Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure: a) the Antibiotic Stewardship Program (ASP) Policy and Procedure, part of the facility Infection Prevention Control Program (IPCP) was reviewed at least annually and included a procedure for the reporting of multidrug- resistant organisms (MDRO), and communicable diseases to local/state public health authorities, b) a standardized infection assessment tool or management algorithm (IST) was consistently utilized for prescribed antibiotics (Resident #2), c) residents with chronic urinary tract infection with multiple prescribed antibiotics were tracked to prevent development and/or transmission of MDRO, d) staff were educated when a Multidrug-Resistant Organism was identified (Resident #7), and e) the facility maintained evidence of an ongoing analysis of surveillance data for organisms with a documented follow-up in response to the collected data. The deficient practices was identified for 2 of 7 sampled residents (Resident #2 and Resident #7) during a review of the facility Antibiotic Stewardship program (April, May, and June 2024) and was evidenced by the following: 1.) On 08/07/24 at 12:45 PM, the facility provided the undated, Antibiotic Stewardship Program (ASP) policy which revealed: Purpose: The policy is intended to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy, resident safety, and reducing treatment related cost. Accountability: The ASP Team is accountable for stewardship activities. The ASP team will consist of Medical Director, Administrator, Director of Nursing, designated Infection Preventionist (IP) MDS coordinator and pharmacy consultant. As a team, they will review infections and monitor antibiotic usage pattern on a regular basis . Monitor multi-drug-resistant organisms (MRSA, VRE, ESBL, CRE etc.) and Clostridium difficile infections .Include a separate report section for the number of residents of antibiotics that did not meet criteria for active infection. Tracking: included that the Infection Preventionist will collect and report data per program such as, number of positive cultures . Number of patients treated with antibiotics who meet Mc Geer criteria for active infection. Education: Educational opportunities as identified by the ASP Team will be provided for clinical staff as well as residents and their families on appropriate use of antibiotics. The ASP policy did not include a procedure for the reporting of MDRO, and communicable diseases to local/state public health authorities. In addition, the policy did not reflect a protocol for the utilization of the assessment tool or management algorithm in one or more infection. On 8/8/24 at 9:27 AM, during an interview with the Registered Nurse/ Infection Preventionist (RN/IP), the surveyor discussed the concern regarding the ICPC policies and procedure received that did not include a process for the reporting of multidrug-resistant organisms (MDRO), and communicable diseases to local/state public health authorities. At that time, the RN/IP confirmed she did not have additional policies and procedures regarding reporting and would speak with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) regarding the concern. On 8/8/24 at 9:30 AM, the surveyor informed the DON of the concern regarding reporting. 2.) The surveyor reviewed the closed medical record for Resident #2 which revealed: According to the Face Sheet, an admission summary, Resident #2 was admitted to the facility with diagnoses that included but were not limited to elevated white blood cell count (an indication of infection, inflammation, injury and/or immune system disorder), carcinoma in situ (abnormal cells in a limited area) of skin of scalp and neck and unspecified dementia (loss of memory, language, problem-solving and other thinking abilities interfering with daily life) without behaviors. The admission Minimum Data Set (AMDS) an assessment tool dated 6/20/24, reflected a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated Resident #2's cognition was severely impaired. -Bactrim (Sulfamethoxazole - Trimethoprim) 800/160 milligram (mg) give one (1) tablet by oral route every 12 hours for 28 doses, diagnosis of left neck wound infection, started on 6/14/24, ordered by [Physician #1/name redacted]. -Augmentin 500/125 milligram (mg) give one tablet by mouth every 12 hours for left neck wound infection, start date of 6/24/24. Ordered by [Physician #2/name redacted]. A review of the nurses' Progress Note (PN) for Resident #2 included the following: On 6/14/24 At 3:28 PM, the RN/IP documented the resident had a post op (operation) wound on the left side of the neck. The wound was described as with slough, large purulent drainage, and strong odor. Bactrim 800 mg twice a day for 28 doses. A review of the ASP surveillance book did not reflect the utilization of a standardized infection assessment tool or management algorithm when antibiotics were prescribed for Resident #2. On 6/24/24 at 5:29 PM, [facility staff #1; name redacted/ no title] documented that the resident returned to the facility after visiting Physician #2 for wound evaluation. A new antibiotic for the Augmentin 500-125 mg to be given one (1) tablet every 12 hours for wound infection on the neck. On 6/24/24 at 10:02, facility staff #1 documented Physician #3 was made aware of the new antibiotic ordered: Augmentin. An order to hold Bactrim until the Augmentin was completed. On 6/25/24 at 3:44 PM the RN/IP documented that Physician #1 (oncologist) was informed of Physician #2 (provided wound consult) both discussed the duplicate antibiotic orders and agreed the resident was able to take both antibiotics for the duration of therapy. Physician #3 (the medical director) was notified of the order clarifications. A message was also left for family representative regarding the same information. A review of the June 2024, line listing of infections reflected the resident was admitted with infection of skin, symptoms were present during admission, the pathogen was blank, community associated infection (CAI) or health care associated infection (HAI; acquired within the facility) was blank and the comment was documented as surgical. A review of the June 2024, Infection Control Tracking Report reflected Resident #2's name but did not indicate discontinuation date of infection/treatment, the source of infection (i.e. skin, surgical, other wounds), and the MDRO pathogen was blank. A review of the June 2024, Infection Prevention and Control Surveillance (IPCS) for June 2024, did not include Resident #2's name, admission date, onset date, area of infection, signs, and symptoms, change in mental status, organism on culture, x-ray, antibiotics utilized for the treatment, CAI or HAI, and that the antibiotic met the criteria [of the IST]. Further review of the IPCS for June 2024 reflected 7 names of residents all of which did not have an indicator to reflect each treatment received met the criteria of the IST was utilized. Resident #7 was not included in the report. On 8/8/24 at 12:40 PM, during an interview with the survey team, the RN/IP stated that she did not use the IST for Resident #2 however had documentation on 6/14/24 at 3:38 PM that included, the resident had a post operation wound on the left side of the neck, with slough, purulent drainage and strong odor on the resident ' s PN. At that time, the RN/IP was unable to explain why the IST was not utilized and not documented on the IPCS for tracking. 3. On 8/7/24 at 9:35 AM, during the initial tour the surveyor observed an orange dot, and oxygen in use signage outside the door frame. Immediately inside the door was another signage of Enhanced Barrier Precaution above a white plastic cabinet with drawers that contained Personal Protective Equipment (PPE). Resident #7 was in bed sleeping and receiving oxygen via nasal cannula. The catheter drainage bag (urine bag) contained a light-yellow liquid. The surveyor reviewed the medical record for Resident #7. According to the resident s Face sheet, an admission summary, Resident #7 was admitted to the facility with diagnoses that included Type 2 diabetes mellitus (an impairment in the way the body regulates glucose-sugar), neuromuscular dysfunction of bladder (lack of bladder control), and history of urinary tract infections (UTIs). A review of the quarterly Minimum Data Set (qMDS) an assessment tool dated 6/20/24, reflected a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated Resident #7's cognition was severely impaired. A review of the resident's Care Plan (CP) included that the resident had a Foley [a tube inserted into the bladder to drain urine into a collection bag] catheter, with an effective date of 4/26/23. The goal was for the resident's foley to remain patent (absence of blockage) and the resident would not have bladder distention (swollen from internal pressure) by next review date with an effective date of 5/20/24. The interventions included to give peri care twice daily and as needed to be sure perineum is clean and dry. Cleanse around urinary meatus to help prevent UTI. Further review of the CP included the following under interventions: On 4/26/23, give peri care twice daily and as needed to be sure perineum is clean and dry. Cleanse around urinary meatus to help prevent UTI. On 6/12/24 the RN/IP spoke with resident representative regarding the need to change the Foley catheter frequently and was educated on the discomfort, risk of infections and the need for urology consult. On 6/20/24 Physician #3 discussed with resident representative the frequent Foley catheter changes, discomfort, infection, and the need for urology consult. A review of the June 2024, line listing of infections reflected the date of resident's admission, date of infection, site of infection, no symptom was present, the name of the pathogen, HAI, and the comment was documented as MDRO. A review of the June 2024, Infection Control Tracking Report reflected Resident #7's name, the discontinuation date of infection/treatment, HAI, the source of infection (i.e. catheter), and the MDRO pathogen associated was blank. A review of the June 2024, Infection Prevention and Control Surveillance (IPCS) for June 2024, did not include Resident #7's name, area of infection, signs, and symptoms, change in mental status, organism on culture, x-ray, antibiotics used for treatment, indication of CAI or HAI, and that the antibiotic met the criteria [of the IST]. On 8/7/24 at 12:45 PM, in the presence of the survey team, the RN/IP stated that the orange dot on the door frame indicated to staff that resident was in an enhanced barrier precaution (i.e. residents on a Foley catheter). At that time, the RN/IP stated that there were a handful of residents with chronic urinary tract infections, their sign and symptoms were monitored closely, the Mc Geer's criteria were used as the IST. At that time, the surveyor asked how residents with recurrent UTI and prescribed multiple antibiotics were tracked to prevent the occurrence of an MDRO. At that time, the RN/IP stated that she had to establish a recurrent use of antibiotic to identify which resident had a higher risk of infection with a MDRO and overuse of an antibiotic. The RN/IP stated she would work on that and confirmed it was not done prior to surveyor inquiry. On 8/8/24 at 12:40 PM, during an interview with the survey team, the RN/IP stated that that Resident #7 had a complicated UTI, had multiple antibiotics and after MDRO was identified she did not provide education relating to the discovery or prevention of an MDRO. The RN/IP acknowledged that they should have. 4.) The surveyor reviewed the Antibiotic Stewardship Tracking Forms. A review of the June 2024, epidemiology reflected five resident's names and revealed that (2) two of (5) five residents were positive for a pathogen (organism) Escherichia coli (E. coli) and one (1) of (5) five was positive for Enterobacter cloacae complex. A review of the May 2024, epidemiology reflected five resident's names and revealed that (3) three of (4) four residents were positive for a pathogen (organism) E. coli. A review of the April 2024, epidemiology reflected five resident's names and revealed that (2) two of (4) four residents were positive for a pathogen (organism) E. coli. On 8/8/24 at 12:40 PM, in the presence of the survey team, and the RN/IP the surveyor asked the RN/IP to provide evidence of ongoing analysis of surveillance data for organisms and documentation of follow-up activity in response to collected data. The RN/IP stated that E. coli was from feces and that the CNAs were probably not cleaning residents from front to back but did change manufacturers for the incontinence pads and could not specify the time frame when it occurred. At that time, the RN/IP stated that she had not provided education to the staff regarding the source, prevention, or evidence of the lab data from April 2024 to June 2024 of the E. coli pathogen within the reports. On 8/8/24 at 1:29 PM, in the presence of the survey team, the Licensed Nursing Home Administrator, the Administrator in Training, the Regional Consultant, the DON, and the RN/IP, the surveyor discussed the above concerns regarding the antibiotic stewardship program. No further information was provided. NJAC 19.4(d) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, it was determined that the facility failed to ensure that all licensed staff received training and competencies in accordance with the Facility Assessment, and to ensure facility policies and procedures for wound care competencies were met. This deficient practice was identified during an Initial Certification Survey for 1 of 7 Residents sampled for wound care (Resident #1) and one closed medical record (Resident #2). The deficient practice effected 2 of 2 Resident Units and was evidenced by the following: On 08/07/24 at 9:09 AM, during the facility entrance conference the surveyors requested a list of all the residents who received wound care. The Director of Nursing (DON) stated there was one resident (Resident #1) who received wound care treatments three times per week, and it was completed by the Wound Care Nurse. The DON stated there were no daily wound treatments provided at the facility. On at 08/07/24 at 9:45 AM, the surveyor toured the Long-Term Care Unit and the unit identified as the Dementia Unit. The surveyor observed Resident #2 in bed propped with supportive pillows. The resident was non-verbal. The surveyor interviewed the LPN in charge of Resident #2's care. The LPN stated that Resident #2 had a wound to the sacral area that was cared for three times weekly by the wound care nurse. The nurses were responsible for wound care on the other days. On 08/07/24 at 10:20 AM, the Licensed Nursing Home Administrator (LNHA) provided a copy of the Facility assessment dated [DATE]. The Facility Assessment revealed the requirement, purpose, and the competencies and training required by staff to provide care for residents competently during both day-to-day operations and during emergencies. The facility assessment contained staff training/education and competencies that were necessary to provide care and services to their resident's population and the resources the facility needs to care for their residents. The Facility Assessment included staff certification requirements, hiring, Certified Nursing Assistant (CNA) skill Competency Checklist, Orientation Checklist for Registered Nurse (RN) and Licensed Practical Nurse (LPN) training, competency instruction, and testing policies. All staff members were to be provided with annual education and competencies that are necessary to their job responsibilities. The Current Competencies by Department listed RN/LPN and 4 competencies that included: Medication Administration Observation, Mechanical Lift, Handwashing and Heimlich. There were no wound care competencies listed. Additionally, the LNHA provided staff training which including monthly computer education topics which did not include wound care. On 08/07/24 at 11:10 AM, the surveyor interviewed the wound care nurse (RN) who happened to be at the facility that day. The RN stated that Resident #1 had an unstageable wound to the sacral area that required packing. The surveyor requested a copy of the wound care order. On 08/07/24 at 11:20 AM, the surveyor received a copy of the wound care treatment order. The order revealed a daily wound treatment order: Cleanse with Dakin's (topical antiseptic used to treat and prevent infections in wounds.) Solutions ¼ solution, gently packed with Dakin's moistened gauze, cover with sterile 4 x 4 gauze and dry dressing daily. On 08/07/24 at 11:30 AM, the surveyor interviewed the LPN (LPN #1) and inquired regarding having received a wound competency to ensure that the daily wound treatment was appropriately applied. The LPN #1 stated that she observed the wound care nurse performing wound care several times and that she thought she was able to perform wound care thereafter. When inquired if the facility had deemed that she was competent to perform wound care, she stated, No. She added that had not completed a competency evaluation. On 08/08/24 at 8:40 AM, the LNHA provided the surveyor with a Wound Care Policy, dated 8/2024 which revealed: Training Requirements: Nurse Orientation, Annual Nurse Competencies with a blank Competency Skill Checklist for a wound dressing change attached. On 08/08/24 at 10:30 AM, the surveyor was unable to observe wound care for Resident #2, the LPN (LPN #2) stated that the wound care was already completed during morning care. The surveyor then interviewed LPN #2 regarding wound care competencies. LPN #2 stated that she was provided with a competency form to sign this morning (08/08/24) and stated she had not been observed performing wound care. 2. The surveyor reviewed the closed medical record for Resident #2. The admission record reflected that Resident #2 was admitted with a surgical wound to the left cervical area (neck) that required daily dressing change. The staff was to wash the wound with soap and water and applied silver sulfadiazine 1% topical cream, cover with Telfa [non-adherent dressing], Gauze and ABD [abdominal gauze pad] Pad once daily, secure with tape. A progress Notes signed by the RN/ICP (Infection Control Preventionist) dated 06/14/24 revealed the following: Left neck wound is draining large amount of fluid with a strong odor. Keep a washcloth under the shirt and gown to absorb drainage. (There was no documentation regarding that the physician was notified of the wound drainage and that the physician ordered a washcloth to be used to contain the drainage.) A nurse progress note, dated 6/23/24, revealed that the soiled dressing was noted with yellow and green drainage. A nurse progress note, dated 07/01/24, revealed that during wound care, the wound care nurse informed the facility that Resident #2 had flies in the room. On 07/02/24, a note entered by the DON revealed that she consulted the wound care nurse who suggested to pack the wound to absorb the copious amount of drainage. The resident had been at the facility since 06/14/24 and the wound had been documented as draining. There was no documentation that the wound care nurse provided any education to the staff regarding packing a wound. On 08/08/24 at 12:27 PM, the surveyor asked the DON to elaborate on her expectations regarding wound care documentation when treatment was rendered or care provided. The DON stated, staff should monitor and document the wound condition in the progress notes. The DON stated, she was not aware that staff failed to enter documentation regarding the wound following wound care and stated, I don't know how it could not be, when referring to the lack of documentation regarding the draining wound. The DON confirmed there was no staff education or competencies related to wound care. On 08/08/24 at 12:30 PM, the surveyor inquired to the DON and LNHA, in the presence of the survey team, regarding who was responsible for ensuring staff was competent. The LNHA informed the survey team that there has not been anyone fulfilling a staff educator role at the facility. He added that the DON and the ICP were responsible for the staff education. The surveyor then inquired regarding staff competency specially for wound care. The DON stated that she did not have the competency form that had been previously provided to the surveyor on 08/08/24 at 8:40 AM. The DON confirmed that she did not document staff wound care competency. On 08/08/24 at 12:40 PM, the surveyor reviewed the yearly mandatory training provided by the facility based on the facility assessment. The yearly competency skill checklist for wound care covered clean dressing change only. The competency checklist did not include directives related to wound packing. On 08/08/24 at 1:15 PM, the survey team requested education and staff competencies for hand hygiene, wound care or any infection control related competencies for all staff. The LNHA was unable to provide in-services education and completed competencies. The LNHA stated the facility utilizes an online education system and the staff were to complete the requirements. The surveyor specifically asked about wound care competencies related to the LPN #1 and #2's interviews, who both stated that they did not complete competencies on wound care. The DON stated she looked through the yearly education calendar and confirmed that wound care was not included as part of the computer education also. NJAC 8:39-33.4