Based on observation, interview and record review, it was determined that the facility failed to ensure a.) a physician orders for administration was followed, route of administration was clarified (Resident 18), and b.) dosing was clarified for an eye ointment, prior to administration (Resident 44 and Resident #2) in accordance with professional standards of practice and facility policy. The deficient practice was identified for three (3) of seven (7) residents, administered by three (3) of five (5) nurses, observed during the medication administration observation, 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. 1.) On 9/25/24 at 7:41 AM, the surveyor observed Licensed Practical Nurse (LPN #1) prepare two (2) medications for Resident #18. The medications orders were: Prograf (Tacrolimus; medication used to prevent rejection of a transplanted organ such as the kidney, liver, heart or lung) 0.5 milligram (mg) capsule, to be administered by mouth (PO) at 6:00 AM. The order was started on 3/17/24. Prograf 5 mg capsule, to be administered PO twice daily (BID) at 6:00 AM and at 6:00 PM. The order was started on 11/14/22. At that time, LPN #1 was observed removing both capsules from a unit dose package, opened the capsules and poured into a medication cup, drew approximately, drew water into a syringe then emptied the water into a medication cup, and opened the Prograf capsules into the water in the medication cup. LPN #1 drew another five (5) milliliters (mls) of water into a syringe. On 9/25/24 at 7:43 AM, the surveyor observed LPN #1 asked Resident #18 if they can administer the medication by mouth. Resident #18 turned their head left and right twice. LPN #1 attached an enteral tube to a port, administered Prograf through the gastronomy tube (g-tube) and was followed with a water flush of the enteral tube. On 9/25/24 at 7:49 AM, during an interview with the surveyor, LPN #1 was asked why she administered Prograf orders via g-tube without a physician's order for another route and was the physician's order for PO appropriate for Resident #18. The LPN stated she would discuss with the medical team and the Charge Nurse. The surveyor reviewed the medical record for Resident #18. A review of the resident's electronic Medical Record reflected Resident #18 was a long-term care resident with diagnoses that included vocal cord paralysis, developmental delay, oral phase dysphagia (problems with using the mouth, lips, and tongue to control food or liquid) and heart transplant. A review of the quarterly Minimum Data Set, an assessment tool, dated 8/8/24 reflected that Resident #18, sometimes able to be understood and sometimes was able to understand others. The Brief Interview for Mental Status (BIMS; an evaluation for aspects of cognition) was not conducted and the resident had short- term and long-term memory problems. Further review of the qMDS reflected the resident had a swallowing problem that involved loss of liquid/solids from the mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals. A review of Resident #18's comprehensive person-centered care plan reflected Resident #18 had impaired swallowing and the interventions included that the resident was in a puree diet again, had a munching pattern that will not efficiently breakdown food, and safely manage solid foods and no liquids. A review of the physician's progress note dated 9/24/24, included that all medications were given through gastronomy button except for Tacrolimus which was taken orally (most of the time). The resident received pureed diet during daytime with GT supplementation. 2. On 9/25/24 at 9:23 AM, the surveyor observed the Registered Nurse (RN) prepare medications for Resident #44 that included Artificial Tears Lubricant Ophthalmic Ointment (mineral oil and petrolatum; to prevent irritation or to relieve dryness if the eyes), One (1) application every three (3) hours (8 applications per day). On 9/25/24 at 9:42 AM, the surveyor observed the RN administer the Artificial Tears Lubricant Ophthalmic Ointment in varying length in the left and right eye. A review of the Resident #44's physician's order for the Artificial Tears Lubricant Ophthalmic Ointment revealed that the order did not indicate a length of measurement to reflect the dose for each administration. The order was started on 7/2/24. 3. On 9/25/24 at 11:36 AM, the surveyor observed LPN #2 prepare medications for Resident #2 that included Artificial Tears Lubricant Ophthalmic Ointment (mineral oil and petrolatum; to prevent irritation or to relieve dryness if the eyes), One (1) application every two (2) hours (12 applications per day). At that time, LPN #2 stated that Resident #2's family member administered the medication to the resident and had been doing so for years. The surveyor observed LPN #2 in the room, near the resident and resident representative during the medication administration. A review of the Resident #2's physician's order for the Artificial Tears Lubricant Ophthalmic Ointment revealed that the order did not indicate a length of measurement to reflect the dose for each administration. The order was started on 3/8/22. On 9/25/24 at 12:35 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns that occurred the medication pass for Resident #18 wherein the physician order for Prograf to be administered orally, was administered via g-tube to Resident #18 without clarification with the physician. The concern with Resident #44 and Resident #2 ophthalmic ointment order that did not include dosing and was also not clarified prior to administration. On 9/25/24 at 12:44 PM, the DON stated that Resident #18 was able to take the medication by mouth and via g-tube, and acknowledged the orders should have been clarified. A review of the provided facility policy, Medication Management, dated 1/9/24 included the following under procedures: B. Ordering and Transcribing 4. Orders for medication and fluids mist contain name and dosage, frequency, route of administration and an indication for use . D. Administration 6. Just prior to administration, compares the medication to the order and adheres to the 5 rights of medication administration rules: a. right patient b. right medication c. right dosage d. right time e. right route NJAC 8:39-27.1(a), 29.2(d)

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods (PHF) in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 9/24/24 at 10:30 AM, in the presence of the Assistant Dietary Manager (ADM), the surveyor observed the following: In the walk-in refrigerator, the surveyor observed the following: -a 1/4 size steam table pan which contained green beans in a liquid with a sticker on the top of the container that indicated a use by date of 9/20/24, -an opened, half used package of sliced salami with no use by date on it, - an opened, half used package of un-sliced beef bacon with no use by date on it, In the reach in cheese refrigerator, the surveyor observed the following: -an opened package of un-sliced provolone with an open date of 9/8/24, - an opened package of shredded mozzarella with an open date of 9/15/24, -an opened package of sliced yellow cheese with an open date of 9/16/24, In the dry storage room, the surveyor observed an opened package of mixed grain cereal with an open date of 2/4/24. The ADM indicated that the PHF should been stored appropriately and thrown out according the facility policy, between five and seven days. The ADM also stated that all items should have use by dates on them. On 9/24/24 at 11:16 AM, the surveyor discussed the above concerns with the Administrator. A review of the undated policy titled, Disposition of Potentially Hazardous Foods which revealed that all potentially hazardous foods that are prepared in the hospital will have a shelf life of five days, all other potentially hazardous food that have been put into production will have a shelf life of seven days, and pre-prepared items should be discarded after seven days of package being opened form its original package. The policy also indicated that the products are to be dated after opening. NJAC 8:39-17.2(g)

Complaint # NJ175565 Based on observations, interviews, medical record review and review of other facility documentation on 07/19/2024, it was determined that the facility failed to implement appropriate infection control measures for the storage of respiratory equipment. This deficient practice was identified for 1 of 6 resident rooms observed for infection control. This deficient practice was evidenced by the following: 1.) During a tour of a resident room on North Wing of facility unit on 07/19/2024 at 12:11P.M., the Surveyor observed ventilator connector and tubing on the floor of room. During an interview with the Surveyor on 07/19/2024 at 12:13 P.M., the Registered Nurse (RN) confirmed the ventilator connector and tubing was on the floor in the room. The RN further stated that the ventilator connector and tubing should not be on the floor. The RN further stated, tubing is put and stored across ventilator machine.The RN stated that the Respiratory Therapy Staff usually disconnects the ventilator connector and tubing. During an interview with the Surveyor on 07/19/2024 at 12:24 P.M., the Respiratory Therapist (RT) stated when disconnecting a resident from the ventilator, ventilator tubing gets hung over ventilator equipment. The RT further stated the expectation was the ventilator connector and tubing should not be on the floor. During an interview with the Surveyor on 07/19/2024 at 1:13 P.M., the Director of Nursing (DON) stated that ventilator tubing should be stored in the basket next to the ventilator and not on the floor. The DON further stated the expectation was ventilator tubing should not be stored on the floor. During an interview with the Surveyor on 07/19/2024 at 2:21 P.M, the Licensed Nursing Home Administrator (LNHA) stated the expectation was that no respiratory equipment and tubing should be stored on the floor. LNHA further stated, I can't answer how respiratory equipment is supposed to be stored. The Surveyor requested a policy from LNHA on Respiratory Equipment Storage. LNHA stated the facility did not have policy on Respiratory Equipment Storage. NJAC 8.39-19.4 (a)

Complaint # NJ175565 Based on observations, interviews, medical record review, and other pertinent facility documents on 07/18/2024 and 07/19/2024, it was determined that the facility who has been in an active outbreak of the Multi-Drug Resistant Organism (MDRO) of Carbapenem-Resistant Acinetobacter baumannii (CRAB - bacteria resistant to nearly all antibiotics and difficult to control and irradicate from the environment) failed to provide documentation in the residents' medical records of consents, declinations, and family education for CRAB testing. This deficient practice was identified for 51 out of 54 residents and evidenced by the followng: During an interview with the Surveyor on 07/18/2024 at 1:03 P.M., the Advanced Practice Nurse (APN) stated she did obtain some consents for CRAB testing from parents and guardians through emails and phone calls.The APN provided the Surveyor with 3 email communications for consent for testing between APN and 3 residents' families. APN stated, I deleted the other emails containing consents. The APN further stated that there was no documentation that family education or attempts to obtain consent for CRAB was provided in the residents' medical records. The APN stated, documentation of families that declined are only on the spreadsheet. The APN stated that consents were needed every time before testing was conducted. During an interview with the Surveyor on 07/19/2024 at 11:42 A.M., the Infection Preventionist (IP) stated the medical team which consists of the Medical Director (MD) and APN were responsible for notifying resident's families of testing and obtaining consents. During an interview with the Surveyor on 07/19/2024 at 1:08 P.M., the APN stated the medical team was directed by the IP to obtain consents for CRAB testing. The APN further stated, only spreadsheet was proof of documentation that consents were obtained in addition to 3 emails received from parents and guardians. During an interview with the Surveyor on 07/19/2024 at 1:13 P.M., the Director of Nursing (DON) stated the standard of practice was to document in the resident's chart. The DON further stated that the expectation was that all consents should be documented in residents' chart. During an interview with the Surveyor on 07/19/2024 at 2:21P.M., the Licensed Nursing Home Administrator (LNHA) stated consents were the responsibility of the Medical Team. The LNHA further stated the expectation was the medical team would obtain consents from residents' families and guardians. The LNHA stated, the expectation was that whether consents are obtained or not, it should be documented in the resident's medical record. Review of the facility's policy dated 01/22/2024 and titled Nursing Documentation System revealed under Policy, Documentation is a crucial aspect of the implementation of the nursing process. Under Critical Documentation Times/Frequencies, Due to the need for continuity across shifts, there are six critical documentation times. These are initial assessment upon admission/readmission, when baseline assessment changes, evaluation of progress towards outcomes, patient education . Review of the facility's policy dated 01/30/2024 and titled Medical Record Content revealed under Procedures, There is evidence of informed consent in the patient's medical record. Review of the facility's policy dated 01/11/2024 and titled LTC-Medical Records revealed under Policy Statement, The Medical Record shall include (at least) the following: 13. Signed consent and release forms. NJAC 8.39-35.2 (d) (13)

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure a) proper disposal of a controlled substance (narcotic; medications, that due to their high potential for abuse, are tracked with detail) medications, b) medication was crushed, c) proper disposal of non-controlled substance and was identified during the medication administration observation for two of three nurses in accordance to standards of clinical practice and facility policy. 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. A review of the manufacturer's specification for [brand name redacted] oral/enteral syringe with [brand redacted] connector for pharmacy use, included: Indication for use, the device is indicated for use as a dispenser, a measuring device, and a fluid transfer device. It is used to deliver fluids into the body orally and enterally (administration by mouth or esophagus or artificial opening to the intestine). It is intended to be used in clinical or home care settings by users ranging from clinicians to layperson (under the supervision of a clinician) in all ages. Contraindications included: This device is intended for oral /enteral applications only .5) Do not modify this device as this may lead to leakage, inadequate nutrition delivery or patient harm. 1. On 6/02/23, at 9:35 AM, the surveyor began the Medication Observation Pass for Resident #40. The surveyor observed Licensed Practical Nurse #1 (LPN#1) and Registered Nurse #1 (RN #1) obtain a 5 ml syringe that contained Phenobarbital (prevents and controls seizures in people with epilepsy) 20 milligram (mg)/5 milliliter (ml) syringe from the electronic back-up machine. At that time, LPN #1 stated that the pharmacy made 5 ml of the Phenobarbital 20 mg/5 ml and that she had to waste 0.6 ml because Resident's order was for 4.4 ml. At that time, the surveyor observed LPN#1 began to run the water from the faucet and wasted 0.6 ml of the Phenobarbital into the sink. The surveyor observed RN#1 and LPN#1 document the disposal into the electronic backup machine and LPN #1 relabeled the syringe for administration. The surveyor reviewed the medical record for Resident #40. The Registration Form (RF; or facesheet; an admission summary) reflected the resident was admitted to the facility with a diagnosis of homocystinuria (a disorder in which the body is unable to break down certain building block proteins (amino acids)). The electronic Medication Administration Report (eMAR) included an order for: Phenobarbital 20 mg/5 ml, dose 17.6 mg (4.4 ml) GT (gastrostomy; a tube inserted through the belly that allows air, fluid to leave the stomach and can be used to administer food, liquid, and medications) BID [twice a day] 10:00 and 22:00 (8 PM), with a start date of 12/19/22. A review of the manufacturer specifications revealed Phenobarbital was classified as a scheduled 4 (four) Controlled Substance. On 6/22/23 at 12:36 PM, during an interview with the surveyor, LPN #1 stated narcotic medications must be wasted within the medication room in a trash can and a second nurse must sign that we are wasting/disposing of the narcotic. We then have to let the pharmacy know that we wasted the medication. LPN#1 also stated non-controlled medications, are disposed in the garbage with the second nurse present. We have additional doses that we can retrieve from the cassettes [in the medication cart]. 2. On 6/22/23 at 11:19 AM, the surveyor observed LPN #2 prepare medications for Resident #25 in the resident's room. The eMAR included an order for Cortef (Hydrocortisone; is a steroid used to treat many different conditions such as allergic disorders, skin conditions, etc.) 2.5 mg GT schedule for 12:00 PM. At that time, the surveyor observed LPN #2 use an Alcohol based hand rub (ABHR) and donned gloves. At that time, the surveyor observed LPN #2 retrieve the Cortef 2.5 mg tablet from the Resident #25's designated cassette from the medication cart, opened the unit dose of Cortef, leaving the pill within its package and placed it on the medication cart. At that time, LPN #2 retrieved an open system [brand redacted] syringe from the medication cart drawer, pulled the plunger off the syringe and placed the Cortef tablet into the syringe. LPN #2 placed the plunger into the syringe and crushed the tablets that emitted dust particles from the open end of the syringe. The nurse drew water and capped the syringe with her gloved finger and shook the syringe to dissolve its contents. At 11:20 AM, the surveyor observed a [brand redacted] pill crusher on the medication cart and asked the nurse if that was the facility policy to crush the pill in the syringe. LPN #2 stated I was not told I can not crush into a syringe. The surveyor reviewed the medical record for Resident #25. The RF reflected that the resident was admitted to facility with a diagnosis of adenovirus (viruses which are common causes of respiratory illness). A review of the eMAR reflected an order that included: Hydrocortisone 2.5 mg GT scheduled for 6:00 AM, 12:00 PM and 18:00 (6 PM), with a start date of 3/02/23. 3. On 6/22/23 at 11:24 AM, the surveyor observed LPN #2 prepare medications for Resident #1 in the resident's room. The eMAR reflected an order that included Robinul Forte (Glycopyrolate; helps to control conditions such as peptic ulcers that involve excessive stomach acid production) 2 mg GT. At that time, the surveyor observed LPN #2 use an ABHR and donned gloves. At 11:29, the surveyor observed LPN #2 crush the Robinul Forte using the pill crusher, as she was transferring the crushed medication into the syringe, LPN #2 spilled some crushed medication onto the medication cart, and some were in the open system syringe. At that time, the surveyor observed LPN #2 throw the syringe that contained some of the crushed Robinul Forte into the trash bin that was attached to the medication cart. LPN #2 wiped the spilled medication and threw the paper towel into the trash bin. At that time, the surveyor asked LPN #2 what the facility policy for disposal of a non-controlled medication. LPN #2 stated I don't know where else to throw it. LPN #2 could not recall receiving an in-service (education) for medication disposal. The surveyor reviewed the medical record for Resident #1. The RF reflected Resident #1 was admitted with a diagnosis of perinatal asphyxia (failure to establish breathing at birth). On 6/26/23 at 9:31 AM, during an interview with the surveyors the Pharmacy Director (PD) confirmed that Phenobarbital was a scheduled 4 (four) narcotic medication. The PD stated that the Joint Commission recommended that it can be flushed down the sink. The PD stated liquids were flushed down the sink and that tablets were brought back to the pharmacy; We have proper bins to dispose of those. The PD informed the surveyors that the facility did not have a drug disposal solution (bottle of solution used to disintegrate pills and tablets). The PD was unable to respond when asked where should spilled crushed medications be disposed. The PD stated the policy was appropriate. At that time, during an interview with the surveyors the PD stated medications should not be crushed within a syringe because she can not ensure the medication could be completely crushed but can be dissolved within the syringe. The PD stated that crushing a medication through an open system syringe can result to medication being lost through the opening and did not guarantee 100% delivery of the medication. At that time, the PD confirmed the facility policy should be followed. At that time, the PD also stated that placing a finger over the open system syringe was not a clean process and that was an infection control issue. On 6/26/23 at 9:55 AM, during an interview with the survey team, the Consultant Pharmacist (CP) stated she was in the facility once a month and conducted medication pass observations. The CP stated she had observed the nurses crush a medication in a syringe and that it was okay to do. The CP informed the surveyors that she did not report any competency issue with crushing a medication in a syringe. The CP stated she would provide information regarding crushing medications using a syringe. No further information was provided. At that time, the CP stated that all medications including crushed medication should be returned to the in-house pharmacy in the building. At that time, the CP stated she would provide an in-service/education to the individual nurse but has not provided the education yet. The CP stated she has not provided in-service on the topic of medication administration and drug disposal. On 6/26/23 at 01:34 PM, the survey team met with the Minimum Data Set Coordinator, the Director of Nursing (DON #1) and DON #2, the Director of Therapy (DoT), and were made aware of the above findings. On 6/27/23 at 12:09 PM, the survey team met with the AVP (Assistant [NAME] President) of Access Management & Regulatory Affairs (AVPAMRA), Manager of Regulatory Affairs & Accreditation (MRAA), DON#1, DON#2, and the Licensed Nursing Home Administrator (LNHA). The LNHA stated that there was no further information that the facility can share. At that time, DON #2 stated the facility had a [brand name redacted] pill crusher and we would like to streamline the process. At that time, DON #2 stated she would not recommend the use of a hand in dissolving the medication in the syringe because of infection control. A review of the facility policy provided, Destruction of Medication with an effective date of 01/01/23, included following: It is the policy of the [facility name redacted] that the pharmacy department shall be responsible for the destruction of outdated, discontinued, contaminated or otherwise unusable medication. Under section, II. Destruction Procedure subsection A. Non-controlled Substance: 1. Individual, small quantities of liquids that are non-poisonous, non- corrosive, non-hazardous or nonflammable will be kept in their container and deposited in the red medical waste receptacle. 2. Small quantities of tablets and capsules that cannot be returned for credit through an authorized drug disposal company will be kept in the container and deposited in the red medical waste receptacle, 3. Hazardous medications will be discarded in the black hazardous medication bin. B) Controlled Substances: 1. Unused or expired controlled substances will be locked in a designated cabinet in the pharmacy department the prior to planned disposition. A review of the facility policy provided, Medication Management with an effective date of 02/10/23, included following: Purpose: This policy establishes the process for [facility name redacted] for safe medication prescribing, dispensing and administration. Departments Affected: Pharmacy, Nursing, Respiratory, Medical Outpatient Services. Under section D. Administration, subsection 5. Verifies the medication is stable based on visual examination for particulates or discoloration and that the medication has not expired. NJAC 8:39- 19.4(a), 29.7 (c), 29.4(g), 27.1(a),

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to ensure a) that a physician's wound care order was followed and clarified, b) provide wound care in accordance with the facility's policy and professional standards of clinical practice for 1 (one ) of 2 (two) residents (Resident #3) reviewed for pressure ulcers. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: 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 well being, and executing a medical regimen 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 state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/20/23 at 10:59 AM, the surveyors observed wound care performed by Registered Nurse #1 (RN#1) assigned to Resident #3 and assisted by RN#2. RN#1 removed her scissor from her pocket and cut the Hydrofera blue (external dressing for use in the management of wounds such as pressure injuries) into four pieces, cut the Lyofoam (highly absorbent dressing), and poured saline into 4x4 gauze. RN#1 placed a rolled pillow behind the resident and removed the trach ties and the old Lyofoam pad. RN#1 did not performed hand hygiene after removing the old Lyofoam pad. At 11:12 AM, RN #1 stated that the Mepilex border (five-layer all-in-one bordered foam dressing) on the right side of the neck was intact and will not be removed at that time. RN #1 kept the Mepilex border and wiped the skin with saline-soaked gauze. At that time, the surveyors observed RN #1 continued to wipe on the posterior (behind or part of the rear) neck, removed the old Hydrofera blue and Mepilex border, and immediately replaced it with the new Hydrofera blue and Mepilex border. RN #1 did not perform hand hygiene after cleansing the posterior neck and immediately replaced with new dressing. RN #1 took a saline cotton swab and wiped the stoma (surgically created hole in the trachea/windpipe). RN#1 did not perform hand hygiene before going to another site after cleansing the posterior neck. At 11:15 AM, the surveyors observed RN#1 dry the stoma, applied the new Lyofoam pad, threw all the used supplies, removed her gloves, threw it away, and placed the scissors in her pocket. At that time, the surveyor asked the nurse if she was going to disinfect her scissors. The surveyors observed RN #1 remove the scissors from her pocket, used an alcohol-based hand rub cleanser to clean the scissors, and placed it back into the same pocket. The surveyor reviewed Resident #3's medical record. The resident's RF reflected that the resident was admitted to the facility on [DATE] and had a diagnosis of static encephalopathy (a broad term to describe chronic nonprogressive brain disorder). The resident's most recent CMDS with an ARD of 5/12/23, revealed a Cognitive Skills for Daily Decision-Making assessment which indicated the resident's cognition was severely impaired. Further review of the CMDS section M, indicated the resident had 1 (one) unhealed pressure ulcer. A review of the facility provided Interdisciplinary Plan of Care, with a status of active, at that time, revealed a problem of impaired skin integrity. A goal to exhibit intact skin, stage 2 (two) to posterior neck, stage 2 (two) to right neck. Interventions, instruction was skin and wound assessment; See physician orders for wound care. The Physician's Order Sheet contained an order, dated 12/20/22, Instructions: wash the wound with saline and pat it dry. Apply Hyrofera blue cut to wound size and place in the wound bed. Cover with Mepilex border and then the Lyofoam. Repeat every 48 hours or when soiled. For the right side of the neck: Apply the Mepilex border. Change dressing twice daily. On 6/22/23 at 01:04 PM, during a telephone interview with the surveyor, RN#1 stated the scissors were her personal scissors which she did not disinfect prior to using during the wound care treatment that was observed on 6/20/23. On that same date and time, RN#1 stated she noticed that the Mepilex border on the right side of the neck was clean and dry. The right side of the neck did not have a wound and it was a protection barrier for an old wound that healed. At that time, the RN further stated that after removing the old Mepilex border with the Hyrofera blue from the posterior neck, I should have performed hand hygiene, changed gloves then applied the new Hydrofera blue with the Mepilex border, followed by cleaning the stoma. Furthermore, RN #1 stated, I am removing something soiled and touching something clean, and that if she did not perform hand hygiene, and donned new gloves, I could have re-contaminated resident's wound and possibly exposed resident to infections through his/her stoma which is also an opening. On 6/26/23 at 01:34 PM, the survey team met with the Minimum Data Set Coordinator, Director of Nursing #1 (DON #1), DON #2, and the Director of Therapy (DoT), and were made aware of the above findings. On 6/27/23 at 9:06 AM, the surveyor received a subsequent physician order that included an order, dated 6/26/23, to wash the wound on the posterior neck with saline and pat dry. Apply Hyrofera blue cut to wound size and place in the wound bed. Cover with Mepilex border and then the Lyofoam. Repeat every 48 hours or when soiled. For the right side of the neck: Apply Mepilex border. Change dressing twice daily. On 6/27/23 at 12:09 PM, the survey team met with the Manager of Regulatory Affairs & Accreditation, the AVP of Access Management & Regulatory Affairs and Compliance, DON #1 and #2, and the Licensed Nursing Home Administrator (LNHA). DON #1 confirmed that hand hygiene should have occurred. DON #1 further stated that it is a standard of practice before going to the next area, the gloves should have been removed, and hand hygiene should have occurred. A review of the facility provided policy Cleaning of equipment Utensils and Toys, dated 02/13/23 included: The purpose of this policy is to prevent the transmission of infectious organisms from patient to patient and patient to healthcare workers during contact with equipment, toys, and utensils. A review of the facility provided Wound Care, pediatric procedure for the practice of [facility name redacted], revised 02/20/23 included the following : Implementation . Clean versus Sterile Technique for Dressing Changes . Children who are immunocompromised or who have multiple organ dysfunction syndrome, severe nutritional deficits, or impaired ventilation and circulation are better served with sterile technique because of the threats of cross-contamination and new contamination, which could overwhelm the system . Inspect the dressing . discard the old dressing in an appropriate receptacle, observe the condition of the wound, remove and discard your gloves, perform hand hygiene, put on new gloves, clean the wound . inspect the wound bed measure the wound dimensions .apply a primary dressing to the wound surface . A review of the undated, facility provided Wound care, pediatric checklist included the following: Objectives, to perform wound care for a child according to the standard of care Checklist step .Remove the old dressing .inspect the dressing, discard the old dressing, observe the wound, remove and discard gloves. Perform hand hygiene. Put on new gloves .Apply a primary dressing to the wound . A review of the facility provided policy, Pressure Injury and Management, dated 01/01/2023, that included: Purpose, to promote the prevention of pressure injuries and provide evidence-based care to patients at risk of or who have existing pressure injury. Under Pressure Injury Dressings, section 1. Change dressing according to the manufacturer's recommendation, as ordered. at least every seven (7) days, and as needed for excess drainage and soiling. NJAC 8:39-11.2(b), 19.4(a), 27.1(a), 29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 12 of 21 residents, (Residents #2, #3, #11, #14, #21, #27, #28, #33, #36, #41, #44, and #48) reviewed, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified 12/01/21, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of the source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. All assessments are completed within specific guidelines and time frames. According to CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated October 2019, included the following: SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status . I: Active Diagnoses in the Last 7 Days . Planning for Care This section identifies active diseases and infections that drive the current plan of care. Steps for Assessment There are two look-back periods for this section: Diagnosis identification (Step 1) is a 60-day look-back period. Diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period (except for Item I2300 UTI, which does not use the active 7-day look-back period). 1. Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days. Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available. If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered. Although open communication regarding diagnostic information between the physician and other members of the interdisciplinary team is important, it is also essential that diagnoses communicated verbally be documented in the medical record by the physician to ensure follow-up. Diagnostic information, including past history obtained from family members and close contacts, must also be documented in the medical record by the physician to ensure validity and follow-up. 2. Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period . Check the following information sources in the medical record for the last 7 days to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available . If a disease or condition is not specifically listed, enter the diagnosis and ICD code in item I8000, Additional active diagnosis . SECTION N: MEDICATIONS Intent: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident. In addition, an Antipsychotic Medication Review has been included. Including this information will assist facilities to evaluate the use and management of these medications. Each aspect of antipsychotic medication use and management has important associations with the quality of life and quality of care of residents receiving these medications. 1. On 6/15/23 at 10:44 AM, the surveyor observed Resident #2 lying on the bed supine (facing upward), with a tracheostomy (is an opening surgically created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe), intermittent leg tremors, nonverbal and unable to be interviewed. On 6/15/23 at 10:50 AM, the surveyor observed the Respiratory Therapist enter Resident #2's room. The surveyor reviewed Resident #2's medical record. The resident's Registration Form (RF; or face sheet; an admission summary) reflected that the resident was admitted to the facility and had a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own). The resident's most recent Comprehensive Minimum Data Set (CMDS) with an Assessment Reference Date (ARD) of 6/02/23, revealed a Cognitive Skills for Daily Decision-Making (CSDDM) assessment which indicated the resident's cognition was severely impaired. The CMDS indicated the resident had active diagnoses that included, seizure disorder, or epilepsy, respiratory failure, dysphagia (difficulty swallowing), dependence on a respirator. Section G Functional Status of the CMDS revealed that toilet use were coded as 8/8 (activity did not occur/activity did not occur). The CMDS Section H Bladder and Bowel indicated the resident was receiving intermittent catheterization (removing the urine from the bladder by placing a tube into the bladder). Further review of the resident's MDS reflected a previous quarterly MDS (qMDS) with an ARD of 3/03/23, Section G for toilet use was coded 8/8. On 6/26/23 at 11:48 AM, during an interview with the surveyor, Certified Nursing Assistant #1 (CNA #1) stated she was the aide assigned to Resident #2. CNA #1 informed the surveyor that Resident #2 used a diaper and the output of bowel and bladder was documented by her into the electronic Medical Record (eMR). On 6/27/23 at 9:33 AM, during an interview with the surveyor, Licensed Practical Nurse #1 (LPN #1) stated she was assigned to the team that cared for Resident #2 on that day. LPN #1 informed the surveyor that the resident voided into a diaper and was incontinent of bowel and bladder. The LPN informed the surveyor that the resident also received a bladder massage to encourage voiding. 2. On 6/15/23 at 10:50 AM, the surveyor observed Resident #3 seated in a wheelchair, head tilted to the right with saliva dripping uncontrollably from the right side of the face, fitted with trach collar (a medical device used to secure a tracheostomy/windpipe tube). The surveyor reviewed Resident #3's medical record. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of static encephalopathy (a broad term to describe chronic nonprogressive brain disorder). The resident's most recent CMDS with an ARD of 5/12/23, revealed a CSDDM assessment which indicated the resident's cognition was severely impaired. The CMDS also indicated the resident had active diagnoses that included, seizure disorder, respiratory failure, tracheostomy, respiratory failure, dysphagia, pressure ulcer of other site. Section G of the CMDS revealed that eating and toilet use was coded as 8/8. The CMDS Section H indicated the resident was receiving intermittent catheterization. Further review of the resident's MDS showed that on the following MDS assessments: ARD 8/12/22 qMDS, Section G eating and toilet use was coded 8/8 ARD 11/11/22 qMDS, Section G eating and toilet use was coded 8/8 ARD 02/10/23 qMDS, Section G eating and toilet use was coded 8/8 The resident's Nutritional assessment dated [DATE] reflected the resident was on a G-tube (gastrostomy; a tube inserted through the belly that allows air, fluid to leave the stomach and can be used to administer food, liquid and medications) On 6/22/23 at 12:53 PM, the surveyor and the Dietetic Technician Registered (DTR) reviewed the Nutritional Assessment for Resident #3. The DTR confirmed Resident #3 was NPO (nothing by mouth) and received enteral feeding whose weight was monitored monthly. On 6/26/23 at 11:52 AM, during an interview with the surveyor, CNA #1 stated she was the aide assigned to Resident #3. CNA #1 informed the surveyor that Resident #3 had a G-tube and used a diaper; The output of bowel and bladder was documented by the her into the eMR. 9. On 6/15/2023 at 9:37 AM, the surveyor observed Resident #27 seated in a recliner stroller inside their room with a tracheostomy attached to a ventilator. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed the medical records of Resident #27. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of seizures. The resident's PN dated 6/23/23 by the MD with a date of service of 6/22/23 included past medical history diagnoses that were not limited to agenesis of corpus callosum (a brain disorder in which the tissue that connects the left and right sides of the brain (its hemispheres) is partially or completely missing), seizure disorder, respiratory failure with tracheostomy and ventilator dependence and severe global developmental delay. The resident's most recent CMDS with an ARD of 5/05/23 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the CMDS revealed that the toilet use was coded as 8/8. On 6/19/23 at 11:22 AM, the surveyor interviewed CNA #4. The CNA informed the surveyor that Resident #27 was cognitively impaired and required total assistance with ADL, and on TF. She further stated that the resident was incontinent of both bowel and bladder elimination and on strict intake and output measurements. Incontinence care was provided as needed and diapers were being weighed for output. She indicated that the resident was NPO and on a TF for nourishment. 10. On 6/20/2023 at 9:23 AM, the surveyor observed Resident #28 seated in a recliner wheelchair inside their room with a tracheostomy attached to a ventilator. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed the medical records of Resident #28. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of anoxic brain injury (anoxic brain injury occurs when the brain is deprived of oxygen) and quadriplegic cerebral palsy (a form of cerebral palsy that affects both arms and legs and often the torso and face). The resident's PN dated 6/09/2023 by the MD with a date of service of 6/06/23 included past medical history diagnoses that were not limited to, seizure disorder, respiratory failure with tracheostomy and ventilator dependence, severe scoliosis, hypertension, feeding intolerance with gastrostomy dependence and anoxic brain injury with neurological impairments. The resident's most recent CMDS with an ARD of 5/05/2023 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the CMDS revealed that the toilet use was coded as 8/8. Section H of the CMDS revealed that the intermittent catheterization was coded as none of the above. A review of resident #28's personalized care plan revealed Bladder Scan assessment to be done by nursing was initiated on 11/8/2022 with start date of 4/27/2023. On 06/26/23 at 11:11 AM, the surveyor interviewed CNA#2. The CNA informed the surveyor that Resident #28 was cognitively impaired and required total assistance with ADL, and on TF. She further stated that the resident was incontinent of both bowel and bladder elimination. Incontinence care was provided as needed and that nursing was doing straight catheterization on the resident every six hours. 11. On 06/15/2023 at 10:29 AM, the surveyor observed Resident #33 seated in a recliner wheelchair inside their room with a tracheostomy attached to a ventilator. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed the medical records of Resident #33. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of [NAME] syndrome (a rare genetic disorder that can cause structural changes of the skull, bones of the face and other skeletal abnormalities). The resident's PN dated 6/23/2023 by the MD with a date of service of 6/23/23 included past medical history diagnoses that were not limited to, [NAME] syndrome with secondary craniofacial malformation/midface hypoplasia, s/p (status post) reconstructive surgical procedures, chronic respiratory failure with tracheostomy dependence and nocturnal ventilation, dysphagia with gastrostomy dependence, scoliosis, and global developmental delay. The resident's most recent CMDS with an ARD of 4/28/2023 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the CMDS revealed that the eating and toilet use were coded as 8/8. A review of Residents #33's nutrition note dated 5/01/2023 revealed the resident is NPO and is gastric TF dependent. On 6/20/23 at 09:43 AM, the surveyor interviewed RN #3. The RN informed the surveyor that Resident #33 was cognitively impaired and required total assistance with ADL. The RN further stated that the resident is on a TF and wears a diaper because of incontinence of both bowel and bladder elimination. 12. On 6/20/2023 at 10:29 AM, the surveyor reviewed the closed record for Resident #48 for hospitalization. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of tracheostomy dependent long-term care. The resident's PN dated 5/10/2023 by the MD with a date of service of 5/24/23 included past medical history diagnoses that were not limited to, chronic respiratory failure with tracheostomy dependence, dysphagia with gastrostomy dependence, underlying chromosome 3 (three) duplication. The resident's most recent CMDS with an ARD of 5/26/2023 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the CMDS revealed that the eating and toilet use were coded as 8/8. A review of Residents #48's nutrition note dated 5/30/2023 revealed the resident is NPO and is gastric TF dependent. On 6/26/23 at 12:00 PM, the surveyor in the presence of another surveyor interviewed the MDSC/RN. The MDSC/RN informed the surveyors that Section G in the MDS was the responsibility of the PT and OT. The MDSC/RN stated that the PT was responsible for Section G from A to F (where H is for eating) and the OT was responsible from G to J (where I is for toilet use) of Section G. She further stated that she did not have formal training in doing MDS and that her education was from a previous outside contractor who no longer affiliated with the facility. The MDSC/RN stated that it was the previous contractor also who taught her to code 8/8 for toilet use and eating. On that same date and time, the MDSC/RN informed the surveyors that after reviewing the RAI manual, after the surveyor's inquiry, I get it, it should be coded 4/2 for toileting, and that she understood now based on the RAI manual. The MDSC/RN stated that moving forward, we will correct it. She further stated that there was a rationale around it, and we are working on a correction plan. On 6/26/23 at 12:36 PM, the survey team met with the PT who informed the surveyors that she was working at the facility and had been doing the MDS for some Sections of G and O for 10 years. The PT stated that I do the top portion and the OT the other half of Section G, and at times when the OT was not present, she takes care of the whole of Section G. On that same date and time, the PT informed the surveyors that I do not have proper training in doing MDS, and did not have a formal class for MDS training. The PT stated that she answers the portions in Section G of MDS according to her training as a physical therapist. She further stated that after the surveyor's inquiry and the MDSC/RN reached out to her, I am now aware, that the eating and toilet use should have been coded as 4/2 not 8/8. On 6/26/23 at 01:34 PM, the survey team met with the LNHA, MDSC/RN, DON#1 and #2, and the DoT. The surveyor asked the facility management if there will be an additional information regarding the above findings regarding MDS accuracy of assessment for Sections C, H, I, and O. The MDSC/RN stated that I provided you an explanation, there were discrepancies, and there was nothing else to add. On 6/27/23 at 12:33 PM, in the presence of the survey team, LNHA, DON #1, MRAA and AVPAMRA, DON #2 stated that [in response to the residents that were coded incorrectly for eating and toilet use] their perception of coding [Section G eating and toileting] was not the same as the survey team. DON#2 confirmed that they were coded 8/8 and that they misunderstood it. On 6/27/23 at 01:11 PM, the survey team met with the LNHA, DON#1 and #2, AVPAMRA, MRAA, DoT, and there was no additional information provided by the facility management. NJAC 8:39-11.1, 33.2(d) 3. On 6/15/23 at 11:11 AM, the surveyor observed Resident #11 lying in bed with the head of the bed elevated. Resident #11 had a tracheostomy that was connected to a ventilator and was receiving nutrition through a tube feeding (TF). On 6/22/23 at 9:52 AM, the surveyor reviewed Resident #11's medical record. Resident #11's AR showed that the resident was admitted to the facility with diagnoses that included but was not limited to; holoproencephaly (holoprosencephaly; a condition that occurs in the first two or three weeks of pregnancy and results in abnormal development of the brain) and panhypopitutrism (panhypopituitarism; a rare condition in which the pituitary gland stops making most or all hormones). The most recent qMDS with an ARD of 5/05/23, showed that Resident #11's CSDDM assessment was severely impaired. The 5/05/23 qMDS showed on Section G, the resident was coded 8/8 on toilet use. The section for toilet use was coded incorrectly. Further review of the MDS showed the following: ARD of 02/03/23 CMDS: Section G toilet use was coded 8/8 ARD of 11/04/22 qMDS: Section G toilet use was coded 8/8 ARD of 8/05/22 qMDS: Section G toilet use was coded 8/8 On 6/26/23 at 11:18 AM, the surveyor interviewed CNA #2 regarding the care of Resident #11. She stated that the resident was incontinent of urine and had to change the resident's diaper often because the resident had bowel movements frequently. On 6/26/23 at 12:21 PM, in the presence of the survey team, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) who confirmed that Section G toilet use was coded incorrectly for Resident #11. On 6/26/23 at 01:40 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director Of Nursing #1 (DON#1), DON#2, MDSC/RN, and Director of Therapy (DoT) the concern regarding the incorrectly coded MDS. 4. On 6/19/23 at 11:17 AM, the surveyor observed Resident #21 ambulating and mopping the floor with a play mop in the resident's room with a staff member present. The surveyor reviewed Resident #21's medical record. Resident #21's AR showed that the resident was admitted to the facility with a diagnosis that included but was not limited to; prematurity (a birth that occurs before 37 completed weeks (less than 259 days) of gestation and is associated with considerable risk of morbidity and mortality) and respiratory failure. Resident #21's Medication Administration Record for June 2023 included the following orders: Aripiprazole (an antipsychotic medication used to treat schizophrenia, bipolar disorder, depression, and Tourette syndrome and it can also be used to treat irritability associated with autism) 1 mg/ml (1 milligram/milliliter) solution (0.25 mg) via G-tube at 7:30 AM. Aripiprazole 1 mg/ml solution (2 mg) via G-tube at 8 PM. A review of Resident #21's developmental pediatric physician's note dated 6/06/23 included the following: Reason for Evaluation: Resident #21 . with retinopathy of prematurity, respiratory failure, tracheostomy, gastrostomy, osteopenia of prematurity, Autism spectrum disorder, who is being seen for initial assessment and assessment of behavior problems. Medications: Abilify (Aripiprazole) 2 mg at night with added 0.5 mg daytime, as tolerated .Plan: A prescription and written order were provided for Abilify to change to 0.25 mg in am (morning) .but keep Abilify 2 mg at bedtime for now . The most recent CMDS with an ARD of 5/19/23, showed that Resident #21's CSDDM assessment was moderately impaired. The CMDS showed on Section N for medications that the resident received an antipsychotic medication 7 (seven) days. Further review of the CMDS indicated that Section I Active Diagnoses did not include Autism Spectrum Disorder which was the diagnosis indicated for the physicians order of Aripiprazole. Further review of the MDS showed the following: ARD of 02/17/23 qMDS: Section N antipsychotic 7 days; Section I did not include diagnosis of autism. ARD of 11/18/22 qMDS: Section N antipsychotic 7 days; Section I did not include diagnosis of autism. ARD of 8/19/22 qMDS: Section N antipsychotic 7 days; Section I did not include diagnosis of autism. On 6/20/23 at 12:35 PM, the surveyor interviewed Registered Nurse #1 (RN #1) who stated that Resident #21 had a diagnosis of autism and that the resident had behavioral issues. On 6/26/23 at 12:16 PM, the surveyor interviewed the MDSC/RN regarding Resident #21's MDS. The MDSC/RN stated that the resident was on an antipsychotic medication and that the reason the resident was on the medication was that the resident had a diagnosis of autism. The surveyor asked the MDSC/RN the reason the diagnosis of autism was not listed on Resident #21's MDS. The MDSC/RN stated that the diagnoses listed on the MDS were the medical diagnoses that were in the resident's chart in the section of diagnoses. The surveyor asked the MDSC/RN if autism was a medical diagnosis. She stated yes, and added that the diagnosis was documented in other sections of the medical chart. On that same date and time, the surveyor then asked the MDSC/RN if the expectation would be to see the diagnosis on the MDS. The MDSC/RN stated yes maybe. She then added that the diagnosis code was pulled directly from eMR, in the diagnosis section. She then stated that if the diagnosis was not coded in the diagnosis section of the eMR, then it would not go over to the MDS. She further stated that she could manually put in the diagnosis but that she was told not to put the diagnoses in. The surveyor then asked the MDSC/RN if Resident #21's autism diagnosis should have been listed in the MDS. She stated yes. On 6/26/23 at 01:40 PM, in the presence of the survey team, the surveyor notified the LNHA, DON #1 and #2, MDSC/RN and DoT the concern regarding the missing diagnosis associated with the use of the antipsychotic medication in the MDS. On 6/27/23 at 12:24 PM, in the presence of the survey team, the LNHA stated that the diagnosis of autism was in Resident #21's neuro developmental notes. The surveyor then asked the LNHA if the diagnosis of autism should have been in Resident #21's MDS. The LNHA stated that he was not a MDS Coordinator and that he would have to look at the manual. 5. On 6/15/23 at 10:42 AM, the surveyor observed Resident #36 sitting up in bed watching television. Resident #36 had a tracheostomy that was connected to a ventilator and was receiving nutrition through a TF. The surveyor reviewed Resident #36's medical record. The AR showed that the resident was admitted to the facility with a diagnosis that included but was not limited to; myopathy (general term referring to any disease that affects the muscles that control voluntary movement in the body). The most recent qMDS with an ARD of 4/17/23, showed that Resident #36's CSDDM assessment was severely impaired. The 4/17/23 qMDS showed on Section G, the resident was coded 8/8 on eating and toilet use. Section K Swallowing/Nutritional Status indicated the resident had a TF. The sections for eating and toilet use were coded incorrectly. Further review of the MDS showed the following: ARD of 01/06/23 qMDS: Section G eating and toilet use was coded 8/8; Section K-TF. ARD of 10/07/22 qMDS: Section G toilet use was coded 8/8 and eating was coded four (4) total dependence and (2) one person physical assist. Section K-TF. ARD of 7/18/22 CMDS: Section G eating and toilet use was coded 4/2 (total dependence/one person physical assist). Section K-TF. The section for toilet use was coded incorrectly for 3 (three) of 4 (four) MDS reviewed. The section for eating was coded incorrectly for 2 (two) of 4 (four) MDS reviewed. On 6/26/23 at 11:21 AM, the surveyor interviewed CNA #2 regarding Resident #36's care. She stated that Resident #36 was incontinent and that she would change the resident's diaper often. She added that the nurse would give the resident a G-tube feeding. On 6/26/23 at 12:21 PM, in the presence of the survey team, the surveyor interviewed the MDSC/RN who confirmed that Section G eating and toilet use was coded incorrectly for Resident #36 when it was coded 8/8. On 6/26/23 at 01:40 PM, in the presence of the survey team, the surveyor notified the LNHA, DON #1 and #2, MDSC/RN and DoT the concern regarding the incorrectly coded MDS. 6. On 6/15/23 at 11:06 AM, the surveyor observed Resident #44 laying in a crib. Resident #44 had a tracheostomy that was connected to a ventilator and had received nutrition through a TF but the feeding was not currently infusing. The surveyor reviewed the medical records of Resident #44. Resident #44's AR showed that the resident was admitted to the facility with a diagnosis that included but was not limited to; congenital anomalies (comprise a wide range of abnormalities of body structure or function that are present at birth) and prematurity. The most recent qMDS with an ARD of 6/02/23, showed that Resident #44's CSDDM was not assessed. The 6/02/23 qMDS showed on Section G, the resident was coded 8/8 on eating and toilet use. Section K indicated the resident had a TF. The sections for eating and toilet use were coded incorrectly. Further review of the MDS showed the following: ARD of 3/03/23 qMDS: Section G toilet use was coded 8/8 and eating was coded 4/2. Section K-TF. ARD of 12/18/22 CMDS: Section G toilet use was coded 8/8 and eating was coded 4/2. Section K-TF. The section for toilet use was coded incorrectly for 3 (three) of 3 (three) MDS reviewed. The section for eating was coded incorrectly for 1 (one) of 3 (three) MDS reviewed. On 6/26/23 at 11:22 AM, the surveyor interviewed CNA #2 regarding Resident #44's care. She stated that Resident #44 was incontinent and that she would change the resident's diaper often. She added that the nurse would give the resident a G-tube feeding and that the resident had a colostomy bag that the nurse changed. On 6/26/23 at 12:21 PM, in the presence of the survey team, the surveyor interviewed the MDSC/RN who confirmed that Section G eating and toilet use was coded incorrectly for Resident #44 when it was coded 8/8. 7. On 6/15/2023 at 11:57 AM, the surveyor observed Resident #41 seated in a recliner wheelchair inside their room with a tracheostomy attached to an oxygen. The resident was none verbal and unable to respond to the surveyor's questions. On 6/19/23 at 11:29 AM, the surveyor observed the three facility staff transfer the resident from bed to a recliner wheelchair with the use of the mechanical mobility tool as a lift. The three staff were the Nurse Extern (NE), RN #2, and CNA #3. On 6/19/23 at 11:37 AM, the surveyor interviewed CNA#3. The CNA informed the surveyor that Resident#41 was cognitively impaired, and required total assistance with ADL, and on tube feeding. She further stated that the resident was incontinent of both bowel and bladder elimination and that incontinence care was provided as needed. She indicated that the resident was NPO (nothing by mouth) and on a TF for nourishment. The surveyor reviewed Resident #41's medical record. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of diffuse TBI (a type of traumatic brain injury). The resident's most recent qMDS with an ARD of 3/30/23 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the qMDS revealed that the eating and toilet use were coded as 8/8. Section O Special Treatments, Procedures, and Programs in the qMDS revealed that the resident had no pneumococcal (pneumonia) vaccine and was not assessed, and no information. Further review of the resident's MDS showed that on the following MDS assessments: ARD 9/26/22 CMDS=toilet use was coded 8/8 and no pneumonia vaccine information ARD 12/16/22 qMDS=toilet use was coded 8/8 and no pneumonia vaccine information On 6/26/23 at 8:55 AM, the AVP of Access Management & Regulatory Affairs (AVPAMRA) in the presence of the LNHA, and the survey team provided a copy of the resident's Immunization Information System and revealed that the resident received the pneumonia vaccines dated 4/18/2006 (dose one), 7/13/2006 (dose two), 9/28/2006 (dose three), and 02/15/2007 (dose four). A review of the resident's electronic medical record revealed that there was no evidence that the resident had been administered the pneumonia vaccination. The provided list of residents with pneumonia vaccine by DON#2 did not include the resident's name. 8. On 6/19/2023 at 11:43 AM, the surveyor observed Resident #14 seated in a recliner wheelchair inside their room with a padded headboard, lap tray, and leg rest. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed Resident #14's medical record. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of respiratory failure. The resident's Progress Note (PN) dated 6/14/23 by the Medical Doctor (MD) with a date of service of 6/05/23 included past medical history diagnoses that were not limited to hypoxic ischemic encephalopathy (type of brain damage), respiratory failure with tracheostomy and ventilator dependence, seizure disorder, GERD (gastroesophageal reflux disease; occurs when stomach acid repeatedly flows back into the tube connecting mouth and stomach), and severe global developmental delay. The resident's most recent CMDS with an ARD of 4/27/23 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the CMDS revealed that the toilet use was coded as 8/8. Further review of the resident's MDS showed that on the following MDS assessments: ARD 7/15/22 qMDS=toilet use was coded 8/8 ARD 10/14/22 qMDS=toilet use was coded 8/8 ARD[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/19/23 at 11:02 AM, during the initial tour, the surveyor observed Resident #24 from the hallway in a wheelchair with bilateral leg splint, eyes opened and nonverbal. The surveyor reviewed the medical record for Resident #24. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of anoxia (absence or deficiency of oxygen reaching the tissues of the body). The quarterly MDS (qMDS) with an ARD of 4/14/23, reflected that the resident was cognitively impaired. A review of the Advanced Practical Nurse's (APN) Progress Note signed 5/19/23, reflected diagnoses which included, respiratory failure with tracheostomy and ventilator dependence, dysphagia (difficulty swallowing) with G-tube (gastrostomy; a tube inserted through the belly that allows air, fluid to leave the stomach and can be used to administer food, liquid and medications) dependence, spasticity (an abnormal increase in muscle tone or stiffness of muscle, which might interfere with movement, speech, or be associated with discomfort or pain), bilateral sensorineural hearing loss, and severe developmental delay. Further review of the APN progress note, under current medications, reflected an order for Erythromycin Ethylsuccinate (EES) 200 mg/5 ml, 70 mg Q8HRS G-tube with a start date of 4/29/23 and was indicated for improved GI (gastrointestinal) motility. The eMAR dated 6/18/23, confirmed Resident #24 received the EES 70 mg Q8HRS since 4/29/23. A review of the CP's Recommendations report from 01/30/23 through 5/25/23 did not reflect a recommendation to identify the duration of therapy and inform the prescriber of the studies that reflect a rapidly diminishing response to the use of EES that may occur after four (4) weeks of use. 3. On 6/20/2023 at 9:23 AM, the surveyor observed Resident #28 seated in a recliner wheelchair inside their room with a tracheostomy attached to a ventilator. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed Resident #28's medical record. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of anoxic brain injury (anoxic brain injury occurs when the brain is deprived of oxygen) and quadriplegic Cerebral Palsy (a form of cerebral palsy that affects both arms and legs and often the torso and face). The resident's PN dated 6/09/2023 by the MD with a date of service of 6/06/23 included past medical history diagnoses that were not limited to, seizure disorder, respiratory failure with tracheostomy and ventilator dependence, severe scoliosis, hypertension, feeding intolerance with gastrostomy dependence and anoxic brain injury with neurological impairments. The resident's most recent CMDS with an ARD of 5/05/23 reflected that the cognitive skills for daily decision-making indicated that the resident's cognition was severely impaired. The June 2023 eMAR revealed a PO dated 4/29/23 for EES 200 mg/5 ml susp via GT Q8HR with a clinical indication for gastric motility. According to the 5/25/23 CP's Monthly Report for Resident #28, the CP did not identify irregularity with the continued use of EES medication. On 6/26/23 at 10:32 AM, the MD (also the Medical Director of the facility) and the Licensed Nursing Home Administrator (LNHA) met with the survey team. The MD presented herself to be interviewed and stated that there was a concern with EES and that the doctor wanted to talk about it. The LNHA then left. On that same date and time, the surveyor in the presence of the survey team notified the MD of the above findings and concerns regarding EES medication that the CP did not identify and notify the MD and the facility of irregularities even though the CP admitted that she knew about the tachyphylaxis issue with continued use of medication for more than 4 (four) weeks. The MD did not disagree with what the CP informed the surveyors that the CP did not notify the MD of the tachyphylaxis irregularity with continued use of EES and that there was no report about it on 5/25/23 MRR. Furthermore, the MD stated that she can not disagree more with the surveyor about the ABT (antibiotic) stewardship regulation and pharmacy review regulation that the facility should follow concerning the review of unnecessary medications should have been followed and that the irregularity should have been reported to the physician during the monthly MRR. At that same time, the MD stated that moving forward she should document the justification for continued use of EES according to the requirement of the regulation. On 6/27/23 at 12:09 PM, the survey team met with the AVP (Assistant [NAME] President) of Access Management & Regulatory Affairs (AVPAMRA), Manager of Regulatory Affairs & Accreditation (MRAA), Director Of Nursing#1 (DON#1), DON#2, and the LNHA. The LNHA stated that there was no further information that the facility can share about the EES medication. A review of the facility's Pharmacy-Pharmacist Consultation LTC Policy that was provided by DON#2 with an effective date of 01/01/23 included that the consulting pharmacist shall review each patient's drug regimen at least monthly. The monthly review of the patient's drug regimen shall include, but not be limited to, laboratory tests, dietary requirements, physician's and nurse's clinical notes, physician's orders, and progress notes. Potential adverse reactions, allergies, drug interactions, contraindications, rationally of therapy, drug therapy evaluation, and laboratory test modifications shall also be monitored. On 6/27/23 at 01:11 PM, the survey team met with the LNHA, DON#1 and #2, Director of Therapy, AVPAMRA, and MRAA. There was no additional information provided by the facility management. NJAC 8:39- 29.1(a), 29.3 (a)(1) Based on the interview, record review, and review of the facility provided documents, it was determined that the facility failed to identify medication irregularity during the monthly MRR (Medication Record Review) of the CP (Consultant Pharmacist) for three (3) of five (5) residents reviewed for unnecessary medications, Residents#14, #24, and #28. This deficient practice was evidenced by the following: According to [NAME]-Drugs (or Lexicomp an evidenced-based drug referential content; that provides evidence and recommendations to help clinicians as they treat and advise patients with complex conditions) included that review of the Erythromycin with pharmacologic category of antibiotic; Gastroparesis (off-label use; gastoparesis is a condition that affects the normal spontaneous movement of the muscles in stomach). There is a Patients refractory/intolerant to other prokinetic agents (eg, metoclopramide, domperidone; type of drug which enhances gastrointestinal motility) to limit the duration of therapy, tachyphylaxis (the appearance of progressive decrease in response to a given dose after repetitive administration of a pharmacologically or physiologically active substance and tachyphylaxis occurs when medications suddenly become less effective) may occur after four (4) weeks. According to The Use of Long-Term, Low Dose Erythromycin in Treating Persistent Gastric Stasis, volume 29; issue 5, P430-433, May 2005 included that Erythromycin also has been used in other conditions that have gastroparesis as a problem. Most studies have had follow-up periods of less than four weeks, but a recent study followed some patients for up to 18 months and suggested that tolerance may develop over time. A major concern that has been raised about using erythromycin in this way is that resistance of pathogens, such as S. pneumoniae (Streptococcus pneumoniae is a gram-positive bacterium and a cause of community-acquired pneumonia), may increase. Although the doses of erythromycin used are smaller doses than those typically used in treating bacterial infections, they may provide almost ideal conditions for the induction of bacterial mutation, and selection and resistance to erythromycin is well recognized. 1. On 6/19/2023 at 11:43 AM, the surveyor observed Resident #14 seated in a recliner wheelchair inside their room with a padded headboard, lap tray, and leg rest. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed Resident #14's medical record. The resident's Registration Form (RF; or facesheet; an admission summary) reflected that the resident was admitted to the facility and had a diagnosis of respiratory failure. The resident's Progress Note (PN) dated 6/14/23 by the Medical Doctor (MD) with a date of service of 6/05/23 included past medical history diagnoses that were not limited to hypoxic ischemic encephalopathy (type of brain damage), respiratory failure with tracheostomy (is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe) and ventilator dependence, seizure disorder, GERD (gastroesophageal reflux disease; occurs when stomach acid repeatedly flows back into the tube connecting mouth and stomach), and severe global developmental delay. The resident's most recent Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 4/27/23 reflected that the cognitive skills for daily decision-making indicated that the resident's cognition was severely impaired. The June 2023 electronic Medication Administration Record (eMAR) revealed a physician order (PO) dated 4/29/23 for Erythromycin Ethylsuccinate (EES; an antibiotic used to treat many different types of infections caused by bacteria) 200 mg/5 ml (200 milligrams/5 milliliters) susp (suspension) (80 mg) via GT (gastrostomy tube) every 6 (six) hours (Q6HR) with a clinical indication for gastric motility. According to the 5/25/23 CP's Monthly Report for Resident#14, the CP did not identify irregularity with the continued use of EES medication. A review of the provided documents of the CP via email showed that the CP included the article about The Use of Long-Term, Low Dose Erythromycin in Treating Persistent Gastric Stasis as a reference. The article provided by the CP did include the whole report that showed the article above regarding a major concern that has been raised about using EES in this way is that resistance of pathogens, such as S. pneumoniae, may increase and although the doses of EES used are smaller doses than those typically used in treating bacterial infections, they may provide almost ideal conditions for the induction of bacterial mutation, and selection and resistance to erythromycin is well recognized. On 6/26/23 at 9:55 AM, the survey team met with the CP. The CP stated that she was responsible for monthly MRR where she reviews residents' medications, identify irregularities, and notify the nursing and the physicians of the recommendations. The surveyor asked the CP if she was familiar with and use Lexicomp for medication reviews, and the tachyphylaxis concern with continued use of EES, and the CP stated Yes. The CP stated that tachyphylaxis does not mean that the medication was not working, but the efficacy was reduced, meaning that there is still a clinical benefit even though the efficacy was reduced over time. On that same date and time, the surveyor asked the CP if she was aware of the tachyphylaxis effect of continued use of EES to Resident #14, why she did not include it in her monthly MRR on 5/25/23, and if she notify the physician about it. The CP stated that I did not inform the doctor about it. The CP further stated that I do not have it, documented, that she discussed the medication with the doctor, but I know the doctor knows about the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of documentation provided by the facility, it was determined that the facility failed to a) maintain proper kitchen sanitation practices and b) properly store dry and refrigerated foods in a safe and sanitary environment to prevent the development of foodborne illness. The deficient practice was observed and was evidenced by the following: On 09/22/21 at 10:17 AM, during the initial tour of the kitchen in the presence of the Dietary Supervisor (DS), the surveyors observed the following: 1. The ceiling vent located above the slicer had a heavy buildup of black and grayish material. 2. The ceiling vent located above the food prep area had a heavy buildup of black and grayish material. 3. The silver pole located between the slicer and the sink had a heavy buildup of black and grayish material where the pole connected to the ceiling. The DS stated that maintenance would clean the ceiling vents and the silver pole. She further stated they should be free of dust because dust could fall into the food and contaminate it. 4. The bracket that secured the pot/utensil holding rack to the ceiling, which was located above the food prep area, had a heavy buildup of black and gray material. The DS stated that it was the responsibility of the kitchen staff to keep clean. 5. Located under the food prep area on the coffee side, there were 4 screening pans and 8 sheet pans, nested on top of each other, that had a heavy buildup of black substance around the edges of the pans. The DS stated that they should have been scrubbed better and now they just needed to be replaced. 6. The seasoning rack contained the following opened spices: -16-ounce (oz) Curry Powder with a received by date of 9/21/20, the DS was unable to locate an opened date -16 oz whole mustard, the DS was unable to locate a received or an opened date, -16 oz celery seed with an opened date of 5/28/18 -16 oz container that contained an orange-colored seasoning that had the letters [NAME] handwritten on it. The DS confirmed that the container did not contain any dates. The DS stated it was taken from a larger container of [NAME]'s seasoning and put into the smaller container for use. The DS further stated it should have been more clearly marked and that it should have contained an opened date. The DS stated that it was important to label clearly so that you know when it comes in and when it expires. -16 oz whole sesame seed with an opened date of 6/23/2019 and a use-by date 6/23/21 -16 oz ground mustard with an opened date of 6/2018 and a use-by date of 6/2021 -12 oz poultry seasoning with an opened date of 5/28/2018 and a use-by of 5/2021 -13 oz ground oregano with a received on date of 11/2017 and an expiration date of 6/23/21 -14 oz ground cayenne pepper with a received on date of 4/1/2019, the DS was unable to locate an opened date -16 oz ground allspice with a received on date of 1/10/2018 and a date opened of 3/4/2018 -16 oz ground nutmeg with a received on date of 11/2009, the DS confirmed that there was not an opened date -11 oz spice white cloves with a received on date of 5/14/18 and an opened date of 6/15/2018 7. Hanging from the pot/utensil holding rack there was the following: -4 pans, the DS stated that they were 12 inch () or 16 pans, that had a black nonstick protective coating on the inside of the pan that had multiple scrape marks and pieces of loose protective coating on the inside of the pan. - 2 6 sauté pans that had a black nonstick protective coating on the inside of the pan that had multiple scrape marks and pieces of loose protective coating on the inside of the pan. The DS stated that the pans were not usable because the scrapings could get in the food and contaminate it. -1 4 quart (qt) saucepot with a black substance in the bottom of the pot. The DS rubbed it off and stated it should not be there because it could contaminate food - 1 large sauté pan, the DS stated it was 18 or 20pan, that had multiple deep grooves with a black substance in the grooves, on the inside of the pan. The DS stated it needed to be scrubbed off. - a brown clipboard that the DS identified as the cook's menu clipboard, was hanging on the rack touching the serving spoons 8. Two male kitchen staff members, a cook and a kitchen aid (KA) wearing surgical masks with facial hair exposed around the mask, exiting the kitchen area: During an interview with the surveyor at that time, the cook stated that facial hair should be contained in a beard net, so hair doesn't fall into the food. He felt around his surgical mask and confirmed that all his facial hair was not contained in the surgical mask. The KA stated that he did not know the facility's policy on facial hair. The KA's facial hair was coming out below and around the sides of the surgical mask. The DS stated that a beard guard must be worn, and facial hair needs to be cut low to the face. The DS instructed both staff members to put beard guards on. They then came back to the DS to inform her that the facility does not have beard guards, so the DS instructed them to put hair nets on to cover their facial hair. 9. The walk-in refrigerator contained the following opened dressing and sauces: -1-gallon honey mustard with a received on date of 12/2020 dated and an opened date of 12/10 no year, The DS stated that the dressings were good for 2 months after opening. -1-gallon French dressing with a received on date of 12/2019 and 12-2 written (nothing else) -1 gallon thousand island with a received on date of 3/15/21 and an opened date of 4/4/21 -1-gallon sweet pickle relish with a received on date of 3/5/21 and an opened date of 4/9/21 -1-gallon blue cheese dressing with two opened dates: 12/14/20 and 1/29/21 and a use-by date of 4/27/21 -1-gallon sweet pickle relish with a received on date of 3/15/21 and an opened date of 7/13/21 -4.5 pounds sweet and sour ready to use sauce with an opened date of 4/29/21, the DS confirmed that there was not a received on date. The DS stated that the sauces were good for 2 months after opening. -20 oz caramel sundae syrup with an opened date of 7/12/20, no received on date. The DS stated that syrups were good for 2 months after opening. -24 oz chocolate flavor syrup with an opened date of 4/17/21, no received on date. -24 oz chocolate flavor syrup with an opened date of 2/15/21, no received on date. A review of the facility's Policy and Procedure Dietary Department, reviewed 8/20, Procedure-The Cooks Area to be cleaned includes these four areas, overhead rack area, stainless steel work area, drawers, and underneath stainless steel storage. Each area should be stripped of all its items and cleaned properly. Any items of questionable quality should be disposed of. A review of the facility's Policy and Procedure Labeling and Dating Spices, reviewed 10/20, Procedure: Whole spices, ground, and dried leaf spices have a shelf life up to three years. Spices will be labeled with receiving dates. To ensure freshness once spices have been open they will be dated with an opening date to ensure freshness and disposal of after three years. A review of the facility's Policy and Procedure WASHING of POTS, PANS, AND UTENSILS, reviewed 6/15, Doing one item at a time, you: 1. Use pot and pan agitator to loosen food, which is baked on. 2 Thoroughly scrub the inside and outside of all Pots and pans, using brush. A review of the facility's Policy and Procedure, Sanitation Guidelines for Pantries, reviewed 8/20, 8. All counters and equipment must be cleaned thoroughly. 9. Silverware should be displayed and stored in such a way the person will only touch the handle and not the eating side. 13. Ceilings and walls must be cleaned and in good repair. A review of the facility's Policy and Procedure, Personal Hygiene and Good Grooming, reviewed date 8/20, HAIR-Clean hair is an essential part of personal hygiene. All hair must be confined either in a cap or a hairnet. A review of the facility's Policy and Procedure, Dietary Dress Code, reviewed 8/20, Procedure: 4. All men with facial hair must be cut close and wear bearded guard. A review of the facility's Policy and Procedure, Salad Bar, reviewed 8/20, All dressing need to be label and date upon entering with a receiving and open date and discarded 60 days after opening. A review of the resident diet orders revealed that 2 out 34 residents were on diets provided by the kitchen. NJAC 8:39-17.1(a);17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure 4 of 5 unvaccinated facility staff were tested for COVID-19 twice a week in accordance with the Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements; and nationally accepted guidelines for infection prevention and control, and the facility's testing schedules related to the high COVID-19 county positivity rate. The evidence was as follows: According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 [COVID-19] Spread in Nursing Homes updated 9/10/21 included, In nursing homes located in counties with substantial to high community transmission, unvaccinated HCP should have a viral test twice a week. According to the Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements revised 9/10/21 included, Routine testing of unvaccinated staff should be based on the extent of the virus in the community .Facilities should use their community transmission level as the trigger for staff testing frequency .Routine Testing Intervals by County COVID-19 Level of Community Transmission: Low (blue) testing frequency: not recommended; Moderate (yellow) testing frequency: once a week; Substantial (orange) testing frequency: twice a week; and high (red) testing frequency: twice a week. On 9/22/21 at 10:48 AM, during the Entrance Conference the Team Coordinator (TC) requested a list of facility staff who were unvaccinated for COVID-19 from the Licensed Nursing Home Administrator (LNHA). Later on that same date, the surveyor reviewed the level of community transmission via the CDC COVID-19 Integrated County View site which indicated the facility's level of community transmission was high and in the red. On 9/24/21 at 1:45 PM, the LNHA stated that staff who were not vaccinated were being tested for COVID-19 twice a week and their results were recorded in the electronic medical record for staff. He further stated that the unvaccinated staff have to be checked one by one regarding their testing records and that supervisors were aware who should be tested before working. On 9/27/21 at 10:01 AM, the surveyor selected five unvaccinated facility staff for COVID-19 testing. The surveyor identified that 4 of the 5 facility staff did not have evidence of twice a week COVID-19 testing in accordance with the aforementioned testing requirements. The following was revealed: A review of a Registered Professional Nurse #1 (RN #1) work schedule revealed the RN #1 worked on the following dates: 9/5/21, 9/8/21, 9/10/21, 9/14/21, 9/18/21, 9/21/21, 9/22/21 and 9/25/21. The RN #1 was tested for COVID-19 via rapid antigen on 9/8/21, 9/14/21, 9/21/21 and 9/25/21. A review of a Licensed Practical Nurse (LPN) work schedule revealed the LPN worked on 9/12/21, 9/15/21 and 9/20/21. The LPN was tested for COVID-19 via rapid antigen on 9/21/21. A review of RN #2's work schedule revealed RN #2 worked on 9/20/21, 9/22/21, and 9/25/21. RN #2 was tested for COVID-19 via rapid antigen on 9/25/21. A review of a Certified Nursing Assistant (CNA) work schedule revealed the CNA worked on 9/12/21, 9/17/21, 9/18/21, 9/19/21, 9/24/21, and 9/25/21. The CNA was tested for COVID-19 via rapid antigen on 9/24/21. On 9/27/21 at 12:20 PM, the surveyor interviewed the LNHA who stated that the staff should have been tested twice a week and could not speak to why the aforementioned unvaccinated staff were not tested twice a week. On 9/28/21 at 9:10 AM, the LNHA provided the surveyor a copy of the SARS-CoV-2 [COVID-19] Pandemic Plan Long-Term Care Practices for All Phases at All times which included, Ongoing weekly testing of all staff until guidance from the NJDOH changes based on epidemiology and data about the circulation of virus in the community. He stated, this is our policy regarding staff testing and we follow the CDC guidelines with [NAME] report. NJAC 8:39-5.1(a)