**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean and sanitary environment for 1 of 5 units, 3 west reviewed for environment. This deficient practice was evidenced by the following: On 6/15/2025 at 09:51 AM during initial tour the surveyor observed what appeared to be a spill of an orange/brown substance and a spoon on the floor of room [ROOM NUMBER] B on the 3 [NAME] unit. On 06/16/2025 at 09:19 AM and 06/17/2025 at 09:56 the surveyor observed the same orange/brown substance in the same location on the floor in room [ROOM NUMBER] B on 3 [NAME] unit. During an interview on 06/18/2025 with the surveyor, the Housekeeping Director (HD) said the residents' rooms are cleaned and mopped every day. He said that housekeeping removes trash from 7 AM -9 AM, then goes back to the rooms to dust, clean bathrooms and mop starting at 11AM and then does a second trash removal at 7 PM. When asked if the substance in room [ROOM NUMBER] B should have remained on the floor for 3 days, the HD replied, No that should have been mopped up. During an interview on 06/18/2025 at 12:01 PM with the surveyor, the Licensed Nursing Home Administrator (LHNA) replied, No it shouldn't be. When asked if the substance in room [ROOM NUMBER] B should have remained on the floor for 3 days. A review of the facility provided Housekeeping Operations Manual revised on 3/2020 revealed under Procedure for Wet Mopping that, 13. Inspect area cleaned and repeat cleaning process if necessary. A review of a facility provided policy titled Quality of life- Homelike Environment reviewed on 12/20/24 revealed that, 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. Clean, sanitary and orderly environment. N.J.A.C. 8:39-31.4(f)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the resident's environment is free from accident hazards and the resident received adequate supervision to prevent accidents specifically by leaving a cup of two, unidentified tablets at the bed side. The deficient practice was identified for 1 of 5 residents (Resident # 249) reviewed for Accidents. The deficient practice was evidenced by the following: On 06/15/2025 at 9:53 AM during the initial tour of the facility, the surveyor observed a plastic cup containing two, unidentified tablets on the bed side table. Resident # 249 was asleep in bed and no staff were in the room at the time. A review of the admission Assessment Minimum Data Set (an assessment tool) dated 4/30/2025 revealed under section C that Resident # 249 had a Brief Interview for Mental Status score of 15/15, indicating he/she was cognitively intact. A review of the Electronic Medical Record revealed under Diagnoses that Resident # 249 had diagnoses of but not limited to a Fracture of the Left foot and Acute osteomyelitis (bone infection). On 06/16/2025 at 10:45 AM during an interview with the surveyor, Resident # 249 denied having medications left at the bedside. On 06/18/2025 at 12:02 PM during an interview with the surveyor, the Director of Nursing said medications should never be left at the bedside. A review of the untitled facility policy reviewed 12/27/24 revealed under Procedure that the Licensed Nurse, Assures medications are not left unattended. Keeps medications secured in a locked area or in visible control at all times. N.J.A.C. § 8:39-29.4 (h)

Based on observations, interview, record review, and review of pertinent facility documents it was determined that the facility failed to provide appropriate and sufficient care specifically by having the catheter drain bag in contact with the floor, outside of a privacy bag, and left on top of the bed. The deficient practice was identified for 2 of 2 Residents (Resident # 7 and 250) reviewed for Urinary Catheter or Urinary Tract Infections. The deficient practice was evidenced by the following: A review of Resident # 250's orders located in the Electronic Medical Record (EMR) revealed that he/she had an order to change the indwelling catheter and urine drainage bag as ordered/as needed based off clinical indications such as (but not limited to) infection, obstruction, or when the closed system is compromised. A review of Resident # 250's diagnoses located in the EMR revealed that he/she had a diagnoses of but not limited to a pressure ulcer of the sacral region. On 06/15/2025 at 10:42 AM during the initial tour, the surveyor observed Resident # 250 in bed the room. At that time, Surveyor # 1 observed the urinary catheter drainage bag on the floor, unhooked from the bed frame and not within a privacy bag. On 06/16/2025 at 11:14 AM while visiting Resident # 250, Surveyor # 1 was unable to located the urinary catheter drain bag from either side of the bed frame. At that time, a Certified Nurses Aide entered the room and found the urinary catheter drainage bag under the sheet on the bed. She then attached it to the side of the bed. On 06/18/2025 at 12:02 PM during an interview with Surveyor # 1, the Director of Nursing (DON) replied, suspended from the bed frame when asked should an indwelling urinary catheter be left on top of a bed, or on the floor instead of secured to the bed frame. The DON replied that it is important for infection control and when the resident is in bed, gravity should be more towards the floor. A review of the facility policy titled, Indwelling Catheter Maintenance last reviewed 4/12/25 revealed, 3. Keep drainage bag below the level of the bladder at all times . The policy continued, Do not place the drainage bag on the floor (Rationale: to prevent contamination). N.J.A.C. 8:39-27.1 (a) On 06/15/2025 at 09:52 AM during initial tour surveyor # 2 observed Resident # 7 indwelling urinary catheter bag on the floor and not in a privacy bag. On 06/16/2025 at 09:19 AM during rounds surveyor # 2 observed Resident # 7's indwelling urinary catheter bag hung on the bed frame not in the privacy bag. A review of Resident # 7's diagnoses located in the admission Record revealed that the resident had a diagnosis of but not limited to retention of urine. A review of the most recent annual Minimum Data Set (MDS), an assessment tool used to manage care dated 04/10/2025, revealed Resident #7 had an indwelling urinary catheter. During an interview on 06/18/2025 at10:39 AM with surveyor #2, the Unit Manger (UM) on the 3rd floor said that indwelling catheters should be kept inside a privacy bag attached to the bed frame below the bladder. The UM also said they should not be on the floor. During an interview on 06/18/2025 at 12:01 PM with surveyor # 2, the DON said that indwelling urinary catheter bags should not touch the floor due to infection control. A review of the facility policy titled, Indwelling Catheter Maintenance last reviewed 4/12/25 revealed, 3. Do not place the drainage bag on the floor (Rationale: to prevent contamination), and Place drainage bag in cover/privacy bag (to maintain resident's dignity) N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) provide documentation of an individualized and resident specific Peritoneal Dialysis ([PD] a way to remove waste products from blood using a cleansing fluid and a catheter tube in the abdomen) training for staff; b.) obtain individualized PD prescription; and c.) document assessments of the PD treatment, post complications, catheter site, and signs of infection. This deficient practice was identified for 1 of 1 resident (Resident #45) reviewed for dialysis and was evidenced by the following: On 06/15/2025 at 10:58 AM, the surveyor Resident #45 in bed. The resident did not respond to surveyor inquiry when knocked on the door. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Sepsis and Pneumonia. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/15/2024, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 04/21/2025, that the resident received peritoneal in house. Interventions included, but not limited to: We will monitor your BP (blood pressure) and Pulse; We will observe you for any changes in mentation; we will teach you how to protect your access site from injury; and we will teach you how to monitor for s/s of infection to check skin around vascular access noting redness, swelling, local warms, exudate draining or tenderness. A review of the Physician Order Activity Report (POAR), dated as of 06/18/2025, failed to reveal the following: A Physician's Order (PO) that included, the number of exchanges or cycles (the process of filling and draining the abdomen) to be done during each dialysis session, the volume of fluid with each exchange, duration of fluid in the peritoneal cavity (space within the abdomen that contains vital organs), and the use of automated, manual, or combined dialysis techniques. A review of Resident #45's medical record and PO, including the electronic medical record and written dialysis records, failed to reveal the following: Documentation of vital signs during the PD; Assessment of the resident's stability level of consciousness, and comfort or distress; Consistent monitoring for post-PD complications and symptoms such as, but not limited to, dizziness, nausea, fatigue (tiredness) or hypotension (low blood pressure); Ongoing evaluation of the peritoneal catheter; Monitoring for complications, including peritonitis (a serious infection of the abdominal lining that be life threatening), such as cloudy PD fluid. Documentation that the facility staff was fully educated and trained on Resident #45's individualized and specific Peritoneal Dialysis During an interview with the surveyor on 06/17/2025 at 11:37 AM, Charge Licensed Practical Nurse (CN #1) advised that if a resident was to undergo any type of treatment, the facility should provide ongoing documentation of how the treatment was tolerated. Upon reviewing Resident #45 Medication Administration Record (MAR) and Treatment Administration Record (TAR), CN#1 agreed that as a nurse she would have entered a full note documenting how the PD was tolerated, vital signs, and signs/symptoms of possible infection. CN #1 explained that the biggest complication of PD is infection, especially peritonitis, and that early detection such as a change in vital signs, along with documentation of signs/symptoms, was important. CN #1 further agreed that documentation for Resident #45 was not provided on a daily basis before, during, or after PD. During an interview with the surveyor on 06/18/2025 at 10:49 AM, the Assistant Director of Nursing (ADON) stated that they were not aware of any specific criteria that had to be on the PO regarding Resident #45's PD. The ADON further advised that blood pressures were not being obtained during the PD because it was completed at night while the resident was sleeping. When asked for clarification, the ADON confirmed that if Resident #45 was not voicing any complaints, then it indicated that they were stable. The DON explained that ongoing assessment of the catheter site was completed via check mark on the MAR/TAR in place of a descriptive assessment or narrative. When asked to review the facility PD policy, that went into effect 10/4/2021, and questioned if was being followed, the ADON responded that the policy was only a guideline, it is not set in stone, and that it doesnt not have to be thoroughly followed. When asked if the staff was monitoring the return PD fluid, the ADON denied but confirmed that it was important to document the color for infection purposes. A review of the facility's Peritoneal Dialysis Policy, effective 10/4/21 and reviewed 1/2024, under the heading Preparation it included: [ .] 2. Review all existing orders and instructions for care pertaining to the resident's dialysis. Verify the following: a. dialysate solution/concentration; b. medication(s) to be added; c. Number of exchanges and infusion, dwell, and drain times; d. monitoring parameters; and e. Laboratory Orders [ .]. Under the heading Steps in the Procedure; Assessment it included: [ .] 6. Measure abdominal girth; 7. Observe for signs and symptoms of fluid volume overload (hypervolemia) including: labored breathing, increased blood pressure, edema, and neck vein distention; 8. Observe for signs and symptoms of hypovolemia including poor skin turgor, tachycardia and hypotension. Under the heading Documentation it included: The following information should be recorded in the resident's medical records: [ .] 2. The date and time infusion was started and stopped (fill time); 3. Amount of dialysate infused; 4. The time drain was started (dwell time); 5. The amount of dialysate that was drained; 6. The number of exchanges; [ .] 9. The condition of the catheter, insertion site, and surrounding skin; 10. Signs and Symptoms of complications and or infection; 11. How the resident tolerated the procedure [ .] A review of the facility's Nursing Assessment Policy, effective 10/1/21 and reviewed 12/22/24, under the heading Policy Statement it included: All residents will receive a thorough nursing assessment upon admission and regular reassessments thereafat3er in accordance with federal, state, and facility specific regulations. Assessments must be documented clearly and used to guide care planning and interventions. A review of the facility's Charting and Documentation Policy, effective 10/18 and reviewed 10/2024, under the heading Policy Interpretation and Implementation it included: [ .]3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. NJAC 8:39-2.9;2.10

**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 store medical supplies in accordance with professional standards, as evidenced by the presence of expired supplies. This deficient practice was identified in 2 of 2 medication storage rooms inspected. The deficient practice was evidenced by the following: On [DATE] at 10:30 AM, the surveyor inspected the 1 East Unit medication storage room in the presence of Licensed Practical Nurse #1 (LPN #1) and observed the following expired items: five safety needles (23G x 1.5) dated [DATE], two staple removal kits dated [DATE], and three boxes of thermometer probes dated [DATE]. On [DATE] at 11:42 AM, the surveyor inspected the Subacute Unit medication storage room in the presence of Registered Nurse #1 (RN #1) and observed 10 expired feeding tube extension kits dated [DATE]. During an interview with the surveyor on [DATE] at 10:45 AM, LPN #1 said that the facility previously had a staff member responsible for stocking the medication storage room and managing supplies; however, that individual is no longer employed at the facility. LPN #1 indicated that she now feels it is her responsibility to manage the supplies and acknowledged that expired supplies should not be present in the medication storage room. During an interview with the surveyor on [DATE] at 11:55 AM, RN #1 said that the facility previously had a staff member responsible for stocking the medication room and managing supplies; however, that individual is no longer employed at the facility. RN #1 also said that expired supplies should not be present in the medication room. During an interview with the surveyor on [DATE] at 11:39 AM, the Director of Nursing (DON) said that nurses are responsible for checking for expired supplies in the medication room. The DON also confirmed that expired supplies should not be kept in the medication storage rooms. A review of the facility's dated policy [DATE], titled, Storage of Medications, revealed that, The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. N.J.A.C. § 8:39-29.4 (g)

2. Upon initial tour of the facility on 06/15/2025 at 10:05 AM, surveyor #2 observed Resident #139 seated in bed. The surveyor observed an Auto-Adjusting Positive Airway Pressure machine (APAP- a machine designed to a condition where the throat muscles relax during sleep and block the airway) with the tubing and nasal piece hanging over the side table. When asked if the facility has ever provided a storage bag Resident #139 stated that they were never offered and would have accepted since it is always hitting the floor'. A review of the [admission Record], an admission summary, revealed the resident had diagnoses which included, but were not limited to: Respiratory Failure and Hypoxemia (low levels of oxygen in the blood). A review of the resident's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/30/2025, identified that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of the Physicians Orders (PO), dated as of 06/15/2025, included the following: A PO, dated 05/05/2025 for APAP 5/12cm H20 ( a measure pressure in centimeters of water (cmH2O), which indicates how much pressure is needed to keep the airway open during sleep) : Apply at HS (nighttime) and remove in AM. During an interview with the surveyor on 06/17/2025 at 11:37 AM, Certified Nursing Assistant (CNA #1) confirmed that any respiratory equipment should be stored in a plastic bag when not in use by the residents. During an interview with the surveyor on 06/17/2025 at 11:37 AM, Charge Licensed Practical Nurse (CN #1) confirmed that resident's respiratory equipment should be kept in a plastic bag with room number and the date. During an interview with the surveyor on 06/18/2024 at 09:54 AM, Infection Preventionist (IP) in the presence of the Assistant Director of Nursing (ADON) stated that respiratory equipment, including an APAP, was always stored in plastic bag and placed in the resident's drawer. A review of a facility provided policy tilted Respiratory Care last reviewed in January 2025 revealed under, Duties that, 6. Ensure that nebulizers are for single resident used and are cleaned and stored as per facility policy, and 8. At all times, the nurse will ensure that respiratory tubing does not touch the floor. There was no policy for the care of APAP provided. NJAC 8:39-19.4 (k) Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility staff failed to use appropriate infection control practices specifically with respiratory equipment for 3 of 3 residents reviewed for oxygen. (Resident #101, Resident # 108, and Resident # 139). The deficient practice was evidenced by the following: 1. On 06/15/2025 at 09:48 AM during initial tour surveyor # 1 observed Resident # 101 sitting on his bed. The resident's BiPAP (a device that helps you breathe by delivering air through a mask on your face) mask was observed laying across the pillow on the bed open to air and not in a bag. The resident's nebulizer (a device that converts liquid medication into a fine mist, allowing it to be inhaled directly into the lungs) mask was observed in the resident's nightstand drawer open to air and not placed in a bag. A review of Resident # 101's admission Record revealed the resident was admitted with but not limited to), Chronic Obstructive Pulmonary Disease COPD (a group of lung conditions that cause breathing difficulties) and Sleep Apnea (disruptions of breathing during sleep). A review of Resident # 101's physician's orders revealed orders for Budesonide (a medication in the inhaled corticosteroid class used to help control and prevent COPD) 0.25mg/2ml twice a day by nebulization, and DuoNeb (bronchodilators that relax muscles in the airways and increase air flow to the lungs) 0.5mg-3mg/3ml four times a day by nebulization. The physician's orders also revealed and order for the BiPAP to be worn at bedtime. 2. On 06/15/2025 at 09:57 AM during initial tour surveyor 1 observed Resident # 108 sitting in the wheelchair in his room. The Resident's BiPAP was observed on the nightstand open to air and not in a bag. On 06/17/2025 at 09:58 AM during rounds surveyor # 1 observed the nasal cannula (a tube that delivers oxygen through the nose) hanging over the oxygen concentrator and touching the floor not in a bag. A Review of Resident #108's admission record revealed the resident was admitted to the facility with but not limited to obstructive Sleep Apnea, and Chronic Congestive Heart Failure. A review of Resident 108's physician's orders revealed orders for, BiPAP at bedtime and Oxygen 6l/min continuous. During and interview on 06/18/2025 at 09:49 AM with surveyor # 1 the Unit manager (UM) of the 3rd floor said that all respiratory equipment should be kept in a plastic bag when not in use. During an interview on 06/18/2025 at 09:58 AM with surveyor # 1 the Infection Preventionist said that all respiratory equipment is labeled and dated and kept in a plastic bag and stored in the nightstand drawer when not in use. During and interview on 06/18/2025 at 12:01 PM with surveyor # 1 the Director of Nursing said that respiratory equipment is changed weekly and kept in a placed in a plastic bag for infection control purposes. A review of a facility provided policy tilted Respiratory Care last reviewed in January 2025 revealed under, Duties that, 6. Ensure that nebulizers are for single resident used and are cleaned and stored as per facility policy, and 8. At all times, the nurse will ensure that respiratory tubing does not touch the floor. There was no policy for the care of BiPAP provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C #: NJ177500 Based on interviews, medical record review, and review of other pertinent facility documents on 12/04/24 and 12/05/24, it was determined that the facility staff failed to consistently document in the Resident CNA (Certified Nursing Assistant) Documentation Record (RCDR) on care provided to the resident according to the facility policy and protocol for 3 of 5 residents (Resident #2, Resident #3, and Resident #5) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the Resident Face Sheet (RFS), Resident #5 was admitted with diagnoses including but not limited to Stage 4 Sacral Pressure Sore (damage to the skin and tissue caused by prolonged pressure on a bony area of the body), and Age-related osteoporosis (a bone disease that causes bones to become weak and more likely to break). A review of the Minimum Data Set (MDS), an assessment tool dated 9/20/24, revealed that Resident #5 had a Brief Interview of Mental Status (BIMS) score of 02, indicating that Resident #5 had severe cognitive impairment and was dependent on staff with Activities of Daily Living (ADLs). Resident #5's CP (Care Plan) initiated on 9/07/24 indicated that Resident #5 had a focus for skin as evidenced by an actual pressure skin injury upon admission. Interventions included but were not limited to: providing daily skin care and once a week with showers, providing nutritional supplements as ordered: liquid protein, Zinc, and Vitamin C. Additionally, Resident #5 had a focus for nutrition with a goal to consume more than 75% of meals/fluids. Interventions included but were not limited to monitoring and encouraging fluid intake. Review of the RCDR (ADL Record), dated September 2024 for completion of ADL under Task did not indicate that Bed Mobility, Eating, and Nutrition were provided to the Resident at the following times: Bed Mobility: During the 7:00 a.m. to 3:00 p.m. shift, 22 out of 23 days did not have documentation. During the 3:00 p.m. to 11:00 p.m. shift, 12 out of 23 days did not have documentation. During 11:00 p.m. to 7:00 a.m. shift, 16 out of 24 days did not have documentation. Turn and Position: At 12:00 a.m., 16 out of 23 days did not have documentation. At 2:00 a.m., 16 out of 23 days did not have documentation. At 4:00 a.m., 15 out of 23 days did not have documentation. At 6:00 a.m., 16 out of 23 days did not have documentation. At 6:00 p.m., 16 out of 23 days did not have documentation. At 8:00 p.m., 16 out of 23 days did not have documentation. At 10:00 p.m., 15 out of 23 days did not have documentation. Eating: During 7:00 a.m. to 9:00 a.m., 22 out of 23 days did not have documentation. During 11:00 a.m. to 1:00 p.m., 23 out of 23 days did not have documentation. During 4:00 p.m. to 6:00 p.m., 16 out of 23 days did not have documentation. Nutrition: At 10 a.m., 23 out of 23 days did not have documentation. At 2 p.m., 23 out of 23 days did not have documentation. At 8:00 p.m., 16 out of 23 days did not have documentation. Review of the RCDR, dated November 2024 for completion of ADL under Task did not indicate that Bed Mobility, Eating, and Nutrition were provided to the Resident at the following times: Bed Mobility: During the 7:00 a.m. to 3:00 p.m. shift, 24 out of 30 days did not have documentation. During the 3:00 p.m. to 11:00 p.m. shift, 3 out of 30 days did not have documentation. During the 11:00 p.m. to 7:00 a.m. shift, 29 out of 30 days did not have documentation. Turn and Position: At 12:00 a.m., 28 out of 30 days did not have documentation. At 2:00 a.m., 29 out of 30 days did not have documentation. At 4:00 a.m., 26 out of 30 days did not have documentation. At 6:00 a.m., 29 out of 30 days did not have documentation. At 6:00 p.m., 10 out of 30 days did not have documentation. At 8:00 p.m., 16 out of 30 days did not have documentation. At 10:00 p.m., 20 out of 30 days did not have documentation. Eating: During 7:00 a.m. to 9:00 a.m. meal, 25 out of 30 days did not have documentation. During 11:00 a.m. to 1:00 p.m. meal, 23 out of 30 days did not have documentation. During 4:00 p.m. to 6:00 p.m. meal, 4 out of 30 days did not have documentation. Nutrition: At 10 a.m., 24 out of 30 days did not have documentation. At 2 p.m., 25 out of 30 days did not have documentation. At 8:00 p.m., 15 out of 30 days did not have documentation. 2. According to the Resident Face Sheet (RFS), Resident #2 was admitted with diagnoses including but not limited to Type 2 Diabetes Mellitus (a long-term medical condition in which your body doesn't use insulin properly, resulting in high blood sugar levels). and Dermatitis (a common condition that causes swelling and irritation of the skin). A review of the Minimum Data Set (MDS), an assessment tool dated 9/20/24, revealed that Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that Resident #2 had intact cognition and was independent with ADLs. Review of the RCDR, dated November 2024 for completion of ADL under Task did not indicate that Bed Mobility and Eating, were provided to the Resident at the following times: Bed Mobility: During 7:00 a.m. to 3:00 p.m. shift, 8 out of 30 days did not have documentation. During the 3:00 p.m. to 11:00 p.m. shift, 30 out of 30 days did not have documentation. During the 11:00 p.m. to 7:00 a.m. shift, 30 out of 30 days did not have documentation. Eating: During the 7:00 a.m. to 9:00 a.m. meal, 8 out of 30 days did not have documentation. During the 11:00 a.m. to 1:00 p.m. meal, 8 out of 30 days did not have documentation. During 4:00 p.m. to 6:00 p.m. meal, 30 out of 30 days did not have documentation. 3. According to the RFS, Resident #3 was admitted with diagnoses that included but were not limited to: Cerebral Palsy (a group of neurological disorders that affect a person's ability to move, balance, and maintain posture), Infection of amputation stump, and colostomy (a surgical procedure that creates an opening in the abdominal wall to divert the large intestine, or colon, and allow stool to drain into a bag). The MDS, dated [DATE] indicated that Resident #3 had a BIMS of 02 indicating severe cognitive impairment, and was dependent for all ADLs. Resident #3's CP (Care Plan) initiated on 11/11/24 indicated that Resident #3 had a focus for ADLs. Interventions included but not limited to: Extensive assist with bed mobility and extensive assistance with eating. Review of the RCDR, dated November 2024 for completion of ADL under Task did not indicate that Bed Mobility, turn and position and eating, were provided to the Resident at the following times: Bed Mobility: During 7:00 a.m. to 3:00 p.m. shift, 2 out of 30 days did not have documentation. During 11:00 p.m. to 7:00 a.m. shift, 2 out of 30 days did not have documentation. Turn and Position: At 12:00 a.m., 13 out of 30 days did not have documentation. At 2:00 a.m., 13 out of 30 days did not have documentation. At 4:00 a.m., 12 out of 30 days did not have documentation. At 6:00 a.m., 12 out of 30 days did not have documentation. At 6:00 p.m., 6 out of 30 days did not have documentation. At 8:00 p.m., 8 out of 30 days did not have documentation. At 10:00 p.m., 7 out of 30 days did not have documentation. Eating: During 7:00 a.m. to 9:00 a.m. meal, 3 out of 30 days did not have documentation. During 11:00 a.m. to 1:00 p.m. meal, 2 out of 30 days did not have documentation. Nutrition: At 10 a.m., 2 out of 30 days did not have documentation. At 2 p.m., 3 out of 30 days did not have documentation. At 8:00 p.m., 1 out of 30 days did not have documentation. During an interview with the surveyors on 12/05/24 at 9:35 a.m., the CNA, stated that CNAs were responsible for the primary care of the residents, and for documenting the ADLs on the kiosk (a computer that is located on each hall on the units that link to the residents' medical chart). She further stated that documentation includes incontinent care, skin assessment, feeding residents, and if showers and bed baths were performed. When the CNAs documented, they were to select performed or not performed, and if the CNA selected not performed, then a reason for the task not being completed needed to be entered. For example, a reason for a task not being completed would be, a resident out of the building for an appointment. The CNA further stated that the documentation needs to be completed by the end of the shift. During an interview with the surveyors on 12/05/245 at 10:46 a.m., the Unit Manager/Registered Nurse, stated that CNAs were responsible for ADL care on the unit. She stated that the CNAs have their own assignments and were responsible for documenting the care on the kiosk. She stated that ADL care should be documented by the end of their shift. She explained that the documentation must be completed in the residents' chart by the end of each shift to show that the care was provided to the residents, and to identify changes with residents. During an interview with surveyors on 12/05/24 at 1:23 p.m., the DON (Director of Nursing) and ADON (Assistant Director of Nursing), both stated that CNAs were responsible for ADL care on the floors, and that care is documented in the kiosk. DON states that documentation is important to show that care has been completed. Review of the facility policy titled Charting and Documentation, dated October 2018, and reviewed October 2024, reflected POLICY Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record .c. Treatment or services performed .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . NJAC: 8:39-35.2 (d)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00168186 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that a non-certified Temporary Nurse Aide (TNA) a.) was currently enrolled in a Certified Nursing Assistant (CNA) training program and had completed the first 16 hours of the training program by [DATE], and b.) had completed the CNA training program by [DATE]. This deficient practice was identified for 1 of 2 TNAs (TNA #1) who worked on 5 of 5 nursing units (1 East, 1 West, 2 East, 2 West, and 3 West) and was scheduled to work on an independent resident assignment during 2 of 3 shifts (day and evening shift). The deficient practice was evidenced by the following: The surveyor reviewed TNA #1's employee file: Review of TNA #1's, Certificate of Completion revealed that they were a Temporary Nurse Aide as of [DATE]. Review of TNA #1's Hire Date revealed that they became an employee at the facility on [DATE]. Review of TNA #1's Time Cards revealed that they worked the following dates and shifts: 7 AM-3 PM: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 3:00 PM-11 PM: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. Review of the, Unit Assignment Sheets revealed that TNA #1 was written on each assignment sheet as a CNA. Review of the Unit Assignment Sheets also revealed that TNA#1 also worked the following dates and shifts: 7:00 AM- 3 PM: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. During a telephone interview with the surveyor on [DATE] at 12:15 PM, TNA #1 stated that he worked at the facility for almost a year. TNA #1 continued that he had a TNA certificate not a CNA certification and that he just registered for CNA classes a few days ago. TNA #1 continued that when he was hired that the facility was hiring TNAs without a CNA certification. TNA #1 stated that on [DATE] the Assistant Director of Nursing (ADON) told him that he had to enroll in CNA school to continue working as an aide at the facility. The TNA added that this was the first time that he was told by facility staff that he needed to enroll in CNA classes. During an interview with the surveyor on [DATE] at 1:21 PM, the Licensed Practical Nurse (LPN) #1 stated that she knew and worked with TNA #1. LPN #1 stated that she, thought he was a CNA but I'm hearing that he might have been a TNA. LPN #1 continued that she did not supervise his care any differently than the way that she supervised the care that was provided by all the aides. LPN #1 stated that no one told her anything was different about him than any of the aides. During an interview with the surveyor on [DATE] at 09:20 AM, the ADON stated that the Human Resources Coordinator (HRC) checked to make sure that all the staff's licenses were up to date. She was told by the HRC that TNA #1 had a TNA certificate and that they were not a CNA. The ADON continued that once she found this out, last week, she removed TNA #1 from the schedule and had a conversation with him. TNA #1 had to show proof that he was enrolled in CNA school before he could continue to work at the facility. The ADON continued that the HRC was responsible for making sure that TNAs were not in the building after the expiration of the waiver. During an interview with the surveyor on [DATE] at 10:35 AM, the HRC stated that she was familiar with TNA #1 as a team member at the facility. The HRC stated that as far as she knew that he was in CNA school. The HRC stated that she tracked licensed nurses and CNAs monthly to ensure that their licenses and certifications were not expired. The HRC continued that TNAs did not have a license number to track but that if an aide was uncertified and was a CNA student, she would track their progress during school until they became certified. The HRC stated that TNA #1 told people at the facility that he was in school but stated that he started at the facility before she was hired as the HRC. The HRC continued that she did not know what the prior HRC did to confirm that TNA #1 was enrolled in school, but that she assumed that they would also have a tracking mechanism in place because it was, part of the role for the HRC. The surveyor asked if TNA #1 should have been working in the facility without providing documentation that he was in CNA school. The HRC stated, I'm not firm on his situation, he's [from an] agency. The HRC continued that she could not tell the surveyor about the process that the former HRC followed but that she assumed that it was a similar process to what she followed to track uncertified aides. During a follow up interview with the surveyor on [DATE] at 11:03 AM, TNA #1 stated that depending on the day that he would have roughly 8 residents that he cared for on his assignment. TNA #1 continued that he worked on all the floors of the facility. TNA #1 stated that he fed, bathed, dressed, ambulated, and provided incontinence care for the residents assigned to him. TNA #1 stated that his role in the facility was the same as that of a CNA. During an interview with the surveyor on [DATE] at 11:19 AM, the Director of Nursing (DON) stated that she could not provide documentation that TNA #1 was enrolled in a CNA school. The DON stated that after the [DATE]th cutoff that TNA #1 should have been taken off the schedule. The DON stated that the importance of nurse aide certification was to ensure that they were knowledgeable and skilled enough to care for the residents. Review of the [DATE] job description for the, Human Resources Coordinator indicated under the, Duties and Responsibilities section, Coordinates new employee for Orientation with Staff Development [ .] Monitors Applicant Tracking system [ .] Supervises process of employee disciplines, suspensions and terminations. NJAC 8:39-25.2(g); 43.1; 43.2

Based on observation, interview, and record review it was determined the facility failed to maintain professional standards of clinical practice for 3 of 28 residents reviewed (Resident #78, #135 and #44 ) by a.) not monitoring meal intake for a resident with excessive weight loss (Resident #78), b.) not completing pain assessments before and after administering pain medications to assess for effectiveness for a resident (Resident #135) and c.) not following Physician's Orders by not removing an elopement alarm once the order was discontinued (Resident #44). 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. a.) On 03/07/23 at 11:32 AM, the surveyor observed Resident #78 in the day room of the unit. Resident #78 was in a wheelchair waiting for lunch. The surveyor asked the resident about the food and the resident stated, if its ok I eat it, if not I don't eat. The surveyor asked if there were alternatives, and the resident didn't respond to the question. Review of the admission record indicated that Resident #78 was initially admitted to facility on 3/2019. Medical diagnoses included, but were not limited to dementia, anxiety, hypertension (high blood pressure), and anemia (low blood counts). Review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 01/20/23 indicated that Resident #78 had a Brief Interview of Mental Status of 3, meaning the resident had severe cognitive impairment. Review of section G, functional status, indicated the resident was a one person set up for dressing, transfer, and a set up for eating. On 03/07/23 at 11:41 AM, the surveyor reviewed Resident #78's weights which showed he/she weighed 100 pounds in September 2022 and 88 pounds in March 2023, which indicated the resident had a 12 percent weight loss within six months. On 03/07/23 at 11:50 AM, the surveyor reviewed the physician orders which revealed that Resident # 78 was prescribed the following diet: Diet: No Added Salt (low sodium); Consistency: Chopped; Special Instructions: low cholesterol, thin liquids. On 03/07/23 at 11:54 AM, the surveyor reviewed Resident #78's care plan which included the following focus: I will consume more than 75% of meals/fluids. On 03/07/23 at 12:40 PM, the surveyor went to observe Resident #78 with lunch, the trays were gone, and the resident had a sandwich wrapped in front of him/her on the table. At the same time, the surveyor interviewed the Certified Nursing Assistant (CNA) in the day room regarding documentation of amount eaten for residents. The CNA told surveyor that, a percentage gets put in the computer by us, (25 %, 50 % 75% or 100 %). The surveyor asked the CNA about Resident #78's appetite, and the CNA said the resident did not eat well maybe 25%. The CNA said that Resident # 78 picks with his/her fingers and would not let the staff assist with eating. On 03/13/23 at 09:46 AM, the surveyor reviewed the dietician notes regarding weight loss, and it showed the following: On January 8, 2023: Weight trend: 9lb weight loss x 1 month; 9.1% Loss; 11lb weight loss x 3 months; 11% weight loss; 18 lb. weight loss x 6 months;16% weight loss and the resident was put on weekly weights. On 03/13/23 at 10:15 AM, the surveyor reviewed the care plan which had a focus of nutrition with interventions that included monitoring intake, providing a health shake twice daily, and a fortified pudding twice daily. The intervention was put in place on 11/2/2020 and remained active. Further review did show the intervention was updated to the following: We will provide you with supplements as ordered: fortified pudding twice daily; @ Breakfast and 7pm, snack Health Shake twice daily (200 calories, 6 g protein per 4oz). On 03/13/23 at 10:18 AM, the surveyor reviewed the resident's meal intake documentation in the Electronic Medical Record (EMR) that was completed by the CNAs. The surveyor reviewed documentation from 12/2/22 to 02/28/23. There was a total of 272 meals during that time and 70 of the meals did not have documentation of the amount Resident #78 had eaten, the status on the documentation was not documented. On 03/13/23 at 10:21 AM, the surveyor interviewed the Director of Nursing (DON) regarding the documentation that was provided to the surveyor on the resident's meal intake. The surveyor asked what it meant when the status was not documented. The DON said that means the aide did not document that meal or how much the resident consumed. On 03/13/23 at 11:23 AM, the surveyor interviewed the facility dietician regarding Resident #78. The dietician told the surveyor that the resident had weight loss following a fall and hip fracture with hospitalization. She stated that on return to the facility the resident was on weekly weights because of the weight loss. The surveyor asked if food intake for the resident was monitored, and the dietician told the surveyor that the CNA's monitor and document a resident's intake in the EMR, or the nurses will write a progress note. b. On 03/14/23 at 10:22 AM, the surveyor reviewed Resident #135 Electronic Medical Record (EMR) which indicated that Resident #135 was receiving oxycodone/acetaminophen 5 mg/325 mg (a narcotic pain medication) one tablet every six hours for moderate to severe pain. The surveyor reviewed the Medication Administration Record (MAR) for the resident which indicated the days that the resident received the pain medication. The surveyor was able to see that the nurse who administered the pain medication had signed on the bottom of the MAR but the surveyor could not locate a pain assessment (a numeric pain scale done prior to administering medication to confirm that the resident had moderate or severe pain) done by nursing before administering the medication or a pain assessment completed following administration of the medication to assess for effectiveness. Review of the admission record indicated that Resident #135 was admitted to the facility on 01/2023. Medical diagnoses included, but were not limited to diverticulitis (inflammation of pouch in digestive tract), embolism (obstruction of an artery by air or blot clot), obesity, respiratory failure, and diabetes (high blood sugar). Review of the admission Minimum Data Set (MDS), an assessment tool dated 01/21/23 indicated the resident had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. Under section G, functional status showed the resident was a two-person assist for transfers and a one-person assist for personal hygiene and toileting. On 03/14/23 at 11:32 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding pain assessments for Resident #135. The surveyor asked the ADON to show the pain assessments that were completed prior to the medication given, and again after the pain medication was administered to assess for effectiveness on 03/01/23 and 03/02/23. The ADON said they should be under monitoring. The ADON went to the monitoring section and no pain assessments were present. The ADON said they could also be in the progress notes and proceeded to go to the progress notes. There were no pain assessment notes for 03/01/23 or 03/02/23. The ADON showed the surveyor a note from 03/06/23 which indicated the resident received pain medication and it was documented as effective. The surveyor asked the ADON what moderate to severe pain was and the ADON said 6 to 10. The surveyor asked how one would know what the resident's pain level was before and after the resident received the pain medication on 03/06/23 and the ADON could not answer. The ADON provided progress notes which indicated the resident either had pain or did not have pain, but a pain scale was not utilized to show the level of Resident #135's pain. On 03/14/23 at 11:46 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was caring for Resident #135 regarding medicating resident's for pain. The LPN said that vital signs are checked prior to giving pain medication and pain is checked for what number it is before and after administering pain medication. The surveyor asked the LPN to show where in the computer it would be documented, and the LPN opened a box in the EMR titled monitoring. A box opened which had a section where the administering nurse could select the location of the pain on a drop-down list and there was a comment box. The LPN pointed to the comment box and said, that is where you would write the residents pain number. The LPN then showed the surveyor Resident #135's MAR for 03/01/23 and 03/06/23 and there was no documentation of pain assessments. The surveyor then asked the nurse what moderate to severe pain was on the numeric scale and the LPN said moderate is greater than 6 and severe is 9 to 10. On 03/14/23 at 12:22 PM, the surveyor reviewed the monitoring section of the EMR which included pain assessments. There were two pain assessments documented from 12/27/22 to 03/14/23, the day of review and the pain assessments were dated 02/25/23. No further numeric pain assessments could be located in the EMR. On 03/17/23 at 09:15 AM, the surveyor reviewed the active care plan dated 01/26/23. The care plain included a focus of pain. The interventions included to assess for signs and symptoms of pain and establish baseline pain through pain assessment. On 03/17/23 at 09:30 AM, the surveyor reviewed the policy titled, Pain, with a reviewed date of January 2023. The Assessment and Recognition section of the policy indicated that the staff would assess for pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Under the section titled monitoring, number 1 stated that the staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain, changes in chronic pain. c. On 03/01/23 at 11:01 AM, the surveyor observed Resident #44 wearing an elopement alarm on his/her right ankle. According to the admission Record, Resident #44 was admitted to the facility with diagnoses including but not limited to depression and alcohol dependence. The admission Minimum Data Set (MDS) an assessment tool dated 11/30/22 revealed that Resident # 44 had moderate cognitive deficits. Review of the Physician Orders (PO) dated 12/16/22 revealed an order for the elopement alarm to be placed on Resident #44's right ankle. Review of the PO dated 01/18/23 revealed an order for the elopement alarm for Resident #44 to be discontinued. Review of the December 2022, January 2023, February 2023, and March 2023 Treatment Administration Record (TAR) of Resident #44 reflected an order for the elopement alarm from 12/16/22 until 01/18/22 that was being signed by the nurse. On 03/03/23 at 10:46 AM, on 03/06/23 at 12:08 PM, and on 03/07/23 at 10:31 AM, the surveyor observed the elopement bracelet on Resident #44's right ankle. This was after the order was written on 01/18/23 for the elopement alarm to be discontinued. During an interview on 03/14/23 at 11:44 AM, the Corporate Nurse stated that once the elopement alarm was discontinued, it should have been removed from Resident #44's right ankle. During an interview on 03/14/23 at 12:48 PM, the Nurse Manager stated that she discontinued the elopement alarm for Resident #44 on 01/18/23 by accident. She confirmed that the elopement alarm remained on Resident #44's right ankle until 03/09/23. She furthered stated that the elopement alarm remained in place even though the order was discontinued. During an interview on 03/15/23 at 10:45 AM, the Director of Nursing stated that when the elopement alarm was discontinued on 01/18/23, the elopement alarm bracelet should have been removed from Resident #44's right ankle. During an interview on 03/16/23 at 11:37 AM, the Assistant Director of Nursing stated there was no policy regarding removing an elopement alarm bracelet once it is discontinued. She stated that it is the facility's protocol. NJAC 8:39-11.2 (b), 27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to a.) accurately account for and document the administration of controlled medications, b.) maintain clean and sanitary medication storage areas, and c.) ensure the accountability of the narcotic shift count log was completed in accordance with facility policy. This deficient practice was identified in 1 of 3 medication storage rooms and 2 of 4 medication carts reviewed and evidenced by the following: a.) On [DATE] at 10:31 AM, the surveyor in the presence of the Licensed Practical Nurse #1 (LPN1) inspected the second-floor west wing's (2 West), B - medication cart (2WB). A review of the narcotics located in the secured and locked narcotic box and compared to the declining inventory sheet revealed Unsampled Resident #1's amphetamine/dextroamphetamine ER 5 milligram (mg) capsules, a medication used for attention deficit hyperactivity disorder (ADHD) and narcolepsy (chronic sleep disorder that causes overwhelming daytime drowsiness), did not match. The blister pack contained #17 capsules and the declining inventory sheet indicated there should be #18 capsules remaining. LPN1 then stated she had forgotten to sign the declining inventory sheet for the dose she had given that morning. She further acknowledged she should have recorded on the declining inventory sheet immediately after she had administered the medication. Upon further inspection of 2WB medication cart, the surveyor observed Unsampled Resident #2's declining inventory sheet for acetaminophen/codeine #3 300-30 mg tablet, a medication used for pain and/or cough, dose #16 was administered on [DATE] at 5:30 AM, but did not have the administering nurse's signature documented. At this point LPN1 stated that it should have a nurse's signature. b.) On [DATE] at 10:58 AM, the surveyor in the presence of LPN1 and the Assistant Director of Nursing (ADON) inspected the 2 [NAME] medication storage room. The surveyor observed the following: one small sharps container (a container used to dispose of used sharp medical waste) containing used medical waste stored on a shelf next to clean supplies; two laboratory specimen (blood tube) centrifuges (a machine used to spin lab tubes); one lab specimen refrigerator containing a sealed plastic bag containing multiple lab specimens, and two unopened boxes of afluria Quadrivalent 2022-2023 formula (influenza vaccine) each box containing #10 prefilled syringes. At this point the ADON acknowledged that the used (dirty) sharps container should not be stored in the medication storage room, because the storage room is considered a clean room. She further stated that the centrifuges are used to spin blood drawn for labs by the laboratory technicians, and only labs should be stored in the lab refrigerator. The ADON acknowledged that the influenza vaccines should not have been stored there, and should have been stored in the designated medication refrigerator, and was unsure why it was placed in the lab refrigerator. On [DATE] at 11:01 AM, in the presence of the survey team, the ADON approached the surveyor and stated that due to construction, the medication room was the only available space to place the lab specimen refrigerator and laboratory centrifuges and they should be moved to a secured utility room that does not contain clean supplies and medication, and that she was unsure as to how the flu vaccines ended up in the lab specimen refrigerator since there is a big label on the refrigerator door which indicated lab specimen only. c.) On [DATE] at 11:32 AM, the surveyor in the presence of the Licensed Practical Nurse #2 (LPN2) inspected the third-floor west wing's (3 West), B - medication cart (3WB). A review of the Controlled Medication Audit Sheet for the month [DATE] revealed the column labeled Nurse Signature was blank for the following nursing shifts: 03/08 11 - 7 ON, 11 - 7 OFF 03/10 11 - 7 ON, 11 - 7 OFF, 7 - 3 ON, 7 - 3 OFF 03/11 11 -7 ON, 11 - 7 OFF 03/12 11 -7 ON, 11 - 7 OFF, 3 -11 ON, 3 -11 OFF 03/13 11 - 7 ON, 11 - 7 OFF, 7 - 3 ON, 7 - 3 OFF 03/15 11 - 7 ON, 11 - 7 OFF, 7 - 3 OFF 03/16 11 - 7 ON, 11 - 7 OFF Also, the following signatures were pre-signed: 03/16 7 - 3 OFF, 3 -11 ON, 3 -11 OFF At this point the surveyor interviewed LPN2, who stated this audit sheet is for nurses to complete together to verify control medication and that these medications are accounted for and nothing is missing. She further stated that the audit sheet is supposed to be signed on the exchange of shift and it is protocol to always verify the narc box. She acknowledged the pre-signed shifts on 03/16, I pre-signed for today because I'm working all day. On [DATE] at 11:59 AM, in the presence of the survey team the surveyor interviewed the ADON who stated, the nurses should not be pre-signing the sheet and should be signing every shift changes together to make sure controlled drugs are accounted for. She also acknowledged that declining inventory and controlled medication logs should not be blank like this. A review of the facility provided policy Medication Storage, Labeling and Expiration with a revised date of [DATE] included, 3. Medications will be stored in an orderly, organized manner in a clean area . 7. Expired, discontinued and/or contaminated medication will be removed from the medication storage areas and disposed of in accordance with facility policy. A review of the facility provided policy Narcotics: ensuring the security of narcotics dated [DATE] and reviewed [DATE] included, All nurses must ensure that the narcotic count is accurate at the time they receive the keys and at the time they are handing over the keys to the oncoming shift. At no time should any nurse be performing narcotic count alone. Each nurse is responsible for ensuring that the count is correct by standing side by side during the narcotic count . As a narcotic is used, it should be signed for immediately in the narcotic log/book and count reconciled. NJAC 8:39- 29.2(d) NJAC 8:39- 29.7

Based on observation, interview and review of facility documentation, it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b. properly wash hands and c.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 03/01/2023 at 9:40 AM, the surveyor toured the kitchen, in the presence of the Regional Food Service Director (RFSD) and the Food Service Director (FSD) and observed the following: On the overhead shelf, there was an unlabeled bag of rice and a bag of beans wrapped in clear plastic along with a cup of chicken broth that was unlabeled. The RFSD confirmed there should have been a label on the plastic wrapping of the bag of rice, beans, and a label should have been placed on the cup containing the chicken broth. In the cleaned food preparation area, there were crumbs on the top counter as well as on the bottom counter, and several areas throughout the kitchen counter, the surveyor observed a wet, watery substance on the base of the counters, which the surveyor touched, and it was determined to be wet to the touch. The two handwashing sinks were visibly dirty with suds, area surrounding the sink was dirty, and both sinks were not turned completely off. One had a slow drip and the other had a constant flow, which left the floors of both areas below the sinks wet. The RFSD confirmed the sinks should be clean and the water at the sinks should be turned completely off, when not in use. On 03/16/2023 at 10:17 AM, during the second tour of the kitchen, the surveyor advised the RFSD and the FSD that the handwashing sink at the entrance of the kitchen was clogged and would overflow before the proper handwashing time could be achieved. The FSD confirmed the clogged sink and stated they would contact maintenance. While standing in the same area and speaking with the RFSD and the FSD, surveyor observed the dietary aide (DA) go to the clogged sink and washed their hands for 11 seconds and used their clean hands to pull the garbage can from under the counter to discard wet paper towels. The DA then proceeded to the food preparation area. The dietary aide was interviewed and confirmed they should not have touched the garbage can with their clean hands as this would cause contamination. The FSD further confirmed that the DA should not have touched the garbage can with clean hands, should have used the foot propelled garbage can and the FSD confirmed that the DA should have been redirected from using the clogged sink since proper handwashing could not be achieved. Review of the facility's CCS Dating and Labeling policy with a review date of January 2023 revealed the kitchen will assure food safety by maintaining proper dates and labels for all ready to eat products, and all food items will be labeled with a received date upon acceptance of delivery. Review of the facility's handwashing policy with a review date of January 2023, policy interpretation and implementation revealed the following: employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water. NJAC 8:39-17.2

**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 maintain professional standards of clinical practice by a.) not following manufacturing specifications for the administration of a delayed released medication and b.) not clarifying a physician's order for 2 of 27 residents (Resident #22 and Resident #90) reviewed. 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. 1. On 5/17/21 at 9:20 AM, during the medication observation pass, the surveyor observed a Licensed Practical Nurse (LPN#1) preparing to administer medications for Resident #22. The surveyor observed LPN #1 opened a capsule of Duloxetine (Cymbalta) 20 mg Delayed Release Capsule and pour the contents into apple sauce. The LPN #1 was then observed mixing the contents of Duloxetine in apple sauce and then administering the medication to Resident #22. On 5/17/21 at 10:30 AM, the surveyor reviewed the admission Record for Resident #22 which indicated that the resident was admitted to the facility on [DATE] with diagnoses which included, but not limited to Major Depressive Disorder, Hypertension and Dementia with Behavioral Disturbances. Review of the May 2021 Physician's Orders revealed an order for Duloxetine 20 mg capsule, delayed release dated 4/27/21 with a direction of 1 Capsule by mouth once daily at 9:00 AM for Major Depressive Disorder. A review of Manufacturer's Specifications revealed that Duloxetine 20 mg delayed release capsule must be administered whole. Duloxetine should not be crush or opened. On 5/17/21 at 11:00 AM, the surveyor interviewed LPN #1 who stated that he was unaware that Duloxetine couldn't be opened and mixed in apple sauce. After reviewing the manufacturing specifications with the surveyor, LPN #1 stated that he should have not opened the Duloxetine capsule. On 5/17/21 at 1:00 PM, the surveyor met the Regional Nurse and the Director of Nursing (DON), and there was no additional information provided by the facility. 2. On 5/10/21 at 12:52 PM, the surveyor observed Resident #90 who was dressed and groomed and self-ambulating on the nursing unit. On 5/18/21 at 12:10 PM, the surveyor reviewed the admission Record for Resident #90 which indicated that the resident was admitted to the facility on [DATE] with diagnoses which included, but not limited to Type II Diabetes Mellitus, Major Depressive Disorder, Anxiety Disorder and Schizoaffective Disorder. A review of the Progress Note (PN) dated 5/5/21 revealed that Resident #90 had a Gradual Dose Reduction (GDR) for Abilify. The PN indicated that the Abilify was decreased from 2 mg to 1 mg. A review of the May 2021 Physician's Orders revealed an order dated 5/5/21 for Abilify 2 mg to give 1 tablet (2 mg) by mouth at bedtime ½ tablet (1 mg) for Schizoaffective disorder. A review of the May 2021 Electronic Medication Administration Record (eMAR) revealed an order dated 5/5/21 for Abilify 2 mg give 1 tablet (2 mg) by mouth once daily at bedtime 1/2 (1 mg) for Schizoaffective disorder. Further review of the May 2021 eMAR indicated that the Abilify was plotted to be administered at 9 PM from 5/6/21 through 5/17/21. On 5/18/21 at 12:30 PM, the surveyor in the presence of a Licensed Practical Nurse (LPN#1) inspected the 1 East medication cart. The surveyor observed a bingo card (medication delivery system) dated 4/13/21 for Abilify 2 mg tablets that contained whole tablets. The LPN #1 was unable to find a bingo card that contained Abilify 1 mg tablets. Further review of the 4/13/21 Abilify bingo card's cautionary auxiliary label indicated this tablet must be swallowed whole. Do not chew or crush. Furthermore, Abilify tablet cannot be scored (broke in half). At that same time, the surveyor interviewed LPN #1 who stated there were no bingo cards for 1 mg Abilify inside the active inventory medication cart. The LPN #1 stated that the directions for Abilify in the Physician Orders and the eMAR were confusing and should have been clarified with the physician. On 5/19/21 at 2:00 PM, the surveyor met with the Administrator, the Regional Nurse and DON and discussed the above observations and concerns. There was no additional information provided by the facility. A review of the facility's policy for Transcribing Orders in Sigma dated October 2020 indicated Two nurses will review each order to assure accuracy and appropriateness of the orders and the nurse will click Authorization, read back the order to the Medical Doctor or Nurse Practitioner, click read back and complete. NJAC: 8-39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services for a resident who was receiving tracheostomy (trach) care and nebulizer (neb) treatment according to standards of practice. This deficient practice was identified for 1 of 1 resident (Resident # 278) reviewed for tracheostomy care. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 23, 2021, included, Hand Hygiene: HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly; routine cleaning and disinfection procedures (e.g. using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed. According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Immediately after glove removal. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. On 5/11/21 at 10:02 AM, the surveyor observed Resident # 278 seated in a wheelchair in his/her room. The nebulizer machine was on the floor, the nebulizer mask was on top of the resident's bed, not stored in a plastic bag. The resident's trach was capped, allowing the resident to speak. The resident stated that they used oxygen as needed (PRN) and on a routine nebulizer treatment. The resident further stated that it was the nurse's responsibility to administer oxygen and the nebulizer treatment. The resident indicated that the trach care and changes were being done once a day by a nurse. On that same date and time, the surveyor observed the Certified Nursing Aide (CNA) who was also in the resident's room picked up the neb mask and hung it on the hook attached to the wall just below the light. The neb mask was not stored in a plastic bag and was not dated. The CNA stated, I just finished am care of the resident, and left the resident's room. On 5/12/21 at 9:28 AM, the surveyor observed the resident seated on the bed with the trach capped. The neb mask was hung onto the hook on the wall not stored in a plastic bag and was not dated. The neb machine was on the floor near the head part of the bed. The resident stated it was the nurse who administers neb treatments and hung the neb mask on the wall. The resident further stated, I don't know, if nurses store the neb mask in a plastic bag when not in use. The resident also stated that he/she forgot who the nurse was who administered neb treatment this morning. On 5/12/21 at 9:34 AM, the Licensed Practical Nurse #1 (LPN #1) informed the surveyor that she was the nurse of the resident. LPN #1 stated that Resident # 278 was cognitively intact, on a neb treatment, and PRN oxygen. She further stated that the neb mask should be inside a plastic bag and dated when not in use for infection control purposes. LPN #1 indicated that it was the 11-7 shift nurse's responsibility to change neb masks every 24 hours, and sign the electronic Treatment Administration Record (eTAR) for accountability. On that same date and time, the surveyor and LPN #1 entered the resident's room and observed the neb mask hung on the wall, not inside a plastic bag, and was not dated. Also, the neb machine was on the floor. After exiting the resident's room, LPN #1 stated I don't know why the neb mask was not inside a plastic bag and undated. She further stated that the neb machine should not have been on the floor. She indicated that she did not administer neb treatment to the resident this morning, and that it was the 11-7 nurse, but she forgot the nurses name. On 5/12/21 at 9:39 AM, the CNA informed the surveyor that Resident # 278 was cognitively intact. The CNA stated that it was the nurse's responsibility to administer neb and oxygen treatments and takes care of the trach. The CNA further stated, Yesterday was the first time I hung the neb mask on the wall. I don't normally do that. She further stated, I know it should be inside a plastic bag, but I couldn't find a plastic bag at that time. On 5/12/21 at 9:55 AM, the Registered Nurse/Charge Nurse (RN/CN) informed the surveyor that she was aware of the above concerns and stated, it should have been inside a plastic bag, when not in use and neb machine should not be on the floor. The RN/CN further stated that the 11-7 nurse was LPN #2. She indicated that the accountability for changing the neb mask and dating was in the eTAR and signed by the nurses. On 5/12/21 at 1:31 PM, the surveyors met with the Licensed Nursing Administrator (LNHA), Director of Nursing (DON), Regional Registered Nurse#1 (RRN#1) and discussed the above observations and concerns. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included Malignant Neoplasm of the upper respiratory tract (which means cancer), Carcinoma in situ of thyroid and other endocrine glands (cancer in which abnormal cells have not spread beyond where they first formed), and Anxiety. A review of the 3/4/21 Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate care management, revealed a Brief Interview for Mental Status (BIMS) score was 12, which indicated that the resident's cognition was moderately impaired. The CMDS noted that the resident was on trach care and respiratory therapy. A review of the May 2021 Physician's Orders revealed an original order date of 3/7/21 for trach care every shift. There was an order dated 5/17/21 for changing the neb tubings once a week every Thursday. Further review of the May 2021 Physician's Orders showed that the order for neb tubing change was ordered after the surveyor's inquiry. On 5/17/21 at 9:45 AM, the surveyor in the presence of the survey team conducted a telephone interview with LPN #2 who confirmed that she was the 11-7 nurse on 5/12/21. LPN #2 stated that the order for Resident # 278's neb treatment was 3 times a day at 9:00 AM, 1:00 PM, 5:00 PM, and not on my shift that was why I was not paying attention that the neb mask was hung on the hook and was not inside a plastic bag. LPN #2 further stated that it was the 11-7 shift nurse's responsibility to change the neb mask every Thursday, put a date on the plastic bag for infection control purposes. She indicated that it was the facility's policy to make sure the neb mask was inside a plastic bag when not in use, date the bag, and keep the machine off the floor. On 5/17/21 at 10:32 AM, the surveyors observed the RN/CN performed tracheostomy care of Resident #278. The RN/CN disinfected the table before trach care, removed used gloves, and performed handwashing for 14 seconds. The RN/CN after cleaning the trach removed used gloves and performed handwashing for 13 seconds. The RN/CN did not disinfect the table after use and left the resident's room. After exiting the resident's room, the RN/CN informed the surveyors that handwashing should be done for at least 20 seconds according to facility policy and protocol. The RN/CN stated that she was educated and had competency with regards to handwashing by the Infection Preventionist Nurse (IPN). She further stated that she should have disinfected the table after use. The RN/CN had no response when the surveyor informed her of the above observations with handwashing. Furthermore, the RN/CN informed the surveyors that there should have been an order and accountability for checking and changing neb mask/tubing, and neb mask should be changed every Thursday according to the facility policy and protocol. The RN/CN stated that the order should be reflected in the eTAR and signed by the nurses. The surveyor asked the RN/CN in the presence of RRN #2 to show the order for neb mask care and change in the electronic medical record. The RN/CN stated there was no order for neb mask care and changes and there should be one. On 5/17/21 at 12:46 PM, the surveyors met with the Director of Nursing (DON), RRN#1 and 2, and discussed the above observations and concerns. RRN#1 informed the surveyors that LPN #1 was disciplined because of the above concerns. RRN #1 stated that as a standard of practice, a neb mask must be placed in a ziplock if not in use, and the neb machine should not be on the floor. On 5/19/21 at 12:48 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), RRN#1, and Regional LNHA. RRN #1 informed the surveyors that handwashing starts when you wet your hands and not when you scrub your hands. RRN#1 stated that that's why LPN #1 felt that she counted 20 seconds when she washed her hands during the trach care. On 5/20/21 at 9:30 AM, the IPN informed the surveyors that staff should perform handwashing with soap and water and lather for 20 seconds. The IPN stated that 20 seconds starts when you vigorously scrub your hands with soap and water, and not when you start to open the faucet and wet your hands according to CDC guidelines. The IPN further stated that the RN/CN should have disinfected the table after use. On that same date and time, the IPN stated that it was facility policy to change the neb and tubing every 72 hours, and should have been kept in a plastic bag when not in use and dated. She further stated that the neb machine should be off the floor. A review of the facility Respiratory Care Policy and Procedure that was provided by the DON with a reviewed date of June 2020 included #6. Ensured that nebulizers are for single resident used and are cleaned and stored as per facility policy. #7. At all times, the nurse will ensure that respiratory tubing does not touch the floor. #9. Respiratory tubing should change weekly on the 11-7 shift. #10. If at any time, the nurse sees the tubing resting and/or touching the floor, tubing will be discarded and replaced with new tubing. A review of the facility Cleaning/Disinfecting Policy and Procedure that was provided by the DON with a reviewed date of March 2021 included It is the policy of this facility to clean and disinfect PPE, Resident-Care Equipment, Resident Areas and Laundry, including reusable items and durable medical equipment to current CDC, DOH, and OSHA recommendations for disinfection. A review of the facility Hand Hygiene Competence Assessment form that was provided by the DON with a copyright 2013-2014 included Demonstrates Hand Hygiene Technique: Using Antimicrobial Soap and Water. 1. Turns on the faucet and wets the hands with warm water. 2. Applies the amount of soap necessary to cover all surfaces. 3. Vigorously rubs the hands together for a minimum of 20 seconds covering all surfaces of the hands and fingers. 4. Rinses the hands with water to remove residual soap. 5. Pats the hands dry with a disposable, single-use paper drying material. 6. Turns off the faucet using a technique that does not recontaminate the hands. 7. Discards the disposable paper drying material without re-wiping the hands. On 5/21/21 at 10:47 AM, the surveyors met with the LNHA, DON, Regional LNHA, RRN#1 and 2. There was no additional information provided by the facility. NJAC 8:39-11.2 (b); 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to a.) ensure that the Consultant Pharmacist (CP) reported irregularities of a drug regimen to the facility, and b.) act upon the CP report of irregularities found while reviewing the monthly drug regimen. This deficient practice was identified for 2 of 26 residents, #31 and #119 reviewed. This deficient practice was evidenced by the following: 1. On 5/11/21 at 10:11 AM, the surveyor observed Resident #31 lying in bed awake and confused. The surveyor observed a tube feeding pump at bedside which was turned off and there was no formula hanging. The surveyor reviewed the medical record for Resident #31. A review of the Resident Face Sheet (admission information), reflected the resident was admitted on [DATE] with diagnoses which included Cerebral Infarction (stroke), Dysphagia (difficulty swallowing), and Gastrostomy [g-tube] status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). A review of the residents Physician's Orders for May 2021 in the Electronic Medical Record (EMR) reflected the following: Diet: NPO (nothing by mouth) with an original order date of 11/17/20. Acetaminophen 325 mg (milligram) tablet give 2 tablets (650 mg) by oral route every six hours as needed for pain with an original order date of 11/17/20. Milk of Magnesia 400 mg/5 mL (milliliter) oral suspension, give 30 mL by oral route once daily as needed, followed by a full glass (8 oz) of liquid with an original order date of 11/17/20. Baclofen 20 mg tablet give 1 tablet (20 mg) by oral route 3 times per day every day at 1PM, 5PM and 9AM with an original order date of 3/11/21. A review of the November 2020 through May 2021 Electronic Medication Administration Record (EMAR) reflected the above corresponding physicians' orders. Further review of the EMAR indicated that the Milk of Magnesia had not been administered and the Acetaminophen was administered on 5/12/21, 5/13/21, and 5/17/21. The Baclofen was administered three times per day at 1PM, 5PM and 9AM from 3/11/21 through 5/19/21 at 9AM. A review of the December 2020 through April 2021 Certified Consultant Pharmacist (CP) Monthly Progress Notes reflected the following: 12/28/20 Meds reviewed, see comment. 1/19/21 Meds reviewed, see comment. 2/25/21 Meds reviewed, no irreg. 3/25/21 Meds reviewed, no irreg. 4/27/21 Meds reviewed, no irreg. A review of the 12/28/20 Monthly Consultant Pharmacy Report (MCPR) reflected the CP recommended to add check placement q shift to the EMAR for an order of Scopolamine Patch. On the 1/19/21 MCPR the CP made another recommendation for the Scopolamine Patch. There was no documented evidence that the CP recommended to change an oral route of medication administration to via g-tube for a resident who had a physician's order for NPO. On 5/19/21 at 9:50 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) in the presence of another surveyor. The LPN reviewed the EMAR and acknowledged that the Baclofen she administered at 9 AM was written as an oral route for administration and should have been written via g-tube because the resident was NPO. She further stated that she crushed the medication and administered it to the resident via the g-tube. The LPN then stated that she should have called the doctor to get the order clarified. On 05/19/21 at 9:56 AM, the surveyor interviewed the resident's Registered Nurse/Charge Nurse (RN/CN) in the presence of another surveyor. The RN/CN stated that she did not notice the resident had orders for medications to be administered via an oral route. She stated that the physician as well as the CP reviewed the medications monthly and could not speak to why the mistake was not discovered earlier. The RN/CN acknowledged that the resident was NPO and the physician orders should have been written to be administered via g-tube. On 5/20/21 at 10:35 AM, the surveyor conducted a phone interview with the CP in the presence of the survey team. She stated that she reviewed her notes for her review of the resident's medications on 4/27/21 which indicated that all the medications were being administered via g-tube. She stated that when no irreg was indicated in her progress notes that meant she found no issues during her review. She acknowledged that a resident whose diet was NPO should not have medications administered via an oral route. The CP further stated, I made a mistake. On 5/20/21 at 1:29 PM, in the presence of the survey and administrative team, the Regional RN stated that anyone who opened that chart should have picked up on it. The administrative team acknowledged that the CP should have picked up the error as well. A review of the facility's policy Physician Medication Orders, with a review date of January 2021 indicated that drug and biological orders recorded in the residents' EMR were reviewed by the Pharmacist on a monthly basis. A review of the facility's policy Remote Access Medication Regimen Review, with a review date of March 2021 indicated that the CP conducts a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated medication. The process included review of the medical record in order to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities. 2. On 5/11/21 at 10:27 AM, the surveyor toured 3 [NAME] with the Registered Nurse/Charge Nurse (RN/CN), and both observed Resident #119 seated in a wheelchair watching television in his/her room. The resident stated that he/she was ok. On that same date and time, upon exiting the resident's room, the RN/CN informed the surveyor that the resident was cognitively intact and independent with most activities of daily living (ADLs). On 5/18/21 at 11:56 AM, the surveyor interviewed the resident who stated, I have pain in my knees and back due to Arthritis but the pain is manageable with medications. The resident further stated that he/she was happy with the care at the facility. The surveyor observed the resident was able to self-propel the wheelchair and there was no concern. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included Nontraumatic subdural hemorrhage (a condition due to bleeding under the membrane covering the brain), Rheumatoid arthritis, Scoliosis (is an abnormal curvature of the spine), Gastro-esophageal reflux disease (GERD-occurs when stomach acid flows back into the tube connecting mouth and stomach), Low back pain, Anxiety disorder, and Nicotine Dependence. On 5/19/21 at 12:34 PM, the Director of Nursing (DON) provided a binder of Medication Regimen Review (MRR) for new admission and re-admission which included a copy of the Pharmacy Consulting Services Nursing Recommendations dated 4/23/21 of Resident #119. The 4/23/21 MRR Action and Signature were blank and did not indicate that the recommendations were acted upon by nursing. The following were the nursing recommendations: 1.Clarify Fentanyl patch (a medication used for pain management) coding, should be every 72 hours (hrs), update please. Document Fentanyl removal time. Action:______ Signature:____ 2.Clarify need for Protonix (used to treat certain stomach and esophagus problems) BID (twice a day) dosing and duration of therapy at this high dose. Action:______ Signature:____ 3.Monitor for bleeding and bruising while on Heparin (blood thinner that prevents the formation of blood clots), rotate sites. Action:______ Signature:____ 4.Document Nicotine patch removal time. Action:______ Signature:____ 5.Monitor for dizziness, drowsiness, muscle weakness, confusion, falls, etc. with Carisoprodol (used short-term to treat muscle pain and discomfort) use. Action:______ Signature:____ 6.Monitor for sedation, dizziness, confusion, falls with higher-dose Xanax. Action:______ Signature:____ 7.Monitor for anticholinergic side effects/adverse reactions, sedation, confusions, falls, etch with Atarax (an antihistamine used to treat allergies, also used as a sedative to treat short-term anxiety and tension) use, evaluate continuous dosing need, clarify duration of therapy. Action:______ Signature:____ On 5/19/21 at 12:48 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), DON, Regional Registered Nurse#1 (RRN#1) and discussed the above concerns. On that same date and time, the DON informed the surveyors that she receives the MRR report from the CP, makes a copy, and sends it to the nurses to respond to the recommendations. The DON stated that the nurse have to call the doctor if necessary, write the responses to the recommendations in the Action, and then the nurse will sign which means the recommendations were addressed and acted upon. She further stated that the nurse would document in the progress notes if the doctor declined the recommendations. The DON stated that she will get back to the surveyor to provide a copy of the completed 4/23/21 MRR of Resident #119 with action-filled out and signature of the nurse. On 5/20/21 at 11:31 AM, the DON provided another copy of Resident #119's 4/23/21 MRR with the following information that the recommendations were acted upon with a signature of the RN/CN: 1. Clarify Fentanyl patch coding, should be every 72 hours, update please. Document Fentanyl removal time. Action: done. Signature: RN/CN 2. Clarify need for Protonix BID dosing and duration of therapy at this high dose. Action: decreased to 40 once a day (OD) 4/24/21 Signature: RN/CN 3. Monitor for bleeding and bruising while on Heparin, rotate sites. Action: 4/24/21 Signature: RN/CN 4. Document Nicotine patch removal time. Action: discontinued (d'cd) 4/24/21 Signature: RN/CN 5. Monitor for dizziness, drowsiness, muscle weakness, confusion, falls, etc. with Carisoprodol use. Action: 4/24/21 Signature: RN/CN 6. Monitor for sedation, dizziness, confusion, falls with higher-dose Xanax. Action: 4/24/21 Signature: RN/CN 7. Monitor for anticholinergic side effects/adverse reactions, sedation, confusions, falls, etch with Atarax use, evaluate continuous dosing need, clarify duration of therapy. Action: 4/24/21 Signature: RN/CN A review of the April 2021 and May 2021 electronic Medication Administration Record (eMAR) revealed that the above 4/23/21 MRR was not acted upon not until 5/19/21 after the surveyor's inquiry. The May 2021 eMAR reflected that the above changes were documented on May 2021 eMAR on 5/19/21 and not on 4/24/21. A review of the medical record revealed that there was no documentation supporting why the CP's MRR was not acted upon by the facility, not until the surveyor's inquiry. On 5/20/21 at 11:38 AM, the surveyor informed the DON of the above concerns. The DON informed the surveyors that it was the RN/CN who documented and signed that the 4/23/21 MRR was acted upon on 4/24/21. The DON stated I don't know when inquired by the surveyor why the Action part of the 4/23/21 MRR was documented as done on 4/24/21 when it reflected in the May 2021 eMAR that the above recommendations were carried out on 5/19/21. On 5/20/21 at 11:59 AM, the RN/CN informed the surveyors that it was my fault that I put the 4/24/21 date in the CP's MRR. The RN/CN stated that when she received the 4/23/21 MRR on 4/24/21 honestly, I was interrupted and I was busy, and I forgot to go back to respond to the recommendations. She further stated that the intention was to act upon the recommendations on 4/24/21 as soon as she received the CP's 4/23/21 MRR according to the facility protocol. On that same date and time, the RN/CN stated I called the doctor yesterday for the orders regarding the 4/23/21 MMR recommendations that was why it was reflected in the May 2021 eMAR effective 5/19/21. Furthermore, the RN/CN informed the surveyors that there was no negative effect on the resident. On 5/21/21 at 10:47 AM, the surveyors met with the LNHA, DON, RRN#1 and 2, Regional LNHA, and discussed the above concerns. A review of the facility's Remote Access Medication Regimen Review that was provided by the DON with a reviewed date of March 2021 included The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist reviews the resident's medication therapy and communicates their findings to the nursing staff/physician to implement the recommendations, and respond in an appropriate and timely fashion. On 5/21/21 at 11:35 AM, the surveyors met with the LNHA, RRN#1 and 2, DON, Regional LNHA, Concierge staff, and there was no additional information provided by the facility. NJAC 8:39-29.3 (a) (1)

**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 4 of 7 medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 11:00 AM, the surveyor inspected 2 [NAME] B side medication cart in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened bottle of Xalatan Eye Drops with an opened date of [DATE]. An opened bottle of Xalatan eye drops have a 42-day expiration date. The surveyor interviewed LPN#1 who stated that the opened bottle of Xalatan eye drops was expired and should have been removed from the active inventory medication cart. On [DATE] at 11:10 AM, the surveyor inspected the 2 East medication cart in the presence of LPN #2. The surveyor observed an opened Basaglar Insulin Pen with an opened date of [DATE]. An opened Basaglar insulin pen has a 28-day expiration date. The surveyor interviewed LPN #2 who stated that the opened Basaglar insulin pen was expired and should have been removed from the active inventory medication cart. On [DATE] at 11:17 AM, the surveyor inspected the 3 [NAME] A side medication cart in the presence of LPN #3. The surveyor observed an opened Humalog Mix 50/50 insulin pen with an opened date of [DATE], an opened Advair inhaler with an opened date of [DATE] and an opened bottle of Lumigan eye drops with an opened date of [DATE]. An opened Humalog Mix 50/50 insulin pen has a 10-day expiration date, an opened Advair Inhaler has a 30-day expiration date and an opened bottle of Lumigan eye drops have a 28-day expiration date. The surveyor interviewed LPN #3 who stated that Humalog Mix 50/50 insulin pen, an opened Advair Inhaler, and an opened bottle of Lumigan eye drops were expired and should have been removed from the active inventory medication cart. On [DATE] at 11:20 AM, the surveyor inspected the 3 [NAME] PUI medication cart in the presence of LPN #4. The surveyor observed an opened Advair inhaler that was not dated. The surveyor interviewed LPN #4 who stated that the resident was discharged from the facility and that an opened Advair inhaler should have been dated and that all medication belonging to a discharged resident should have been removed from the medication cart. A review of the Manufacturer's Specifications for the above medications indicated the following: 1. Xalatan eye drops once opened had an expiration date of 42-days. 2. Basaglar Insulin pen once opened had an expiration date of 28-days. 3. Humalog Mix 50/50 insulin pen once opened had an expiration date of 10-days. 4. Advair inhaler once opened had an expiration date of 30-days. 5. Lumigan eye drops once opened had an expiration date of 28-days. A review of the facility's policy for Medication Storage, Labeling and Expiration dated 12/20 indicated to record date opened as required on the medications package/labeled container received from the pharmacy and Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with the facility policy. NJAC: 8:39-29.4 (a) (h) (d)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was observed during kitchen tours and was evidenced by the following: On 5/10/21 at 9:54 AM, two surveyors toured the kitchen with the Food Service Director (FSD) and observed 35 loaves of white bread stored in a dry storage area dated 5/2 with a handwritten marker. The FSD stated that 5/2 was the date the bread was delivered. There was no expiration date on the loaves of white bread. The FSD informed the surveyors that if the bread was in the freezer it would last for seven days and since the 35 loaves of white bread were not in the freezer or refrigerated it should have been discarded. On 5/11/21 at 9:53 AM, two surveyors toured the kitchen with the FSD and observed the following: There was an opened five-pound tub of peanut butter with no opened date in the walk-in dairy refrigerator. There were also three closed, two-pound cartons of creamer stored horizontally in a shallow restaurant pan leaking a large amount of white fluid. There was food stored less than 18 inches from the ceiling in the dry storage area. There was ice buildup on a pipe leading to a sprinkler head in the walk-in freezer. There were six, six-inch-deep full-size metal restaurant pans that were heavily blackened stored on the meat pot rack. In the meat walk-in refrigerator there were four wire racks, each with four wire shelves with buildup that was able to be wiped off with a paper towel. There was also a dark fuzzy buildup on two fan covers and a brownish sticky buildup on 2 light covers. In addition, there was loose white wall board near the door which formed a gap. There was a hanging S hook over a meat preparation area with a blackish fuzzy buildup. There was no food being prepared there at that time. There was a stainless-steel preparation table on the meat side of the kitchen. The bottom shelf was heavily pitted and was covered with a blackish, reddish substance. There was a buildup of dry food debris on the underside of a shelf over a six well steam table on the dairy side of the kitchen. There was no food on the steam table at that time. There was a hard-plastic beige dunnage rack under the dairy pot sink that had a blackish reddish substance on top of it. There were two deep pots, a standing mixer bowl and whisk stored on top. There was a standing mixer with a yellow flaky substance on the underside of the mixer. The mixer was not in use at that time. A review of the facility's policy Bread Dating, dated 1/15/21 indicated that upon arrival bread is marked with the delivery date and should be used or discarded within seven days. A review of the facility's policy Labeling, Dating, and Food Storage, dated 1/26/21 indicated that food should be stored 18 inches from the ceiling. It also indicated that opened food should be labeled and dated. A review of the facility's policy Small Wares, dated 1/5/21 indicated that hotel pans, pots and pans will be replaced as needed. A review of the facility's policy Kitchen Sanitation/Maintenance, dated 3/23/21 indicated that policy was to ensure that the kitchen was clean and sanitary for food service operations. NJAC 8:39-17.1(a);17.2(g)

**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 staff failed to ensure a resident received and consumed liquids in the appropriate amount according to physician orders for 1 of 1 resident (Resident #92) who was on a fluid restricted diet. This deficient practice was evidenced by the following: On 5/11/21 at 1:34 PM, two surveyors observed Resident # 92 lying upright in bed with an overbed table positioned over his/her lap. The resident was alert, oriented and interviewable. The surveyors observed an opened 12-ounce can of diet gingerale on the overbed table. On 5/13/21 at 8:51 AM, two surveyors observed the resident in bed with eyes closed. The surveyors observed a 12-ounce can of diet gingerale and a water pitcher on the resident's overbed table and a 16-ounce bottle of diet gingerale on the resident's dresser. The resident had not eaten breakfast yet. The surveyors reviewed the residents breakfast tray and meal ticket. The meal ticket indicated that the resident was on a Renal/Carb Controlled - Regular diet. A note on the bottom of the meal ticket indicated NO EXTRA FLUIDS ON TRAY. There was no notation of a fluid restriction nor a specific volume allotted for the breakfast meal. There was a four-ounce cup of skim milk, a four-ounce cup of apple juice and a six-ounce mug of coffee on the tray; all of which were indicated on the meal ticket. A review of the Resident Face Sheet (admission information) reflected that Resident # 92 was admitted to the facility on [DATE] and had diagnoses which included but were not limited to; end stage renal disease (ESRD) and dependence on renal dialysis. A review of the Annual Minimum Data Set (MDS), dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 which reflected that the resident had an intact cognition. It also reflected the active diagnoses of renal insufficiency, renal failure or ESRD and dependence on renal dialysis. It further reflected that the resident was on a therapeutic diet and the Care Area Assessment (this process is the link between the MDS data collection and the individualized resident care plan) indicated that staff discussed risk verse benefits with the resident regarding snacking and weight gain. There was no indication that the resident was non-compliant with a fluid restricted diet. A review of the Physician Order's dated 2/5/21 reflected that the resident had an order for Fluid Restrictions 1320 ml (milliliters) with 960 ml allotted to dietary and 120 ml per each nursing shift 7-3, 3-11, 11-7. The resident also had a diet order for Renal/Carb Controlled Regular consistency dated of 2/5/21. A review of the Electronic Medication Administration Record (eMAR) for February 2021 through May 2021 revealed the above corresponding physician's order. A review of the resident's Care Plan Activity Report (CPAR) reflected a Nutrition focus dated 7/31/19 with a goal to adhere to the diet prescribed. Interventions included We will monitor and encourage fluid-water intake within fluids restricted and We will provide nutritional education as needed. In addition, the CPAR reflected a Renal Failure (Hemodialysis [HD]) focus dated 10/5/20 with interventions that included We will send your communication book with you for each session. We will communicate needed concerns, vitals, weights and other important information and receive information from the dialysis center. There was also a note dated 4/15/21 on the CPAR that indicated the resident was on a Renal CCD (carbohydrate controlled) Regular diet and fluid restriction 1320 ml in 24 hours. Further review of the CPAR reflected a Fluid Restriction focus dated 10/6/20 with goals that included I will be complaint with my fluid restriction and I will demonstrate understanding of the need for fluid restriction. Interventions that were indicated were, We (Dietician and nursing) will determine how much fluid should be offered by each discipline and at which times . and We want to give you the fluids you need per day without exceeding the restriction. There was also notes on the CPAR that reflected the resident had been compliant with the fluid restriction dated 10/20/20, 1/19/21 and 4/15/21. A review of the residents HD communication composition book reflected a note from the HD Registered Dietitian (RD) that indicated the resident's diet should be diabetic, renal with 1320 ml of fluid. A review of the RD's Progress Notes reflected the following: On 3/2/21, the RD documented he/she met with the resident and discussed the resident's diet. This included a fluid restriction of 1320 ml/day which was documented to be appropriate. Dietary to provide 960 ml/day and nursing 360 ml (120 ml/shift). On 3/8/21, 3/15/21, and 4/14/21 the RD documented the same as above in regard to the fluid restriction. On 4/18/21, the RD completed a Dietary-Readmission/Quarterly Assessment which reflected an answer false to the question, Is resident on a fluid restriction? On 5/14/21, the RD documented the resident was able to verbalize likes and dislikes and that he/she updated the kitchen as appropriate to the diet order. There was no documented evidence after 2/5/21 (date fluid restriction was ordered) that the resident was not compliant with the prescribed fluid restriction. A review of the breakfast, lunch and dinner meal tickets dated 5/9/21, reflected the pattern of fluids provided equaled 1320 ml/day which was 360 ml more per day than the prescribed diet of 960 ml from dietary. The words fluid restriction was not observed on the meal tickets. During an interview with the surveyor on 5/18/21 at 10:19 AM, and in the presence of another surveyor, the Food Service Director (FSD) stated that when a new diet was prescribed or there was a diet change, nursing communicated this via a computer notification. She further stated that when there was a change a red bubble would appear on the screen of their food service software program Meal Tracker which would alert her or the supervisor to make the appropriate changes. The FSD also stated that this system had been in place for two years and she thought it was fail proof. She added that she and nursing communicate as well. During an interview with the surveyor on 5/18/21 at 11:12 AM, and in the presence of another surveyor, the Certified Nursing Assistant (CNA) stated that she would have to check the meal ticket to know the type of diet a resident was prescribed. During an interview with the surveyor on 5/18/21 at 11:28 AM, and in the presence of another surveyor, the resident stated that he/she was prescribed a low carbohydrate diet and had to avoid foods like potatoes and tomatoes. The resident also stated that the HDRD informed the facility that he/she should be on a fluid restriction. The resident further stated that he/she received excess fluids and that I would follow the fluid restriction if it was given correctly. During an interview with the surveyor on 5/19/21 at 10:17 AM, and in the presence of another surveyor, four-ounces of skim milk, four-ounces of apple juice and six-ounces of coffee was observed on the breakfast tray. The surveyors also observed a gray water pitcher on the resident's overbed table approximately a quarter filled with water. The resident stated,they give me ice if I ask cause my mouth is dry, it must have melted. During an interview with the surveyor on 5/19/21 at 10:17 AM, and in the presence of another surveyor, Licensed Practical Nurse (LPN) # 1 stated that when there were diet changes they enter this into the Electronic Medical Record (EMR) but was not sure how the kitchen received that information. LPN # 1 reviewed the resident's fluid restriction order in the EMR and stated that she would have expected the RD to breakdown the 960 ml of fluid allotted to dietary for breakfast, lunch and dinner and that he/she provided that information to the kitchen. During an interview with the surveyor on 5/19/21 at 10:41 AM, and in the presence of another surveyor, the Food Service Supervisor (FSS) and the Regional FSD (RFSD), the FSD stated that a fluid restriction order would be noted at the bottom of the meal ticket in the notes section. She also stated that the RD would have given them a fluid breakdown for breakfast, lunch and dinner to ensure the correct amount of fluid was provided. The food service staff reviewed the meal tickets for that day and acknowledged that they were providing 10 ounces more than the prescribed allotment of 960 ml that day. The food service staff reviewed three communication binders (dietary related communication sheets from the RD to the kitchen) in the presence of the surveyors which did not reveal any communication for February 2021. The FSD then reviewed the Meal Tracker Activity Log in the food service software program in the presence of the surveyors and the RFSD. There was no evidence of communication for a fluid restriction prescription for Resident # 92 from nursing. The FSD and the RFSD acknowledged that if a resident on HD received too much fluid, they could gain weight. During a telephone interview with the surveyor on 5/20/21 at 9:20 AM, and in the presence of the entire survey team, the HDRD stated that the resident had been her patient since he/she started on HD in October of 2020. She also stated that in the beginning the resident was not compliant with fluid restricting but has since greatly improved with education. The HDRD further stated the resident should be on a renal, carbohydrate controlled, high protein diet with a fluid restriction of 1320 ml/day. During an interview with the surveyor on 5/20/21 at 10:59 AM, and in the presence of another surveyor, LPN # 2 stated that the resident was on a fluid restriction and the water pitcher was for ice. She stated that the resident was allowed to have ice in place of water. LPN #2 reviewed the resident's orders in the EMR and acknowledged there was no physician's order to allow ice chips. During an interview with the surveyor on 5/20/21 at 11:12 AM, and in the presence of another surveyor and the RFSD, the FSD stated that a RD had not been to the kitchen to crosscheck diets and preferences in a long time and would expect the RD to have provided a breakdown of fluids for breakfast, lunch and dinner to ensure the correct amounts of fluid were served. During a telephone interview with the surveyor on 5/20/21 at 1:08 PM, and in the presence of the entire survey team, the RD stated that she visited the resident this month to update food preferences. She did not recall if the resident was on a fluid restricted diet. The RD further stated that when a resident was on a fluid restricted diet she would ensure there was a correct breakdown of fluids for breakfast, lunch and dinner in accordance with the physician's order and would cross check with the food service department to ensure the resident received the correct amount of fluid. During an interview with the surveyor on 5/20/21 at 1:31 PM, in the presence of the entire survey team, the Licensed Nursing Home Administrator (LNHA), the Regional LNHA, and the Director of Nursing, the Regional Nurse stated that the fluid restriction order was entered into the EMR incorrectly should have been a dietary entry not a general entry and that it did not translate to the food service software program. He further stated,it should have been picked up. He also stated that if the resident wanted ice, he would have discussed that with the RD to incorporate that into the fluids allotted on the fluid restriction. A review of the facility's policy for Diet Order with a review date of March 2021 indicated that a diet order should be entered into the EMR under dietary orders. A review of the facility's policy for Fluid Restriction with a review date of November 2020 indicated that it's the facility's policy to maintain fluid restrictions as per MD/NP order and/or in accordance with the recommendations from nephrology or dialysis. The dietitian or designee determine the amount of fluid that will be provided on the dietary tray and communicates this with the dietary department. The dietitian documents the fluid restrictions and updates care plans. A review of the facility's policy for Dialysis with a review date of March 2021 indicated to remove water pitcher from bedside and the resident should carry a notebook to and from dialysis to foster communication between facilities. A review of an undated Dietician Job Description indicated that an administrative function included review therapeutic and regular diet plans and menus to assure they comply with the physician's orders. NJAC 8:39-17.4(a)(1)

Based on observation, interview, and record review, it was determined that the facility failed to: a.) perform handwashing appropriately for 4 of 10 staff and, b.) disinfect and sanitize the equipment used in the COVID-19 screening process, and table used in testing visitors for 3 of 3 staff in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 23, 2021, included, Hand Hygiene: HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly; routine cleaning and disinfection procedures (e.g. using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed. According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Immediately after glove removal. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. According to the U.S. CDC Guidance for SARS-CoV-2 Point-of-Care and Rapid Testing, page updated on 3/12/21 included, Disinfect surfaces within 6 feet of the specimen collection and handling area before, during, and after testing and at these times: before testing begins each day, between each specimen collection, at least hourly during testing, when visibly soiled, in the event of specimen spill or splash, at the end of every testing day. 1. On 5/10/21 at 09:10 AM, the surveyors entered the facility and were instructed by the receptionist to use the kiosk to answer screening questions for COVID-19. There was an alcohol-based hand rub (ABHR) mounted on the wall, one pen next to a binder with a paper screening COVID-19 questionnaires, and a thermometer that was placed directly on top of the table in the screening area where the kiosk was located. There were no disinfecting wipes on top of the table. On that same date and time, the Occupational Therapist (OT) and the Director of Maintenance (DM) were in the screening area. The DM and the OT both used the thermometer on top of the table and used the same pen to answer the COVID-19 screening questions on the paper without performing hand hygiene. Both the DM and OT did not disinfect the thermometer and pen after use. On 5/10/21 at 9:14 AM, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that there were no disinfecting wipes in the screening area because it was the housekeeper who cleans the kiosk area every now and then. The LNHA had no answer when asked by the surveyor why the thermometer was placed directly on top of the table. At that same time, the surveyor informed the LNHA of the above concerns. On 5/17/21 at 12:46 PM, the surveyors met with the Director of Nursing (DON), Regional Registered Nurse #1 and 2 (RRN#1, and RRN#2). RRN #1 informed the surveyors that there was no need to disinfect commonly used equipment like the pen and the thermometer if the staff performed hand hygiene. On 5/18/21 at 9:12 AM, the OT informed the surveyors that he was educated on the screening process, use of the thermometer and the paper COVID-19 questionnaire when unable to use the kiosk. He stated that he was educated about disinfecting and performing hand. He further stated, I was in a hurry on that day, which was why he was not able to perform hand hygiene in the screening area. He stated that there were no disinfecting wipes and the thermometer was placed directly on top of the table without a barrier. On 5/18/21 at 10:30 AM, the DM informed the surveyors that he was educated on the proper way of performing hand hygiene. He stated that he should have performed hand hygiene after using the pen and the thermometer. He further stated that staff utilizes the paper COVID-19 questionnaire for screening if the kiosk was not available to use. He indicated that there should have been disinfecting wipes available in the screening area. On that same date and time, the DM stated, oops, I was in a hurry, when asked by the surveyor why he did not perform hand hygiene on 5/10/21 and did not disinfect the equipment used. 2. On 5/10/21 at 9:16 AM, the receptionist informed the surveyors that she would conduct the COVID-19 BINAX testing at the back of the reception area. The receptionist did not disinfect the table used for testing after each use. There were no disinfecting wipes in the testing area. Three surveyors were tested on e after the other. The receptionist did not answer when asked why she did not disinfect the table before and after each surveyor was tested for COVID-19. On that same date and time, the receptionist informed the surveyor that she was educated on the proper way of performing COVID-19 testing for visitors. On 5/11/21 at 8:43 AM, the Director of Nursing (DON) assisted the surveyor to perform a COVID-19 BINAX test at the back of the reception area. There were disinfecting wipes on a hard-plastic utility cart and a pen to fill out a testing form. The DON did not disinfect the surface area before and after she conducted the test. On 5/12/21 at 1:31 PM, the surveyors met with the LNHA, DON, RRN #1 and discussed the above concerns. On 5/17/21 at 8:50 AM, the DON informed the surveyors that it was the receptionist's responsibility to perform the COVID-19 test for visitors, and will call the nurse to read the results. The DON stated that the receptionist was educated on the proper procedures for COVID-19 testing and the table should have been disinfected before and after use. 3. On 5/17/21 at 10:26 AM, the surveyors observed the Physical Therapist Assistant (PTA) did not perform hand hygiene after removing vinyl gloves while inside Resident #278's room. The surveyors observed the PTA was wearing double gloves and the second pair of gloves were not removed after exiting the resident's room. Resident #278 was a non-COVID, non-PUI, and not on any transmission-based precautions. At that same time, during the interview, the surveyors observed the PTA was wearing white cloth gloves (second pair) that had holes in it. The PTA informed the surveyors that she had an allergy to all gloves. The PTA provided the surveyor a doctor's handwritten prescription which indicated she can use the cloth gloves while at work. The PTA stated that she wears the cloth gloves all the time, and applies vinyl gloves over the cloth gloves. The PTA showed the surveyors an extra pair of cloth gloves which she kept inside her uniform pocket. The pair of cloth gloves were not in a plastic bag. On that same date and time, the surveyor asked the PTA if she should have washed her hands after removing the vinyl gloves. The PTA stated, not me. The surveyor asked the PTA if she was able to perform hand hygiene after removing the vinyl gloves. The PTA stated, yes. Further review of the doctor's handwritten prescription provided by the PTA indicated Patient will need to use cloth gloves along with the with other protective gloves while working. There was no documentation on the prescription that the PTA does not need or cannot perform hand hygiene after removing protective gloves. On 5/17/21 at 12:46 PM, the surveyors met with the DON, RRN #1, and #2. Both RRN #1 and #2 informed the surveyors that no staff was exempt from performing hand hygiene in the facility. On 5/19/21 at 12:48 PM, the surveyors met with the LNHA, DON, RRN #1, Regional LNHA. RRN #1 informed the surveyors that the PTA acknowledged that she did not perform hand hygiene after removing gloves when she exited a resident's room and she should have washed her hands. On 5/20/21 at 9:30 AM, the Infection Preventionist Nurse (IPN) informed the surveyors that hand hygiene must be done when hands are visibly soiled, before and after personal protective equipment (PPE) use were some criteria when to perform hand hygiene. The IPN further stated that the PTA should have washed her hands after removing gloves. Furthermore, the IPN stated that the facility follows the CDC guidelines with regards to COVID-19 screening and testing. The IPN further stated that the thermometer should not be on top of the table. She indicated that the receptionist should have disinfected the table before and after the COVID-19 testing of the visitors. A review of the facility's Cleaning/Disinfecting Policy and Procedure that was provided by the DON with a reviewed date of March 2021 included It is the policy of this facility to clean and disinfect PPE, Resident-Care Equipment, Resident Areas and Laundry, including reusable items and durable medical equipment to current CDC, DOH, and OSHA recommendations for disinfection. A review of the facility's Infection Control Guidelines that was provided by the LNHA with a reviewed date of October 2020 indicated under General Guidelines # 3. Employees must wash their hands for twenty seconds using soap and water under the following conditions d. after removing gloves. #4. In most situations, the preferred method of hand hygiene is with an ABHR .i. after contact with objects (e.g. medical equipment) . and j. after removing gloves. NJAC 8:39-19.4 (a) (1) (n) (2)