**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level 1 assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 1 resident reviewed for PASRRs (Resident #54) and was evidenced by the following: On 04/15/2024 the surveyor reviewed Resident #54's electronic medical record (EMR) which included review of the PASRR level 1 completed on 06/21/2019, which was negative and marked no for any diagnosis of mental illness. A review of the admission Minimum Data Set (MDS), an assessment tool dated 07/15/2019, revealed a Brief Interview of Mental Status (BIMS) score of 7/15, indicating severe cognitive impairment and review of section I did not include any psychiatric diagnoses. A review of the annual MDS dated [DATE], indicated diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia noted in Section I. A review of the quarterly MDS dated [DATE], indicated diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia noted in Section I. A review of Resident #54's care plans included but were not limited to a focus of At risk for changes in mood related to anxiety, depression, hx (history) of alcohol dependence and At risk for adverse effects related to use of antidepressant medication, use of antipsychotic medication. No additional PASRR including the diagnosis of anxiety disorder, depression, psychotic disorder, or schizophrenia was located. On 04/15/24 at 10:50 AM, the surveyor interviewed the Social Worker (SW) who stated that if a resident presents with a new diagnosis, then a new PASRR was done and sent to the state. When asked for new PASRR on Resident #54, after searching the EMR, SW stated, I don't see where that is captured. I don't see one. A new PASRR should've been completed. On 04/17/24 at 12:38 PM, the surveyor interviewed the Administrator who stated there was no policy on reevaluating PASRR. She stated that audits were done, but there is no regulation that they have to be updated annually. Review of facility policy admission Criteria, edited 06/23/22, which addressed PASRR under number 9, does not address a resident with a new psychological diagnosis after admission. N.J.A.C. 8:39.5.1(a)

Based on observation, interview, and review of facility documentation, it was determined the facility failed to develop a comprehensive person-centered care plan for a resident with pain. This deficient practice was identified for Resident #27, 1 of 24 residents reviewed for care plans and was evidenced by the following: On 04/10/24 at 10:06 AM, during the initial tour of the facility Resident #27 told the surveyor he/she had right hip pain and left foot pain. The surveyor asked if he/she received pain medication and the resident replied, Oh they are so busy. The surveyor asked the resident to rate the pain on a zero to 10 scale and the resident said it was a seven, meaning moderate pain level. Review of the admission Record revealed Resident #27 had medical diagnoses which included but were not limited to sciatica (pain affecting back, hip, and outer side of leg), fibromyalgia (long term condition that involves body pain and tiredness), depression, anxiety, and low back pain. Review of the admission Minimum Data Set (MDS), an assessment tool dated 03/31/24, indicated the resident had a Brief Interview of Mental Status of 14/15, which indicated the resident was cognitively intact. Section J of the MDS, health conditions, showed the resident had moderate pain and was receiving pain medications when necessary. On 04/12/24 at 12:10 PM, the surveyor reviewed the following orders: Acetaminophen Tablet 325 milligrams, give two tablets by mouth every six hours as needed for mild pain (Pain Score 1, 2, 3, 4). Do not exceed three grams in 24 hours. Total 650 mg. Pain Score every shift 0=No pain 1,2,3,4 =Mild Pain 5,6,7 = Moderate pain 8,9,10 =Severe pain every shift for Pain. Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give one tablet by mouth every eight hours as needed for moderate to severe pain (5-10). On 04/12/24 at 12:24 PM, the surveyor reviewed the Medication Administration Record (MAR) which showed that for the month of April 2024 the resident's pain was assessed every shift. Twice the resident had a pain level of 1, meaning mild pain, and once the resident had a pain level of 7, meaning severe pain. On 04/15/24 at 01:17 PM, the surveyor reviewed the care plan which did not include a focus of pain. At the same time, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) regarding the pain care plan. The care plan was then updated with a focus of pain after surveyor inquiry. On 04/17/24 at 01:10 PM, the surveyor reviewed the most recent physician progress note which indicated the following documentation under the physician assessment: Right sided sciatica-Continue Lyrica, lidocaine patches, and tramadol. On 04/22/24 at 11:55 PM, the surveyor reviewed the policy titled, Care plans, Comprehensive Person-Centered, the policy was dated 04/25/22. Under number eight it indicated that services are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. On 04/22/24 at 12:38 PM, the surveyor reviewed the policy titled, Pain Assessment and Management, a policy dated 11/10/22. Under the section titled, Defining Goals and Appropriate Interventions, number one indicated that the pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. NJAC 8:39-11.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a safety device used to prevent residents from elopement was in place for 1 of 3 residents reviewed for accidents (Resident #35). This deficient practice was evidenced by: According to the admission record Resident #35 was admitted with diagnoses that included, but were not limited to, paranoid schizophrenia and major depressive disorder. The surveyor reviewed the 1/20/24 Minimum Data Set (MDS), an assessment tool, and observed that the facility had identified Resident #35 as not being cognitively intact. The MDS reflected that Resident #35 had no wandering behavior during the lookback period and he/she used an elopement alarm daily. During initial tour on 04/10/24 at 10:45 AM, the surveyor observed Resident # 35 in the activity area painting. According to the Registered Nurse/Unit Manager (RN/UM) Resident #35 utilized an elopement alarm. On 04/11/24 at 10:27 AM, the surveyor observed Resident #35 in the room ambulating. The resident did not have an elopement alarm to the right wrist. On 04/12/24 at 9:30 AM, the surveyor observed Resident #35 in the room on the telephone. The resident did not have an elopement alarm to the right wrist. The surveyor spoke to a staff member who is familiar with this resident. The staff member stated that Resident #35 had never tried to leave the facility. On 04/15/24 at 10:54 AM and 12:57 PM, the surveyor observed Resident #35 in bed. The resident did not have an elopement alarm to the right wrist. The surveyor reviewed Resident #35's Physician's Orders. There was an order dated 7/13/23 for: Wanderguard every shift Wanderguard to right wrist. Check placement and function every shift. The April 2024 Medication Administration Record reflected that the wanderguard was in place each shift from 4/2/2024 through 4/15/24. A review of Resident # 35's care plans reflected a focus of wandering/pacing related to Dementia and elopement risk related to Cognitive impairment. The interventions included but were not limited to check for replacement and function of security bracelet (elopement alarm) as indicated. During an interview on 04/16/24 09:51 AM, the Lisensed Practical Nurse1 (LPN1) stated that elopement alarms require a physician's order. LPN1 furthered that the nurses check for placement and function each shift and document in the MAR. She stated that if the elopement alarm is missing then the nurse should replace the elopement alarm immediately. On 04/16/24 at 09:58 AM LPN1and the surveyor visualized Resident #35. LPN1 confirmed that Resident #35 should have an elopement alarm on her wrist but did not. LPN1 stated that she did not thouroughly check Resident #35 to ensure that the elopement alarm was in place. During an interview on 04/16/24 at 10:10 AM, the RN/NM stated the nurses should ensure that an elopement alarm is in place and if not on the resident it should be replaced. When the surveyor informed the RN/NM that Resident #35 did not have an elopement alarm in place she stated that the nurses should have replaced the elopement alarm. During an interview on 04/16/24 at 12:01 PM, the Lisenced Nursing Home Administrator(LNHA) stated that the PO for the elopement alarm for Resident #35 was dated July 2023. She stated that Resident #35 was reassessed for the need for the elopement alarm in October 2023 and it was determined that he/she did not need the elopement alarm but the PO was not updated. The LNHA stated that the nurses were not following the PO for the elopement alarm. A review of the facility policy Wandering and Elopements revised March 2019 reflected that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. NJAC 8:39 - 27.1 (a)

Based on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to provide appropriate and sufficient services based upon current standards of practice and the resident's comprehensive care plan to document urinary output in the Treatment Administration Record (TAR). The deficient practice was identified for 1 of 2 residents (Resident # 72) investigated for Urinary Catheter or UTI. The deficient practice was evidenced by the following: A review of Resident # 72's Minimum Data Set (MDS; an assessment tool) dated 03/16/2024 under section, H revealed that he/she had an indwelling urinary catheter (tube inserted into the bladder through the urethra to allow urine to drain from the bladder for collection). A review of Resident # 72's Electronic Medical Record (EMR) revealed under the section, Diagnoses that he/she was diagnosed with Paraplegia (paralysis typically of the lower body) and Neuromuscular Dysfunction of Bladder (lack of lack bladder control due to a brain, spinal cord or nerve problem). A review of Resident # 72's EMR under the section, Orders revealed a physician's order to, Measure and record foley catheter output Q [every] shift every shift for Neurogenic Bladder. The order became active on 03/28/2023. A review of Resident # 72's EMR under the section, Care Plan revealed an intervention to, Report changes in amount, color or odor of urine. The intervention was initiated on 11/28/2022. A review of Resident # 72's Treatment Administration Record for March, 2024 revealed blank sections of documentation to measure and record catheter output Q [every] shift on the following dates and shifts: 03/04/2024 night shift blank 03/08/2024 day shift blank 03/12/2024 night shift blank 03/13/2024 day shift blank 03/21/2024 night shift blank 03/27/2024 evening & night shift blank 03/30/2024 day shift blank A review of Resident # 72's Treatment Administration Record for February, 2024 revealed blank sections of documentation to measure and record catheter output every shift on the following dates and shifts: 02/02/2024 day shift blank 02/06/2024 day shift blank 02/09/2024 day shift blank 02/12/2024 night shift blank 02/24/2024 day shift blank 02/27/2024 day shift blank On 04/17/2024 at 12:29 PM during an interview with the surveyor, the Director of Nursing replied, Document in the MAR [Medication Administration Record] or TAR if there is an order for it. Secondly, the DON replied, No when the surveyor asked should the Treatment Administration Record be left blank. Lastly, the DON replied, I wouldn't say it was or was not. It could be they forgot to document it. A review of the facility policy with a revised date of August 2022, titled, Catheter Care, Urinary revealed under section, Input/Output to, 2. Follow the facility procedure for measuring and documenting input and output. A review of the facility policy titled, Medication and Treatment Orders did not reveal pertinent information. N.J.A.C. § 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain the necessary care and maintenance of respiratory equipment for 3 of 4 residents, reviewed for respiratory care. This deficient practice was evidenced by the following: On 04/10/2024 at 10:02 AM during initial tour, the surveyor observed Resident # 53 oxygen tubing not labeled, and the bag that held the tubing when not in use was dated 04/2/2024. According to the admission Record, Resident #53 was admitted to the facility with diagnoses including but not limited to; Chronic obstructive pulmonary disease (COPD). COPD is an airflow limitation caused by airway narrowing and/or obstruction, loss, or elastic recoil, or both. A review of the Order Summary Report for resident # 53, revealed a physician order for oxygen at 2 liters/minute via nasal canula (a device that delivers extra oxygen through a tube into the nose) every shift for shortness of breath. There was no order to change oxygen tubing weekly. On 04/15/2024 at 11:21 AM during an observation of other residents on oxygen, the surveyor observed Resident # 15's nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing and mask laying on the bed side table not stored in a bag. The surveyor also observed Resident # 17's nebulizer mask and tubing laying not in a bag, and the oxygen tubing laying across the bed. A review of the admission Record revealed, Resident # 15 was admitted to the facility with diagnoses including but not limited to, Interstitial Pulmonary Disease. A term used for a large group of diseases that case scarring of the lungs. A review of the Order Summary Report for resident # 15, revealed a physician order for oxygen at 2 liters/minute via nasal canula every shift for shortness of [NAME], and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams/3milliters, 1vial inhale orally every 6 hours for shortness of breath. There was no order to change respiratory tubing weekly. A review of the admission Record revealed, Resident # 17 was admitted to the facility with diagnoses including but not limited to, Acute Respiratory Failure with hypoxia. A condition where you don't have enough oxygen in the tissues in your body, A review of the Order Summary Report for resident # 17, revealed a physician order for oxygen at 2 liters/minute via nasal canula every shift for desaturation, Albuterol Sulfate Nebulization Solution (2.5 milligrams/3 milliliters) 0.083% 1 vial inhale orally via nebulizer every 4 hours as needed for wheezing or shortness of breath. There was also an order to change respiratory disposable supplies weekly and as needed. During an interview on 04/15/2024 at 11:06 AM with the surveyor, The Licensed Practical Nurse Unit Manager (LPN/UM) said we change respiratory tubing weekly, we label the tubing and bag with the date. LPN/UM also said the tubing is placed in the bag when not in use. When asked how do you know when to change the tubing, LPN/UM stated, there are orders, we change them on Tuesday's The LPN/UM agrees there should be orders for changing the tubing weekly. During an interview on 04/15/2024 at 11:16 AM with surveyor, The Director of Nursing (DON) said the Respiratory Therapist changs the respiratory tubing once a week, they date the tubing and the bags. The DON said there aren't orders in for the weekly change due to the nurses don't change them. The DON agreed that respiratory tubing should be placed in the bag when not in use. A review of the facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection with an edited date of 03/18/2024 revealed under Infection Control Considerations Related to Oxygen administration 6. Change the oxygen cannulae and tubing every seven (7) days. Or as needed.; 8. Keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use. Revealed under Infection Control Consideration Related to Medication Nebulizers/Continuous Aerosol: 7. Store circuit in plastic bag, marked with date and residents name, between uses.; 9. Discard the administration set up every seven (7) days. N.J.A.C. § 8:39-27.1(a)

Complaint # NJ163924 Based on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 1 of 7 days reviewed for the week of 04/30/2023 through 05/06/2023 under the Sufficient and Competent Nurse Staffing Task. The deficient practice was evidenced by the following: A review of the Nurse Staffing Report completed by the facility for the week of 04/30/2023 through 05/06/2023 revealed the facility documented one Registered Nurse (RN) as having worked on 05/06/2023 during the day shift. A review of the facility provided schedule for 05/06/2023 revealed the previous Director of Nursing was scheduled. However, the Nurse Staffing Report, completed by the Facility revealed a resident census of 87. On 04/15/2024 at 12:49 PM during an interview with the surveyor, the Licensed Nursing Home Administrator confirmed that the previous Director of Nursing was counted as the RN on duty. A review of the facility policy with a revised date of August 2022 titled, Staffing, Sufficient and Competent Nursing revealed under the section titled, Sufficient Staff that, 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RN may be scheduled more than eight (8) hours depending on the acuity needs of the resident. N.J.A.C. § 8:39-25.2 7(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, it was determined that the facility failed to ensure that medications were stored appropriately. This deficient practice was identified in two (2) of four (4) medication carts inspected on one (1) of two (2) units. This deficient practice was evidenced by the following: On 04/12/2024, Surveyor #1 was observing medication pass on the 100 unit. At 08:40 AM, Agency Licensed Practical Nurse #2 (Agency LPN #2) left medication cart 2 in the hallway, locked, with a grey box of individual medication envelopes on top of the cart, in the hallway on the opposite side of the hallway from room [ROOM NUMBER], while he went into room [ROOM NUMBER] to take the resident's vital signs. Surveyor #1 stayed with the medication cart. While Agency LPN #2 was in room [ROOM NUMBER], another resident wheeled past the medication cart. When Agency LPN #2 came back to the medication cart at 08:43 AM, Surveyor #1 asked if the cart should've been left in the hallway the way it was. Agency LPN #2 stated, Sorry, the medications should not have been left on top of the cart. On 04/12/2024 at 09:07 AM, Surveyor #1 approached medication cart 3 on the 100 unit and noted a grey box with individual medication envelopes on top of the locked unattended medication cart. When Agency LPN #3 approached the medication cart, Surveyor #1 asked if the medication cart should've been left in the hallway as it was. Agency LPN #3 stated that the cart was okay, then added that she's only been to this facility a few times. On 04/12/24 at 09:23 AM, Surveyor #1 interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the grey boxes with medication envelopes should not be left on top of the medication carts if the medication nurses walk away from the cart. On 04/17/24 at 12:35 PM, Surveyor #1 interviewed the Administrator and Director of Nursing who stated that the individual medication envelopes should not have been left on top of the medication cart unattended. A review of the facility policy Administering Medications edited on 5/21/19, revealed: #19. During administration of medications . No medications are kept on top of the cart. On 04/11/2024 at 10:37 AM during a tour of the 200 Unit communal shower room, Surveyor # 2 observed two, sealed plastic bottles filled with clear liquid located in an opened cabinet on the wall. Upon closer observation, the bottles both had pharmacy labels. The labels revealed that the bottles contained, acetic ac 1000ml 0.25% irrig s (Acetic Acid Irrigation Solution; a sterile, nonpyrogenic hypotonic solution for irrigation of the urinary bladder). The labels revealed the name of an unsampled resident. On the same date at 10:41 AM during an interview with Surveyor # 2, Licensed Practical Nurse/Unit Manager (LPN/UM) replied I didn't know these were in here and they should not be in here. when Surveyor # 2 asked is there a any reason the bottled were in there. LPN/UM confirmed that the bottles belong in a medication cart or in the medication room. On 04/17/2024 at 12:29 PM during an interview with Surveyor # 2, the Director of Nursing (DON) replied, No when asked if prescribed medications be stored in the shower room cabinets. The DON confirmed that prescribed medications should be stored in a treatment cart of medication cart. A review of the facility policy titled, Medication Labeling and Storage revised February 2023 revealed under, Policy Heading that, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls . N.J.A.C. 8:39-29.4(h)

Based on observation, interview, and pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness in 1 of 2 Pantries, Pantry on Unit 1. This deficient practice was evidenced by the following: On 04/12/2024 at 09:42 AM during observations of the pantry on Unit 1, the surveyor observed 3 frozen meals, and a container of rice pudding not labeled in the freezer. On 04/16/2024 at 10:11 AM during a second observation of the pantry on Unit 1, the surveyor observed, a burger not labeled or dated in the refrigerator. Also observed in the refrigerator was a muffin tin covered with in foil with the edge folded back and a muffin exposed, and a cup with pink liquid without a lid not dated or labeled. During an interview with the surveyor on 04/10/2024 at 09:22 AM, the Food Service Director, they said that the pantries on the nursing floor are managed by housekeeping and nursing. During an interview with the surveyor on 04/16/2024 at 10:13 AM with Licensed Practical Nurse (LPN) # 3. The LPN # 3 stated all food should be labeled and dated, if they aren't they get thrown away. During an interview with the surveyor on 04/17/2024 at 10:01AM, the Director of Nursing (DON) said all food should be labeled and dated. When asked if all food should be covered the DON replied with yes. During an interview with the surveyor on 04/17/2024 at 10:33 AM, the Director of Environmental Services stated, the golden rule is that if it is not labeled it is thrown out. A review of a facility provided policy revised on March 2022 titled Foods Brought by Family/Visitors revealed under, Policy Interpretation and implementation that 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility food. The policy also revealed under section 5., b. Perishable foods are stored in re-sealable containers with tight-fitting lids. Containers are labeled with the resident's name, the item and the use by date. N.J.A.C. 18:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 04/11/2024 at 12:04 PM during the initial tour, Surveyor # 2 entered room [ROOM NUMBER]-D and observed linen mixed with unpackaged incontinence briefs in the chair. Further, there were pillows and more linen observed on another chair in the corner. On 04/16/2024 at 10:22 AM, Surveyor # 2 entered room [ROOM NUMBER]-B, and observed untied bags of linen on the floor. On 04/17/2024 at 12:38 PM, during an interview with surveyor # 2, the Director of Nursing (DON) confirmed that resident's linen should be kept in the supply closet. Secondary, the DON confirmed that the nursing staff was responsible for removing linen and incontinence briefs from resident rooms. Lastly, the DON and the Licensed Nursing Home Administrator confirmed that linen and incontinence briefs should be kept in the resident's room closet and not on their chairs. A review of the facility policy titled, Departmental (Environmental Services) - Laundry and Linen with a revised date of January 2014, revealed under Washing Linen and Other Soiled Items but not limited to, 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. N.J.A.C. § 8:39-31.4 (a) Based upon observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain an orderly physical environment for 2 of 2 facility units (100 & 200) reviewed under the Environmental Task. The deficient practice is evidenced by the following: On 04/11/2024 at 10:20 AM during a tour of the 100 Unit communal shower room, the surveyor observed a shelf on the wall adjacent to the shower stall. On the shelf was an unpackaged incontinence brief, a hairbrush with hair entangled in the bristles, and various hygienic bottled toiletries. The room also emanated a foul odor. On the same date at 10:27 AM during a tour of the 100 Unit common area across from the nurses station, the surveyor observed a table that had food debris and two partially consumed beverages left on top. On the floor under the table was a single, blue slipper. The surveyor observed Residents participating in an activities exercise in the same common area at the time of the observation. On the same date at 10:37 AM during a tour of the 100 Unit communal shower room, the surveyor observed five PVC (polyvinyl chloride) constructed mobile trash bins stored in the shower room. At least one of the trash bins still contained clear plastic bags filled with trash. The room contained a scale chair (chair fitted with a scale to measure a persons weight) that had but was not limited to unpacked incontinence briefs, disposable glove boxes, and plastic bags on top of it. On the same date at 10:52 AM, the surveyor observed Resident # 72's room. At that time, the surveyor observed a chair near the foot of the bed. The chair had an unpackaged incontinence brief, towels, a linen sheet, and a hospital gown left on the seat. At that time, during an interview with the surveyor, Resident # 72 stated, I don't want it [items observed on chair] there because my son and grandbaby visit and I don't want them seeing a diaper. I keep telling them [the facility] to not do that. On 04/16/2024 at 10:58 AM in the hallways outside of room [ROOM NUMBER], the surveyor observed a geriatric recliner chair. On the chair was a grey plastic container that included unpackaged, blue incontinence briefs. On the same date at 11:02 AM while in Resident # 11's room, the surveyor observed a chair near the foot of the bed. The chair had a hospital gown and white linens left on the seat. At that time during an interview with the surveyor, Resident # 11 replied , I don't want that there. when the surveyor asked if he/she wanted the hospital gown and linens on the chair. Resident # 11 further said he/she does not use hospital gowns because they are not warm enough. On 04/16/2024 at 10:58 AM during an interview with the surveyor, Housekeeper # 1 said he was not responsible for removing linens from room. He said he was responsible for mopping, sweeping, garbage, and cleaning. On 04/17/2024 at 12:29 PM during an interview with the surveyor, the Director of Nursing (DON) replied, They should be stored in the closets and if on the floor, in carts. when the surveyor asked what was her expectation for storing linens including but not limited to unpackaged incontinence briefs and linens. Lastly, she replied, Closets in the rooms. when the surveyor asked where should they (incontinence briefs, linens) be stored.

d.) On 4/16/24 at 9:56 AM, the surveyor reviewed Resident #468's closed medical records. Review of the resident's admission Record indicated Resident #468 was admitted to the facility with diagnosis which included but were not limited to hemiplegia and hemiparesis (weakness and paralysis of one side) following cerebral infarction (stroke), seizures, and nontraumatic subarachnoid hemorrhage from unspecified middle cerebral artery (the accumulation of blood in or around the brain not caused by trauma). Review of the resident's admission MDS indicated the resident had a BIMS score of 9 out of 15, which indicated moderate impaired cognition. Review of the physician orders included an order with a start date of 8/31/2023 to check helmet placement every two (2) hours. Must be worn at all times. Review of Resident #468's TAR for September and October 2023 revealed the following missing or blank documentation areas for the physician's order to check placement every two hours: 9/10 4 PM, 6 PM, 8 PM, 10PM 9/30 4 AM, 6 AM 10/3 4 AM, 6 AM 10/8 10 AM 10/27 2 PM On 4/17/24 at 11:09 AM, the surveyor interviewed LPN2 who stated that when administering medication or performing ordered treatments, nurses should document in the electronic medical record. She further stated there should be no blanks in the TAR and that if it is blank, it would indicate it was not done. LPN2 also informed the surveyor that there are appropriate codes to use in the TAR to indicate why a treatment was not completed, for example, if the resident was unavailable at that time, but it should still be documented and not left blank. On 4/17/24 at 11:15 AM, the surveyor interviewed the DON who confirmed that there should not be any blanks in documentation on the TAR and nursing staff should use one of the available numeric codes to document why a treatment was not done. The DON stated she did not agree with the adage if it's not documented, it's not done stating, I would say it was done, just forgot to sign it. While presenting the DON with the blank documentation in the resident's TAR to check for helmet placement, the DON stated, the resident has his helmet on in the picture referring to the picture used on the medical record for resident identification. Review of the facility's Charting and Documentation policy with edited date 5/27/2022 included but was not limited to: 4. The following information is to be documented in the resident's medical record: a. objective observations; b. medications administered; c. treatments or services performed; d. changes in the resident's condition; e. events, incidents or accidents involving the resident; and f. progress toward or changes in the care plan goals and objectives. b. On 04/10/24 at 10:21 AM, during the initial tour of the facility Resident #84 was in the bed awake. The resident told the surveyor that he/she was on intravenous (IV) antibiotics (medications given through an access in a vein) for a long time. The surveyor asked the resident about his/her IV access and the resident showed the surveyor a clear plastic dressing on the resident's right chest wall and said it was a Hickman (central line catheter placed on the right side of the chest wall). The surveyor asked if the staff were changing the dressings or if the dressing had a date and the resident showed the surveyor the dressing that was dated 03/27/24. The resident then told the surveyor that it's been a long time since they changed it, maybe they didn't change it because it may come out soon. Review of Resident #84's admission Record (an admission summary) revealed that the resident had medical diagnoses which included but were not limited to bacteremia (bacteria in the blood stream), appendicitis (appendix becomes inflamed and painful), and septic shock (a widespread infection causing organ failure and dangerously low blood pressure). The surveyor reviewed the most recent Minimum Data Set (MDS), an assessment tool dated 03/05/24, which indicated the resident had a Brief Interview of Mental Status of 15/15, which indicated the resident was cognitively intact. On 04/12/24 at 09:52 AM, the surveyor reviewed the physician orders which showed the following order dated 2/28/24: Dressing: PICC (peripherally inserted central catheter, a type of central catheter inserted in the arm)/Midline/ Tunneled & Non-Tunneled: 24 hours after insertion, then weekly and as needed. Change needleless connector with weekly dressing change and after blood draw. If securement device is used, change at time of dressing change. No signs and symptoms of any infusion related complications present. Dressing is adherent and intact; catheter & tubing properly secured; needleless connectors are present. After reviewing the physician orders, it revealed the resident was no longer on IV antibiotics. On 04/12/24 at 10:01 AM, the surveyor reviewed the care plan which showed a focus of IV insertion and potential for complications. The care plan was initiated 01/02/24. One of the interventions included: Change IV site dressing per physician order and as needed if soiled or wet. On 04/12/24 at 11:42 AM, the surveyor reviewed the Treatment Administration Record (TAR) for Resident #84 which showed the resident was scheduled for a tunneled catheter dressing change on 04/03/24 and it was left blank, meaning not signed as completed by the nursing staff. Further review of the TAR showed that the dressing was changed on 4/10/24. On 04/17/24 at 11:48 AM, the surveyor interviewed facility Licensed Practical Nurse (Agency LPN #1) regarding care of central catheters. The surveyor asked what was the date that on a central line dressing indicated and Agency LPN#1 said, That is the date that it was changed. The surveyor asked how often the dressings for central catheters were changed and Agency LPN#1 said, weekly and as needed. The surveyor then asked where the dressing changes would be documented when completed by the nursing staff and Agency LPN#1 said it would be documented in the Medication Administration Record (MAR) or TAR. Agency LPN#1 said, It will pop up for the weekly changes on the MAR or TAR and there will also be an area for the as needed changes. On 04/18/24 at 10:50 AM, the surveyor reviewed the policy titled, Central Venous Catheter Care and Dressing Changes, a policy with a revision date of 03/2022. Under the general guidelines section of the policy, number 3 indicated to change the catheter dressing if it becomes damp, loosened or visibly soiled and at least every seven days for transparent dressing. Review of the documentation section indicated that the medical record should include the date and time the dressing was changed. c. On 04/17/24 at 11:08 AM, the surveyor reviewed the physician orders for Resident #467 which showed an order to offload heels while in bed as tolerated. It was ordered on 02/13/24. The surveyor reviewed Resident #467 admission Record which revealed the resident was admitted to the facility for short term rehabilitation. Medical diagnoses included but were not limited to hypertension (high blood pressure), repeated falls, heart failure, and muscle weakness. Review of the admission Minimum Data Set (MDS) indicated the resident had a Brief Interview of Mental Status score of 12/15, which indicated the resident had moderate cognitive impairment. Review of section M, skin conditions indicated the resident was at risk for developing pressure ulcers. On 04/17/24 at 11:30 AM, the surveyor reviewed Resident #467's Medication Administration Record (MAR) and the Treatment Administration Record (TAR). The order for offloading of the heels was not documented on either record. On 04/17/24 at 11:46 AM, the surveyor reviewed the Certified Nursing Assistant (CNA) task list which included float/offload heels marked as for your information. There was no documentation by the CNA that the task was completed, tolerated, or refused by the resident. On 04/17/24 at 11:52 AM, the surveyor interviewed Agency LPN #1 regarding residents with orders to offload heels while in bed and was that a task that would be documented if done. Agency LPN #1 said, If it was a physician order it would pop up on the MAR or TAR for nursing to sign it as done. On 04/17/24 at 1:20 PM, the Director of Nursing (DON) met with the surveyor and provided a care plan that showed offload heels while in bed. The intervention was initiated on 2/19/24. The surveyor asked where it was documented from the order date of 2/13/24 until the care plan intervention was initiated on 2/19/24 and the DON responded, I understand. e. According to the admission record Resident #35 was admitted with diagnoses that included, but were not limited to, paranoid schizophrenia and major depressive disorder. The surveyor reviewed the 1/20/24 Minimum Data Set, an assessment tool, and observed that the facility had identified Resident #35 as not being cognitively intact. On 4/16/24 at 9:51 AM, the surveyor reviewed the March and April Medication Administration Record (MAR) for Resident #35. When medications are ordered by the physician, the order is placed on the MAR. When administered by the nurses, the nurse will sign their initials on the MAR indicating that they have given the medication. The surveyor noted a 11/9/2023 physician's order (PO) for the cognition enhancing medication donepezil give 1 tablet by mouth at bedtime. The surveyor observed a blank on the MAR, there were no nurse's initials indicating administration on 3/29/24 and 4/7/24 at 2100. The surveyor observed a PO for levothyroxine sodium (a medication used to treat a low thyroid) 50mcg ordered on 3/16/24 give 1 capsule by mouth in the morning. The MAR had a blank on 3/22/24 at 2200. The surveyor observed a PO for Lipitor (used to treat high cholesterol) 40mg ordered on 7/13/23 give 1 tablet by mouth at bedtime. The MAR had blanks on the MAR on 3/29/24 and 4/7/24 at 2100. The surveyor observed a PO for metoprolol succinate (used for high blood pressure) ER 25mg ordered on 7/14/23 give 1 tablet by mouth in the evening. The MAR had blanks on 3/3/24, 3/29/24, 4/7/24, and 4/8/24 at 1700. The surveyor observed a PO for Paxil (an antidepressant) ordered on 7/14/23 give 1 tablet by mouth in the evening. The MAR had blanks on 3/3/24, 3/29/24, 4/7/24, and 4/8/24 at 1700. The surveyor observed a PO for Seroquel (a medication used for schizophrenia) ordered on 2/28/24 give 1 tablet by mouth at bedtime. The MAR had blanks on 3/29/24 and 4/7/24 at 2100. The surveyor observed a PO for Depakote delayed release (used for mood disorders) ordered on 10/13/23 give 1 tablet two times a day. The MAR had blanks on 3/3/24, 3/29/24, 4/7/24, and 4/8/24 at 1700 and on 4/14/24 at 0900. The surveyor observed a PO for metformin (used for diabetes) ordered on 7/14/23 give 1 tablet two times a day. The MAR blanks on 3/3/24, 3/29/24, 4/7/24, 4/8/24 at 1700 and on 4/14/24 at 0900. The surveyor observed a PO for Namenda ( a medication used to improve cognition) ordered on 7/14/23 give 1 tablet by mouth every morning and at bedtime. The MAR had blanks on 3/29/24 and 4/7/24 at 2100 and 4/14/24 at 0900. The surveyor observed a PO for Xanax (a medication used for anxiety) ordered on 3/21/24 give 1 tablet every 12 hours. The MAR had blanks on 3/27/24, 3/29/24, and 4/7/24 at 2100 and 4/14/24 at 0900. The surveyor observed a PO for amlodipine besylate (used to treat high blood pressure) ordered on 7/14/23 give 1 tablet once a day. The MAR had a blank on 4/14/24 at 0900. The surveyor observed a PO for Aspirin delayed release 81mg (used for the heart) ordered on 7/14/23 give 1 tablet by mouth once a day. The MAR had a blank on 4/14/24 at 0900. There was no documented evidence in the medical record that Resident #35 experienced a negative reaction/harm for not receiving the medications. During an interview on 4/16/24 at 9:58 AM, Licensed Practical Nurse (LPN)1 stated that If there is a blank in the MAR the medication was not signed out. She would assume that if the MAR was not signed out, the medication was not given. During an interview on 04/16/24 at 10:15 AM the Registered Nurse/Nurse Manager stated that if the MAR is blank, it means the medication was not signed out. If not signed out there is no way of knowing if a medication was given or not. A review of facility provided policy titled Documentation of Medication Administration edited on 04/06/2023, reflected that administration of medication is documented immediately after it is given. Documentation of medication administration includes at minimum: g. initial, signature, and title of the person administering the medication. NJAC 8:39-27.1(a) NJ Complaint # NJ00169132, NJ00171624 Based on observations, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) obtain a physician's order for residents to be discharged from the facility prior to discharge, b). change a central line catheter dressing as ordered by the physician (Resident #84), c.) follow physician orders to offload a residents heels while in bed (Resident #467), d.) follow physician order to check for helmet placement every two hours (Resident #468), and e.) maintain medication records that were complete with staff signatures according to professional standards of clinical practice for Resident #35, 1 of 29 residents reviewed for professional standards. This deficient practice was identified for 3 of 3 residents (Residents #88, #34 and #46) on 2 of 2 nursing units (100 and 200 units) and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as 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. a. The surveyor reviewed Resident #88, Resident #34, and Resident #46's closed medical records. Review of the physician orders revealed that none of the resident's had a physician's order placed in the medical record prior to resident discharge from the facility. On 04/17/24 at 12:45 PM, during an interview with both the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) in the presence of the survey team, the LNHA stated that she confirmed that Resident #88, Resident #34 and Resident #46 did not have a physician's order to be discharged from the facility but were required to. On 04/18/24 at 8:49 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) and asked why Resident #88 and Resident #34 did not have discharge orders placed in their medical records prior to being discharged from the facility. LPN/UM stated a discharge order was required to be obtained from the physician prior to resident discharge. LPN/UM stated the nurse must have forgotten to put the order in the computer. LPN/UM further stated that the assigned desk duty nurse was responsible to put the discharge order in the computer prior to a resident being discharged from the facility. On 04/18/24 at 8:55 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that a discharge order was required prior to resident discharge from the facility. RN/UM stated the doctor was notified and a discharge order was obtained prior to resident discharge. RN/UM stated that she was responsible to put the order in the computer. RN/UM further stated that it must have been a nursing oversight that a discharge order not placed in the computer before Resident #46 was discharged from the facility. Review of the facility policy, Discharging a Resident without a Physician's Approval (Revised 10/22) revealed the following: An order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record no later than seventy-two (72) hours after the discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices and store, label, and date potentially hazardous foods to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 02/09/2022 at 09:21 am, during the initial tour of the kitchen in the presence of the Assistant Dietary Director (ADD), the surveyor observed the following: 1. The ADD was in the kitchen wearing a hair net. The hair net did not cover her hair to the hairline on the forehead and there were multiple long strands of hair that were not contained in the hair net. The ADD stated that she did not realize that all her hair was not contained in the hair net. The ADD stated that her hair should have been completely contained in the hair net to avoid hair from falling in the food. 2. There was a large stand-up mixer that had a clear plastic bag covering it. The ADD stated that the clear bag indicated that the mixer was clean and ready for use. The ADD removed the clear plastic bag in the presence of the surveyor. There was a dry white substance on the underside of the mixer above where the mixer blade would be attached. The ADD stated that the white substance should not have been there due to cross contamination. 3. In the reach-in refrigerator the following was observed: -A silver tray labeled red gelatin covered with clear plastic wrap with a use by date of 2/6/22 -A silver tray labeled sliced deli turkey covered with clear plastic wrap with a use by 2/5/22 -A sandwich wrapped in clear plastic labeled jelly sandwich with a use by date of 2/7/22 At that time, the ADD stated that the reason the items were dated was to make sure it was used by allotted time, so it doesn't go bad, 4. In the walk-in refrigerator: -An opened 1-gallon container of ranch dressing with a use by date of 1/16/22 -An opened 8-pound (lb) 10 ounce (oz) container of enchilada sauce with a use by date of 1/16/22 -An opened 1-gallon container of thousand island dressing with a use by date of 1/14/22 -An opened 5 lbs. container of teriyaki glaze with no open date -An opened 4 lb. 15 oz container of [NAME] style sauce with no open date The ADD stated that it was everyone's responsibility check the dates to make sure the items were labeled and still good. At 09:45 AM, the Dietary Director (DD) joined the tour. 5. In the walk-in freezer, the DD identified the following: -An opened box of chicken cutlets that contained a bag of the chicken cutlets that was opened to air. The DD stated that they shouldn't be open to air due to cross contamination. -A clear bag of long white logs, there was no identifier label, received on label, or use by label. The DD identified them as French fries. -A clear bag of long oval brown logs, there was no identifier label, received on label, or use by label. The DD identified them as hot dogs. -A clear bag of brown circular patties, there was no identifier label, received on label, or use by label. The DD identified them as beef steak fritters. -A clear bag of tan circular nuggets, there was no identifier label, received on label, or use by label. The DD identified them as chicken nuggets. -3 clear bags of white circular items, there was no identifier label, received on label, or use by label. The DD identified them as cookie dough. At that time, the DD stated the purpose of labeling items was so that everyone knows what the item was and when to use it. He also stated that it was everyone's responsibility to label the items. At 09:55 AM, the surveyor reviewed with the DD all the findings that were observed while touring with the ADD. On 02/16/22 at 01:12 PM, the above findings were reviewed with the Administrator and the Director of Nursing. Review of the facility's policy, Preventing Foodborne Illness-Employee hygiene and Sanitary Practices dated October 2017, Policy Interpretation and Implementation: 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Review of the facility's policy, Preventing Foodborne Illness-Food Handling revised July 2014, Policy Interpretation and Implementation: 9. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendation. Review of the facility's policy, Refrigerators and Freezer revised December 2014, Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines. Policy Interpretation and implementation: 7. All food shall be appropriately dated to ensure proper rotation by expiration dates .Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a meal observation on 02/10/22 at 12:03 PM, Surveyor #2 observed a four-tiered rolling beverage cart positioned in the hallway on the Subacute Rehabilitation (SAR) Unit. On the top shelf of the cart, a ceramic coffee mug was noted inside of an ice filled silver-colored metallic ice bucket. The surveyor observed a Hospitality Aide (HA) as she utilized the ceramic coffee cup to scoop the ice out of the ice bucket and into a cup with her bare hands as she prepared a beverage for a resident. When interviewed, the HA stated that she just started working at the facility on Monday. At 12:05 PM, Surveyor #2 observed CNA #2 as she utilized the coffee mug to scoop out of the ice bucket and into a cup with her bare hands. When interviewed, CNA #2 stated that she utilized a coffee mug to scoop the ice instead of an ice scoop because it was just easier, as the handle of the ice scoop was too long. During an interview with Surveyor #2 at 12:10 PM, the Dietary Aide (DA) stated that staff was supposed to use an ice scooper when they scooped ice, not a coffee cup. She stated that the nurses should have had an ice scoop on the unit. At 12:11 PM, Surveyor #2 observed CNA #2 as she utilized the coffee mug to scoop ice into a cup a second time with her bare hands. At 12:12 PM, Surveyor #2 observed CNA #2 as she removed the coffee cup from the ice bucket with her bare hands and placed an ice scooper into the ice bucket. When interviewed, CNA #2 stated that there was no problem with using a coffee cup to scoop ice for the residents instead of an ice scooper because the coffee cup was clean. During an interview with Surveyor #2 at 12:15 PM, LPN #2 stated that she had never seen a staff utilize a coffee cup to scoop ice from the ice bucket before. She stated that nursing did not have an ice scoop on the unit. She stated that the ice scoop should have been sent to the unit on the beverage cart from the dietary department. She further stated that the problem with using a coffee cup instead of an ice scoop was that there was a potential that the cup could chip and break off into the ice. During a later interview with Surveyor #2, at 12:18 PM, CNA #2, examined the inside of the ceramic coffee cup utilized to scoop ice and stated that the coffee cup was not chipped but was stained with a brown substance on the inside of the cup. During an interview with Surveyor #2 on 02/11/22 at 1:47 PM, the Registered Nurse/Infection Preventionist (RN/IP) stated that it was not appropriate for the DA or CNA #2 to use a coffee cup to scoop ice for the residents instead of an ice scoop. She stated that by not using a plastic ice scoop that went through the dishwasher and was sanitized prior to use, there was a break in protocol and was an infection control issue due to the risk of contamination. During an interview with the surveyor on 02/14/22 at 12:36 PM, the Food Service Director (FSD) stated that staff was required to utilize an ice scooper when they served beverages because if they used a ceramic coffee mug it may be subject to chipping. He stated that he did not know if there was a possibility of contamination if the cup was stained with a brown substance on the inside as it was used to serve beverages. He further stated that if staff forgot to stock the beverage cart with an ice scoop, then they should have known to come back to the kitchen to get an ice scoop and should not have used a coffee cup. During an interview with the surveyor on 02/16/22 at 12:06 PM, the Licensed Nursing Home Administrator (LNHA) stated that she thought that since the coffee cup was previously run through the dishwasher that it was sanitized. The Director of Nursing (DON) who was present during the interview, stated that the staff would tend to touch the ice when a coffee cup was utilized to scoop ice and there was a risk of contamination if the handle touched the ice. The LNHA stated that it was also possible for the cup to chip into the ice. The DON stated that the coffee cup should not have been left in the bucket. 2. On 2/11/22 at 8:25 AM, Surveyor #2 observed LPN #3 on the SAR Unit, as she performed the medication administration pass. LPN #3 reviewed the Electronic Health Record (EHR) of an unsampled resident and utilized both a mouse and keyboard to review the resident's medications on the computer screen. She then opened a drawer of the medication cart and stated that the resident's medications were not available and were required to be obtained from the back up medication storage room. LPN #3 entered the medication storage room and obtained the first medication from the automated medication dispensing system and then proceeded to remove a multi-dose bottle of Acetaminophen (used to treat pain and fever) 325 milligrams (mg) that was located on an opened shelf within the medication storage room. LPN #3 returned to the medication cart and opened the drawer of the medication cart without first performing hand hygiene. She stated that she previously overlooked a bottle of Acetaminophen 325 mg that was in the top drawer of the cart and stated that she would use it instead of the bottle that she removed from the medication storage room. LPN #3 then placed the bottle of Acetaminophen in the right pocket of her uniform and stated that she would return it to the storage room after the medication pass. She placed both medications into a plastic medication cup. At 8:35 AM, LPN #3 entered the unsampled resident's room and stated that the resident's oxygen tubing was not properly positioned within the resident's nostrils. She donned (put on) a pair of gloves and adjusted the oxygen nasal cannula accordingly and accidentally knocked the resident's television remote off of the table and onto the floor. LPN #3 picked up the remote control with her gloved hands and handed it to the resident without cleaning it first. The resident placed the television remote on the over-bed table. LPN #3 then doffed (removed) her gloves without performing hand hygiene. She then handed the resident a cup of water and medications that were contained within the plastic medication cup. LPN #3 proceeded to obtain the resident's blood pressure, pulse oximetry level (a probe is used to measure the amount of oxygenated hemoglobin in the blood obtained from capillaries of a finger or ear), and temperature with a portable automated blood pressure cuff, touchless thermometer and pulse oximeter that she stated belonged to her and were not supplied by the facility. She placed the pulse oximeter probe on the resident's left index finger and removed it after and placed it in the left pocket of her uniform without cleaning it first. At 8:44 AM, LPN #3 returned to the medication cart and rolled it down the hall, and positioned it in front of a resident room. She donned one glove on her left hand and cleaned her portable blood pressure cuff with a disinfectant wipe that she obtained from a canister that was stored within a basket that was attached to a rolling automated blood pressure, pulse oximetry, and thermometer device that was positioned in the hallway. She did not perform hand hygiene after she doffed the single glove. She then returned her portable blood pressure cuff to a storage case that she kept in the bottom drawer of the medication cart. At 8:46 AM, LPN #3 picked up a plastic medication cup and placed it on top of the medication cart and the tip of her bare index finger touched the bottom of the inside of the medication cup as she laid it down on top of the med cart. She stated that she had to get Resident #267's blood pressure first and obtained the rolling automated blood pressure device from the hallway and applied the cuff to the resident's left wrist. She removed the blood pressure cuff from the resident and then cleaned the blood pressure cuff with a disinfectant wipe. She did not don gloves before she cleaned the blood pressure cuff and failed to perform hand hygiene after she cleaned it. LPN #3 then utilized the mouse and computer keyboard as she reviewed the medications that she prepared to administer in the resident's EHR. She then prepared the resident's scheduled medications and placed them in the plastic medication cup that she had previously placed on the cart. At 8:48 AM, LPN #3 entered Resident #267's room and administered his/her medications. She removed a portable pulse oximeter from her left pocket and placed it on the resident's left index finger. After she removed the pulse oximetry probe, she cleaned it with a disinfectant wipe with her bare hands and did not perform hand hygiene after. At 8:57 AM, Surveyor #2 interviewed LPN #3 who stated that she should have returned the multi-dose bottle of Acetaminophen to the medication storage room when she realized that she was not going to administer it. She stated that she also should have washed her hands after she left the medications storage room before she prepared the unsampled resident's medications. She stated that she also should have washed off the television remote and washed her hands before she returned the remote and cup of water to the resident. She further stated that she should have washed her hands each time that she doffed her gloves during the medication pass to prevent the spread of infection. Surveyor #2 observed that LPN #3 did not perform hand hygiene before she reached into her pocket and obtained the bottle of Acetaminophen and returned the medication to the storage room. During an interview with Surveyor #2 on 02/11/22 at 12:30 PM, the LPN/UM (Unit Manager) of the SAR Unit stated that nursing was required to clean their hands before they entered a resident room to administer medications and clean their hands before they exited the room after medications were administered. She stated that she would have placed the multi-dose bottle of Acetaminophen in the drawer of the medication cart instead of in her pocket so that the bottle did not become contaminated. She stated that when the television remote control fell on the ground, LPN #3 should have donned gloves and wiped the remote with a disinfectant wipe and doffed the gloves, and performed hand hygiene after. She stated that by failing to clean the remote before she handed it to the resident, she now contaminated the table where the remote was placed. She stated that she also potentially contaminated the resident's cup that she handed to her after she touched the remote that had been on the floor. The LPN/UM stated that nursing staff were required to don gloves and clean all reusable equipment in between resident use and should have used equipment that was provided by the facility rather than their own for accuracy. She stated when LPN #3 finished cleaning medical equipment, she should have doffed her gloves and performed hand hygiene. She stated that LPN #3 was also required to wash her hands after resident contact when she obtained a blood pressure to prevent contamination. She further stated that if LPN #3 returned a multi-dose vial of Acetaminophen to the medications storage room from her pocket without first performing hand hygiene or wiping the outside of the bottle with a disinfectant wipe it could potentially contaminate other medications that were stored on the shelf as both LPN #3's hands and pocket were contaminated. During an interview with Surveyor #2 on 02/11/22 at 12:50 PM, the RN/IP stated that LPN #3 could have immediately returned the multi-dose bottle of Acetaminophen to the medication storage room when she decided not to use it and failure to do so was an infection control issue. She stated that hand hygiene should have been performed before LPN #3 prepared the medications after she left the medication storage room. She stated that when LPN #3 dropped the television remote on the floor and picked it up and handed it to the resident there was a potential for the spread of infection. She stated that nursing was required to wear a pair of gloves when they sanitized equipment, not a single glove, and perform hand hygiene after gloves were doffed for infection control purposes. She stated that the nurse should have performed hand hygiene before and after she obtained vital signs and before and after medication administration. She stated that it was not appropriate for LPN #3 to touch the inside of a medication cup without first performing hand hygiene as it could have become contaminated. She further stated that the nurse should have performed hand hygiene after medication administration and before she returned the multi-dose bottle of Acetaminophen to the medication storage room for infection control purposes. On 2/14/22 at 7:39 AM, Surveyor #2 observed LPN #4 on the Elmwood Unit, during the medication pass. After LPN #4 used a blood glucose meter (a small, portable machine used to measure how much glucose (type of sugar) is in the blood for people with diabetes and was obtained via a finger stick with a lancet) to obtain Resident #23's blood glucose level she washed her hands, donned gloves and used a 75% alcohol wipe to disinfect the glucose meter. LPN #4 then doffed her gloves and did not perform hand hygiene after. LPN #4 then used the mouse and keyboard as she reviewed the resident's Electronic Health Record (EHR) in the computer and obtained the supplies from the medication cart that were required to obtain Resident #75's blood sugar (lancet (instrument used to pierce the skin), test strip, alcohol pad, glucose meter, and adhesive bandage) without first performing hand hygiene. At 7:41 AM, after LPN #4 obtained Resident #75's blood sugar, she doffed her gloves and washed her hands before she donned a pair of gloves and cleaned a second glucose meter that she used alternatively with a 75% alcohol wipe. She doffed her gloves and did not perform hand hygiene after. At 8:07 AM, LPN #4 washed her hands, donned gloves, and administered insulin to resident #11 via an insulin pen (a device that delivered insulin into the subcutaneous tissue) into the resident's left upper arm, doffed her gloves, and failed to perform hand hygiene before she removed the insulin pen tip and discarded it in the sharps container and returned the resident's insulin pen to the medication cart. She then accessed Resident #23's EHR in the computer and prepared the resident's medications without first performing hand hygiene. At 8:22 AM, LPN #4 prepared Resident #34's medications and carried the medications into the resident's bathroom and placed the plastic medication cup that contained the resident's medications on a paper towel on the edge of the sink, and washed her hands. She then handed the plastic medications cup to the resident and directed the resident to take the medications. During an interview with Surveyor #2 at 8:52 AM, LPN #4 stated that she should have washed her hands after she cleaned the glucose meter and doffed her gloves and before she accessed the computer and medication cart as it posed an infection control issue. She stated that she should have washed her hands after she disposed of the insulin pen tip and related supplies in the sharps container before she resumed medication preparation as it posed an infection control issue. LPN #4 stated that she should not have placed Resident #34's medications on the edge of the sink while she washed her hands as there was a chance that she could have splashed water on them which was a potential infection control problem. She further stated that she thought that she was required to keep the medications within her sight and was not sure where to put the medications while she washed her hands. During an interview with Surveyor #2 at 12:49 PM, the LPN/UM of the Long-Term Care Unit (LTC), stated that if LPN #4 failed to wash her hands when she doffed her gloves after she cleaned the blood glucose meter it posed a potential infection control issue. She stated that if medications were kept on the side of the sink while LPN #2 washed her hands, there was a potential for cross-contamination. During an interview with Surveyor #2 on 02/15/22 at 12:21 PM, the RN/IP stated LPN #4 should have performed hand hygiene with hand sanitizer after she doffed her gloves when she finished cleaning the blood glucose meter because there could have been blood on the meter when it was handled for the resident it was used for. She stated that there was a risk for contamination if medications were poured without hand hygiene after blood glucose meter contact. She further stated that the edge of the sink was not an appropriate place to store medications during hand hygiene and there was a risk of contamination. She further stated that LPN #4 posed a risk of contamination after she doffed her gloves and put the insulin pen in the medication cart and began to pour medications without first performing hand hygiene. 3. During the initial tour of the facility on 02/09/22 at 9:55 AM, Surveyor #2 observed a Personal Protective Equipment (PPE) (protective clothing, or equipment used to protect the wearer's body from injury or infection) caddy that was hung on the outside of Resident #46's door. A Registered Nurse (RN) hung a sign on the wall above the resident's room number that cautioned: Stop, See Nurse. The RN stated that the resident had just came to the facility the prior night. Surveyor #2 donned a gown and gloves and entered the resident's room and observed the resident lying awake in bed. The resident stated that he/she had a history of MRSA (Methicillin-resistant staphylococcus aureus) (a bacterium with antibiotic resistance that is difficult to treat in humans) related to a prior hip surgical infection. According to the admission Record (an admission summary), Resident #46 was readmitted to the facility in February of 2022 with diagnosis which included but were not limited to: Infection and inflammatory reaction due to internal right hip prosthesis, MRSA, Extended Spectrum Beta Lactamase (ESBL) Resistance (an enzyme found in some strains of bacteria that can not be killed by many antibiotics which makes it hard to treat). Review of Resident #46's admission Minimum Data Set (MDS), an assessment tool dated 12/23/21, reflected that the resident had a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was fully, cognitively intact. Further review of the MDS revealed that the resident required extensive assistance of two persons for bed mobility and transfers. A review of Resident #46's Care Plan revealed an entry dated 02/13/22, indicated that the resident had an infection of ESBL in the urine and was maintained on isolation precautions as indicated. Review of the Order Summary Report dated 02/17/22, revealed that an order was placed on 02/08/22 for Isolation and contact precautions (MRSA onj [sic.] right hip) and on 02/09/22 an order was placed for Contact Isolation-ESBL in urine. On 02/11/22 at 11:34 AM, as Surveyor #2 interviewed Resident #46 at his/her bedside, Licensed Practical Nurse (LPN) #3 entered the resident's room and did not don a gown or gloves prior to entry. LPN #3 held a glove in her left hand and a plastic medication cup in her right hand. She asked the resident about his/her air mattress function and pressed down on the mattress over top of the blankets that covered the foot of the bed with her bare hands. She stated that she would call Maintenance and inform them that there was a problem with the air mattress. LPN #3 left the resident's room with both the glove and plastic medication cup still in her hands without first performing hand hygiene. During an interview with Surveyor #2 at 11:47 AM, LPN #3 stated that she had not planned to administer medications to Resident #46 when she entered his/her room. She stated that both the plastic medication cup and the gloves that she held in her hands when she entered the resident's room were trash and she should have thrown them away before she entered the resident's room. She stated that she only wanted to look at the resident's bed and forgot to put a gown and gloves on before she entered the room. During an interview with Surveyor #2 at 12:30 PM, the LPN/UM of the SAR Unit stated that before LPN #3 entered Resident #46's room who was on transmission-based precautions ( initiated when a resident develops signs and symptoms of a transmissible infection), she should have donned both a gown and gloves. She stated that by failing to do so she risked contamination when she touched the resident's bed linens. She further stated that the nurse should not have carried gloves or a medication cup into the resident's room and should have discarded them prior to entry and washed her hands before and after entry due to the risk of contamination. Review of LPN #3's Personal Protective Equipment (PPE) Competency Validation Donning and Doffing Standard Precautions and Transmission Based Precautions dated 01/27/22 revealed the following: Perform hand hygiene, don gown ., don gloves ., doff PPE, remove gloves ., remove gown ., discard in waste container, perform hand hygiene. 4. During the initial tour of the facility on 02/09/22 at 12:06 PM, Surveyor #2 attempted to meet with Resident #41 and was instead greeted by his/her family member (FM) who stated that transport was at the facility to take the resident to the dialysis center (clinical purification of blood as a substitute for normal kidney function) and further stated that he/she did the resident's peritoneal (type of dialysis which used the peritoneum in a person's abdomen to remove excess fluid, correct electrolyte problems, and remove toxins in those with kidney failure) dialysis treatments and the resident went to the center primarily for lab draws three times per week. A review of the admission Record revealed that Resident #41 was readmitted to the facility in December of 2021 with diagnosis which included but were not limited to: Cerebrovascular disease (stroke), end-stage renal (kidney) disease, dependence on dialysis, speech and language deficits following stroke. Review of the admission MDS dated [DATE], revealed that Resident #41 had a BIMS Score of 15 which indicated that the resident was cognitively intact. Further review of the MDS specified that the resident required extensive assistance of two persons for bed mobility and transfers. On 02/11/22 at 12:14 PM, Surveyor #2 entered Resident #41's room and saw that there were multiple boxes of peritoneal dialysis supplies stored both directly on the resident's floor and three boxes were opened with their contents exposed and were placed on top of a thin, dark-colored piece of wood. There were seven boxes, stacked on top of one another stored directly on the floor and the top box was opened and contained supplies. There was another pile stacked on the floor that was two boxes high and had a plastic wash basin stored on top which contained additional sealed dialysis supplies. The resident was asleep and unable to be interviewed at that time. The resident's FM, who was present, stated that he/she waited for a shipment of dialysis supplies to be delivered to the facility and brought the supplies that were stored on the floor from home. The resident's FM further stated that he/she did not know who placed the piece of wood on the floor that held some of the opened boxes. During an interview with Surveyor #2 on 02/11/22 at 1:10 PM, the RN/IP stated that Resident #41 was hospitalized prior with peritonitis (inflammation of the peritoneum, typically caused by bacterial infection. She stated that the resident's peritoneal dialysis supplies were stored in the resident's private room and must be stored four inches from the floor on stacked pallets. She stated that it was an infection control issue if the boxes were stored directly on the floor. At 1:16 PM, Surveyor #2 and the RN/IP went to Resident #41's room and saw that there were boxes of peritoneal dialysis supplies stored directly on the floor, and some of the boxes were opened and laid on top of a thin piece of wood that was less than four inches thick. The RN/IP stated that the boxes should not have been stored directly on the floor and that was not protocol due to a risk of contamination. She stated that she did not know what the thin, slab of wood was that was placed beneath some of the opened boxes. She stated that staff should have used pallets and the boxes were required to remain at least four inches off the floor for infection control purposes. She stated that there was no way that staff would not have seen that many boxes being delivered when they were going in and out of the room and should have noticed that the boxes were laid directly on the floor. During an interview with Surveyor #2 on 02/14/22 at 11:22 AM, Resident #41's FM stated that last friday, their FM brought in boxes of peritoneal dialysis solution from home and used both a wheelchair and cart that were supplied by the front desk to bring them into the resident's room. She further stated that the wooden board was placed there previously and was supplied by the facility. The surveyor noted that the boxes were all now elevated off the floor on plastic pallets. During an interview with Surveyor #2 on 02/14/22 at 11:33 AM, Licensed Practical Nurse/Charge Nurse (LPN/CN) ,who was assigned to Resident #41, stated that the resident's boxes of peritoneal dialysis supplies were required to be stored off the floor for infection control purposes and to keep them from getting wet. She stated that she did not recall what the boxes were stored on to ensure that they remained elevated off the floor. During an interview with Surveyor #2 on 02/15/22 at 11:03 AM, the RN/IP stated that on friday, she notified Maintenance who then placed Resident #41's peritoneal dialysis supplies on pallets as required. She stated that she was unsure of how the boxes were placed on the floor or where the thin piece of wood came from that was utilized to hold some of the boxes previously and stated that it was too thin. During an interview with Surveyor #2 on 02/15/22 at 11:13 AM, the Director of Maintenance (DOM) stated that when peritoneal dialysis supplies were delivered to the facility, maintenance was responsible to transport them to the room on a dolly. He stated that the problem was that lately they delivered pallets of supplies and there was limited storage. He stated that when they stacked them, they had to be off the floor. He stated that they typically used a shelving base and in dire conditions, a milk crate was used. He stated that the piece of wood appeared to have come off the side of a cabinet and was too thin to be utilized to hold the boxes and thought that maybe a porter placed it there after hours. He stated that it was an infection control issue if the boxes of peritoneal dialysis supplies were stored on the floor because of the risk of germs, disease and opened boxes may have served as a nest for varmints. He stated that all boxes in the facility were required to be elevated off the floor by four inches and stated that he was unable to provide the surveyor with a policy that detailed this specification. During a later interview with Surveyor #2 on 02/15/22 at 12:08 PM, the RN/IP stated that she was unable to provide the surveyor with a policy though she knew that all boxes had to be either four or six inches off the floor for infection control purposes even though the inside of the box was sterile, and supplies were enclosed in plastic. During an interview with Surveyor #2 on 02/16/22 at 11:43 AM, the LNHA stated that when a peritoneal dialysis delivery arrived at the loading docks, the shipment would be delivered to the resident's room and Maintenance would be notified to ensure that the supplies were elevated off the resident's floor. She stated that if the delivery occurred at night, and the supplies were left on the floor then we need to raise it with what materials we have. She stated that if staff found the boxes on the floor, then they needed to get the boxes off the floor in the interim. During an interview with Surveyor #2 on 02/17/22 at 11:15 AM, the RN/IP stated that she never reviewed a policy that specified how many inches of peritoneal dialysis supplies needed to be stored off the floor. The Director of Nursing (DON) who was present during the interview stated that she just knew that peritoneal dialysis supplies were required to be raised off the floor but corporate was not able to provide a policy that detailed a requirement. Review of the facility policy titled, Handwashing/Hand Hygiene (Reviewed 02/28/2020) revealed the following: This facility considers hand hygiene to be the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap .and water for the following situations: Before and after coming on duty, before and after direct contact with residents, before preparing or handling medications, Before and after handling an invasive device, After contact with a resident's intact skin, after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident, after removing gloves, Before and after entering isolation precaution settings. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health-care associated infections. Review of the facility policy titled, Obtaining a Fingerstick Glucose Level Level III (Revised October 2011) revealed the following: Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Remove gloves and discard into designated container. Wash hands Review of the facility policy title, Administering Medications (Edited 05/21/19) revealed the following: Staff follows established facility infection control procedures (e.g., handwashing ., gloves, isolation precautions, etc.) for the administration of medications, as applicable. NJAC 8:39-19.4 Based on observation, interviews, review of medical records, and other facility documentation, it was determined that the facility failed to prevent the potential spread of infection and cross-contamination in accordance with current infection prevention standards and failed to: a) ensure that staff utilized proper serving utensils to scoop ice in a safe and hygienic manner during the meal pass b) follow appropriate infection control protocol for hand hygiene, ensure that medications were handled in a sanitary manner and that medical equipment was properly cleaned and disinfected between residents during the medication pass c) maintain the infection prevention protocol for a resident on transmission-based precautions and d) failed to ensure that dedicated medical supplies were stored in a safe and sanitary manner. This deficient practice was identified for 2 of 2 nursing units (Elmwood Unit and Subacute Rehabilitation Unit) observed during meal pass, 2 of 2 nurses observed on 2 of 2 units during the medication pass which included 6 of 8 residents observed for medication administration (Residents #267, #75, #11, #23, #34 and an unsampled resident), 1 of 4 residents reviewed for Transmission-Based Precautions (Resident #46) and 1 of 3 residents reviewed for dialysis (Resident #41). This deficient practice was evidenced by the following: 1. During a meal service observation on 02/09/22 at 12:05 PM, Surveyor #1 observed the beverage cart enter the Elmwood Unit. The beverage cart included an ice bucket filled with ice. Surveyor #1 observed staff use a ceramic coffee cup to dispense ice to the residents from an ice bucket. The following was observed: At 12:05 PM, Surveyor #1 observed a staff member use a ceramic coffee cup to scoop ice from an ice bucket and placed the cup on the counter of the beverage cart. At 12:10 PM, Surveyor #1 observed another staff member use a ceramic coffee cup to scoop ice from an ice bucket and placed the cup on the counter of the beverage cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that staff wear the appropriate personal protective equipment (PPE) for residents on contact isolation, to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This deficient practice was identified for Residents #85 and #56, 2 of 5 residents reviewed for infection control practices and was evidenced by the following: 1. According to the facility's admission Record, Resident #85 was admitted to the facility in September 2020 with diagnoses that included, but were not limited to; Osteomyelitis and Extended Spectrum Beta Lactamase (ESBL), a type of bacteria that is resistant to some antibiotics. Review of Resident #85's Physician Orders revealed an order dated 09/01/2020 for contact precaution, ESBL right foot wound. During the initial tour on 09/24/2020 at 11:12 AM, the surveyor observed a stop/isolation sign on Resident #85's room door. There was no isolation/PPE kit observed near the room. During that time, the surveyor interviewed a Certified Nursing Assistant (CNA) #1 regarding the purpose of the stop/isolation sign. CNA #1 stated the sign meant that you should put on a gown and gloves before performing resident care. CNA #1 stated that there should have been a PPE kit (a kit that hung on the door containing isolation PPE) on the door. CNA #1 then entered the resident's room, donned gloves, walked across the room, and retrieved a linen cart that was near the resident's bed. CNA #1 placed the linen cart against the inside wall near the door entrance. On 09/24/2020 at 11:15 AM, the surveyor observed a housekeeper place a PPE kit on Resident #85's room door. During an interview with the surveyor at that time, the housekeeper stated that CNA #1 just reported that Resident #85 was on isolation and needed a PPE kit. The housekeeper stated that staff informs housekeeping when a resident was on isolation and the housekeeping staff would place the PPE kit on the door. During an interview with the surveyor on 09/24/2020 at 11:20 AM, a Licensed Practical Nurse (LPN) #1 stated that Resident #85 was on isolation for ESBL in the wound. LPN #1 stated that full contact isolation consisted of wearing a gown and gloves when coming into contact with Resident #85 or the linen cart. LPN #1 stated that the purpose of PPE was to protect the resident and staff from infection and if PPE wasn't worn, the illness could be spread. LPN #1 stated that the linen cart in the room of Resident #85 could have been contaminated and that CNA #1 should have been wearing a gown and gloves. During an interview with the surveyor on 09/30/2020 at 12:10 PM, the Activities Director (AD) stated that the stop/isolation sign meant that she had to see the nurse before she could enter the room. 2. According to the admission Record, Resident #56 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to; fusion of lumbar spine and Extended Spectrum Beta Lactamase (ESBL). Review of Resident #56's Physician Orders revealed an order dated 08/17/2020 for ISO [isolation] ESBL in back wound. On 09/24/2020 at 11:27 AM, the surveyor observed a Certified Occupational Therapy Assistant (COTA) enter Resident #56's room, wearing only a mask and goggles. The COTA donned gloves once inside the resident's room but did not don a gown. The surveyor noted there was a full PPE kit on the door but there was no stop see nurse sign on the resident's door. The surveyor observed that the COTA stood right next to Resident #56 while she counted and demonstrated dumb bell therapy to the resident while the resident performed the dumb bell therapy. The COTA was not wearing a gown during this observation. On 09/24/2020 at 11:40 AM, the surveyor observed the Unit Manager (UM) stand in Resident #56's room doorway and tell the COTA to put on a yellow isolation gown. The surveyor interviewed the UM at that time. The UM stated that gown and gloves should be worn because Resident #56 had ESBL in the wound and was on contact isolation. The UM stated that the purpose of the gowns and gloves was to avoid spreading the infection. At that time, the surveyor also interviewed the COTA who stated she was aware that the resident had ESBL in the incision and that she should have been wearing a gown along with the gloves in the room to keep any type of contaminant from me and the resident. On 09/30/2020 at 11:15 AM, the surveyor interviewed CNA #2 who stated that when an isolation [PPE] kit or a stop sign was on the door that meant full PPE consisting of gowns, gloves, mask and goggles, must be worn any time staff enter the room, even if it is just to pass a food tray. CNA #2 stated that the reason for PPE was to protect yourself and the residents so infections aren't passed. During an interview on 10/01/2020 at 10:07 AM, the DON/Infection Control Nurse (IC) stated if there was an isolation stop sign and/or a PPE kit on the door, staff should always stop and see the nurse before entering the resident's room. The DON stated staff should don a gown and gloves before entering a room for anything, even if only answering the call bell, if the resident was on contact isolation. The DON stated that CNA #1 should have donned a gown and gloves before entering Resident #85's room to move the laundry bin and that the COTA should have donned a gown and gloves before entering Resident #56's room and while doing therapy with the resident. The DON stated that the purpose of always wearing a gown and gloves before entering the room was to prevent the spread of an infection, even if the infection was contained, because you never know what the resident may need when entering the room. During an interview with the survey team on 10/02/2020 at 9:55 AM, the DON stated that if there was an active physician order for isolation then the isolation protocol should be followed. Review of CNA #1 and COTAs' Personal Protective Equipment (PPE) Competency Validation, dated 08/21/2020, revealed they were both deemed competent with standard precautions and transmission based precautions and that they correctly identified the appropriate PPE for Contact/Contact Enteric Precautions (gown & gloves). Review of the facility's Isolation-Initiating Transmission-Based Precautions policy, revised August 2019, revealed that when Transmission-Based Precautions were implemented, the Infection Preventionist (or designee) would determine the appropriate notification on the room entrance door. The policy reflected that the signage informed the staff of the type of CDC precautions(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. The policy included to ensure that protective equipment (i.e., gloves, gowns, masks, etc.) were maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment and that Transmission-Based Precautions would remain in effect until the Attending physician or Infection Preventionist discontinued them. Review of the facility's Multidrug-Resitant Organisms (MDRO) policy, revised August 2019, revealed under Enhanced Infection Control Precautions, to implement Contact Precautions routinely for all residents colonized or infected with a target MDRO. The policy included that Because environmental surfaces and medical equipment, especially those in close proximity to the resident may be contaminated, don gowns,and gloves before or upon entry to the resident's room or cubicle. Review of the facility's Personal Protective Equipment policy, reviewed 03/04/2019, revealed that training on the proper donning, use and disposal of PPE was provided upon orientation and at regular intervals. NJAC 8:39-19.4(a)(1-2)(c)