**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 ensure the proper administration of Fluticasone (Flonase; nasal spray used to relieve allergies and nasal congestion) in accordance with manufacturer's specifications and professional standards of practice during the medication pass observation on 12/13/24. The deficient practice was identified for 1 of 4 nurses who administered medications to 1 of 4 residents (Resident #11) 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 or 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. A review of the manufacturer's specification for Fluticasone under instructions for use included the following: Step 1: Blow nose to clear the nostrils; Step 2: Close 1 nostril. Tilt head forward slightly and keeping the bottle upright, carefully insert the nasal applicator into the nostril; Step 3: Breathe in through nose, while breathing in press firmly and quickly 1 time on the applicator to release the spray . On 12/13/24 at 9:04 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #11. The medications included a physician's order for Flonase Allergy Relief nasal suspension 50 microgram /actuation, 1 spray in both nostrils one time a day for allergies with an order start date of 9/24/24. At 9:06 AM, the surveyor observed the LPN pull one piece of tissue and folded it into her hand. At 9:07 AM, the LPN confirmed with the surveyor that she was ready to administer Resident #11's medication and walked into the resident's room with the medication and one tissue. At 9:08 AM, the surveyor observed the LPN explain to the resident that she would be administering their nasal spray. The LPN sprayed 1 spray into each of the resident's nostril and handed a tissue to the resident. The resident used the tissue to dab at the dripping from the nose. At 9:10 AM, outside the resident's room, in front of the medication cart, the surveyor and the LPN reviewed the medication package for the Fluticasone nasal spray that was stored in the LPN's medication cart. The manufacturer's specification for the Fluticasone was not in the box. The surveyor and the LPN reviewed the electronic Medication Administration Record for Resident #11's Fluticasone. The medication instructions did not include ancillary instruction as per manufacturer's specification for the resident to blow their nose to clear their nostril prior to administration. At that time, the LPN stated that she could always look up the information on her phone if there was information that she did not know. The LPN also stated that she would look for the proper administration of Fluticasone at the nurse's station. On 12/16/24 at 11:40 AM, during an interview with the surveyor, Registered Nurse/Unit Manager (RN/UM) for [NAME], Chestnut, and Juniper, stated that the manufacturer's package insert for the Fluticasone should have been with the medication package. At that time the RN/UM also stated that the LPN who administered the medication to Resident #11 should have instructed Resident #11 to blow their nose prior to administration of the Fluticasone nasal spray to ensure full effectiveness of the medication. The RN/UM stated that she would educate the staff on proper administration of Fluticasone nasal spray and ensure that the manufacturer's package insert would be left in the medication package for reference. The RN/UM informed the surveyor that she would communicate the concern with the Director of Nursing (DON) and believed that upper management was aware of the concern. On 12/16/24 at 1:37 PM, during a meeting with the survey team, the DON, the Infection Preventionist (IP), the Assistant Director of Nursing (ADON) and the Licensed Nursing Home Administrator (LNHA), the surveyor discussed the concern regarding the improper administration of the Fluticasone nasal spray to Resident #11, that was not in accordance with manufacturer's specifications and professional standards of practice. On 12/18/24 at 11:11 AM, the DON acknowledged the medication pass concern. The ADON provided in-services that was started with the nursing staff. A review of the provided facility policy, Medication Management dated October 2024, included the following: It is the policy to maintain safe and competent medication management system that is based on best practice and care process of the resident . NJAC 8:39-11.2(b), 29.2(d)

**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 maintain infection control standards and procedures during wound care treatment for 1 of 2 residents (Resident #89), reviewed for care and services for pressure ulcers. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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 12/12/24 at 12:20 PM, the surveyor observed Resident #89 in bed on a specialty mattress. The surveyor reviewed the medical record for Resident # 89. A review of the admission Record revealed the resident was admitted to the facility with diagnoses that included but were not limited to diabetes mellitus, neoplasm of the rectum, gastrostomy status (a tube inserted through the wall of the abdomen into the stomach to provide nutrition) and stage 3 pressure ulcer of the sacrum (a wound that involves the full thickness of the skin). A review of the admission Minimum Data Set assessment tool (MDS) dated [DATE] indicated the resident had a moderate cognitive impairment as referenced by a score of 11 on the Brief Interview for Mental Status (BIMS) in Section C. Section M indicated the resident was admitted with two stage 3 pressure ulcers. The 12/9/24 Weekly Wound Assessment Report included documentation regarding the stage 3 sacral pressure ulcer which was currently unchanged. A review of the Physician Order (PO) dated 12/16/24 included: soak sacral wound with ¼ strength Dakin's Solution (a topical antiseptic) for 15 minutes, remove the soaked dressing after 15 minutes, pat dry, apply Santyl (ointment used to remove dead tissue from wounds to promote healing), pack with Calcium Alginate (used to absorb wound fluid) and cover with Mepilex (absorbent foam dressing). On 12/17/24 at 11:05 AM, the surveyor observed the pressure ulcer treatment. The Licensed Practical Nurse (LPN), assisted by the Registered Nurse (RN) performed the treatment. After reviewing the physician's treatment order, the LPN gathered all of the supplies and placed them on top of the treatment cart. The LPN and RN then donned (put on) surgical masks, disposable gowns and gloves, and entered Resident #89's room. The LPN placed the supplies on top of the uncleaned dresser, disinfected the resident's overbed table, picked up the trash can and moved it next to the bed. The LPN, with the same gloves (now considered soiled), applied a clean barrier to the overbed table and put the supplies on top of the clean barrier. The LPN removed her gloves and performed hand hygiene. The LPN removed the soiled dressing and packing from the resident's sacral area, removed her gloves, and proceeded to the bathroom to perform hand washing. On 12/17/24 at 11:20 AM, the LPN applied clean gloves and packed the wound with Dakin's Solution-saturated gauze. The LPN and RN repositioned the resident, doffed (took off) their Personal Protective Equipment (PPE) washed their hands and left the room, allowing the wound to soak for 15 minutes according to the physician's order. On 12/17/24 at 11:35 AM, the LPN gathered the needed supplies and placed them on top of the treatment cart. The supplies included a tube of Santyl ointment, Calcium Alginate dressing, scissors, sterile Q-Tips, a foam dressing and a marker. The LPN put a small amount of Santyl ointment into a plastic cup and put the tube back into the treatment cart. The LPN and RN donned PPE and entered Resident #89's room. The LPN set the supplies onto the dresser, disinfected the overbed table and with the same gloves (now considered soiled) applied the clean barrier, and then placed all the supplies on the clean barrier. The LPN performed hand hygiene, donned gloves, and removed the packing from the sacral wound. The LPN removed her gloves, performed hand hygiene, and applied the Santyl to the wound with a sterile Q-Tip. The LPN without cleaning the scissors, cut the Calcium Alginate package, packed the wound with the Calcium Alginate, and applied the dated initialed foam dressing. The surveyor interviewed the LPN and RN after the LPN had completed the treatment. The LPN confirmed that she should not have placed all of the treatment supplies on an unclean surface. The LPN acknowledged that she should have removed her soiled gloves and washed her hands after she disinfected the overbed table and touched the garbage can. The LPN stated that the facility policy was to clean the scissors before and after each use. On 12/17/24 at 12:29 PM, the surveyor discussed the treatment observation with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). On 12/19/24 at 12:45 PM, the surveyor interviewed the DON who confirmed the LPN should not have put the supplies on an unclean surface, should have changed her gloves after disinfecting the overbed table and handling the trash can, and should have disinfected the scissors before and after each use. A review of the facility's undated Wound Care Competency included performing hand hygiene before setting up a clean field. No further information was provided by the facility. NJAC 8:39 19.4 (a)

Based on observation, interviews, and record review it was determined that the facility failed to ensure a fall intervention, specifically a bathroom door alarm, was in place and functioning for a resident with a history of falls. This deficient practice was identified for 1 of 2 residents reviewed for falls, Resident #49, and was evidenced by the following: According to the admission Record, Resident #49 had diagnoses that included but were not limited to Alzheimer's disease and fracture of the left radius (forearm). A review of the Quarterly Minimum Data Set (MDS), an assessment tool, dated 9/10/2023, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 3 which indicated that the resident's cognition was severely impaired. An additional review of the MDS revealed the resident had falls with injuries. A review of the Resident's care plan revised on 9/7/23 included that the resident was at risk for falls related to confusion, limited mobility, and poor safety awareness with a goal that the resident would be free of major fall related injuries. Interventions included but were not limited to; bathroom door alarm added for safety which was initiated on 8/29/23. A review of progress notes, dated 8/27/23 at 3:10 am, reflected that the staff responded to an alarm and found the resident lying on the bathroom floor holding onto their wheelchair. A review of the resident's Incident Report (IR), dated 8/27/23, revealed that the resident was found on the floor in the bathroom and sustained a skin tear to their left leg. The fall investigation review indicated that a bathroom door alarm was added for safety on 8/28/23. On 09/27/23 at 10:45 AM the surveyor observed Resident #49 seated in a wheelchair in their room. The surveyor observed the bathroom door was open with no audible alarm sounding. On 09/27/23 at 10:58 AM, the assigned certified nurses aide (CNA) entered the resident's room. The surveyor asked the CNA how they knew how to take care of residents who had falls. The CNA stated they used a paper cheat sheet, that let the staff know about resident care and alarms the resident should have. At that time, the surveyor asked the CNA to check the bathroom door. The CNA stated she didn't know about that alarm, looked at the bathroom door alarm and stated that the alarm wasn't working. On 09/27/23 at 10:59 AM the assigned Licensed Practical Nurse (LPN) was outside of the resident's room and stated she hadn't seen the resident yet, but the alarm was working the day prior. She added that the bathroom door should be closed. On 09/27/23 at 11:10 AM, the surveyor reviewed the CNA cheat sheet (titled daily report) with the CNA which indicated that the resident had a bathroom alarm. During an interview with the surveyor on 09/27/23 at 11:22 AM, the LPN stated that she and the Unit Manager (UM) informed the staff of interventions for the residents verbally and that their assignment (daily report) sheet would be updated. She stated that Resident #49's bathroom door should have been closed so if it was opened, the alarm would go off. During an interview with the surveyor on 09/27/23 at 12:12 PM, the Director of Nursing (DON) stated after a fall, the resident's care plan was updated by the nurse or the Unit Manager, and the transfer sheet (daily sheet) with interventions would be updated for the CNAs. The DON added that the CNAs also access the resident's care plan. She stated the CNAs completed safety checks at the start and the end of the shift to ensure alarms were in place and functioning. She explained that the door to Resident #49's bathroom should have been closed and the alarm should have been checked for placement and functioning. During an additional interview with the surveyor on 09/28/23 at 10:01 AM, the DON stated that the door alarm was part of the resident's care plan and the CNA should have ensured Resident #49's alarm was in place for safety. A review of a facility policy titled, Comprehensive Resident Centered Care Plans dated 6/1/2023, included but was not limited to; It is the policy of the facility to promote seamless Interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. NJAC 8:39- 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the administration of controlled medication for 1 sampled resident (Resident #7) identified upon inspection of 1 of 4 medication carts (Willow unit). The evidence was as follows: On 9/28/23 at 10:44 AM, the surveyor in the presence of the Registered Nurse (RN) inspected the [NAME] unit medication cart. The surveyor and the RN reviewed the controlled medications located in a secured and locked controlled medications box. When the controlled medication inventory was compared to the corresponding declining inventory sheet, the surveyor identified the following concerns. Resident #7's morphine sulfate oral solution 100 milligram (mg)/ 5 milliliter (ml) oral solution container, a medication used for pain, did not match the declining inventory sheet quantity. The bottle of morphine had the tamper evident seal removed indicting the bottle had been opened and the corresponding declining inventory sheet indicated there had been no doses removed from that morphine bottle. At that time, the RN stated she had not administered morphine to the resident that day and acknowledged the tamper evident seal had been removed from the bottle of morphine and the declining inventory sheet reflected there had been no doses removed from the bottle. The RN further stated when administering a controlled substance, the nurse was to remove the dose from inventory and complete the declining inventory sheet indicating the medication had been removed from stock, administer the medication, and then sign the medication administration record (MAR) which indicated the medication had been administered. On 9/28/23 at 11:22 AM, the surveyor interviewed the Assistant Director of Nursing (ADON). Together the surveyor and the ADON reviewed the declining inventory sheet for morphine for the resident, and the corresponding MAR. The ADON acknowledged according to the September 2023 MAR a dose of morphine had been given on 9/22/23 at 8 AM, however the corresponding declining inventory sheet did not indicate a dose of morphine had been given on that date. The ADON further acknowledged the tamper evident seal had been removed from the resident's morphine bottle. The ADON stated the process was the nurse removed the medication, signed the declining inventory sheet, administered the medication, and then signed the MAR that the medication was given. The ADON acknowledged the nurse did not follow that process on 9/22/23. On 9/29/23 at 10:09 AM, the surveyor attempted to interview via telephone the nurse who had signed the MAR on 9/22/23 at 8:00 AM, the nurse did not pick up the call. On 9/29/23 at 10:20 AM, the surveyor interviewed the facility consultant pharmacist (CP) who stated the declining inventory sheet was for inventory control, to ensure the medication counts were accurate. The CP acknowledged the nurse should have documented on the declining inventory sheet that the medication had been removed from stock, administered the medication, and then documented the dose on the MAR. A review of the admission Record face sheet reflected the resident was admitted to the facility in August of 2023 with diagnoses which included chronic kidney disease, depression, and ventricular premature depolarization (irregular heartbeat). A review of the Order Summary Report (OSR) included physician's orders (PO) dated 9/20/23, for morphine sulfate oral solution 20mg/5 ml; give 0.25 ml by mouth every 2 hours as needed for moderate to severe pain and morphine sulfate oral solution 20mg/5 ml; give 0.25 ml by mouth every 2 hours as needed for dyspnea (air hunger) 0.25 ml =5 mg. A review of the corresponding September 2023 Medication Administration Record (MAR) revealed the resident received a dose of morphine on 9/22/23 at 8:00 AM. A review of the facility's undated Controlled Substances policy dated 6/1/23 .when a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the declining inventory sheet and the medication administration record (MAR): 1. date and time of administrations (MAR and declining sheet) 2. amount administered (declining sheet) 3. remaining quality (declining sheet) 4. initials of the nurse administering the dose, completed after the medication is actually administered (MAR and declining sheet). NJAC 8:39- 29.2(d), 29.7(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 09/26/23 at 11:30 AM, the surveyor observed resident #41 in the room laying on a low air mattress bed. The resident was not interviewable, and their eyes were closed. Two Hospice aides were in the room and one Hospice aide stated the resident does not respond now. The resident used to get out of bed using a mechanical lift to transfer to a wheelchair but is now declining and stays in bed. The resident has been in Hospice Care for about four months. On 09/26/23 at 11:37 AM, the surveyor observed the urinary leg bag laying on the bed at the same level as the resident's bladder. The catheter contained blood-tinged urine in the tube and in the drainage bag. The surveyor observed the Hospice aide wearing gloves and emptying urine from the leg bag into the urinal. The aide then disconnected the tube from the leg bag and drained the blood-tinged urine from the tube into the urinal and then re-attached the tube into the leg bag. The surveyor observed the aide empty the urine in the toilet, washed the urinal in the sink and then came out of the bathroom with the same gloves on. No changing of gloves or handwashing was observed. The aide proceeded to touch the overhead bed table, bed sheets, bed rails and the resident with the same gloves on. On 09/26/23 at 12:05 PM, the surveyors interviewed the Hospice Registered Nurse, who stated the resident has a Diagnoses of Urinary Retention, Parkinson's, Dementia, Alzheimer's, and history of Bladder Cancer and has been using a leg bag for years. On 09/28/23 at 10:25 AM, the DON submitted the facility Policy and Procedure for Urinary Catheter Care dated 12/8/2021 and updated 9/28/23. The Policy and Procedure for Catheter Care stated, Maintain a sterile, continuously closed drainage system; leg bags are not routinely used, unless resident is ambulatory; The only place, in the closed system, intended to be open is the empty spout at the bottom of the drainage bag; The catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. On 09/28/23 at 12:15 PM, the surveyor discussed the above concerns with Administration, DON, Infection Preventionist and Assistant Director of Nursing. 3. On 9/26/23 at 11:14 AM, the surveyors observed Resident #20 lying in bed with urinary catheter leg bag attached to the right upper leg laying on top of the bed. The surveyor reviewed the medical record for Resident #20, which reflected the following: A review of the admission Record face sheet reflected the resident was admitted to the facility on [DATE] with diagnosis which included but not limited to Benign Prostatic Hypeplasia (BPH) is a condition in men in which the prostate gland is enlarged with lower Urinary symptoms, and presence of urogenital implants (indwelling catheter). The admission MDS, an assessment tool, dated 7/03/23 reflected that the resident was admitted to the facility on [DATE] and had a BIMS score of 14 out of 15, reflecting an intact cognition. The assessment reflected that the resident's urinary incontinence is not rated, and always incontinent of bowel elimination. The admission MDS also revealed that the resident functional status reflected that the resident walk in room and walk in corridor, revealed that the activity did not occur. The Care Plan created on 7/01/23 reflected that Resident #20 has an indwelling catheter related to a history of retention, and BPH. The care plan intervention includes secure catheter tubing to leg or abdomen to avoid tension on urinary meatus and keep drainage bag below the bladder. On 9/28/23 at 9:58 AM, the surveyor interviewed the nurse's aide and stated that the leg bag was not meant to be hung and an anti-backflow tube was attached. On 9/28/23 at 01:24 PM, the surveyor verified the resident's ambulatory status with the MDS Coordinator. The MDS Coordinator verified with the surveyor that the resident has non ambulatory since admission. The policy titled Heath Village Urinary Catheter Care dated 9/28/23 revealed under procedures, 9. Leg bags are not routinely used, unless resident is ambulatory. 11. The catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. 2. On 09/26/23 at 10:52 AM, a surveyor observed Resident #23 in bed with a leg catheter bag next to their right knee. The surveyor reviewed the medical record for Resident #23. A review of the admission Record face sheet reflected the resident was re-admitted to the facility in June of 2023 with diagnosis which included Urinary Tract Infection, Urinary Retention, and Congestive Heart Failure. A review of the admission MDS dated [DATE], the resident had a BIMS score of 15 out of 15, which indicated a fully intact cognition. Further review of the MDS indicated the resident as dependent on staff for all activities of daily living (ADLs) and required the use of an indwelling urinary catheter. A review of the ICCP included a focus area created on 06/28/2023, that the [Resident] has indwelling catheter [related to] retention [ .] at risk for complications associated with indwelling [foley catheter]. Interventions included: Secure catheter tubing to leg or abdomen to avoid tension on urinary meatus and keep drainage bag below the bladder. On 09/28/2023 at 10:00 AM, the surveyor entered the resident room and did not observe a foley bag hanging from Resident #23's bed. On 09/28/2023 at 10:01 AM, the surveyor interviewed CNA #1 who confirmed that the resident had a foley bag and prefered to stay in bed. CNA confirmed that the foley bag could also be used as a leg bag, but the resident did not like to wear it. On 09/28/2023 at 11:01 AM, the surveyor, in the presence of RN #1, entered the room of Resident #23 and requested permission to look at their foley catheter. RN #1 removed the blanket and revealed the foley catheter bag on the bed by the resident's right knee. On 09/28/2023 at 11:45 AM, the surveyor interviewed RN #1 who confirmed that Resident #23 had history of urinary retention and Extended Spectrum Beta-Lactamase (ESBL- a drug resistant bacterial infection) in the urine. Upon viewing the foley bag on the bed, RN #1 acknowledged that the foley bag ideally should be positioned below the level of the bladder. When asked why is it was important for the foley bag to be below the level of the bladder RN #1 reported, to get all the urine out [of the bladder], [they have] ESBL in the urine so [it should be below the bladder] for infection control and to get the 40 milliliters of drainage that they [the physicians] want to see per hour. When asked if there was a way to hang the foley bag on the bed, RN #1 stated no. The policy for urinary catheter care dated 9/28/23 stated that the catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. Based on observation, interview and record review, it was determined that the facility failed to maintain proper care of indwelling urinary catheters to prevent Urinary Tract Infections (UTIs) for 4 of 4 residents (Resident #41, #23, #20 and #14) reviewed for urinary catheter care use. This deficient practice was evidenced by the following: 1. On 9/27/23 at 10:33 AM, Resident #41 was observed lying in bed with both eyes closed. The surveyor reviewed the medical record for Resident #41. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in October 2020 with diagnoses that included urinary retention (difficulty urinating), a history of malignant neoplasm of the bladder (bladder cancer), and Alzheimer's disease(a brain disease that causes memory loss). A review of the 9/13/23 Quarterly Minimum Data Set (MDS), an assessment tool, revealed the resident had a Brief Interview for Mental Status (BIMS), which indicated that the resident had a score of 9 out of 15 indicating the resident had moderate cognitive impairment. A review of the order summary revealed a physician order dated 3/14/23, to change the foley catheter on the 8th of each month on 7-3 shift. Further review revealed that the urinary leg bag combination pack was to be changed weekly every Thursday on the 11 to 7 shift. A review of the Individualized Comprehensive Care Plan (ICCP) included a focus area created on 5/26/21, which revealed the resident had an indwelling catheter related to urinary retention and bladder cancer. Interventions included securing the catheter tubing to the leg or abdomen to avoid tension on the urinary meatus and to keep the drainage bag below the bladder. On 9/27/23 at 11:55 AM, the surveyor interviewed the Certified Nursing Assistant (CNA), who stated the resident used a leg bag and the leg bag stayed in the bed with the resident. On 9/27/23 at 12:00 PM, the surveyor interviewed the Registered Nurse (RN), who stated that the urinary catheter bags were changed weekly and she monitored the resident's output. The nurse exposed the urinary bag that was lying in the bed next to the resident. The urinary bag had blood-tinged urine in the bag. The RN further stated that that was the type of bag that the facility used and the staff did not change to a leg bag. On 9/28/23 at 9:41 AM, the surveyor observed the Infection Preventionist/Registered Nurse (IP/RN) and the Director of Nursing (DON) at the resident's bedside with the urinary catheter leg bag lying next to the resident. The IP/RN stated that urinary bags lay in the bed with residents and the urinary bags do not hang on the side of the bed. On 9/28/23 at 9:51 AM, the surveyor interviewed the IP/RN who stated the facility used a combination urinary pack at the facility for 6 years. She further stated that it was the system that the facility used, and the collection bag did not hang off the side of the bed. The policy for urinary catheter care dated 9/28/23 stated that the catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. 5. On 9/26/23 at 10:55 AM, the surveyor observed Resident #14's room door with a STOP sign indicating Contact Precautions. The surveyor donned the proper personal protective equipment (PPE) and entered the resident's room. The surveyor observed Resident #14 sitting in a wheelchair. The resident stated that he/she was very happy with the care living here in the facility and had no issues. On 9/27/23 at 11:17 AM, the surveyor interviewed the IP who stated that Resident #14 recently was placed on Contact Precautions because he/she had a multi-drug-resistant organism (MDRO) in the urine and had a foley catheter. The surveyor reviewed the medical record for Resident #14. A review of the quarterly MDS, an assessment tool used to facilitate the management of care, dated 8/20/23, reflected that the resident had a BIMS score of 15 out of 15, indicating that the resident had an intact cognition. A review of the Order Summary Report reflected a physician's order dated 4/23/22 for Foley Catheter care every shift for hygiene. A review of the individualized plan of care (IDCP) created on 4/2/22 with a revision date of 9/26/23 reflected a focus area that the resident has indwelling catheter r/t (related to) retention, hx (history) of bladder cancer-chronic infections in the urine-at risk for reoccurrence. The IDCP also reflected an intervention initiated on 5/20/22 to Secure catheter tubing to leg or abdomen to avoid tension on urinary meatus (the opening of the urethra) and keep drainage bag below the bladder. On 9/28/23 at 10:30 AM, the surveyor donned the proper PPE and entered the room of Resident #14. The surveyor observed the resident sitting in a wheelchair. The resident stated that he/she had a catheter and showed the surveyor his/her left leg which had a bulge by the resident's ankle that was covered by the resident's sweatpants. The resident stated that the catheter was strapped to his/her leg. The resident stated that the nurses took care of the catheter. The resident then stated that at night when he/she went to bed the catheter remained strapped to his/her leg while he/she was lying in bed. On 9/28/23 at 10:44 AM, the surveyor interviewed the CNA #2 who stated that Resident #14 had a leg bag catheter. The CNA #2 added that the catheter bag was strapped to the resident's leg by applying two straps, one strap was placed higher up on the leg and the second strap was placed lower above the ankle. The CNA #2 also stated that the leg bag was always used, and no other catheter bag was used. The CNA #2 added that she had worked at the facility for 30 years and a while back they had used a different kind of catheter bag which hung on the side of the bed but that was no longer used. The CNA #2 added that only leg bag catheters were used even when residents were lying in bed. On 9/28/23 at 12:24 PM, the survey team met with the LNHA, DON, IP, and Assistant Director of Nursing (ADON). The DON stated that after surveyor inquiry they were reviewing the continued use of only the leg bag catheters and updating the facility Catheter Care policy. A review of the facility policy dated 9/28/23 for Urinary Catheter Care provided by the DON revealed that the procedures included Leg bags are not routinely used, unless resident is ambulatory. In addition, The catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. NJAC-8:39-19.4 (a)5, 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 properly label, store and dispose of medications in 2 of 6 medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 10:30 AM, the surveyor inspected the [NAME] unit medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened bottle of Timolol Ophthalmic drops (medication used for Glaucoma. Glaucoma is a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye) and an opened bottle of Cosopt Ophthalmic drops (medication used for Glaucoma) that were both opened on [DATE] and were expired. The surveyor interviewed LPN #1 who stated that both the Timolol and Cosopt Ophthalmic drops were expired and should have been removed from the medication cart. On [DATE] at 10:55 AM, the surveyor inspected the Juniper unit medication cart in the presence of LPN#2. The surveyor observed an opened Glargine Insulin Pen (medication used for Diabetes) with an opened date of [DATE] that contained no resident's name on the pen. The surveyor interviewed LPN #2 who stated that all insulins including pens and vials should contained the name of the resident. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Timolol Ophthalmic drops once opened have an expiration date of 28-days 2. Cosopt Ophthalmic drops once opened have an expiration date of 28-days. On [DATE] at 11:20 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and no further information was provided by the facility. A review of the facility's policy for Disposal of Medications and Medication-Related Supplies that was dated 4/22 and was provided by the DON indicated the following: When medications are discontinued by the prescriber or the resident is discharged and medications are not sent with the resident, the medications are marked as discontinued and stored in a secure and separate area from the active supply, marked discontinued and securely stored until destroyed. C. Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue (to avoid inadvertent administration). Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy. A review of the facility's policy for Specific Medications Administration Procedures that was dated 4/22 and was provided by the DON indicated the following: D. Check expiration date on package/container before administering any medications. When opening a multidose container, place the date on the container. NJAC: 8:39-29.4 (a) (h) (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to follow professional standards of clinical practice concerning 1.) administration of medications for 1 of 4 residents(Resident #15) and 2.) following a physician's order for a resident who is on daily weight for 2 of 2 residents (Resident #38 and Resident #45). This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes 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. This deficient practice was evidenced by the following: 1. On 06/07/22 at 10:02 AM, the surveyor observed Resident #15 in his/her room sitting in a wheelchair. The surveyor observed two small plastic cups, one containing pills and the second containing applesauce sitting on the overbed table. Resident #15 stated that he/she takes medications by themselves but never signed papers to be able to do so and nobody ever educated him/her on what to do. Resident #15 stated that he/she didn't know what each pill was for but knew some of them and would take the medications when he/she wanted to. Resident #15 tilted the small plastic cup and the surveyor observed seven pills. Resident #15 was unable to identify the pills. The surveyor reviewed Resident #15's medical records. The admission Record (an admission summary) revealed that Resident #15 had been admitted with diagnoses which included but were not limited to: bacterial pneumonia (lung infection and inflammation), dementia without behavior disturbance, anxiety, panic disorder, hypotension (low blood pressure), need for assistance with personal care, and Type 2 Diabetes Mellitus. According to the Annual Minimum Data Set (MDS) dated [DATE], a tool used to facilitate the management of care, revealed that Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The Nursing admission Assessment, dated 5/10/22, revealed that Resident #15 had both short- and long-term memory problems, poor balance, and behaviors of being anxious, and could be resistive. The facility provided; Order Summary Report for June 2022, did not reflect documented evidence to indicate Resident #15 was able to self-administer his/her medications. According to the Care Plan with an initiated date of 3/15/22, revealed a focus area that Resident #15 displayed signs/symptoms of impaired cognition/impaired thought process as evidenced by forgetfulness and/or confusion related to dementia. On 6/07/22 at 10:11 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that she was an agency nurse who had been working at the facility for four weeks. The LPN stated that Resident #15's medications were scheduled for 9 AM and she was aware it was after the hour time range to administer the medications. The LPN stated, I ran out for a bell. I usually let Resident #15 take them [medications] but I have to watch him/her. That was on me. I should not leave them.[medications] Anyone could walk in and take them [medications] and the resident might not take them [medications]. The LPN further stated that she knew at least one of the medications was a vitamin but would have to look up the other medications to see what they were and that she would go get the pills from the resident room. On 6/07/22 at 10:17 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) for Resident #15. She stated that the process for medication pass would be to follow the five rights, knock on the resident's door, and administer medications with precautionary measures. The LPN/UM stated that no residents on the unit were able to self-administer medications. The LPN/UM further stated that pills should never be left in a resident's room because the pills might not be taken by the resident or someone else could take them. On 6/07/22 at 10:46 AM, the surveyor interviewed the Director of Nursing (DON) who stated that medication administration consisted of the five rights, nurses should introduce themselves to the resident, know the medications they are administering, check the medications against the Medication Administration Record (MAR), watch the resident take the medications, and never leave medications in the resident's room. The DON stated that others could take the medications and/or the resident may not remember to take the medications. If a resident refused to take the medications at that time, the nurse must take the medications away and destroy them. The DON stated that nurses all have medication competencies including the agency nurses. On 6/09/22 at 10:10 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she was told by the LPN that she went to administer Resident #15's pills, heard an alarm, went to answer the alarm, and forgot to go back to Resident #15. The ADON stated that the LPN should have taken the medications with her and not have left them in the resident's room. The ADON further stated that since it was after 10 am and the medications were not in her sight, the LPN should have removed the medications and gave new pills because the LPN would not have known what medications were in that cup or missing from the cup. The ADON stated that the LPN should have called the physician about the late administration of medications and should have documented the conversation, but it did not get done. 2. On 6/8/2022 at 9:35 AM, the surveyor observed Resident #38 at the bedside sitting in their chair and able to respond to the surveyor's question appropriately. The resident had no shortness of breath and denied discomfort at that time. The resident stated he/she had weight fluctuations since admission but had no concerns. The surveyor reviewed Resident #38's medical records. The admission Record reflected that the resident had diagnoses that included but were not limited to: Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, which occurs when the heart muscle doesn't pump blood as well as it should. The admission MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15, which reflected the resident had an intact cognition. It also reflected that the resident had no shortness of breath (SOB). According to the Order Summary Report for June 2022, revealed an order dated 4/20/22 for daily weights everyday shift and to call the medical doctor (MD) if there is a weight gain of 2 Lbs. (pounds) or more/day. The electronic Medication Administration Record (eMAR) reflected the following dates with 2 pounds (Lbs.) or more/day weight gain: 6/3/22 130 Lbs. (4 Lbs. weight gain) 5/30/22 126.6 Lbs. (2.6 Lbs. weight gain) 5/21/22 126 Lbs. (2 Lbs. weight gain) A review of the resident's hybrid (paper and electronic/computer-generated) medical records did not reflect documented evidence that the physician was notified of the resident's 2 Lbs. or more/day weight gain on 5/21/22, 5/30/22, and 6/3/22. On 6/8/22 at 10:08 AM, the surveyor interviewed the Registered Nurse (RN). She acknowledged that the resident had an MD order for daily weights and that the nurse should have called the MD for 2 Lbs. or more/day weight gain. She further stated that the resident was weighed daily during the morning shift by the Certified Nursing Aide (CNA). The CNA was then expected to record the weight in the resident's electronic medical record (EMR) and report it to the RN. The RN reviewed the resident's 6/2022 EMAR in the presence of the surveyor and she acknowledged to surveyor that the resident had more than 2 Lbs. weight gain on 6/3/22. She further explained that the nurse should've called [name redacted] to notify him of the weight gain, and should've documented in the nurse's notes that the MD was notified of the weight gain. The RN could not provide any information to reflect that the MD was notified of the weight gain on 6/3/22. On 6/8/22 at 10:34 AM, the surveyor interviewed the LPN/UM who stated that the resident had a diagnosis of Congestive Heart Failure (CHF). She could not speak to why the MD was not contacted about the resident's weight gain of at least 2 Lbs./day on 5/21/22, 5/30/22, and 6/3/22 and why there was documented evidence in the EMR to reflect that the MD was alerted of the weight gain. Furthermore, she stated that the nurses should have called and notified the MD of the resident's weight gain and should've documented in the nurse's notes that the MD was notified. The LPN/UM also stated that it was important for the nurses to follow the MD's order for daily weight and to notify the MD if the resident had a weight gain of 2 or more Lbs. as this could be an indication of resident's change in condition. At 11:08 AM, the LPN/UM informed the surveyor that the resident's MD visited the resident on 4/21/22, 5/2/22, and 5/28/22. She acknowledged to the surveyor that there was no documented evidence in the Office/Outpatient Visit physician's notes dated 5/28/22, that the MD was notified and aware of a 2 Lbs. weight gain on 5/21/22. 3. On 6/3/22 at 11:45 AM, the surveyor observed Resident #45 sitting in their high back chair, awake, alert, and he/she was able to respond to the surveyor's question appropriately. The resident had no shortness of breath and denied discomfort at that time. The resident stated he/she had weight fluctuations since admission but was not worried about it. The surveyor reviewed Resident #45's medical records. According to the resident's admission Record reflected that the resident had diagnoses that included but were not limited to: Chronic Diastolic (Congestive) Heart Failure and Hypertensive Heart Disease with Heart Failure. The Quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 14 out of 15, which indicated that the resident had an intact cognition. It also reflected that the resident had no SOB. The Order Summary Report dated June 2022, revealed an order dated 1/29/2022 for daily weight one time a day and to call the MD if there was a weight gain of 2 Lbs. or more/day. The eMAR reflected the following dates with 2 lbs. or more/day weight gain: 6/6/22 198.8 Lbs. (3.8 Lbs. weight gain) 6/2/22 198.4 Lbs. (2.7 Lbs. weight gain) 5/27/22 194.6 Lbs. (3.4 Lbs. weight gain) 5/20/22 193 Lbs. (4.6 Lbs. weight gain) 5/17/22 190.8 Lbs. (4.4 Lbs. weight gain) 5/7/22 196.4 Lbs. (3.4 Lbs. weight gain) 5/3/22 197.6 Lbs. (6 Lbs. weight gain) 4/26/22 195.8 Lbs. (3.8 Lbs. weight gain) 4/23/22 190.8 Lbs. (2.3 Lbs. weight gain) 4/10/22 193.5 Lbs. (4.9 Lbs. weight gain) 4/7/22 183.5 Lbs. (2.5 Lbs. weight gain) 4/5/22 184.6 Lbs. (3.6 Lbs. weight gain) 4/1/22/ 190 Lbs. (2.8 Lbs. weight gain) 3/31/22 187.2 Lbs. (5.5 Lbs. weight gain) 3/15/22 184.8 Lbs. (3 Lbs. weight gain) 3/3/22 182.6 Lbs. (3.8 Lbs. weight gain) 2/22/22 178.4 Lbs. (3 Lbs. weight gain) 2/17/22 179 Lbs. (3 Lbs. weight gain) 2/4/22 177.2 Lbs. (2.9 Lbs. weight gain) 1/31/22 170 Lbs. (2.2 Lbs. weight gain) 1/30/22 167.8 Lbs. (2.4 Lbs. weight gain) According to the resident's hybrid medical records did not reflect documented evidence that the physician was notified of the resident's 2 Lbs. or more/day weight gain on the dates indicated above. Furthermore, there was no evidence for a daily weight on 5/11/22, 3/27/22, 2/6/22 and 2/5/22. On 6/9/22 at 10:09 AM, the LPN/UM stated that she could not speak to nor provide documented evidence that the MD was notified of the resident's at least 2 Lbs. weight gain but did acknowledge there should have been documentation. She stated that the MD should have been notified at that moment when the nurses discovered a 2 Lbs. or more weight gain for that resident. Furthermore, she acknowledged to the surveyor that there was no weight documented on 5/11/22, 3/27/22, 2/6/22, and 2/5/22 and could not speak to why the weights were not documented. At 10:15 AM, the LPN/UM acknowledged to the surveyor that the resident's MD visited the resident on 2/13/22, 3/25/22, and 4/23/22 and that there was no documented evidence in the MD Office/Outpatient Visit notes that the MD was notified and made aware of 2 Lbs. or more weight gain on the dates indicated above from the eMAR. At 10:23 AM, the surveyor conducted a phone interview with the RN in the presence of the LPN/UM. The RN acknowledged to the surveyor that she was the day shift nurse assigned to the resident on 6/2/22. She also acknowledged that the resident had a 2.7 Lbs. weight gain on that day. She stated that she did not call the MD to notify the resident's weight gain because she was not comfortable with the resident's weight given by the CNA and stated that the resident may be wearing too much clothing. She stated that she asked the CNA to reweigh the resident for weight verification, but she did not follow up with the CNA and stated, I should have followed up and documented it in the nurse's progress notes and acknowledged that she did not do so. The RN stated that she did record and sign for the resident's weight in the eMAR on 6/2/22. She also stated that she should have called and notified the MD of the resident's weight gain and potential weight discrepancy and documented it in the nurses notes but she did not do so. The LPN/UM was present all throughout the surveyor's interview with the RN. At that time, the LPN/UM acknowledged that the RN should have followed up with the CNA for the resident to reweigh for verification, notified the MD of the resident's weight gain and potential weight discrepancy, and documented this in the nurse's notes, and stated absolutely. On 6/10/22 at 11:16 AM, the team met with the Administrator (LNHA), DON, and Executive Director to discuss the above concerns. The DON stated that the nurses should have notified the MD and assessed the residents for signs and symptoms of CHF, and it should have been documented in the nurses' notes in the EMR. Furthermore, she stated that a weight change beyond the prescribed parameters would be considered a change in condition which is why the nurses should perform physical assessments to ensure the weight gain was not related to CHF. On 6/14/22 at 11:55 AM, the team met with the DON, ADON, Infection Preventionist Nurse (IPN), and the Executive Director. No further information was provided prior to the survey team's exit. A review of the facility's policy on Weight Policy and Procedure updated on 10/15/22 reflected that a charge nurse was to report a weight increase as ordered by the physician. It was also indicated that for daily weights, the nurse must document the weight of greater than or equal to 2 Lbs. and what was addressed to the MD. A review of the facility's Procedure for Notification of Changes for Resident reflected that the nurse would notify the resident, resident's physician and the resident representative(s) for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician. It also indicated to document the notification and record any new orders in the resident's medical record. A review of the facility provided, Medication Pass Observation, dated 05/02/22, included but was not limited to 9.c. resident observed to ensure swallowed meds [medications], and revealed LPN was deemed competent to follow all steps to administer medications safely. A review of the facility provided, Position Description, Performance and Competency Review for position title LPN, undated, included but was not limited to duties and responsibilities to perform medication and treatment duties. A review of the facility provided, Self-Administration of Medications policy and procedure, dated 10/30/17, included but was not limited to a resident may only self-administer medications after the [Interdisciplinary Team] IDT has determined which medications may be safely self-administered. The facility was unable to provide any documentation or determination that Resident #15 was deemed competent to self-administer his/her own medication. A review of the facility provided, Administration of Medications, undated, included but was not limited to 4. Administer oral medication and remain with the resident while he/she takes the medication. Never leave a drug in resident's room. 10. If a resident refused to take a medication, indicate by a circle on administration record and on back of record. NJAC 8:39-11.2(b), 27.1(a)

Based on observations, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to a.) ensure that the facility's policy for the appropriate personal protective equipment (PPE) for staff to wear for a resident who was newly admitted to the facility, to address the risk for infection transmission, and was in accordance with acceptable standards of infection control practice, and b.) wear all required PPE in the room of a newly admitted resident who was on droplet precautions and was unvaccinated for COVID-19 for 2 of 3 staff, according to the facility policy and New Jersey Department of Health guidance. This deficient practice was identified for one of two unvaccinated new admission residents reviewed, Resident #172, and was evidenced by the following: a) During an interview with the survey team on 06/06/22 at 09:39 AM, the Assistant Director of Nursing (ADON) stated that unvaccinated residents that were new admissions were placed on droplet and contact precautions requiring PPE: face shield, gown, gloves, and a surgical mask, when entering the room. The ADON stated that exposed residents were placed on Droplet precautions with an N95 mask (an N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particle), requiring full precautions: gown, gloves, face shield and N95. During a tour of the Laurel Unit on 06/06/22 at 11:19 AM, Surveyor #1 observed a sign outside the room of Resident #172 that read Contact/&Droplet Precautions. The door did not have a Stop sign: must wear an N95 mask. There was a PPE isolation cart outside the door. On 06/06/22 at 11:29 AM, Surveyor #1 observed Physical Therapist (PT) #1 knock on the door of Resident #172's room. She was wearing a surgical mask and a face shield. She donned (put on) a gown and gloves. She entered the room and closed the door. The surveyor reviewed Resident #172's medical records. According to the admission Record (AR), Resident #172 was admitted from an acute care hospital with diagnoses which included but were not limited to: chronic kidney disease and Heart failure. The physician orders revealed an order for Isolation droplet and contact for preventative measures every shift for 10 Days with a started date of 6/3/22 and end date of 6/13/22. The on-going personalized Care Plan revealed a focus area that Resident #172 was not vaccinated for COVID-19, dated 06/05/22. The Interventions included but were not limited to encourage to wear mask during visitations and during close contact activities due to increased risk. According to the social services note dated 6/6/22 at 11:30 AM, indicated that Resident #172 declined the flu shot, PNA (pneumonia), and Covid-19 vaccines. Resident #172 is not vaccinated for COVID-19 . Resident #172 and family were educated on the need for PPE during visitation until he/she is off isolation due to not being vaccinated. They are aware the PPE is located outside the room and that surgical masks can be provided should they only have cloth masks. During an interview with Surveyor #1 on 06/07/22 at 11:48 AM, the Director of Nursing (DON) stated that unvaccinated new admissions had signs for droplet/contact precautions requiring gown, gloves, a face shield, and a surgical mask to be worn in the room. She stated that exposed residents had signs for droplet/contact precautions with a Stop Sign: A N95 must be worn, requiring a gown, gloves, face shield, and a N95 be worn in the room. During an interview with Surveyor #1 on 06/08/22 at 10:31 AM, the Infection Preventionist Registered Nurse (IP/RN) stated that new admissions that were not vaccinated were placed on contact /droplet isolation for 10 day, requiring a surgical mask, gloves, gown, and face shield to enter the room. She stated that Resident #172 was not vaccinated and was on droplet/contact precautions, requiring PPE: gown, surgical mask, gloves, and face shield to be worn in the room. She stated that the facility followed guidelines from the Center of Disease Control (CDC) and New Jersey Department of Health (NJ DOH) and discussed the guidelines with team, which included the Infectious Disease (ID) doctor. In the presence of the survey team and the Licensed Nursing Home Administrator (LNHA) on 06/08/22 at 11:38 AM, the IP/RN stated that they were following the guidance from NJ DOH dated 2/25/22. The IP/RN read #5 of the guidance: New or readmitted asymptomatic patients/residents who are not up to date . the patients/residents should be placed in quarantine and cared for using full PPE (gown, gloves, eye protection that covers the front and sides of face, and a NIOSH-approved N95 or equivalent or higher-level respirator). The LNHA stated that the purpose of special precautions was to minimize the risk of exposure. She stated that the guidance was for the facility to follow. She further stated that guidance is open for interpretation per their ID doctor and that the guidance refers to consideration for cohorting for covid 19. During an interview with Surveyor #1 on 06/09/22 at 09:42 AM, Certified Nursing Assistant (CNA) #1, stated that the signage outside the room of Resident #172 was for droplet/contact precautions which meant that a surgical mask, face shield, gown and gloves must be worn when entering the resident's room because the resident was not vaccinated. In the presence of the survey team, the Executive Director, and the LNHA on 06/10/22 at 11:06 AM, the DON confirmed that they are standing by their policy for unvaccinated new admissions isolation protocol as advised by their ID doctor that a surgical mask, face shield, gown and gloves was required in the room. During an interview with Surveyor #1 on 06/13/22 at 11:06 AM, PT#1 stated that unvaccinated precaution included a surgical mask, goggles/shields, gloves and gown. She stated that Resident #172 was unvaccinated and that a N95mask was not required in the resident's room. b) On 06/08/22 at 10:02 AM, two surveyors observed a staff member inside of Resident #172's room. The surveyors observed that the staff member was wearing eye goggles, a surgical mask, and was standing within arm's length of the resident. The surveyors observed the outside of the room with signage that included contact and droplet precaution, stop see nurse, instructions to use hand hygiene, [PPE] gown and gloves required to enter the room, mask with eye shield for potential body fluids splashes or sprays, and hand hygiene when exiting. There was a plastic bin which contained PPE gowns, gloves, surgical masks, and disinfectant wipes, right outside the door. At that time, a Licensed Practical Nurse (LPN) came to Resident #172's room to inform the staff member inside the room, that she was required to wear PPE while in Resident #172's room. The staff member was identified as a contracted x-ray technician. The x-ray technician stepped out of the room into the hallway, donned a PPE gown and gloves, and re-entered the room. The LPN informed the x-ray technician and surveyors that Resident #172 was on transmission-based precautions because he/she was a new admission and was not vaccinated for COVID-19. On 06/08/22 at 10:07 AM, the two surveyors observed the door open, the x-ray technician move the resident's tray table and she proceeded to write information on paperwork. The x-ray technician was observed to be in close proximity to the resident's face, and Resident #172 was unmasked. The x-ray technician discarded her PPE. The x-ray technician was still wearing the same surgical mask and eye goggles. On 06/08/22 at 10:09 AM, during an interview with the two surveyors, the x-ray technician stated she did not know if she saw the precautionary signs on Resident #172's door. The x-ray technician stated, they are doing this because he/she is unvaccinated, that is silly. Surveyor #2 asked about the required PPE and the x-ray technician showed the surveyor her eye goggles and stated that her company said, eyewear is eyewear. She acknowledged that according to the signage on Resident #172's door, that going into the room she should wear all PPE such as eye wear, mask, gown, and gloves. The x-ray technician further stated the facility never told her what PPE she should wear. On 06/08/22 at 10:15 AM, during an interview with the two surveyors, the LPN stated all staff would need to wear a surgical mask, face shield, PPE gown and gloves to enter Resident #172's room because he/she was not vaccinated for COVID-19. The LPN further stated that PPE was used to protect staff if a resident were to spit while talking. The LPN stated that if the x-ray technician had followed the signage to see nurse, she would have instructed the x-ray technician what PPE she was required to wear. In the presence of the survey team on 06/08/22 at 11:47 AM, the IP/RN stated the hospital would have to do contact tracing on residents being admitted to the facility. The IP/RN stated she could not say that all residents were in the hospital 10-14 days prior to admission and could not say if they were possibly exposed at the hospital or even by the transport company. On 06/08/22 at 12:02 PM, during an interview with Surveyor #2, the IP/RN stated the x-ray technician should have entered Resident #172's room wearing a surgical mask, PPE gown, gloves, and should have followed the signs on the resident doors regarding transmission-based precautions (TBP). The IP/RN stated if there were no nurse around, the x-ray technician should have reported to the nurse's station. The IP/RN stated if the proper PPE was not worn, it would increase the risk of the spread of infection. The IP/RN further stated that contract staff would be told by the nurse on duty, to always see well residents first and the ill or TBP residents last. In the presence of the survey team on 06/10/22 at 11:10 AM, the DON stated when the facility used contract workers they are expected to abide by standards of practice. On 6/13/22 at 12:53 PM, during a telephone interview with Surveyor #3, the Local Health Officer (LHO) who oversees the public health department, stated several weeks ago her department was asked to speak with Communicable Disease Service (CDS) and the facility on a phone call. The LHO stated that CDS informed the facility that they must follow the guidance (Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated 2/25/22) including wearing the full PPE which included an N95 mask. The LHO stated the guidance as written should be followed. A review of the Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities guidance dated 2/25/22, included but was not limited to: 5) New or readmitted asymptomatic patients/residents who are not up to date with all recommended COVID-19 vaccine doses and have a viral test negative upon admission or readmission, 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 [National Institute for Occupation Safety and Health] approved N95 or equivalent or higher-level respirator), even if they have a negative test upon admission. A review of the facility provided Completed Development Opportunities in-services from the x-ray contracted company, dated 12/02/21, revealed that the x-ray technician had completed the Infection Control Practices course including infection prevention and control, standard and transmission-based precautions, barriers and use of personal protective equipment, and strategies for preventing the spread of infectious disease to healthcare workers and patients. A review of the facility provided Field Personnel COVID-19 Procedures/Use of PPE guidance from the x-ray contracted company, undated, included but was not limited to 3. PPE required for patient encounters with suspected or known positive COVID-19. a. mask; b. gloves; c. eye protection/shield; d. gown/approved covering; e. wash hands with soap and water or hand sanitizer; and f. for patient, covering for patient's nose and mouth if the patient is symptomatic. These procedures are based on current CDC guidance/guidelines . All field personnel should routinely review the CDC's website for updates A review of the facility's policy, [name redacted] COVID19-Resident Admission/Re admission Protocols revised 5/10/2022, revealed For unvaccinated COVID19 residents they will be on contact and droplet precautions isolation for 10 days. When on isolation, full PPE will continue to be used. If no know exposure to COVID 19, an approved NIOSH N-95 will not be required. A review of the facility's policy, Application of Transmission-Based Precautions revised 6/8/22, revealed Purpose: transmission-Based precautions are used for residents who are known or suspected to be infected or colonized with infectious agents, which require additional control measures to effectively prevent transmission. Cohorting: Readmissions/new admissions that are unvaccinated for COVID19 vaccine should be on droplet precautions and contact precautions for 10 days. NJAC 8:39-19.4(a)