Based on observations, interviews, and review of facility policy, the facility failed to ensure two dietary aides and one Certified Nurse Aide (CNA) performed appropriate hand hygiene. This failure to perform adequate hand hygiene can lead to cross contamination. Findings include: Observation and interview on 02/12/25 at 11:50 AM, revealed CNA1 entered the Bistro (a kitchenette where all meals are brought from the kitchen, placed in the steaming tables, and prepped for meals) where two Dietary Aides (DAs) were preparing lunch trays. CNA1 proceeded to open the ice machine, retrieve the blue ice scooper, and scoop ice from the machine. CNA1 placed ice into her personal water vessel. CNA1 did not wash or sanitize her hands (perform hand hygiene) prior to handling the ice scoop or after leaving the Bistro. A further observation during this same time revealed DA2 preparing meals inside the Bistro. DA2 exited the Bistro, entered the dining room area, and placed four placemats on a dining room table where four residents were sitting. DA2 returned to the Bistro and continued to assist with preparing lunch meals. DA2 was not observed using proper hand hygiene. During this same time, CNA1 was asked to share the facility policy for entering the Bistro during meal passes. CNA1 stated, during meal services only the DA and cook were allowed to be in the Bistro. CNA1 continued to share, she had been trained on the proper hand hygiene protocol and should have asked the DA to retrieve the ice for her. Observation on 02/12/25 at 12:05 PM revealed Dietary Aide (DA) 1 preparing meal trays in the Bistro. DA1 was donning a red knit cap over her hair net. DA1 was observed to remove the red knit cap, walk out of the Bistro, enter the nursing office located behind the Bistro, return to the Bistro, and continue to prepare resident's meal trays. DA1 failed to perform hand hygiene before returning to handle residents' meal trays. During an interview on 02/12/25 at 12:45 PM, the Dietary Manager (DM) revealed only the DA and cook were to be in the food prep (Bistro) area while food services were being conducted. The DM continued to share hand hygiene protocols were to be followed before starting food service, leaving and returning to the Bistro, or if the hands were visibly soiled. During an interview on 02/12/25 at 1:45 PM, the Infection Preventionist (IP) revealed her expectation was for all staff to wash or sanitize their hands before preparing food items. The IP continued to state that only dietary staff should be in the Bistro during meal preparation. During an interview on 02/12/25 at 2:31 PM, DA2 confirmed he did not follow proper hand hygiene protocol. DA2 continued to share, once he left the Bistro to assist residents in the dining room, he should have washed his hands before returning to the Bistro and preparing meal trays. During an interview on 02/12/25 at 2:38 PM, DA1 confirmed, during the lunch meal pass, she failed to use proper hand hygiene protocols. DA1 continued to share, she should have washed her hands after removing her hat and returning to the Bistro. Review of the facility's policy titled, Hand Hygiene Policy and Table, undated, revealed, . All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections . Hand hygiene is indicated . immediately before touching a resident . after contact with . contaminated surfaces . after touching the residents environment . Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Between resident contacts . [and] after handling contaminated objects . The use of gloves does not replace hand hygiene if your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

**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 code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 12 residents, Resident #6 and #26 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1.On 11/24/24 at 11:04 AM the surveyor interviewed Resident #6 in their room. Resident #6 stated they occasionally feel anxious but receive medication when needed. On 11/25/24 at 10:30 AM, the surveyor reviewed the electronic medical record for Resident #6 which revealed the resident's face sheet (a one-page summary of important information about the patient) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to chronic kidney disease, hyperlipidemia, and protein-calorie malnutrition. A review of the November 2024 Physicians Orders (PO) revealed a PO with a start date of 11/13/24, Lorazepam Oral Tablet 0.5 milligram (MG), Give 0.25 milliliter (ml) by mouth every 6 hours as needed for anxiety/ agitation. A review of the November 2024 electronic Medication Administration Record revealed Resident #6 received one dose of Lorazepam on 11/16/24 at 3:15 AM. On 11/25/24 at 11:28 AM, the surveyor reviewed the Significant Change in Status Assessment MDS dated [DATE], under Section N (Medications) N0415. High-Risk Drug Classes: Use and Indication, B: Antianxiety medication was listed as No On 11/26/24 at 11:58 AM, the surveyor interviewed the Registered Nurse/Case Manager (RN/CM), who stated, Resident #6 MDS should have been checked yes for the antianxiety medication. RN/CM further stated the facility followed the RAI manual as their policy. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2024) on Chapter 2-page 39 . According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2024). This item documents the type of medication to which the resident is or is not receiving. Steps for Assessment: 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look back period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care settings where the resident may have received any of these medications while a resident of the nursing home (e.g., valium given in the emergency room). Coding Instructions: Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. Column 1: Check if the resident is taking any medications by pharmacological classification during the 7-day observation period (or since admission/entry or reentry if less than 7 days). Column 2: If Column 1 is checked, check if there is an indication noted for all medications in the drug class. 2. On 11/26/24 at 10:40 AM, the surveyor reviewed the discharge medical records for Resident #26. The resident was admitted to the facility on [DATE]. Further review of the medical records revealed that the resident was discharged to home on 9/15/24. A review of the MDS Discharge Return Not Anticipated assessment for Resident #26 dated 9/15/24 revealed that the resident was discharged to an acute hospital. A review of the interdisciplinary progress notes dated 9/15/24 documented that Resident #26 was discharged to home. On 11/26/24 at 11:59 AM, the surveyor interviewed the facility's RN/CM who was also responsible to oversee the MDS completion and she confirmed that Resident #26 was discharged to home and not to an acute hospital. The RN/CM also stated that it was entered in error. On 11/26/24 at 1:18 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, Regional Director of Operations, Regional Nurse Consultant, RN/CM, and Regional Director of Clinical Services to review the above concerns. No further information was provided. NJAC 8:39-11.1, 11.2(e)(1)