to clarify pre and post dialysis access site evaluations. The worksheet did not include post dialysis assessments. Requested the DON to provide additional documentation for access site assessments by nursing staff. On 7/25/24 at 8: 45 AM, the DON provided documentation of Dialysis Worksheet for pre assessment of dialysis access for residents but did not provide documentation for post dialysis access site assessments. The DON stated in the presence of another surveyor, The documentation in this place is really bad. The post dialysis access site assessment documentation should be in the nursing progress notes in the computer if the nurses did them. On 7/25/24 at 11:03 AM, interviewed the RN who stated, The process is you have to check the dialysis site every shift for drainage, bruit, thrill and bleeding, and we also check it before and after dialysis and document in the computer. I don't see any post dialysis access site assessment documentation for the Resident #55 in the EHR for the last few weeks and Resident #146, I see one time documentation in progress notes for 6/25/24 only. The RN acknowledged that there should be documentation every time the resident comes back after dialysis. On 7/25/24 at 1:30 PM, the surveyor discussed findings and concern with post dialysis site nursing assessment, in the presence of the survey team, the DON, LNHA and the Regional Director of Operations. No additional documents were provided by the facility. A review of the facility policy and procedure titled Hemodialysis with a revision date of 3/2024 revealed, The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. NJAC 8:39-27.1(a); 2.9

Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services by ensuring the accurate administration of a medication, Midodrine, (medication used to increase the blood pressure), according to the physician's order to meet the needs of the resident. The deficient practice was identified for one (1) of 34 residents, (Resident #55) reviewed for medication management. The deficient practice was evidenced by the following: On 7/22/24 at 11:07 AM, the surveyor observed the Resident #55 in the Unit 3 North Wing in their room, lying in bed with the television on, wearing glasses, and call light within reach. On 7/24/24 at 9:34 AM, the surveyor reviewed the electronic health records (EHR) for Resident #55 which revealed diagnosis that included but not limited to hypotension, the pressure of blood circulating around the body is lower than normal. Blood pressure (BP) is the pressure of blood on the walls of your arteries as your heart pumps blood around your body. A review of the Quarterly Minimum Data Sheet (MDS), an assessment tool used to facilitate the management of care, dated 5/17/24 reflected the resident had a brief interview for mental status (BIMS) score of 3 out of 15, indicating the resident had severe impaired cognition. A review of the resident's Order Summary Report reflected a physician's order dated 5/10/24 for Midodrine HCl Oral Tablet 5 MG (Midodrine Hydrochloride) Give 1 tablet by mouth at bedtime for Hypotension Hold for SBP>130. The systolic blood pressure (SBP) is the first number, it is the pressure caused by your heart contracting and pushing out blood. A review of the electronic medication administration (eMARS) from April 2024 through July 2024 (three months) revealed Midodrine HCL was administered and not held for parameters of SBP>130 as ordered for: April 2024, received 13 dosages (4/1, 3, 4, 5, 9, 12, 13, 14, 15, 16, 17, 18, 19}; May 2024 received 11 dosages (5/12, 13, 15, 16, 18, 20, 21, 22, 23, 25, 30); June 2024 received 15 dosages (6/1, 5, 7, 8, 9, 10, 14, 17, 18, 19, 20, 21, 22, 26, 28); and on July 2024, received 17 dosages (7/2,, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 19, 21, 23, 24). A review of the resident's blood pressure at its highest revealed the resident's BP on 5/18/24 was 172/81 and on 7/12/24 BPwas 168/71. The resident had no indication of a negative outcome from Midodrine administration when given above the parameter of SBP >130 during those times. Reviewed the primary physician's progress notes dated 7/15/24 who stated, Reviewed medications and vital signs with no changes. On 7/25/24 at 11:13 AM, the surveyor interviewed the registered nurse (RN) from Unit 3 North Wing who has been working in the facility for 20 years. She stated, The evening nurse should have held the Midodrine medication at night because the SBP is above 130. The nurse didn't pay attention because you can make the blood pressure go higher. On 7/25/24 at 11:35 AM, interviewed the Unit 3 Unit Manager (UM), who has been working in the facility for five months. The UM stated, The Midodrine should had been held when the SBP was above 130 as ordered. I see that it was the evening shift nurse who has been giving it. The resident has had no problems with his BP or had complained to me that he doesn't feel well. On 7/25/24 at 1:30 PM, in the presence of the survey team, the surveyor discussed findings with the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA) and the Regional Director of Operations regarding the concern of Midodrine administration outside the SBP parameters. On 7/26/24 at 8:48 AM, interviewed the 3-11 shift Licensed Practical Nurse (LPN), regarding Midodrine administration on his shift. The LPN stated, Midodrine is a medication for a low blood pressure. The resident sometimes has a low or high BP. I take the BP to make sure it's in range before giving it. I've been making mistakes in the computer; I've been holding the medication, but I didn't know that I had to go back to strike it out. The DON showed me yesterday how to hold it in the computer. I didn't know I had to document in the progress notes if I held a medication. I've been working with this EHR for about three years. If I sign a medication, it means it was given, but I made a mistake with the Midodrine on how to cancel it in this EHR. I've been working in the facility for four years. I didn't know I had to notify anyone when a medication has been held for a couple of times. On 7/26/24 at 10:30 AM, the surveyor received from the DON, the Scriptive Consultants Medication Administration Observation competencies for the LPN dated 5/24/23, 2/5/24 and 7/25/24 which revealed competencies for blood pressure check and cautionaries for the preparation and administration of medications were met by the LPN. On 7/26/24 at 10:40 AM, interviewed the registered pharmacy consultant (RPH), who has been a consultant in the facility for four years, stated, They get their Medication Review Report (MRR) once monthly. We follow up a month later to make sure it was done. If it was a med error, we call them up to look into it. If I get the report again the next month, the facility needs to follow it up, that's the expectation. A review of the Consultant Pharmacist's MRR dated 5/19/24, and 6/25/24 revealed Midodrine was signed numerous times as given when it should have been held for SBP >130. Please reevaluate the resident's need for Midodrine and consider discontinuing. On 7/26/24 at 11: AM, the surveyor in the presence of the survey team discussed with the DON the MRR process and recommendations above and she stated, The unit manager follows through the MRR recommendations, unfortunately in this case it fell through the cracks for the 5/19/24 and 6/25/24 MRR. I did speak to the LPN involved yesterday and he did not know how to work the screen of EHR, but the expectation is, if something is held for a few days, the LPN should have told his manager, the primary doctor and should have documented in the progress notes when medications were held. No additional documentation was provided by the facility. A review of the facility policy and procedure titled, Medication Administration revised on 6/7/24 revealed, Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. NJAC 8:39-29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REPEAT DEFICIENCY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) minimize the potential spread of infection to residents during medication administration for 1 of 2 nurses observed during medication pass on 1of 2 units (Unit 3 Low side) and b.) follow Center for Disease Control recommendations and guidelines for Hand Hygiene. This deficient practice was evidenced by the following: On 7/24/24 at 7:56 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN) prepare medication for administration to an unsampled resident in room [ROOM NUMBER]. The RN opened the drawer of the medication cart, retrieved the blister packs (multi-use medication packs), and removed the medications amlodipine besylate10mg tablet, colace 100mg tablet and doxazosin mesylate 2mg tablet. The RN administered the medications, returned to the medication cart, opened the drawer, removed the blister packs from the cart, and utilized the computer to sign the electronic medical record (eMR) indicating the medications had been administered. The RN did not perform hand hygiene before preparation or after administration of the medications. On 7/24/24 at 8:06 AM, the surveyor observed the RN prepare medication for administration to Resident #47. The surveyor observed signage posted to the left of the entrance door to Resident #47's room which read: Enhanced Barrier Precautions STOP. Everyone must clean their hands before entering and exiting the room. Providers and staff must also wear gloves and gown during high-contact resident care activities. The surveyor observed the RN open the drawer of the medication cart, retrieve the blister packs and remove the medications duloxetine hcl 60mg caplet, furosemide 40mg tablet and vitamin C 500mg tab from the blister packs. The RN administered the medications, returned to the medication cart, opened the drawer, removed the blister packs from the cart, and utilized the computer to sign the eMR indicating the medications had been administered. The RN did not perform hand hygiene before preparation or after administration of the medications. On 7/24/24 at 8:14 AM, the surveyor observed the RN prepare medication for administration to Resident #117. The surveyor observed signage posted to the left of the entrance door to Resident 47's room which read: Enhanced Barrier Precautions [EBP] Stop. Everyone must clean their hands before entering and exiting the room. Providers and staff must also wear gloves and gown during high-contact resident care activities. The surveyor observed the RN opened the drawer of the medication cart, retrieved the blister packs and removed the medications buspirone 30mg tablet, citalopram 40mg tablet, Keppra 750mg tablet, clozapine 100mg tablet, colace 100mg tablet, from the blister packs. The RN administered the medications, returned to the medication cart, opened the drawer, removed the blister packs from the cart, and utilized the computer to sign the eMR indicating the medications had been administered. The RN did not perform hand hygiene before leaving Resident #117's room or after administration of the medications. On 7/24/24 at 8:27 AM, the surveyor discussed the breaks in technique with the RN. The RN stated that she had not performed hand hygiene during the medication administration because she didn't touch the residents. The surveyor asked the RN if she should perform hand hygiene before preparing medications and after handling the cups that the residents had also handled. The RN acknowledged that she should have performed hand hygiene before preparing medications and after administration of medications. The surveyor showed the EBP signage outside of Resident #47 and Resident #117's rooms. The RN acknowledged that she should have performed hand hygiene before entering and exiting a resident's room who was on EBP to prevent the spread of infection. The surveyor reviewed the facility policy titled, Medication Administration last reviewed 6/7/24, which revealed the following: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .wash hands prior to administering medication per facility protocol and product. The surveyor reviewed the facility policy titled, Enhanced Barrier Precautions last reviewed 3/20/24 which revealed the following: Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves. 2. On 7/22/24 at 02:00 PM, in a conference room inside the facility, the surveyor observed a House Keeper (HK) go to the sink to wash his hands. The surveyor observed the HK put soap on his hands and rubbed his hands together for 12 seconds, then, with his soapy hands, he turned the faucet on and rinsed his hands off. The surveyor observed the HK turn the faucet off with his bare hands and the surveyor observed the HK rub his hands directly onto his pants to dry his hands off. A review of the Hand Hygiene policy and procedure, dated 5/29/24, revealed that All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility .including between resident contacts .before preparing or handling medications. And, Hand Hygiene technique when using soap and water: wet hands with water, apply to the hands the amount of soap recommended by the manufacturer, rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers, rinse hands with water, dry thoroughly with a single-use towel, use clean towel to turn off the faucet. On 7/24/24 at 2:00 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations. The DON acknowledged that the RN was expected to wash her hands or use Alcohol Based Hand Rub (ABHR) prior to handling medications, between residents and before entering and exiting resident rooms who were on EBP. On 7/29/24 at 10:42 AM, the surveyor interviewed the Infection Preventionist (IP), who stated that the HK was recently educated on hand hygiene and should have known how to properly wash their hands according to CDC and facility policy. The IP also stated that nurses during medication pass should also be performing hand hygiene between residents, especially those who are on any type of precautions. According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents and immediately after glove removal. In addition, when cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, and this should be done outside the water when rubbing your hands, then rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take approximately 20 seconds. NJAC 8:39-19.4 (a)

Repeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to a.) store potentially hazardous foods (PHFs) in a manner to prevent food borne illness and b.) maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: (PHFs) are foods that must be kept at certain temperatures to minimize the growth of pathogenic microorganisms that may be present in the food or to prevent the formation of toxins in the food. Generally, PHFs are moist, nutrient-rich and have a neutral ph.) On 7/24/24 at 10:05 AM in the presence of the Food Service Director (FSD) and the Administrator in training (AIT) the surveyor observed the following: 1. The surveyor and FSD went into the walk-in freezer, during observation it was noted that there were sheets of ice on the floor, icicles hanging from the ceiling, the condenser fans and food boxes. The kitchen supervisor was actively scraping the ice off the floor with a long-handled ice scraper. 2. In the walk-in freezer, the surveyor observed several boxes of opened, not labeled with open or expiration dates, and unsealed food items. The items are as follows: croissants, turkey burgers, and breaded eggplant. All the items in the freezer were covered with snow, frost, and ice crystals. 3. On 7/22/24 at 10:18, the surveyor observed that the walk-in refrigerator #1 had inconsistent temperature readings from 3 different thermometers. ~44 degrees Fahrenheit (F) interior built in thermometer, ~46 degrees F, exterior built in thermometer, ~42 degrees F, portable interior thermometer, ~Survey reviewed Refrigerator #1 temperature log which revealed a written temperature of 36 degrees F on 7/21/24 at 730pm. 4. Further observations in Refrigerator #1 by the surveyor was a box of bacon that was opened, unsealed and unlabeled. 5. Walk-in refrigerator #2, was out of service and not working, upon surveyor entry on 7/22/24 there was not a plan for it to be repaired. Surveyor reviewed service order # 4548236, dated 6/26/24 and two emails dated 6/26/24 and post survey team entry on 7/23/24. All three indicated communication FROM the repair service. There were NOT any emails or documents provided to the surveyor indicating correspondence FROM the facility or that repairs were in the process of being initiated or waiting for parts. 6. On 07/22/24 at 01:17 PM, the FSD, Surveyor #1 and Surveyor #2 took temperatures of 2 items in walk-in refrigerator #1. FSD stated that the kitchen thermometers had been calibrated. ~Heavy Cream: 1 liter container, The FSD inserted the calibrated thermometer into the center of the container, it read 46.7 degrees F. ~Cottage Cheese: 32-ounce container. The FSD inserted the calibrated thermometer straight down in the center of the container. The temperature read 50.4 degrees F with the first thermometer. The FSD inserted a second calibrated thermometer that read 49.4 degrees F. 7. The microwave interior ceiling was covered with multi-color splatter debris. The FSD acknowledged that it had not been cleaned correctly. 8. The meat slicer was covered in a plastic bag which the FSD indicated it meant that it was clean. Upon removal of the bag the slicer pusher spikes were soiled with caked on brown debris. The FSD stated that it should have been cleaned and then covered with the bag. 9. The shelf under the griddle had sediment and debris. The FSD acknowledged it had not been clean thoroughly. On 7/22/24 at 11:00 AM, the surveyor interviewed the FSD. who stated, the freezer items should have been labeled with an opening date and if only partial of a bag was used it should be resealed and labeled. He further stated, the cooking equipment should be cleaned and maintained in a sanitary way to prevent food borne illness and contamination. On 7/22/24 at 10:44 AM the surveyor interviewed the kitchen supervisor (KS), who stated, the ice and frost in the freezer is a reoccurring issue. He acknowledged that the frost and snow in the freezer and on the products can degrade the food quality and has the potential to cause food borne pathogens. On 7/22/24 at 11:26 AM, the surveyor interviewed the clinical dietary manager (CDM) who stated, the freezer has been an issue for last 4 months. It is discussed in morning meeting. On 7/24/24 at 10:33 AM, the surveyor interviewed the licensed nursing home administrator (LNHA) who stated, the refrigerators and freezer need to be in working condition because it can cause potentially hazardous food, food borne illnesses and degrades the quality of the food. I acknowledge what the survey team saw. A review of the policy titled, Food Safety Requirements Policy dated 4/9/24, which was provided by the LNHA read . Policy: Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Definition: food service safety refers to the handling, preparing, and storing food in ways that prevent food borne illness. Food borne illness refers to an illness caused by the ingestion of contaminated food or beverages. Policy Explanation and Compliance Guidelines: #1-b) Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. e) Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food. #3-c) Refrigerated storage- foods that require refrigeration shall be refrigerated immediately upon receipt or placed in the freezer whichever is applicable. Practices to maintain safe refrigerated storage include: iv.) labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used-by date, or frozen (where applicable) /discarded. v.) Keeping food covered or in tight containers. #6) all equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. a) Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. #8) Additional strategies to prevent foodborne illness include but are not limited to: d) Proper refrigeration of meat, poultry, and pasteurized dairy products. A review of the policy titled, Physical Environment: Electrical Equipment dated 7/2024, which was provided by the LNHA read . #4) Essential equipment shall be repaired or replaced as soon as practicable. e) Kitchen refrigerator /freezer. A review of the policy titled, Monitoring of Cooler / Freezer Temperature dated 7/2024, which was provided by the LNHA read . Policy: It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. This policy also addresses refrigerated storage. Policy Explanation and Compliance Guidelines: #2) Thermometers shall be placed inside each cooler/ freezer and calibrated at least once per week. #3) All refrigerated storage must be maintained at or below 41 degrees F, unless otherwise specified by law. #5) If temperatures are above 41 degrees F for coolers or 10 degrees F for freezer, the supervisor will be notified immediately for corrective action. a) The unit will be repaired as soon as possible. If the problem cannot be corrected within 2 hours, all food items will be relocated to another unit that can hold foods in an acceptable temperature range. b) Internal temperature readings of all perishables of potentially hazardous food shall be taken and discarded if not in an acceptable range. 11) Refrigerated food shall be labeled, dated, and monitored so that it is used by the use-by date, frozen or discarded, whichever is applicable NJAC 8:39-17.2(g)

Based on the interview, and review of medical and facility policy, it was determined that the facility failed to provide information in a manner easily understood by the resident or resident representative about the right to formulate an Advanced Directive (AD). This deficient practice was identified in 1 of 3 residents reviewed for AD (Resident #150) and evidenced by the following: During an interview of the surveyor on 7/15/22 at 11:11 AM, Resident #150 stated that he/she does not recall if staff offered them AD information. The surveyor reviewed the electronic Medical Record (eMR) for Resident #150. The resident's admission Record (face sheet; an admission summary) indicated that the resident was admitted to the facility and had diagnoses that included but were not limited to; acute respiratory failure with hypoxia (an absence of oxygen in the tissues of the body to sustain bodily functions), unspecified protein-calorie malnutrition, muscle wasting and atrophy (the wasting, thinning, or loss of muscle tissue), tracheostomy (a surgically created opening into the trachea or windpipe), and gastrostomy. The admission Minimum Data Set (MDS), an assessment tool used for management of care dated 6/20/2022 revealed that Resident #150 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. A social worker's (SW) Social History and Initial Assessment signed 6/12/2022 for Resident #150 indicated the resident did not have an AD and no AD information was given to the resident. A SW note dated 6/8/2022 reflects the SW met with the resident for the initial assessment. The SW note revealed that the resident was admitted for short term rehab and that the resident appeared to be alert but very difficult to understand due to their trachea. In addition, the 6/8/22 SW note indicated that the SW spoke with the family representative (FR) to complete the assessment and that a scheduled care conference for Friday at 11:30 to discuss projected plans. Further review of Resident #150's medical record showed that there was no document evidencing that an AD was offered and the resident or their representative was provided information on formulating an AD. On 7/19/22 at 10:13 AM, the SW for Resident #150 stated she came into the facility it was difficult to understand the resident with the tracheostomy. Furthermore, the SW confirmed that she did not offer the FR information on AD. NJAC 8:39-9.6(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to accurately assess a resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 3 of 35 residents reviewed (Resident #66, #149, and #167) as evidenced by the following: 1. On 7/12/22 at 10:42 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that Resident#66 was cognitively impaired and a wanderer. On that same date at 11:00 AM, the surveyor observed the resident standing in the nursing station with the LPN/UM. The resident was not able to respond appropriately to the surveyor's questions. During the observation the surveyor could not observe a wander guard on the resident. The surveyor reviewed the medical records of Resident #66: The resident's admission Record (admission summary) disclosed that the resident had diagnoses which included, but were not limited to, Alzheimer's disease unspecified (A brain disorder that usually starts in late middle age or old age and gets worse over time), dementia in other diseases classified elsewhere with behavioral disturbance (are often globally described as agitation including verbal and physical aggression, wandering, and hoarding), and unspecified psychosis (conditions that affect the mind, where there has been some loss of contact with reality). The Order Summary Report showed that there was an order dated 12/6/21 for wander-guard to right lower extremity every shift, check placement. The above order for wander guard was transcribed to the electronic Treatment Record (eTAR) and signed by nurses every shift from December 2021 through July 2022. The Comprehensive Minimum Data Set (CMDS) dated [DATE], indicated cognitive skills for daily decision-making were severely impaired. Section P: Restraints and Alarms of 10/29/21 CMDS revealed that it was coded as 0 which means that there was no restraint or alarms used for the resident. The 01/28/2 and 4/25/222 Quarterly MDS (QMDS), indicated there were no changes in cognitive skills for daily decision-making. Section P was coded 0. Further review of the MDS revealed that the wander guard used for the resident was not coded in the MDS. On 7/15/22 at 11:18 AM, the surveyor observed the resident walking in the rotunda (is a round building or room) with handheld assistance from the Certified Nursing Aide (CNA). The surveyor asked the LPN/UM while approaching the resident and the CNA to check if the resident had a wander guard in use. Then, the LPN/UM showed the resident's left ankle with a wander guard. Afterward, the surveyor and the LPN/UM went to wing one nursing station. The surveyor asked the LPN/UM why the order in the eTAR was to check the wander guard on the right lower leg when the wander guard at that time was on the left lower leg. The LPN/UM stated that the wander guard was probably loose and had to change it to the left lower leg and forgot to change the order. On 7/18/22 at 11:38 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and was made aware of the above concerns. On 7/18/22 at 12:11 PM, the surveyor informed the MDS Coordinator/Registered Nurse (MDSC/RN) regarding the above concern with the wander guard. The MDSC/RN stated that the wander guard was not coded on the MDS and it should have been coded for accuracy. On 7/19/22 at 02:22 PM, the surveyors met with the LNHA, Director of Nursing (DON), and the Regional Director of Clinical Services/Registered Nurse (RDCS/RN). The facility team both acknowledged that there was a concern with MDS accuracy for not capturing the wander guard alarms in all MDS and the DON stated that it should have been documented. On 7/21/22 at 9:44 AM, the surveyor interviewed the PT/MDSN via phone call. The PT/MDSN informed the surveyor that the coding for the wander guard was missed. He further stated that the wander alarm should have been coded in the MDS. 2. On 7/13/22 at 11:40 AM, Resident #149 was observed in the activities area of the facility sitting in a wheelchair. During the observation the surveyor could not observe a wander guard on the resident. On 7/13/22 at 11:50 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) regarding a wander guard. The LPN said, let's go see if one is on, we check for placement. The LPN checked the medication administration record in the presence of the surveyor which said the resident should have a wander guard on the right ankle. The LPN approached Resident #149, identified the resident, and checked the right ankle where there was a wander guard in place. The surveyor reviewed Resident #149's admission Record from the electronic medical record which indicated the resident admitted to the facility with diagnoses included, but not limited to seizure disorder, anxiety disorder, depression, cognitive impairment, venous insufficiency (circulation disorder) and venous thrombus (blood clot). The most recent QMDS dated [DATE] showed that Resident #149 had a Brief Interview of Mental Status (BIMS) score of 11, meaning the resident had moderate cognitive impairment. The QMDS, Section P, titled Restraints and Alarms indicated that wander guard was coded 0. On 7/14/22 at 12:36 PM, the surveyor reviewed the physician orders, which showed an active order that was initially ordered on 3/17/22 for checking wander guard placement to the right ankle. On 7/14/22 at 01:00 PM, the surveyor reviewed the June and July 2022 eTAR, which showed that the staff were signing that placement of the wander guard was checked every shift. On 7/14/22 at 01:15 PM, the surveyor reviewed Resident #149's care plan which included a focus for elopement and interventions which included wander guard placement, education and follow wander guard guidelines. On 7/19/22 at 02:22 PM, the surveyors met with the LNHA, the RDCS/RN, and the DON for responses. Both the LNHA and DON acknowledged that there was a concern with MDS accuracy for not capturing the wander guard alarms in all MDS and the DON stated that it should have been documented. 3. On 7/14/22 at 10:00 AM, the surveyor observed Resident #167 in the atrium sitting in their wheelchair listening to music. The surveyor reviewed the medical records for the resident. The admission Record which reflected Resident # 167 was admitted to the facility with diagnoses which included but were not limited to: COVID-19 (Coronavirus disease (COVID-19 is an infectious disease caused by the SARS-CoV-2 virus), and alcohol dependence with alcohol induced dementia (a deterioration of mental function resulting from the persisting effects of alcohol abuse. It is characterized by multiple cognitive deficits, especially of memory, but also including impairment of speech, movement, and sensory capabilities.) The Electronic Medical Record (EMR) in the Risk Management assessment dated [DATE] at 11:00 PM, reflected that Resident #167 had a fall with minor injury. According to the QMDS dated [DATE] revealed that Resident's #167 cognitive skills for daily decision making were moderately impaired. Further review of the resident's MDS, Section - J1800 - Any falls since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent, indicated that that Resident #167 had two falls during the assessment review period. This MDS was not accurately coded to reflect one fall with minor injury. On 7/20/22 at 12:02 PM, the surveyor interviewed the MDSC/RN. The MDSC/RN stated that she does not check for accuracy of my MDS Coordinator. Then the surveyor asked the MDSC/RN what was her process for doing MDS, the MDSC/RN stated, For quarterly, we open the record and based on the section we are entering, we do a look back for falls in the Risk Manager, interview staff and family, check the actual chart and different areas in the EMR, then, we document our findings based on all those factors. During an interview, the MDSC/RN acknowledged that the quarterly MDS was inaccurately coded for falls. NJAC 8:39-11.2(e)1; 27.1(a), 33.2(d)

Based on observations, interviews, and record review, it was determined that the facility failed to clarify a physician order for 1 of 3 residents (Resident #63) reviewed for code status according to professional standards of clinical practice. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 7/12/22 at 11:02 AM, the surveyor observed Resident #63 sitting in a wheelchair at a table with other residents in a small area across from the nurse's station. Resident #63 was awake, alert, and speaking in another language to other residents. Resident #63 was unable to answer any questions from the surveyor. The surveyor reviewed Resident #63's electronic Medical Record (eMR). The admission Record (admission summary) showed that the resident had a diagnosis that included, but was not limited to, Chronic ischemic heart disease (damage in the heart's major blood vessels), essential hypertension (abnormally high blood pressure), anemia (a condition in which the blood does not have enough red blood cells), dementia (impairment of memory loss and judgment), and adult failure to thrive. The quarterly Minimum Data Set (MDS), an assessment tool used for management of care, dated 6/30/22 indicated Resident #63's cognition was severely impaired. A review of the current Order Summary Report (OSR) indicated a physician order (PO) on 12/28/2017 for Full code (Full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive), and another physician order dated 4/14/2022 for DNR (Do not Resuscitate-indicating that a person should not receive cardiopulmonary resuscitation if that person's heart stops beating), and DNI (Do Not Intubate-meaning no breathing tube would be placed). The Nurses Notes dated 4/14/2022 at 4:22 PM indicated a hospice nurse visited Resident #63 and a new POLST (Physician Orders for Life Sustaining Treatment) of DNR, DNI was placed. During an interview with the surveyor on 7/14/22 at 12:58 PM, Resident #63's assigned LPN (Licensed Practical Nurse), stated that a resident's code status was documented in a resident's paper chart and a resident's eMR. The surveyor asked the LPN to show the surveyor where the code status was documented in the eMR for Resident #63. Then, the LPN showed and stated that the resident was Full Code as documented below Resident #63's photo in the eMR. On that same date and time, the surveyor asked the LPN to review Resident #63's PO. The LPN stated that Resident #63 had two PO for code status. The LPN stated that one PO dated 12/28/2017 indicated the resident was a Full code, and another PO dated 4/14/2022 indicated DNR/DNI. The LPN stated that the two PO for code status should have been clarified and corrected. The LPN also added that he/she had entered the PO of DNR/DNI on 4/14/22 in Resident #63's eMR. The LPN stated that he/she should have discontinued the 12/28/2017 Full Code PO after entering the DNR/DNI PO on 4/14/2022. During an interview with the surveyor on 7/15/22 at 9:42 AM, the facility's Social Worker (SW) stated that each resident's code status is documented in their eMR below the resident's photo on the profile screen. The SW stated that if there is a change in the code status, then the nurses would have to enter the change in the resident's eMR. The SW stated that nursing is responsible to update a resident's code status in the eMR and a resident's paper chart. The SW added that the facility team would be informed of any resident code status changes during morning clinical meetings. During an interview with the surveyor on 7/15/22 at 9:50 AM, the Regional Nurse stated that a resident's code status is in the PO and would populate on top of the dashboard below a resident's photo in their eMR. The Regional Nurse added that each resident's code status was reviewed during the 24-hour clinical meetings. On 7/19/22 at 02:24 PM, with the survey team in attendance, the DON (Director of Nursing) stated that there were two physician orders for code status for Resident #63. One PO for full code, and a second order for DNR/DNI. The DON stated that the nurse that put in the DNR/DNI order did not discontinue the previous order of Full Code. The DON stated that the nurse should have discontinued the previous Full Code order after entering the DNR/DNI physician order. NJAC 8:39-35.2 (d)6 N.J.A.C 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow a physician's order (PO) for a right-hand grip splint. This deficient practice was identified for 1 of 3 residents (Resident #73) reviewed for limited range of motion (ROM). This deficient practice was evidenced by the following: On 7/12/22 at 11:30 AM, the surveyor observed the resident awake, dressed, and seated in a wheelchair in the rotunda area. The resident's right hand was observed contracted with no device in use. The resident was alert, and able to answer questions appropriately. Later that same day at 01:00 PM, the surveyor observed the resident out of bed seated in a wheelchair in their room with no device in use. On 7/13/22 at 11:50 PM, the surveyor observed the resident awake, out of bed and seated in a wheelchair. The resident was self-propelling back to their room. There was no right-hand grip splint in use. At that same time, the surveyor interviewed the resident's assigned Certified Nursing Assistant (CNA) who stated that Resident #73 was able to make their needs known, and required extensive assistance of one person with activities of daily living (ADLs). The CNA could not speak to any devices or orthotics the resident wore. Later that same day at 01:15 PM, the surveyor observed the resident in his/her room with no device in use. On 7/18/22 at 10:49 AM, the surveyor observed the resident awake, out of bed seated in a wheelchair working on a word puzzle at a table in the main rotunda area. There was no right-hand grip splint in use. On 7/18/22 at 12:40 PM, the surveyor observed the resident awake out of bed seated in a wheelchair with no right-hand grip splint in use. On 7/19/22 at 12:20 PM, the surveyor observed the resident out of bed seated in a wheelchair with no right-hand grip splint in use. The surveyor interviewed the resident who stated, no body wants to be bothered. I haven't worn the splint in three weeks. On that same date at 12:22 PM, the surveyor interviewed the resident's assigned Licensed Practical Nurse (LPN) who stated that he works per diem but was facility hired. He further stated, its late. I didn't see the order. He acknowledged that it was the nurse's responsibility to make sure the right-hand grip splint was applied according to the PO. He couldn't speak to why the resident hasn't been wearing his/her right-hand grip splint. On 7/19/22 at 12:34 PM, the surveyor interviewed the Director of Rehab (DOR) who stated that the nurses are responsible for applying the splint. The DOR could not speak to why the splint has not been applied by nursing and stated that the resident will be re-evaluated. The surveyor reviewed the medical record for Resident #73. The resident's admission Record reflected that the resident had diagnoses which included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type II diabetes mellitus with diabetic neuropathy, unspecified, and muscle wasting and atrophy, not elsewhere classified, multiple sites. The resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 6/28/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated severe cognitive impairment. Further review of the MDS reflected that the resident had no behaviors for section E for Behavior, section G for Functional Status reflected that the resident required extensive assistance with one person for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing and section O for Special Treatment, Procedures, and Programs reflected that splint or brace assistance was not checked. A review of the electronic Order Summary Report (OSR) reflected a PO dated 7/20/20, to Don [put on] Right hand grip with [NAME] [maximum assistance]; keep splint on for four hours (or more if tolerated), on after AM [morning] care and off before 3:00 PM with skin checks performed. One time a day and remove per schedule. The July 2022 electronic Treatment Administration Record (eTAR) reflected the above corresponding PO. Further review of the eTAR indicated that the right-hand grip splint was plotted to be applied at 10:00 AM and remove at 1359 [1:59 PM]. The eTAR further indicated that the nurses signed as applied for each day. According to the resident's Care Plan (CP) date initiated 3/22/22, reflected a focus area that the resident has right resting hand splint to prevent further contractures. The goal of the resident's CP was that the resident will not have any skin breakdown by the review date of 9/21/22. The interventions for the resident's CP indicated Right-hand splint to be placed as per dr order. Further review of the resident's CP did not reflect that the resident refused to wear or removed the right-hand grip splint. Review of the electronic Progress Notes from April 2022 through July 2022 did not reflect documentation that the resident refused to wear or removed the right-hand grip splint. The Occupational Therapy (OT) Discharge summary dated [DATE], reflected patient will safely wear least restrictive splinting/orthotic device 4 hrs [hours] on/4 hrs [hours] off without pain, swelling/edema and skin irritation in order to reduce pain caused by joint deformity .Prognosis .excellent with consistent staff support .discharge recommendations: splinting, arm troff. The OT Evaluation and Plan of Treatment dated 7/19/22, reflected that the resident is able to tolerate the hand splint for four hours without complaints of pain or redness and the resident would benefit from skilled OT services for further assessment of splint and potential of more hours of tolerance of splint to prevent contractures and skin breakdown. On 7/21/22 at 11:46 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident puts the splint on him/herself. The DON could not speak to why the PO reflected to Don [put on] Right hand grip with [NAME] [maximum assistance]. The DON did not provide additional information. On 7/21/22 at 12:45 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON and discussed the above observations and concerns. There was no additional information provided. Review of the facility's Splinting policy revised 7/1/22, provided by the LNHA included that Certified Nursing Assistants (CNAs) may apply splints under the supervision of the nursing department, a physician's order will be obtained for the use of a splint, an assessment and treatment plan must be completed by OT prior to referral to nursing for splint management, the nurse is responsible for splint application and will document and initial on the TAR/eTAR each time splint is applied and removed. A review of the facility's Splinting and Orthotics policy dated 9/5/17, provided by the LNHA included that the facility is responsible for maintaining cleanliness of devices and cleanliness of the extremity of the resident, and implementing the wearing schedule to include applying and removing devices as ordered by the physician. NJAC 8:39-27.2(m)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly label an opened Blood Glucose test strip, b.) identify, and dispose of an expired biological in 1 of 5 medication carts and 1 of 2 medication rooms inspected. This deficient practice was evidenced by the following: On [DATE] at 9:41 AM, the surveyor inspected wing three (3) medication (med) room in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed one box of Sterile 0.9% NaCl (Sodium Chloride) solution for inhalation dated [DATE]. The surveyor interviewed LPN #1 who stated that the med room is inspected by the Unit Manager (UM) who is away on vacation. LPN #1 also acknowledged the expired Sterile Sodium Chloride for inhalation should not have been in the med room. He further stated that he would remove the expired item from the med room and give it to a UM. On [DATE] at 11:47 AM, the surveyor inspected wing four (4) South med cart in the presence of LPN #2. The surveyor observed an opened bottle of Blood Glucose (BG) test strips that did not contain an open date label. During an interview with surveyor, LPN #2 stated that she would discard the opened bottle of test strip. LPN #2 also stated that she does not know how long the BG test strips has been opened. She added that the opened date of a BG test strip determined the expiration. The surveyor and LPN #2 reviewed the package insert of the BG test strip marketed as [name redacted]. The insert indicated under Storage and Handling section 5. Use within 6 months of first opening or the expiration date in the label whichever comes first. A record review of the Consultant Pharmacist (CP) unit inspection report in the past three months for Unit 3 med room revealed the following: [DATE] All expired and discontinued medications (meds) removed, Y- in compliance [DATE] All expired and discontinued meds removed, Y- in compliance [DATE] All expired and discontinued meds removed, Y- in compliance A record review of the CP unit inspection report in the past three months for 4 South Medication cart revealed the following: [DATE] All expired and discontinued meds out of cart, N- not in compliance All drugs are properly labeled, N- not in compliance [DATE] All expired and discontinued meds out of cart, N- not in compliance All drugs are properly labeled, N- not in compliance [DATE] All expired and discontinued meds out of cart, Y-in compliance All drugs are properly labeled, N- not in compliance On [DATE] at 10:59 AM, during an interview with surveyor, LPN/UM stated expired meds are given to the Assistant Director of Nursing (ADON). LPN/UM also stated expired items are to be discarded to prevent usage with a patient resulting in errors. On [DATE] at 11:27, during an interview with surveyor, the ADON stated that expired and discontinued meds are given to him for disposal. ADON further added that expired and discontinued meds are either returned to the pharmacy or discarded. On [DATE] at 1:57 PM, during an interview with the surveyor, the Director of Nursing (DON) stated all nurses on all shifts, on the med carts were responsible to ensure all items in the med carts were current, expired meds and discontinued meds were removed. The DON also stated that the UMs were responsible for ensuring that expired meds and discontinued med were removed from the med rooms. She further added that in the absence of a UM, that she and the ADON were responsible to conduct a spot check. The DON added that spot checks were conducted randomly and that currently, at that time had no tracking forms for the spot checks completed. Furthermore, the DON stated that the CP conducted all med carts and rooms inspections monthly. The DON stated she expected all expired items and discontinued meds to be removed immediately. On [DATE] at 12:15 PM during an interview with surveyor, CP stated med carts and med room inspections were completed monthly and expired meds are pulled and she exits with UM. On [DATE] at 01:05 PM, during a follow up interview with the surveyor, the DON acknowledged that an open BG test strip should have been dated once opened because not knowing when it is opened means not knowing when it expired. On [DATE] at 01:47 PM in the presence of the survey team, the DON stated she was unable to determine if the Sterile 0.9% NaCl (Sodium Chloride) solution for inhalation was used for inhalation or wound. She acknowledged that the expired item should have been removed from the med room. A review of facility policy for Blood Glucose Monitoring under Procedure section VI subsection A. revealed Check the date on the test strip prior to using the strip. Discard the strip and the remainder of the vial if the strip is past the expiration date. A review of facility policy received from the DON titled 6.0 Medication Storage under Procedure section F revealed Expired, discontinued/or contaminated medications will be removed form [from] the medication storage areas and disposed of in accordance with facility policy. NJAC 8:39-29.4 (c) (g)

Based on observation, interview, and review of pertinent facility documentation, it was identified that the facility failed to safety store Oxygen (O2) equipment in a resident's private room. This deficient practice was identified for one of six resident's reviewed, (Resident #678) for respiratory care and was evidenced by the following: On 7/12/22 at 11:25 AM, the surveyor observed Resident #678 laying in bed in their room. At that time, the surveyor attempted to interview the resident and the resident responded with yes or no answers. The surveyor observed a free standing, portable O2 cylinder in the upright position in the resident's room to the left of the resident's nightstand while facing the head of the resident's bed. The portable O2 cylinder was not observed to be stored in a container. The surveyor further observed that the gauge on the portable O2 cylinder read that it was full. On 7/14/22 at 10:26 AM, the surveyor observed the resident in their room lying in bed watching television. The surveyor observed the portable O2 cylinder in the upright position in the same location as the previous observation in the resident's room. The portable O2 cylinder was observed free standing in the upright position, full, and was not stored in a container. On 7/14/22 at 11:52 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident received his/her O2 via an O2 concentrator and not the portable O2 cylinder tank. The CNA further stated that the portable O2 cylinders were not supposed to be stored in a resident's room because it was not safe. On 7/14/22 at 11:59 AM the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the portable O2 cylinders should be stored in a container because if the resident had to move around the room freely, the O2 could move with the resident. On 7/14/22 at 12:10 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manger (LPN/UM) who stated that all portable O2 cylinders should be stored in a container in the upright position, especially if it was full because it posed a potential hazard to the resident's environment. On 7/14/22 at 12:17 PM, the surveyor interviewed the facility's Maintenance Director (MD) who stated that it was necessary and very important for portable O2 cylinders to be stored in a container for safety purposes. The surveyor reviewed the facility's Oxygen Administration Policy and Procedure revised December 2021 which indicated in the section titled, Safe Handling of Oxygen/Equipment that, Oxygen cylinders are to be secured in a cylinder cart or bracket at all times. NJAC 8:39-31.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/12/22 at 10:55 am, the surveyor observed Resident #140 lying in bed, awake, alert, and appropriately responded to the surveyor. The resident stated that he/she needed help from staff for care. A review of Resident #140's medical record reflected the following: The resident's admission Record reflected that Resident #140 had diagnoses that included but were not limited to muscle wasting and atrophy, not elsewhere classified, right thigh (wasting or thinning of muscle), major depressive disorder, recurrent severe without psychotic features, and palmar fascial fibromatosis [dupuytren] (a gradual thickening and tightening of tissue under the skin in the hand). The QMDS with an ARD of 3/9/22 reflected that Resident #140 had a brief interview for mental status (BIMS) score of 15 which indicated that the resident had an intact cognition. Section G Functional Status of the QMDS revealed that the resident's bed mobility and transfer were coded 3/3, toilet use 3/2 (which means that the resident required extensive assistance with one staff) and eating 1/1 (which means the resident required supervision with set up help only). The QMDS also reflected that the resident had a mood interview (PHQ-9©) that reflected Symptom presence of poor appetite or overeating with a Symptom Frequency of 1 (which means symptom frequency was 2-6 days), and the resident had 0 (which means behavior not exhibited) for verbal behavioral symptoms directed toward others. A review of the QMDS with an ARD of 6/9/22 reflected that Resident #140's cognition was the same. In comparison with March 2022 QMDS, there was an improvement in the resident's functional status and now the resident required 2/2 in bed mobility, transfer, and toilet use (which means limited assistance of one person) and eating 0/1 (which means independent with set up help only). Furthermore, there was a decline in mood which reflected that the resident's symptom frequency for poor appetite or overeating was now 2 (which means symptoms frequency was increased to 7-11 days). There was also a decline in resident's behavior which reflected that the resident's verbal behavior symptoms toward others was now 1 (which means behavior of this type occurred 1 to 3 days). There was no documented evidence that an SCSA (Significant Change in Status Assessment) was initiated when a significant improvement in functional status and decline in mood and behavior were identified on the June 2022 QMDS. On 7/19/22 at 12:35 PM, MDSC/RN informed the surveyor that SCSA should be done if there were at least two areas of either improvement or decline in ADLs and decline in mood and behavior. The surveyor informed her of the above concerns. The MDSC/RN stated that she will verify whether SCSA was missed or if there were MDS coding inaccuracies on the 6/9/22 QMDS assessments. On 7/19/22 at 02:22 PM, the survey team met with the LNHA, the RDCS/RN, and the DON. The DON stated that SCSA should have been initiated for residents with improvements in ADLs and worsening mood and behavior. In a follow-up interview with MDSC/RN on 7/20/22 at 8:51 AM, she acknowledged that the coding in 6/9/22 QMDS assessments were accurate and that SCSA should have been done and stated, that it was missed. On 7/21/22 at 9:52 AM the surveyor interviewed PT/MDSN via telephone. He acknowledged that SCSA should have been done on 6/9/22 MDS assessments and stated, I should have done a significant change. According to the RAI Manual Version 3.0 of CMS (Centers for Medicare & Medicaid Services) guidelines, updated October 2019, page 2-23 reflected that An SCSA is appropriate when: - There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; . It was also indicated on page 2-25 that an SCSA is appropriate if there is a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of ADL decline or improvement). It reflected that Decline in two or more of the following: . - Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-9©), e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E (Behavior); . While on page 2-26, it reflected that SCSA MDS is required if there is an Improvement in two or more of the following: - Any improvement in an ADL physical functioning area (at least 1) where a resident is newly coded as Independent, Supervision, or Limited assistance since last assessment and does not reflect normal fluctuations in that individual's functioning; On 7/25/22 at 12:45 PM, the survey team met with the administrative team. There was no additional information provided. NJAC 8:39-11.1 Based on observation, interview, and record review, it was determined that the facility failed to ensure that a significant change assessment was completed for Residents #66 and #140 for a total of two quarters. This deficient practice was identified for 2 of 2 residents reviewed, and was evidenced by the following: 1. On 7/12/22 at 10:42 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that Resident#66 was cognitively impaired and a wanderer. On that same date at 11:00 AM, the surveyor observed the resident standing in the nursing station with the LPN/UM. The resident was not able to respond appropriately to the surveyor's questions. Later on, the Certified Nursing Aide (CNA) came and accompanied the resident to be toileted by hand-held assistance while walking. The surveyor reviewed the medical records of Resident #66: The resident's admission Record (admission summary) disclosed that the resident had diagnoses which included, but were not limited to, Alzheimer's disease unspecified (a brain disorder that usually starts in late middle age or old age and gets worse over time), dementia in other diseases classified elsewhere with behavioral disturbance (are often globally described as agitation including verbal and physical aggression, wandering, and hoarding), and unspecified psychosis (conditions that affect the mind, where there has been some loss of contact with reality.). The Comprehensive Minimum Data Set (CMDS) dated [DATE], an assessment tool used to facilitate the management of care, indicated cognitive skills for daily decision-making were severely impaired. Section E Behavior of the CMDS showed that the resident was noted with physical behavioral symptoms directed toward others score of one which indicated that behavior of this type occurred one to three days. Section G Functional Status of the CMDS revealed that the resident's bed mobility and transfer were coded 3/3 (which means that the resident required extensive assistance with two staff), eating 4/2 (which means that the resident required total assistance with one staff), and toileting 4/3 (which means the resident required extensive assistance of two staff). The 01/28/2 Quarterly MDS (QMDS), indicated there were no changes in cognitive skills for daily decision-making. Section E Behavior of the 01/28/22 QMDS showed that the resident was noted with physical behavioral symptoms directed toward others and a wandering behavior both scores of one. Section G of the QMDS revealed that the resident's bed mobility and transfer were coded 2/2 (which means that the resident required limited assistance from one staff), eating 2/2, and toileting 3/2 (which means the resident required extensive assistance from one staff). The 4/25/22 QMDS, indicated there were no changes in cognitive skills for daily decision-making. Section E Behavior of the 4/25/22 QMDS showed that the resident was noted with other behavioral symptoms not directed toward others and a wandering behavior both scores of two which indicated that behavior of this type occurred 4 to 6 days but less than daily. Section G of the QMDS revealed that the resident's bed mobility and transfer were coded 2/2, eating 2/2, and toileting 3/2. Further review of the MDS revealed that there was no Significant Change (SC) MDSs completed when the resident was noted with a significant improvement in functional status and worsening of behavior on both QMDS dated [DATE] and 4/25/22. The personalized care plan focused on psychotropic medications related to behavior management initiated on 12/02/21 and revised on 6/7/22. The care plan interventions date initiated on 12/02/21 and revised on 6/7/22 included to monitor/record the occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. and document per facility protocol. The Occupational Therapy (OT) Discharge summary dated [DATE] showed that the resident was discharged (d/c) from Skilled OT and met the goal for maximum assistance for toileting. The Physical Therapy (PT) Discharge summary dated [DATE] revealed that the resident was d/c from Skilled PT and met the goal for the following: Bed mobility=stand by assist (the presence of another person within arm's reach required to prevent injury during the performance of one of the activities of daily living) Transfer=contact guard assist (CGA) (the assisting person has one or two hands on your body but provides no other assistance to perform the functional mobility task) According to the Therapy Screening Form (TSF) dated 01/26/22 for a Quarterly status revealed a comment that the resident was a minimum assist for safety with self-care and was supervision for transfers. The TSF dated 4/25/22 for a Quarterly status showed a comment that the resident was a minimum assist for safety with self-care and supervision for transfers. On 7/15/22 at 9:08 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) in the presence of the survey team. The MDSC/RN informed the surveyor that the facility had no specific policy concerning SC MDS and we follow the RAI (Resident Assessment Instrument) manual. The MDSC/RN stated that if there were two or more areas of a change within adls and a change in mood or behavior of the resident, we discuss it as a team, and a significant change assessment will be done. On that same date and time, the surveyor notified the MDSC/RN of the above concerns. The MDSC/RN stated that there were two opportunities that a SC should have been done on 01/28/22 and 4/25/22 where there were more than two areas of improvement with adls and the other one was worsening of behavior, and it was missed. She further stated that it was the part-time MDS nurse (PT/MDSN) who did the MDS on the above-mentioned MDS on 01/28/22 and 4/25/22. On 7/18/22 at 11:38 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and was made aware of the above concerns. On 7/19/22 at 02:22 PM, the surveyors met with the LNHA, Director of Nursing (DON), and the Regional Director of Clinical Services/Registered Nurse (RDCS/RN). The DON stated that SC should have been initiated for residents with improvements in ADL (activities of daily living) and worsening mood and behavior. On 7/21/22 at 9:44 AM, the surveyor interviewed the PT/MDSN via phone conference. The PT/MDSN informed the surveyor that the SC was missed. He further stated I do agree that a SC should have been done on two opportunities on two quarterlies on 01/28/22 and 4/25/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) follow a Physician's Order (PO) for the use of Oxygen (O2) for 2 of 4 residents (Resident#150 and #678), b.) develop a care plan for the use of O2 for 2 of 4 residents (Resident#93 and #678), and c.) date and store the O2 cannula for 1 of 4 residents (Resident #93) reviewed for respiratory care. The deficient practice was evidenced by the following: 1. On 7/12/22 at 10:59 AM, the surveyor observed resident #150 in their bed with an oxygen nasal cannula (N/C; O2 tubing that is placed in the resident's nose) in place. The oxygen concentrator (a medical device that gives you extra oxygen) reflected the oxygen was set at 5 liters (L). The surveyor reviewed the medical records of Resident #150. The resident's admission Record (face sheet; an admission summary) indicated that the resident was admitted to the facility and had diagnoses that included but were not limited to; acute respiratory failure with hypoxia (an absence of oxygen in the tissues of the body to sustain bodily functions), unspecified protein-calorie malnutrition, muscle wasting and atrophy (the wasting, thinning, or loss of muscle tissue), tracheostomy (a surgically created opening into the trachea or windpipe), and gastrostomy. The admission Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care dated 6/07/22 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated that the resident's cognitive status was moderately impaired. The resident's MDS, Section O - Special Treatments, Procedures, and Programs revealed that the resident received O2 therapy. The July 2022 Order Summary Report (OSR) did not show an oxygen order for Resident #150. The July 2022 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) lacked evidence of oxygen administration. On 7/14/22 at 9:54 AM, the surveyor observed Resident #150 sitting upright in bed watching television. The resident's O2 concentrator was set at 5 L via N/C. The resident stated that he/she was not aware of their O2 order. The resident indicated that it was the nurse who check and operates the O2 concentrator. On 7/15/22 at 11:11 AM, the surveyor observed Resident #150 in their room with O2 N/C in place and the concentrator was set at 2 (two) L. On 7/21/22 at 10:18 AM, the surveyor interviewed Certified Nursing Aide#1 (CNA#1). CNA#1 confirmed that Resident #150 was on oxygen, but stated it was up to the nurse how much the resident is on and for monitoring the O2. CNA#1 stated that she removes the oxygen canula to wash the resident's face, but never touches the oxygen concentrator. On 7/21/22 at 10:23 AM, the surveyor interviewed Licensed Practical Nurse#1 (LPN#1) regarding Resident #150's oxygen administration. LPN#1 explained that the resident was receiving O2 at 2L. LPN#1 checked the electronic Medical Record (eMR), reviewed the physician orders, and confirmed there was an order dated 7/15/22 for O2 2L NC continuously every shift. On that same date and time, the surveyor asked LPN#1 if there was a previous order prior to 7/15/22 for O2. LPN#1 checked the eMAR, electronic eTAR, and OSR for July 2022 and stated that no order could be found prior to 7/15/22. LPN#1 further stated that there should be an order for O2 prior to 7/15/22 because the resident was admitted to the facility with a tracheostomy on 5/20/22. At that time, the surveyor informed LPN#1 that the surveyor observed the resident on 7/12 and 7/14/22 with O2 at 5 L. On 7/21/22 at 10:41 AM, the surveyor informed the MDS Coordinator who was also the acting Manager of unit 5 that the surveyor observed the resident on 7/12 and 7/14/22 with O2 at 5L NC. The surveyor notified the MDS Coordinator of LPN#2's review of OSR, eTAR, and eMAR that did not show an O2 order prior to 7/15/22. The MDS Coordinator confirmed that the expectation is that if a resident is on O2, there should be a physician's order and the assigned nurse is responsible for monitoring the flow rate. 2. On 7/12/22 at 11:25 AM, the surveyor observed Resident #678 lying in bed. CNA#2 was in the room at that time providing incontinence care to the resident. The surveyor waited till the CNA was done performing care and attempted to interview the resident. The resident had a thick accent and responded with yes and no answers. The surveyor observed the O2 concentrator and identified that O2 was being administered to the resident at five (5) Liters Per Minute (LPM) via N/C. The N/C tubing was attached to the O2 concentrator in the resident's room. On 7/14/22 at 10:26 AM, the surveyor observed the resident in their room watching television. The resident was observed wearing the N/C in their nares. The surveyor observed that the O2 concentrator in the resident's room was set at four (4) LMP. The surveyor asked the resident if he/she ever touched the O2 concentrator and the resident stated, No. The surveyor reviewed the medical record for Resident #678. The resident's admission Record reflected that the resident had diagnoses which included but were not limited to COVID-19, heart failure, lack of coordination and need for assistance with personal care. The resident's AMDS dated [DATE] reflected that the resident had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. The resident's MDS, Section O - Special Treatments, Procedures, and Programs revealed that the resident received O2 therapy. The resident's July 2022 OSR reflected a PO dated 7/05/22 for O2 at three (3) LPM via N/C continuous for shortness of breath. A review of the Resident #678's July 2022 eMAR revealed that the nurses were signing on the day, evening, and night shifts that the resident was administered O2 at three (3) LPM via N/C continuous for shortness of breath. A review of the resident Care Plan did not reflect a focus area for the care of and the O2 usage. On 7/14/22 at 11:52 AM, the surveyor interviewed the resident's CNA#2 who stated that the resident required O2 and received the administration of the O2 by way of the O2 concentrator. The CNA told the surveyor that she did not touch the O2 concentrator, and it was the nurses job to monitor the flow rate of O2 from the O2 concentrator. On 7/14/22 at 11:59 AM, the surveyor interviewed the resident's Licensed Practical Nurse#1 (LPN#1) who stated that the resident received O2 via the O2 concentrator and had a PO for the administration of O2 at three (3) LPM via nasal cannula. LPN#1 further stated that the resident would touch his/her nasal cannula tubing, but never the O2 concentrator. LPN#1 told the surveyor that if a resident had a PO for the use of O2, the O2 usage should be reflected in the resident's Care Plan. The surveyor asked who was responsible for creating the resident's Care Plan and the LPN told the surveyor that the Nursing Supervisor was responsible for creating the resident's Care Plan. On 7/18/22 at 9:20 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident's Licensed Practical Nurse/Unit Manager#1 (LPN/UM#1) was unavailable for an interview. The DON told the surveyor that if a resident had a PO for the administration of O2, the expectation was that the PO would be followed. The DON further stated that if a resident had a PO for the use of O2, it should be reflected in a focus area in the resident's Care Plan. The DON stated that the Unit Mangers were responsible for creating the Care Plans for the residents. 3. On 7/12/22 at 10:48 AM, the surveyor observed Resident#93 seated on their bed with O2 in use at 2LPM via N/C with a long O2 tubing attached to an oxygen concentrator. The O2 tubing was not dated. The resident informed the surveyor that the resident had been using O2 for a long time and was aware of the O2 order of 2LPM. The resident further stated that it was the respiratory therapist who changes the O2 tubing once a week. The surveyor reviewed Resident #93's medical records. The resident's admission Record reflected that the resident was admitted to the facility with diagnoses that included Anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), anxiety, and chronic obstructive pulmonary disease with (acute) exacerbation (occurs when your COPD respiratory symptoms become much more severe.). The July 2022 OSR showed an order dated 8/23/21 for O2 therapy for 2LPM via N/C every shift. The order for O2 therapy was transcribed in the eMAR and nurses were signing on the day, evening, and night shifts that the resident was administered O2 at three 2LPM via N/C. A review of the resident's Care Plan did not reflect a focus area for the care of and the O2 usage. According to the 5/6/22 Quarterly MDS (QMDS), with a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. The QMDS indicated that the resident was on O2. On 7/13/22 at 11:14 AM, the surveyor and LPN#2 both went inside Resident #93's room and observed O2 tubing on top of the resident's bed not stored in a bag. The resident was not in the room. LPN#2 stated to the surveyor that the O2 tubing should have been stored in a plastic bag when not in use. On that same date and time, LPN#2 looked around the resident's room and found a plastic bag, and immediately placed the O2 tubing that was found on top of the resident's bed. At that time, the surveyor and LPN#2 observed a N/C wrapped around the portable O2 tank inside the resident's room. The N/C was not stored inside a plastic bag and was not dated. LPN#2 then discarded the N/C and stated that it should have been stored in a plastic bag when not in use. Then the surveyor asked LPN#2 why she placed the O2 tubing that was found on top of the bed inside a plastic bag and did not discard it. LPN#2 stated that the surveyor was right and, Maybe I should throw that. On 7/13/22 at 11:46 AM, the surveyor interviewed LPN/UM#2 and was made aware of the above concerns. LPN/UM#2 stated that we have a clear baggy that we suppose to put in the O2 cannula when not in use. LPN/UM#2 further stated that the nurse should throw the O2 tubing because you don't know what was on the bed. At that same time, the surveyor asked LPN/UM#2 why is it important to store the O2 cannula and tubing inside a plastic bag when not in use and to date the O2 tubing, and LPN/UM#2 replied for infection control. On 7/18/22 at 11:38 AM, the survey team met with the LNHA and was made aware of the above concerns. On 7/19/22 at 02:22 PM, the surveyors met with the LNHA, Regional Director of Clinical Services/Registered Nurse (RDCS/RN), and the Director of Nursing (DON) and were made aware of the above concerns. The DON stated that O2 tubing should be stored if not in use and dated. The DON further stated that the nurse should discard the O2 tubing when found on top of the bed for infection control. A review of the facility Oxygen Administration Policy that was provided by the LNHA with a revised date of December 2021, included Policy I. Initiation of Oxygen A. A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include: i. Oxygen flow rate ii. Method of administration (e.g. nasal cannula) iii. Usage of therapy (continuous or prn) iv. Titration instructions (if indicated) v. Indication for use .III. Infection Control. A. All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen: i. Are for single resident use only. ii. Will be changed weekly and when visibly soiled, or as indicated by state regulation. B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment form dust and dirt when not in use IX. Turn off oxygen when not in use. A review of the facility's Oxygen Administration Policy and Procedure revised December 2021 indicated that a PO was required to initiate O2 therapy, except in an emergency and the PO should include the O2 flow rate, method of administration, usage of therapy, and indication for use. The facility's Oxygen Policy and Procedure further revealed to, Turn on the oxygen at the prescribed rate. NJAC 8:39-27.1(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to assure that a.) a medications were available for administration during the medication administration observation for one (1) of four (4) residents (Resident #98) observed, b.) medications that were ordered by the physician were available for administration during the months of May, June and [DATE] for two (2) of five (5) residents, (Resident #12 and #93) who attended the resident council meeting and c.) a medication was removed from active inventory after being discontinued in [DATE] until surveyor inquiry for one (1) of five (5) medication carts inspected. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as follows: 1. On [DATE] at 9:06 AM, the surveyor observed Licensed Practical Nurse#1 (LPN #1) during medication pass observation for Resident #98. LPN #1 attempted to prepare the medications (meds) for Resident #98 which included the following meds: Delayed Release Aspirin 81 milligram, (mg; medication used as a blood thinner after a transcatheter aortic valve replacement), 1 tablet by mouth one time a day Memantine HCl (hydrochloride) 5 mg, (medication for memory), 1 tablet by mouth one time a day Clopidogrel (Plavix) 75 mg, (medication used as a blood thinner), 1 tablet one time a day Metoprolol Tartrate (Lopressor) 25 mg, (a medication used to lower high blood pressure), 1 tablet by mouth two times a day for HTN (hypertension) HOLD if SBP (systolic blood pressure) less than 100 or HR (heart rate) 60 At the same time, LPN #1 stated Plavix was not available for Resident #98 and presented an empty Plavix bingo card (a multidose card containing individually packaged meds) to the surveyor. The surveyor observed LPN #1 access the electronic Medical Record (eMR) and re-ordered Plavix. The surveyor and LPN #1 reviewed the eMR together which reflected that Plavix was last ordered on [DATE]. LPN #1 stated that she will get the medication (med) from the electronic back up supply machine (EBSM). During the same medication pass observation on [DATE] for Resident #98, LPN #1 stated Metoprolol 25 mg was also not available. LPN #1 showed the surveyor a bingo card for Metoprolol 50 mg. LPN #1 informed the surveyor that Metoprolol was changed from 50 mg to 25 mg on [DATE] and that Metoprolol 25 mg was not yet delivered. LPN #1 stated she will follow up on the med order for Metoprolol 25 mg and will get the med from the EBSM . On [DATE] at 9:36 AM, the surveyor and LPN/Unit Manager#1 (LPN/UM #1) went to the EBSM located in wing 5. In the presence of the surveyor, LPN/UM #1 and LPN/UM #2 removed one tablet of Metoprolol Tartrate 25 mg and one tablet of Plavix 75 mg from the EBSM. LPN/UM#1 and LPN/UM#2 reviewed the EBSM remaining quantity for Plavix and Metoprolol. The EBSM revealed a back-up quantity remaining of seven for Plavix and a back-up remaining quantity of five for Metoprolol. On [DATE] at 11:45 AM, the Director of Nursing (DON) provided a copy of Transactions Item: 85158020100320 for Plavix 75 mg tab page 1 of 1 with the following transactions: [DATE] 09:36:21 AM [DATE] 02:11:50 PM [DATE] 02:11:50 PM [DATE] 02:38:48 PM On [DATE] at 11:45 AM, the DON provided a copy of Transactions Item: 33200030100305 for Lopressor (Metoprolol) 25 mg T page 1 of 1 with the following transactions: [DATE] 09:36:04 AM [DATE] 02:00:16 PM [DATE] 02:33:25 PM On [DATE] at 12:09 PM, the surveyor interviewed LPN #2 who signed the electronic Medication Administration Record (eMAR) on [DATE] at 0800 (8 AM) as administered for Metoprolol 25 mg. LPN #2 acknowledged that she administered the meds to Resident #98. LPN #2 also stated, she recalled that Metoprolol 25 mg was not available on that day and that she had to borrow meds from Resident # 378. She further stated that I don't remember about Plavix, if it was available but she recalled signing the eMAR as administered. At the same time, the surveyor asked LPN #2 why Metoprolol was not available, LPN #1 stated I don't know. LPN #2 stated that she attempted to call the pharmacy about the missing med but the phone was busy. The surveyor asked if she was allowed to borrow meds, and LPN #2 did not respond. During an interview of the surveyor on [DATE] at 12:12 PM, the DON stated I know the regulations does not allow facility to borrow meds, and the nurses have been borrowing meds for Resident #98. The DON also stated that the facility did not have a policy on borrowing meds. A review of the Pharmacy Delivery Manifest dated [DATE] reflected a delivery for Resident 98's Plavix. A review of the Pharmacy delivery packing slip dated [DATE] included a delivery for Resident #98's Metoprolol 50 mg. No additional information was provided for Metoprolol 25 mg delivery prior to [DATE]. On [DATE], the Licensed Nursing Home Administrator (LNHA) provided the surveyor an electronic mail (email) from the pharmacy provider. A review of the email from the Pharmacist in Charge of the pharmacy provider dated [DATE] at 12:47 PM revealed an acknowledgement of an order received from the facility on [DATE]. The same email contained an admission of a dispensing error by the pharmacy which resulted in not sending the Metoprolol until [DATE], after surveyor inquiry. A review of the eMAR revealed Metoprolol 25 mg was administered on the following dates from [DATE]: [DATE] at 1700 (5:00 PM) [DATE] at 1700 (5:00 PM) [DATE] at 0800 (8:00 AM) [DATE] at 0800 (8:00 AM) A review of an investigation conducted by the DON on [DATE], revealed that LPN #2, LPN #3 and LPN #4 admitted to borrowing Metoprolol 25 mg from another resident from [DATE] to [DATE] which reflected the 4 doses administered on the eMAR. 2. On [DATE] at 10:30 AM, during the resident council meeting, the surveyor interviewed five (5) residents who all acknowledged that they had experienced a time when they were told by nursing that their meds were not available. Three (3) of the five (5) residents were unable to identify a specific time or med but acknowledged that it had happened in the past. Two (2) of the five (5) residents were able to identify specific meds that they had been told were unavailable. Resident #12 stated that he/she routinely takes Belsomra (a controlled medication used for insomnia) at night and was told that the pharmacy had not delivered the med. The surveyor reviewed the eMAR for five (5) of the five (5) residents who attended the resident council meeting and identified meds that were not administered for two (2) of the five (5) residents due to not being available. The surveyor reviewed the medical record for Resident #12. The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care dated [DATE], reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. The [DATE] eMAR revealed a physician's order (PO) dated [DATE] for Belsomra 20 mg, give one tablet by mouth at bedtime for insomnia. On [DATE] and [DATE] at 9 PM the Belsomra PO had a medication administration entry 9 by LPN#5 which corresponded to the chart code of other/see nurses notes. Further review of the eMAR revealed a PO dated [DATE] for Lyrica capsule 200 MG, give one tablet by mouth two times a day for pain. On [DATE] at 5 PM the Lyrica PO had a med administration entry 9 by LPN#5 which corresponded to the chart code of other/see nurses notes. A review of the corresponding nursing progress notes dated [DATE] at 9:49 PM, [DATE] at 9:19 PM and [DATE] at 5:05 PM revealed that the meds were not administered because there was documentation awaiting for pharmacy to deliver. According to the resident's Individual Patient's Controlled Drug Record (IPCDR) for Belsomra 20 MG tablets with a received date of [DATE] for 10 tablets revealed that the last date that the med was removed from inventory was on [DATE] and the inventory was zero. A review of the resident's IPCDR for Belsomra with a received date of [DATE] for 10 tablets had the first date that the med was removed from inventory was on [DATE]. There were no entries on the IPCDR for the dates of 6/11, 6/12 and 6/13. Further review of the [DATE] eMAR revealed that on [DATE] the Belsomra had a med administration entry of a checkmark which corresponded to mean that the med was administered at 9 PM which was inconsistent with the IPCDR entries. On [DATE] at 10:47 AM, the surveyor further interviewed Resident #12 who stated that he/she felt there were no repercussions from not getting the meds but could not understand why this would happen. On [DATE] at 11:28 AM, the surveyor interviewed LPN#5 via telephone. LPN#5 stated that she usually worked the 3 PM to 11 PM shift and that she had remembered meds not being available for Resident #12. LPN#5 stated that the meds were not in the facility back up supply, so she called the pharmacy and was told that the pharmacy had not delivered the meds because they were waiting for a prescription from the physician. LPN#5 then stated that she called the physician to let them know a prescription was needed and spoke to the resident to let them know. Then, LPN#5 added that the resident was okay when she explained the situation to the resident. LPN#5 stated that she had not discussed with the physician an alternative for the meds, but she told the next shift if the med came in that they can administer it. LPN#5 added that she had not documented what she had done and acknowledged the documentation awaiting for pharmacy to deliver. A review of the list of meds stored in the electronic back up supply machine provided by the DON revealed that Belsomra 20 MG and Lyrica 50 MG were not available in the back up supply. On [DATE] at 12:08 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that she had done inservices with the nurses regarding proper procedures for med administration and documentation. The CP added that she has instructed the nurses that the proper procedure if a med was not available in the med cart was to check if the med was available in the back up supply, then call the provider pharmacy to see why the med was not delivered to rectify the problem. The CP also stated that if the med was not in the back up supply, then the physician was to be called to notify them and get PO as to what to do until the med could be obtained. On [DATE] at 1:47 PM, the survey team met with the LNHA and DON. The DON stated that she was able to speak with the nurse who signed for the administration of Belsomra on [DATE] when there was no entry for removal of Belsomra on the IPCDR. The DON explained that the nurse had mistakenly signed that the med was administered when she had no supply of the med. The DON further stated that a med error report was completed for the nurse. The LNHA and the DON acknowledged that the nurses had not administered the identified meds because they were not available. The DON also stated that the nurses who had not administered meds because they were not available had not followed the proper procedure and were inserviced on the correct procedure. 3. On [DATE] at 10:30 AM, the surveyor reviewed the eMAR for five (5) of the five (5) residents who attended the resident council meeting and identified meds that were not administered for two (2) of the five (5) residents due to not being available. The surveyor reviewed the medical record for Resident #93. The qMDS dated [DATE], reflected the resident had a BIMS score of 15 out of 15, indicating that the resident had an intact cognition. The [DATE] eMAR revealed PO for the following: Xanax 0.25 MG, give one tablet by mouth every 12 hours for anxiety with a start date of [DATE]. Citalopram (Celexa) tablet 20 MG, give one tablet by mouth at bedtime for depression give with 10 MG tab to total 30 MG with a start date of [DATE]. Azithromycin tablet 250 MG, give one tablet by mouth in the evening every Monday, Wednesday, Friday for upper respiratory infection (URI) dated [DATE]. Digoxin tablet 125 microgram (MCG), give one tablet by mouth in the evening for heart failure. Check apical pulse before administering medication. Hold for heart rate less than 60 with a start date of [DATE]. The following meds with times of administration had a med administration entry 9 by LPN#3 which corresponded to the chart code of other/see nurses notes for: Celexa (Citalopram) on [DATE] at 9 PM. Azithromycin 250 MG on [DATE] and [DATE] at 5 PM. Xanax 0.25 MG on [DATE] at 9 PM, [DATE] at 9 AM and [DATE] at 9 PM. Digoxin 125 MCG on [DATE] at 5 PM. The following were the corresponding nursing progress notes completed by LPN#3 with the dates and times: for Celexa on [DATE] 9:02 PM was waiting for the pharmacy. for Azithromycin 250 MG on [DATE] at 5 PM was waiting for the pharmacy. for Azithromycin 250 MG on [DATE]/at 6:58 PM was awaiting for the pharmacy. for Xanax 0.25 MG on [DATE] at 8:55 PM waiting for the pharmacy. for Xanax 0.25 MG on 514/22 at 10:03 AM waiting for the pharmacy. for Xanax 0.25 MG on [DATE] at 8:59 PM awaiting for the pharmacy. for Digoxin 125 MCG on [DATE] at 7:42 PM waiting for pharmacy. The [DATE] eMAR revealed a med administration entry 9 by LPN #3 which corresponded to the chart code of other/see nurses notes for Azithromycin 250 MG on [DATE] at 5 PM. A review of the corresponding nursing progress notes dated [DATE] at 6:12 PM revealed that the Azithromycin was not administered because there was documentation waiting for the pharmacy. The [DATE] eMAR revealed a med administration entry 9 by LPN#6 which corresponded to the chart code of other/see nurses notes for Lidocaine gel 4% on [DATE] and [DATE]. In addition, for the Lidocaine gel 4% there was the same entry 9 by LPN #4 on [DATE] at 9 PM with the same corresponding chart code. A review of the corresponding nursing progress notes by LPN #6 dated [DATE] at 9:14 PM and [DATE] at 8:24 PM revealed an administration note for the Lidocaine gel but there was no reason or documentation as to whether the Lidocaine was administered. The corresponding nursing progress notes by LPN #4 dated [DATE] at 8:42 AM revealed that the Lidocaine gel was not administered because there was documentation not available. On [DATE] at 10:56 AM, the surveyor interviewed Resident #93 who stated that he/she was told by the nurses that the meds were not available, and he/she would not receive the meds. The resident also stated that there were no repercussions from not receiving the meds but does not understand why this would happen. On [DATE] at 11:10, the surveyor interviewed the Staffing Coordinator who stated that LPN #3 was on vacation. On [DATE] at 11:35 AM, the surveyor attempted to contact LPN #6 but was unable to leave a voicemail. On [DATE] at 9:52 AM, the surveyor interviewed LPN #4 who stated that he remembered on [DATE] that he worked and was administering meds that day to Resident #93. The surveyor with LPN#4 reviewed the eMAR for [DATE] and LPN#4 stated that he had not administered the Lidocaine gel 4% because the med was not in the treatment cart. LPN#4 stated that if he did not have a med then he would usually borrow from another resident, but he was recently instructed that he was no longer allowed to do that. LPN #4 stated that if he did not have the med then he could not administer it. LPN #4 was unable to speak to the procedure to follow when a med was not available. A review of the list of meds stored in the electronic back up supply machine provided by the DON revealed that Xanax 0.25 MG tablets were in the back up supply machine. Further review revealed that Digoxin 0.125 MG tablets were in the back up supply machine, but Digoxin 0.25 MG tablets were not. In addition, Azithromycin 250 MG tablets and Lidocaine gel 4% were not in the back up supply machine. On [DATE] at 12:08 PM, the surveyor interviewed the CP via the telephone. The CP stated that she had done inservices with the nurses regarding proper procedures for med administration and documentation. The CP added that she has instructed the nurses that the proper procedure if a med was not available in the med cart was to check if the med was available in the back up supply, then call the provider pharmacy to see why the med was not delivered to rectify the problem. The CP also stated that if the med was not in the back up supply, then the physician was to be called to notify them and get PO as to what to do until the med could be obtained. On [DATE] at 01:47 PM, the survey team met with the LNHA and DON. The DON stated that she spoke with LPN #3 who had been on vacation but was called in. The DON stated that LPN #3 had said she had called the physician but had not documented what she had done. On that same date and time, the DON also stated that LPN #6 had said that the resident refused the med but had not documented properly. Furthermore, the DON stated that LPN#4 was a per diem nurse and was unaware of the procedure. The LNHA and the DON acknowledged that the nurses had not administered the identified meds because they were not available. The DON also stated that the nurses who had not administered meds because they were not available had not followed the proper procedure and were inserviced on the correct procedure. 4. On [DATE] at 11:47 AM, the surveyor inspected wing four (4) South med cart in the presence of LPN#7. The surveyor found two bingo cards (a multidose card containing individually packaged meds) of Gabapentin 400 mg of Resident #38. Each bingo card was dated [DATE], labeled 1 of 3 and 3 of 3. Both bingo cards found were opened with capsules remaining. At the same time, LPN#7 informed the surveyor that the Gabapentin order for Resident #38 was discontinued. LPN#7 acknowledged that the Gabapentin should have been removed from the med cart to prevent a med error. She stated that the nurse who received the order to discontinue the med, should have removed the med from the med cart. LPN#7 added that the med was placed in the over stock section of the med cart which was the reason she did not notice it was there. A review of the [DATE] eMAR for Resident #38 revealed that Gabapentin 400 mg was discontinued on [DATE]. The PO for Resident #38 revealed Gabapentin 400 mg was discontinued on [DATE]. A review of Resident #38's eMAR from [DATE] to [DATE], did not reveal a current order for Gabapentin 400 mg. The CP unit inspection report in the past three months for 4 (four) South Medication cart revealed the following: [DATE] All expired and discontinued meds out of cart, N- not in compliance [DATE] All expired and discontinued meds out of cart, N- not in compliance [DATE] All expired and discontinued meds out of cart, Y-in compliance On [DATE] at 01:57 PM, during an interview with the surveyor, the DON stated that all nurses on all shifts, on the med carts were responsible to ensure all items in the med carts were current, expired meds and discontinued meds were removed. During a follow up interview on [DATE] at 01:05 PM, in the presence of the survey team and LNHA, the DON stated that the nurse who received the order to discontinue Resident #38's Gabapentin should have removed the med from the med cart. The DON also stated that the Unit Manager should have doubled checked that the med was removed from the med cart. She added that the Assistant Director of Nursing also covered the units, to ensure that discontinued meds were removed from med carts. The DON acknowledged removal of discontinued med should have occurred to avoid med errors. The DON confirmed that the discontinued med for Resident #38 dated [DATE] should have been destroyed. A review of the facility's Administering Medications policy revised on [DATE], under section Policy heading revealed Medications are administered in a safe and timely manner and as prescribed. In addition, Policy Interpretation and Implementation number 26, reflected Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy and approved by the director of nursing services. Medications are administered in accordance with prescriber orders, including any required time frame. A review of facility policy titled Discontinued Medications revised [DATE] revealed under Policy Heading, Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. The policy also reflected under Policy Interpretation and Implementation section 3. Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. A review of facility policy received from DON titled 3.0 Medication Disposal/Destruction under Procedure section 5. Indicated Discontinued medications shall be disposed of within 60 days of the date the drug was discontinued. Section 6 reflected The Consultant Pharmacist and Registered Nurse or two (2) nurses (one of who is a Registered Nurse) shall periodically destroy medications subsection b. Tablets, capsules and liquids will be disposed if according to local, state, and federal regulations. A review of facility policy received from the DON titled 6.0 Medication Storage under Procedure section F revealed Expired, discontinued/or contaminated medications will be removed form [from] the medication storage areas and disposed of in accordance with facility policy. A review of the inservice procedure provided by the DON reflected that the back up supply was to be checked and then the pharmacy contacted to make sure of the delivery time and if the medication could be delivered STAT (immediately). If the medication would not be available within an hour of the scheduled time, then the physician must be notified and receive a hold order for the medication or a new PO or a PO for an alternate medication that was available. NJAC 8:39-11.2(b), 29.2(d), 29.4(g)

Based on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to: a.) appropriately perform hand hygiene during the medication pass observation for 1 of 5 nurses, and during incontinence care for 1 of 3 residents (Resident #158), b.) appropriately don (put on) Personal Protective Equipment (PPE) prior to entering and while providing care to residents on Transmission Based Precautions (TBP), c.) appropriate clean multi-use resident equipment, d.) follow appropriate sequential infection control practices when providing care to residents on TBP, and e.) follow the Center for Disease Control (CDC) guidelines and facility policies and procedures to prevent the spread of infection to residents. This deficient practice was identified for, (Resident #93, #158, #678) and on two out of five nursing units (unit three and five). This deficient practice was evidenced by the following: 1. On 7/14/22 at 9:06 AM, the surveyor observed Licensed Practical Nurse#1 (LPN#1) assisting Resident#149 to be wheeled outside the room after administering medications. On the same date and time, LPN#1 assisted Resident#98 inside the room by propelling the resident's wheelchair. LPN#1 did not perform hand hygiene in between direct contact with Resident #149 and #98, then LPN#1 immediately applied a new pair of gloves when the LPN started to disinfect the blood pressure (bp) cuff. The surveyor asked LPN#1 if she should be performing hand hygiene and the LPN stated I will do it later after I remove my gloves. Afterward, the surveyor observed LPN#1 after disinfecting the bp apparatus, removed gloves, performed handwashing for 7 seconds, and then scrubbed hands under running water. The LPN then checked the resident's vital signs, perform hand hygiene with the use of ABHR, and prepared and administered medications. On 7/14/22 at 9:46 AM, the surveyor interviewed LPN#1 in the presence of the Licensed Practical Nurse/Unit Manager#1 (LPN/UM#1). LPN#1 stated that she received education and competency for hand hygiene that was provided by the facility Infection Preventionist Nurse (IPN). LPN#1 further stated that handwashing should be at least 20 seconds and scrubbing is done under running water. On that same date and time, the surveyor asked LPN#1 when to perform hand hygiene. LPN#1 stated that hand hygiene should be performed in between direct contact with residents with the use of alcohol-based hand rub (ABHR) and then on the 3rd or 4th resident, handwashing should be performed. She further stated that hand hygiene should be done after gloves removal. The surveyor then asked LPN#1 if she perform hand hygiene in between direct contact with Resident #98 and #149, LPN#1 responded I can not remember. Furthermore, the surveyor asked LPN#1 if she should perform hand hygiene after direct contact with Resident #98 and #149, before donning (putting on) gloves and disinfecting the bp apparatus, and she stated I think I should have, performed hand hygiene. On 7/19/22 at 02:22 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), and Regional Director of Clinical Services/Registered Nurse (RDCS/RN). The Director of Nursing (DON) informed the surveyors that LPN#1 acknowledged that she washed her hounds under a stream of running water and did not perform hand hygiene in between direct contact with residents. The DON further stated that LPN#1 should have performed hand hygiene. 2. On 7/19/22 at 6:37 AM, the surveyor observed the Certified Nursing Aide (CNA) on the 500 unit perform incontinence care for Resident #158. After performing care, the surveyor observed the CNA place the soiled linen and garbage in a garbage bag, walk out into the hallway and put the linen and the garbage in the appropriate receptacles. The surveyor further observed the CNA walk into Resident #158's bathroom, wet her hands, apply soap, and wash her hands under running water for 12 seconds. On 7/18/22 at 10:21 AM, the surveyor interviewed the IPN who stated that the appropriate procedure for hand hygiene was to turn on the water to a comfortable temperature, wet hands, apply soap, rub hands together with friction for at least 20 seconds. The IPN further stated that staff had to rub hands outside the stream of water, otherwise the soap would wash off the persons hands and not clean them. The IPN told the surveyor that after lathering hands together for at least 20 seconds, staff were to rinse hands with fingers down, making sure their hands did not touch the sink. Then grab a paper towel, drying hands fingers to wrist, throw away that paper towel, grab a new paper towel, and turn off the water. A review of the CNA's Clinical Competency Validation revised 11/2017 titled, Hand Hygiene indicated that the CNA correctly washed her hands in the presence of the IPN on 6/14/22. 3. On 7/12/22 at 11:23 AM, the surveyor observed on the 500 unit a red sign attached to a plastic tarp with a zipper in the center of Resident #678's bedroom door. The zipper was zipped down to the floor and the resident's bedroom door was shut. The red sign indicated to, STOP that the resident was on droplet and contact precautions, staff were to clean their hands before entering and upon leaving the resident's room, doors were to remain closed, staff were to don gloves, gowns, eye protection, a fit-tested N95 mask, and use dedicated or disposable equipment prior to entering the resident's room. The surveyor donned the appropriate PPE and entered the resident's room. At 11:25 AM, the surveyor observed the resident's Temporary Nursing Aide (TNA) in the resident's room providing care, leaning over, and touching the resident. The TNA was observed wearing a surgical mask with her N95 mask over it. The surveyor reviewed the medical record for resident #678. A review of the resident's admission Record reflected that the resident had resided at the facility for a few months and had diagnoses which included but were not limited to COVID-19, heart failure, lack of coordination and need for assistance with personal care. The resident's July 2022 Order Summary Report (OSR) reflected a Physician's Order (PO) dated 07/05/22 for contact and droplet precautions. The resident's July 2022 Medication Administration Record (MAR) revealed that nurses were signing on the day, evening, and night shifts that the resident was on contact and droplet isolation and nurses were to sign every shift for monitoring. On 7/18/22 at 10:02 AM, the surveyor interviewed the resident's TNA who stated that she would don a gown, gloves, face shield, surgical mask and N95 mask prior to entering a resident's room who was on contact and droplet precautions due to COVID-19. The TNA stated that she would put on a surgical mask and then the N95 mask over the surgical mask. The surveyor asked the TNA if she had received education on how to appropriately don PPE prior to entering a resident's room who was on TBP related to being COVID-19 positive. The TNA told the surveyor that she was educated by the Administrator on how to don PPE. On 7/14/22 at 10:38 AM, the surveyor interviewed the resident's LPN#2 who stated while providing care to a COVID-19 positive resident staff were required to wear a N95, face shield, gloves, and a gown. On 7/18/22 at 10:11 AM, the surveyor interviewed the IPN who stated that prior to entering a resident's room who was COVID-19 positive and while proving care staff were to first perform hand hygiene and don a N95 mask, face shield, gown, and gloves. The surveyor asked the IPN if it was appropriate for staff to wear a surgical mask under their N95 mask in a COVID-19 positive resident room. The IPN stated, No and explained that the purpose of wearing a fit tested N95 mask was to create a seal that was better at preventing the transmission and spread of the COVID-19 virus. A review of the the TNA's Clinical Competency Validation revised 11/2017 titled, Putting on Personal Protective Equipment (PPE)/Taking Off PPE competency dated 05/26/22 indicated that she passed. A further review of the facility's Clinical Competency Validation Form did not reflect N95 masking procedures. 4. On 7/14/22 at 10:02 AM, the surveyor observed LPN#2 on the 500 unit enter a COVID-19 positive room with a mobile blood pressure machine. Upon entering the COVID-19 positive room, LPN#2 shut the door behind her. The surveyor observed a red sign which indicated to STOP that the resident was on droplet and contact precautions, staff were to clean their hands before entering and upon leaving the resident's room, doors were to remain closed, staff were to don gloves, gowns, eye protection, a fit-tested N95 mask, and use dedicated or disposable equipment prior to entering the resident's room. On 7/14/22 at 10:05 AM, the surveyor observed LPN#2 exit the COVID-19 positive room with the mobile blood pressure machine. The bottom of the mobile blood pressure machine was observed to have brown spillage throughout and the wheels were observed to have grey, blackish debris stuck to them. The surveyor observed LPN#2 wipe the blood pressure cuff with a bleach wipe. The surveyor did not observe LPN#2 disinfect any other part of the mobile blood pressure machine. On 7/14/22 at 10:10 AM, the surveyor observe LPN#2 push the mobile blood pressure machine in front of a resident's room who was on TBP. The surveyor observed LPN#2 perform hand hygiene, appropriately don PPE, enter the resident's room, and shut the door behind her. The mobile blood pressure machine remained in the hallway outside of the resident's room who was on TBP. At that time, the surveyor observed a yellow sign on the resident's bedroom door. The yellow sign indicated that the resident was on contact and droplet precautions related to being a Person Under Investigation (PUI) who was newly admitted to the facility and not fully vaccinated for COVID-19. On 7/14/22 at 10:33 AM, the surveyor observed LPN#2 push the mobile blood pressure machine into the resident's room who was on TBP related to being a PUI. On 7/14/22 at 10:38 AM, the surveyor interviewed #LPN2 who stated that there was no single use equipment for the COVID-19 positive or PUI residents who were on TBP and that was why she used the mobile blood pressure machine. LPN#2 told the surveyor that prior to taking the resident's blood pressure she would wipe down the top of the blood pressure machine and the blood pressure cuff. The surveyor observed the bottom of the blood pressure machine in the presence of LPN#2 who stated that she did not clean the bottom of the machine, only the top. LPN#2 explained that the residents who resided in the room with the yellow signs on the door just came from the hospital and were on observation. The LPN confirmed that she used the same blood pressure machine when going from the COVID-19 positive room to the PUI room and she did not wipe down the entire machine. The LPN acknowledged that the sign on the Covid-19 positive room indicated that equipment was designated to that room. On 7/14/22 at 12:35 PM, the surveyor interviewed LPN/UM#2 who stated that the COVID-19 positive resident's had disposable stethoscopes and blood pressure cuffs in their rooms to prevent cross contamination and the spread of infection. This interview with LPN/UM#2 contradicted the surveyor's observation. On 7/14/22 at 12:44 PM, the surveyor interviewed the IPN who stated that if a resident was COVID-19 positive the expectation would be that the multi-use equipment was disinfected between residents. The IPN told the surveyor that if the mobile blood pressure machine or multi-use equipment was appropriately disinfected, it could be used between resident rooms. The surveyor asked the IPN what part of the multi-use equipment should be disinfected? The IPN stated the staff was expected to disinfect the part of the equipment that came in contact with the resident. The IPN further stated that the signs outside the resident rooms indicated the type of precautions the staff should follow. At that time, the surveyor further asked the IPN if it mattered if the resident was COVID-19 positive and if the multi-use equipment could be used between resident rooms? The IPN stated that the staff would be expected to provide care from clean to dirty. The IPN explained that for example, the staff would provide care from non-ill, to PUI/TBP to COVID-19 positive. The IPN stated that LPN#2 brought it to her attention that there was no single use equipment provided for the COVID-19 resident, so she gave LPN#2 a single use stethoscope, blood pressure cuff, and thermometer. 5. On 7/14/22 at 10:38 A.M., the surveyor observed a Maintenance Staff (MS) going into PUI room with a surgical mask, gloves, and gown. A sign posted on the door of PUI room directs to wear a fit-tested N95 and face-shield. The MS did not have a N95 or a face-shield donned. On that same date and time during an interview of the surveyor, the MS stated that he has worked at the facility for a year. He further stated that he uses surgical mask all the time. On 7/14/22 at 10:38 AM, the surveyor interviewed LPN#2 who stated that when a staff member entered a residents who was PUI and on TBP staff must wear a N95 mask, gown, face shield, gloves, surgical mask over N95. LPN#2 explained that she observed the MS entered the PUI room and he should have donned a N95 mask prior to entry to protect himself and the residents from infection. On 7/18/22 at 10:32 AM, the surveyor interviewed the IPN who stated that when a staff member entered a resident's room who was on TBP related to being a PUI, the appropriate PPE to wear were gloves, gown, N95, face shield or goggles. A review of the MS Clinical Competency Validation revised 11/2017 titled, Putting on Personal Protective Equipment (PPE)/Taking Off PPE dated 03/23/22 indicated that he passed. A further review of the facility's Clinical Competency Validation Form did not reflect N95 masking procedures. A review of the facility's Cohorting COVID-19 Policy and Procedure revised April 2022 indicated that Cohort 1 - (Red Zone) included residents who were symptomatic or asymptomatic and tested positive for the COVID-19 virus regardless of vaccination status. The facility's Cohorting COVID-19 Policy and Procedure indicated that COVID-19 positive residents, should be placed in quarantine and cared for using full PPE (gowns, gloves, eye protection that covers the front and sides of face, and NIOSH approved N95 or equivalent or higher-level respirator. The Cohorting COVID-19 Policy and Procedure further indicated that Cohort 5 - (Yellow Zone) consisted of new or re-admitted asymptomatic residents who were not up to date with COVID-19 vaccinations and tested negative for COVID-19 upon admission or re-admission to the facility. The facility's Cohorting COVID-19 Policy and Procedure indicated, These residents should be placed in quarantine and cared for using full PPE (gowns, gloves, eye protection that covers the front and sides of the face, and NIOSH approved N-95 or equivalent or higher-level respirator), even if they have a negative test upon admission. A review of the facility's Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures Policy and Procedure revised 03/2022 revealed, Dedicated or disposable noncritical resident-care equipment (e.g., blood pressure cuffs, blood glucose monitoring equipment) are used, or if not available, then equipment is cleaned and disinfected according to manufacturer's instructions using EPA-registered disinfectant for healthcare setting prior to use on another resident. A further review of the facility's Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures Policy and Procedure did not indicate the sequence for care such as going from non-ill to ill with the usage of multi-use resident care equipment. A review of the facility's Hand Hygiene Policy and Procedure revised 03/2021 indicated that hand hygiene was always the final step after removing and disposing of PPE. The facility's Hand Hygiene Policy and Procedure reflected that the correct procedure when washing hands was to, vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least twenty (20) seconds. NJAC 8:39-19.4; 27.1(a)

Based on observation, interview, record review, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous and dry foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was observed during multiple kitchen tours and was evidenced by the following: On 7/12/2022 at 9:45 AM, the surveyor conducted an initial tour with the Food Service Director (FSD) and observed the following: A large ice machine with a brown and black substance along the entire baffle (device used to restrain the flow of ice or to prevent the spreading of ice in a particular direction) along with dripping condensation into the ice below. The FSD wiped the baffle with a paper towel which removed most of the substance. The FSD acknowledged it was not clean. FSD stated It should not be there, and I will shut it down. The shelf above the stove burners with crusted on drippings. When the surveyor asked what the shelf was used for? The FSD stated it is where the cook places the utensils and dirty pots while cooking. There were 4 of 4 crumb trays under the multi range stove top which were soiled with a black grease like substance and food debris on aluminum foil that covered the crumb tray. When the FSD removed the foil there was another layer of black sticky debris under the foil. One crumb tray had multiple burnt bowtie pasta on it. The FSD could not state when the last time the crumb trays were cleaned. The FSD could not provide a cleaning schedule for the stove or crumb trays. The commercial meat slicer covered with plastic. The FSD director removed the plastic and the surveyor observed brown particles on the shield and on and under the blade. The FSD stated, When a piece of equipment was covered with plastic that indicated the equipment was cleaned and sanitized. The FSD acknowledged the meat slicer was not cleaned and sanitized. The double stack oven with baked on debris on the interior surfaces and door on each unit. When asked what the FSD thought the sediment was? The FSD stated, Sweet and oily residue from splatter. The double stack steamer unit with black debris on bottom shelf and door of each unit. The Freezer had ice condensation build-up on 1 of 3 interior unit fans and ice deposits on the interior floor. The FSD stated she was having the service company come out again to look at it and fix it. Refrigerator Box #1, which had black debris on the ceiling, door frame, in between shelving unit holes and hanging off the fan in the unit. Refrigerator box #2 had black, crusted debris within the openings on the shelves in the unit. The juice dispenser tap placed in a metal holder with copious amounts of sticky red liquid and a white disposable cup lid in the metal holder with black debris on it. The FSD stated, The evening shift was responsible to clean it daily. The FSD stated, The purpose of the cleaning schedule is to prevent fruit flies and cross contamination. No cleaning schedule or check off list could be provided at the time of our tour. Steamer table had 10 of 10 steamer water pans. They were all filled with very dark discolored water with food debris. It was noted and agreed upon by two surveyors, FSD and Kitchen Supervisor, that the breakfast pancakes were served while being warmed by these steamer pans. The surveyor asked the FSD what the cleaning process was? The FSD stated, The steam table is to be broken down and cleaned nightly which clearly has not been done. At that time the FSD stated, Take your picture then I will have all the steam water replaced. A cleaning schedule and/or check off list couldn't be provided. The small trash bin under a sink located in the dishwasher room next to a rack of clean small brown bowls. The FSD asked the food service worker to remove the trash can and rewash the square tray of brown dishes. When asked why she gave that instruction? The FSD stated, The trash can should have a lid, and it is next to the clean dishes. During an interview with the FSD on 07/12/2022 at 10:34 AM, the FSD stated, There was no formal process for scheduled cleaning. There is no accountability, sign off log or checklists available at this time. On 7/25/22 at 11:17 AM, the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) acknowledged the kitchen concerns. A review of an undated [name redacted] cleaning and sanitizing instruction manual under the section cleaning the nozzle indicated, this means our dispenser can be soaked in lukewarm or cold water, which we recommend to be done, when necessary, without being damaged. A review of the [name redacted] Ice Machine cleaning and sanitizing instruction manual, section 4; Maintenance, dated 5/21/08 part # 000014141, General indicated, Descale and sanitize the ice machine every 6 months for efficient operation. An extremely dirty ice machine must be taken apart for descaling and sanitizing. NJAC 8:39-17.2 (g)

Based on observation, interview and record review, it was determined that the facility failed to follow fluid restriction instructions in accordance with the physician's order, professional standards of care and the care plan. This deficient practice was identified for Resident #117, 1 of 9 residents reviewed for nutrition/hydration 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 states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of 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. During the tour of the 500-unit on 10/02/20 at 12:49 PM, the surveyor observed Resident #117 resting in bed with the lunch tray positioned on the overbed table. When interviewed, the resident stated that the lunch meal was okay and that he/she had no concerns with the meal. The surveyor observed Resident #117's lunch meal tray and noted that the resident consumed 100% of fluids on the tray. The surveyor made the same observations during the lunch meal service on 10/06/20 and 10/07/20. According to the admission Record, Resident #117 was admitted to the facility with medical diagnoses that included: sepsis (generalized infection), protein-calorie malnutrition, and moderate chronic kidney disease. Review of the admission Minimum Data Set (MDS) an assessment tool dated 09/17/20, revealed that Resident #117 was cognitively intact and had no behavioral issues. Review of Resident #117's Care Plan (CP) with a revision date of 10/02/20, revealed that Resident #117 had a nutritional risk related to weight increase, was on a mechanically altered diet, and had compromised nutritional status. The CP further revealed an intervention that was initiated on 10/02/20, for fluid restriction of 1200 millimeters (ml) daily. The resident's daily fluid allowance was divided between nursing and dietary departments and indicated for nursing to provide 240 ml/day while dietary provided 960 ml/day for a total of 1200 ml/day. Review of Resident #117's October 2020 Order Recap Report revealed a physician's order dated 10/02/20, for 1200 ml Fluid Restriction per day. Dietary 960 ml per day. Nursing 240 ml per day every shift, due to fluid related electrolyte imbalance. The order further instructed: fluid restriction of 100 ml on 7-3 shift (day shift), fluid restriction of 100 ml on 3-11 shift (evening shift), and fluid restriction of 40 ml on 11-7 shift (night shift). Review of Resident #117's Dietary Alert Sheet (DAS) dated 10/02/20, revealed a clarification of the resident's 1200 ml/day fluid restriction. The DAS further reflected 240 ml/day for nursing and 960 ml/day for dietary for a total of 1200 ml/day. Review of Resident #117's October 2020 Electronic Medication Administration Record (eMAR) reflected the above 10/02/20 order for 1200 ml Fluid Restriction per day. The order was also specified on the eMAR as: 100 ml on day shift, 100 ml on evening shift, and 40 ml on night shift. The October 2020 eMAR reflected that nurses administered fluids outside the physician ordered fluid restriction as follows and on the following dates: 10/03/20: the nurse administered 240 ml on day shift. 10/04/20: the nurse administered 240 ml on day shift. 10/05/20: the nurse administered 240 ml on day shift. 10/06/20: the nurse administered 240 ml on day shift. 10/07/20: the nurse administered 240 ml on day shift. 10/08/20: the nurse administered 240 ml on day shift. 10/09/20: the nurse administered 240 ml on day shift. 10/11/20: the nurse administered 240 ml on day shift. 10/12/20: the nurse administered 240 ml on day shift. Nursing was to administer 100 ml on day shift, not 240 ml. On 10/13/20 at 11:44 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who was responsible for caring for Resident #117 during day shift on 10/03/20, 10/04/20, 10/05/20, 10/06/20, 10/07/20, 10/08/20, 10/09/20, and 10/12/20. LPN #1 confirmed that Resident #117 was on fluid restrictions and stated that the instructions for the administration was documented in the eMAR. LPN #1 stated that nursing had specific amount that they were allowed to administer and that she administered 240 ml of fluids to the resident during her shift on day shift. LPN #1 further stated that Resident #117 liked to drink water and was educated about the ordered fluid restriction by the physician. LPN #1 reviewed Resident #117's fluid restriction order in the presence of the surveyor and confirmed that the order was for nursing to administer 100 ml during day shift. LPN#1 stated that she was supposed to administer 100 ml during her shift. She offered no explanation for why she administered 240 ml and not 100 ml. Further observation of the resident throughout the survey and the review of medical record did not reveal that Resident #117 sustained adverse effects from receiving extra fluid than was ordered. During an interview with the Registered Nurse Unit Manager (RN/UM #1) on 10/13/20 at 11:56 AM, RN/UM #1 stated that the Registered Dietician divided the fluid restriction allowance between nursing and dietary services. RN/UM #1 further stated that nursing had a certain amount they were allowed to administer by shift. RN/UM #1 reviewed Resident #117's order in the presence of the surveyor and confirmed the order of 100 ml for 7-3, 100 ml for 3-11, and 40 ml for 11-7. RN/UM #1 also reviewed Resident #117's eMAR in the presence of the surveyor and stated that nurses should not have administered 240 ml of fluids on 10/03/20, 10/04/20, 10/05/20, 10/06/20, 10/07/20, 10/08/20, 10/09/20, 10/11/20 and 10/12/20 on day shifts because the resident was only allotted 100 ml on day shifts. During an interview with the Director of Nursing (DON) on 10/13/20 at 12:06 PM, the DON stated that fluid restriction instructions were documented within the order. The DON further stated that the amount allotted to nursing was also specified in the order and that nurses were not allowed to administer more than what was specified in the order. The DON further stated the nurse should clarify the fluid restriction orders with the physician and update the order in the electronic medical record. A review of Resident #117's October 2020 Progress Notes revealed no documentation that a change was made to the resident's order, which meant that the order for 1200 ml of fluid per day was the only active order for the resident. A review of the facility's Fluid Restriction Policy, dated 2016, indicated that residents shall obtain fluids as per physician's order for a fluid restriction and not exceed the specified amount. The policy revealed that nursing would be allotted a specified amount per shift as determined by the dietician. The policy further reflected that nursing would record the resident's fluid intake on the eMAR and ensure the total per 24-hour period did not exceed the specified amount. NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to a.) follow appropriate use of a thermometer in accordance with manufacturer instructions during staff screening for COVID-19, and b.) ensure that all staff performed hand hygiene upon removing Personal Protective Equipment (PPE) and before exiting the room of a resident on transmission based isolation precautions to prevent the potential spread of infection. This deficient practice was observed for Resident #6, and for 1 of 1 Certified Nurse Aides (CNA) observed on 1 of 3 units, and was evidenced by the following: 1. On 10/08/2020 at 8:10 AM, the surveyor entered the building and approached the receptionist desk in the lobby. The surveyor observed the receptionist as she checked the temperature of an employee by pointing an infrared thermometer towards the right side of the employee's neck. After she finished with the employee, the receptionist proceeded to check the surveyor's temperature by using the same infrared thermometer and pointing it toward the right side of the surveyor's neck. At the time, the surveyor interviewed the receptionist about the area of the body that temperatures were supposed to be taken. She stated I can take it on your neck and even on your wrist. The surveyor asked the receptionist to demonstrate where she could take a temperature reading with the infrared thermometer and she pointed to the surveyor's wrist. The receptionist stated that she also took temperatures on the neck because sometimes the thermometer readings would register too low if it was done on a person's forehead. On 10/08/2020 at 12:23 PM, the surveyor interviewed the Director of Nursing (DON) regarding the entrance screening process. The DON stated that it was very important to screen people. The DON then reviewed the manufacturer's insert for the infrared thermometer that was used by the receptionist to record the surveyor's neck temperature in the presence of the surveyor. The DON stated that the manufacture's instructions for the above model of infrared thermometer indicated to point the thermometer at a person's forehead. The DON added that the thermometer must be pointed to the forehead as instructed by the manufacturer. When the surveyor inquired about pointing the thermometer to the neck or wrist, the DON stated that she did not see the wrist or neck as one of the choices for checking a person's temperature with the above thermometer. She stated that it was not the facility practice to take temperatures on the wrist or neck. The DON stated: I never heard of a wrist temperature. The DON added that usually if she could not obtain a temperature reading on a person's forehead, she would ask the person to wait a few minutes and then recheck the temperature. The DON stated that the temperature could be invalid if taken incorrectly and that the receptionist needed some education. On 10/13/2020 at 12:28 PM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) in the presence of the survey team. The ADON/IP stated that if temperature was not taken on the right place, the reading might not be accurate and that if a reading was incorrect it could miss capturing a person who had fever, thereby causing potential spread of infection. The surveyor reviewed the manufacturer's specifications provided by the facility for the non-contact infrared thermometer. The document revealed that in order to ensure that precise and accurate temperature measurements was obtained, it is essential that each user has received adequate information and training in the temperature measurement technique when using such a device. It is essential to remember that although procedures such as taking a temperature may be simple, they must not be trivialized. The instructions for taking the temperature indicated to: Aim at the middle of forehead from a distance of about 1.2-2 inches, press the thermometer's measurement button and the temperature is instantly displayed. The reliability of the measurement cannot be guaranteed if the temperature is measured over another part of the body (e.g. arm, torso .). On 10/08/2020 at 1:00 PM, the DON provided the surveyor with a training document for Non-Contact Thermometer use, dated 03/16/2020, which was signed by the receptionist, and indicated that the receptionist was trained. The training included that the preferred site for temperature taking is about 1-2 inches away from the forehead. May repeat temperature reading if Lo reading is given. 2. On 10/09/2020 at 10:00 AM, the surveyor observed that Resident #6's room door was closed. The surveyor noted a stop sign affixed on the resident's room door with instructions that read: contact precautions; everyone must clean hands when entering and leaving room. At that time, the surveyor observed a Certified Nurse Aide (CNA) as she exited Resident #6's room wearing gloves and a cloth gown over her uniform and pushing a mechanical lift. The CNA positioned the mechanical life against the wall in the hallway outside of the resident's room. The CNA then removed her gloves and went into another resident's room. The CNA emerged from the room pushing a resident seated in a wheelchair. The CNA was not observed using hand hygiene upon exiting Resident #6's room or before entering the other resident's room. On 10/09/2020 at 10:03 AM, the surveyor interviewed the CNA who stated that she helped another staff member transfer Resident #6 with the mechanical lift because two people were required. The CNA confirmed that she did not remove her gown after she exited Resident #6's room and did not perform hand hygiene after she removed her gloves. On 10/09/2020 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse/ Unit Manager who stated that staff were supposed to remove their protective gown prior to leaving a resident's room and that she should have washed her hands after she removed her gloves. On 10/09/2020 at 12:01 PM, the surveyor interviewed the ADON/IP and the DON regarding contact isolation procedures. The DON stated that staff were supposed to remove their gowns and gloves prior to exiting a resident's room, for a resident on contact transmission based precautions. The DON added that the facility's Infectious Disease Doctor had indicated that the rash on Resident #6 might be shingles. The ADON/IP stated that staff were supposed to wash their hands prior to entering and exiting the room. On 10/09/2020 at 12:22 PM, the surveyor entered Resident #6's room with the ADON/IP along with the Infectious Disease Nurse Practitioner (IDNP). The IDNP stated that the resident was not contagious and that she was about to discontinue the contact precautions. Review of Resident #6's admission Summary indicated that the resident was admitted to the facility with diagnoses that included: Zoster without complications (reactivation of the chickenpox virus causing a painful rash), major depressive disorder, Hypertension and Stroke. The Order Summary Report dated 09/30/20, revealed an order for Isolation for contact precautions every shift for Shingles for 10 days. A Physician Progress note, dated 10/09/2020 at 9:38 AM, reflected that Resident #6 had rash dermatitis verses shingles. The Care Plan initiated on 09/30/20 revealed that Resident #6 was on antibiotic therapy for an infection and had interventions that included: Isolation for contact precaution. Review of the facility's The Handwashing/Hand Hygiene policy, revised August 2015, indicated to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) after removing gloves. Review of the facility's The Isolation-Initiating Transmission-Based Precautions policy, dated January 2012, indicated to remove gloves before leaving the room and perform hand hygiene for a resident on Contact precautions. NJAC 8:39-19.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility documentation, it was determined that the facility failed to store, label and date potentially hazardous foods in a manner to prevent food-borne illness. This deficient practice was evidenced by the following: On 10/02/20 at 10:00 AM, the surveyor toured the kitchen with [NAME] #1. The Food Service Director (FSD) was not in the facility on the day of the initial tour. During the tour the surveyor observed the following: 1. In a free standing electric refrigerated cooler in the center of the kitchen was a small paper plate with 10 slices of salami covered with clear wrap. On the clear wrap was a use by date of 10/1/2020. 2. In the walk-in refrigerator was a stainless-steel tray of sliced tomatoes and lettuce leaves covered with clear wrap. The tray did not have a received, prepared or use by dates. 3. In the walk-in refrigerator was an eight-pound opened container of macaroni salad with no received, opened, or use by dates. The container was half full. 4. In the walk-in refrigerator was an eight-pound opened container of [NAME] slaw that had no received date but had a use by date of 10/1/2020. The container was less than half full. 5. In the walk-in refrigerator was an opened one-gallon container of Italian salad dressing with a received date of 2/27/20 but no opened or used by date. 6. In the walk-in refrigerator was an opened one-gallon container of mayonnaise with a received date of 09/18/20 but no opened or used by date. 7. On a prep table located across from the stove was one 80 ounce dried paprika, one 80 ounce dried basil, one 80 ounce dried oregano, and one 80 ounce dried dill weed. All of the containers were opened, and more than half used. There were no received, opened, or use by dates. 8. On the lower shelf of a prep table across from the stove was one 43-pound tub of dried powdered chicken base that was opened and half used. There was a plastic scoop in the tub inserted in the chicken base. The tub had no received, opened, or use by dates. 9. On the lower shelf of a prep table across from the stove was one 43-pound tub of dried powdered beef base that was opened and more than half used. There was a plastic scoop in the tub inserted in the beef base. The tub had no received, opened, or use by dates. On 10/02/20 at 11:15 AM, the surveyor interviewed [NAME] #1 regarding the scoops in the chicken base and beef base. [NAME] #1 told the surveyor that the scoops were left in the tubs because that is the way the new director does it. On 10/02/20 at 11:30 AM, the surveyor interviewed cook #2 regarding the spices, salad dressing, salads and mayonnaise regarding dates and he told the surveyor that all food should have been dated with received, opened, and use by dates and that Prepared foods should be labeled with prepared and use by dates. On 10/07/20 at 12:44 PM, the surveyor interviewed the FSD regarding the labeling of items. The FSD told the surveyor that all items should be labeled and dated. The surveyor asked the FSD about the storage of scoops in the chicken and beef base containers. The FSD stated: staff should know better. On 10/07/20 at 12:46 PM, the surveyor reviewed the policy titled: Food Storage which was dated 3/14/18. Under the procedure section, number one, the policy reflected that scoops would be provided for items in bins, such as sugar, flour, rice and other items and that scoops would be stored covered in a protected area near the food containers. Under section two, the policy indicated to date, label, and tightly seal all refrigerated foods and all items should include a use-by date and that all foods are to be labeled with a received dated. The policy also indicated that once a product is opened, the label must include the use by or expiration date. On 10/08/20 at 12:09 PM, the surveyor received another policy titled: Food Storage. The policy did not have a date. Under the section titled Receiving, Storage and use of refrigerated foods, the procedure revealed that items would be dated upon receipt and will be dated upon opening of the product for use. NJAC 8:39-17.2