**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ 175572 Based on interview, record review and review of pertinent documents it was determined that the facility failed to ensure thorough investigations were conducted to ensure abuse or neglect had not occurred for a) a resident who was identified as having a new stage 3 wound that was identified during an outpatient (outside) physician visit conducted on 5/22/24 (Resident # 147), b) when a severely cognitively impaired resident was found laying on the floor in a pool of blood, from an unwitnessed fall that resulted in a head injury and required emergent transfer to the hospital on 6/2/25 (Resident #25), c.) Resident #44) who sustained an unwitnessed fall in the bathroom, and blood was also identified at the bedside on 11/4/24; and on 2/9/25 sustained another unwitnessed fall with skin tear. This deficient practice occurred for 3 of 3 residents reviewed for investigations and was evidenced by the following: a. On 6/18/25 at 4:10 PM, the surveyor reviewed the closed medical record (Electronic and Paper) for Resident #147. According to the admission Record, Resident #147 was admitted to the facility with diagnoses which included but were not limited to; Cirrhosis (a condition in which the liver is scarred and permanently damaged) of liver, Lymphedema (a long-term or chronic condition that causes abnormal and persistent swelling in your body), difficulty in walking and weakness. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 5/1/24, revealed that Resident #147 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. Further review of the MDS indicated that Resident #147 did not have any pressure ulcer to the Left hip upon admission. A review of the Nursing admission Evaluation (head to toe assessment) completed on admission, and dated 4/24/24 at 4:00 PM, reflected under skin condition, on page 2, that Resident #147 had redness to sacrum, peri area, redness to bilateral heels . and Right hip open area. There was no documented skin impairment to the Left hip area. A review of a wound consultation report dated 5/22/24, revealed the following: the patient has New pressure ulcer (PU) on Left hip area probably from wheelchair. The wheelchair is too small. The patient needs a Bariatric wheelchair to accommodate their size. Ulcer is Stage 3. (Stage 3 ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer). There were no measurements for left hip stage 3 pressure ulcer documented on the consultation report. The facility did not measure Resident #147's PU upon return from the consultation. On 6/18/25 at 9:18 AM, the surveyor interviewed the Registered Nurse (RN #1) who stated a head to toe skin assessment was completed twice a week during shower days for all residents. RN #1 further stated the Certified Nurse Aide (CNA) would call the nurse during morning care if the resident had any new skin issues, then the nurse would assess the resident's skin and document any skin breakdown. RN #1 stated the nurse would initial the TAR if the skin was intact. If a skin breakdown was observed, the nurse would write a note and entered in the back of the TAR the documentation regarding the skin breakdown. On 6/24/25 at 10:45 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) in chrage of the unit. The LPN/UM confirmed that skin assessments were completed by the nurses twice a week during the shower days. The LPN/UM further stated there was an order in the Treatment Administration Records (TARs) to complete skin assessments, and if there were any alteration in skin integrity, the nurses would document and complete an incident report in the computer. The LPN/UM added, nurses were to complete a skin assessment on Day 1 (upon admission) and if a resident had any wounds, skin conditions/ alterations including edema (swelling) upon assessments all skin alteration would be documented. The LPN/UM further stated, if the resident had a new alteration to their skin during an assessment, that would also be documented. If the skin was not open, there would not be any measurements, but if the skin was open and it was measurable then the measurements would be documented. The LPN/UM stated if the resident was admitted with open skin/wounds, incident reports are not done but any skin alteration would be documented. The wound Care Team would be consulted depending on the severity of the wound. The LPN/UM stated she was familiar with Resident #147. The LPN/UM showed the surveyor the handwritten Receiving Report from the Hospital Form dated 4/24/24, which did not reflect any skin alterations to Resident #147's Left hip. The LPN/UM stated that her expectation from the admitting nurse would be to perform a head to toe assessment upon admission and document any skin breakdown. The surveyor inquired about the Stage 3 Left hip PU which was identified by the outside consultant physician on 5/22/24. The LPN/UM stated, I do not believe that it was measured after the resident returned from their visit. The LPN/UM stated Resident #147's shower days were Wednesdays and Saturdays, and resident had shower on Wednesday 5/22/24, before the resident went out for their vascular wound consult. The LPN/UM stated that the nursing staff was expected to do skin assessment on the shower days. In the presence of the surveyor, the LPN/UM reviewed the TARs, and could not find any documentation regarding the Stage 3 pressure ulcer identified during the vascular consultation. The nurse initialed the TAR that Resident #147 had intact skin prior to their outpatient vascular wound consult on 5/22/24. On 6/24/25 at 1:27 PM, the LPN/UM stated that she was not at the facility on 5/22/24 during the resident assigned shower day and could not comment on the incident. The LPN/UM further stated the recommendations from the vascular wound consult were reviewed by the nurse and discussed with the Nurse Practitioner (NP). The surveyor then inquired if the Left hip wound was measured upon Resident #147's return to the facility and the LPN/UM stated, I don't believe there were any measurements. The LPN/UM stated that the Director of Nursing (DON) was responsible for investigating new wounds. On 6/24/25 at 2:15 PM, two surveyors interviewed the DON and the Regional Nurse, the DON stated the skin assessments were performed on shower days. The Regional Nurse stated if the CNA observed any skin discoloration on shower days, they would notify the nurse because CNAs were not allowed to assess. The Regional Nurse further stated if Resident #147's skin was intact during the shower day of 5/22/24 and the resident returned with a Stage 3 PU to their Left hip, the wound should have been assessed, measured and an investigation should have been completed. On 6/25/25 at 8:50 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON and presented the above-mentioned concerns. The DON stated, I was not aware of the Stage 3 PU to Left hip. The DON further stated that she was not made aware of the wound consult that identified the new stage 3 PU to Resident #147's Left hip. The surveyor reviewed the TAR with the DON, and the DON verified that there were no measurements for the Stage 3 PU. The DON informed the survey team that the nurse who received and reviewed the recommendation, should have completed an incident report, measured the wound and report the incident to the Unit Manager for follow up. The DON acknowledged that she did not investigate Resident #147's wound. On 06/25/25 at 11:54 AM, during the pre-exit conference the LNHA and the DON informed the survey team that they did not have any additional information to present regarding Resident #147's wound. b. On 06/23/25 at 1:45 PM, Surveyor #2 reviewed the electronic medical record for Resident #25 which revealed: A Nurses Note signed by a Registered Nurse on 6/2/25 at 11:28 PM, which revealed details at time of fall: Occurred 6/2/25 at 17:30 (5:30 PM) in the resident's room and the resident was alone. Resident #25 was alert to self and confused. Narrative: Writer was informed by aide about resident on the floor. Writer found resident laying prone [face down] in room, head in a pool of blood on the floor. Further assessment revealed a hematoma (bruise) to the forehead of the resident. Wound was cleansed with NSS (normal saline solution) and pressure dressing applied. A 911 call was made and Resident #25 was transferred to the emergency room. A review of the Face Sheet (an admission summary) for Resident #25 revealed the resident was admitted with diagnoses including, but not limited to; Displaced intertrochanter fracture of the right femur, vascular Dementia, displaced fracture of second cervical vertebrae, bipolar disorder, difficulty in walking, and cognitive communication deficit. A review of the Initial Care Plan for Resident #25, Effective: 5/12/25, revealed a Problem: Resident at risk for falls. Requires assistance with transfers and physical functioning due to weakness and functional limitation of a fractured right hip and psychotropic drug use, dated 6/2/25; Fall in room, head injury sent to emergency room, Active 5/12/25; Goal: Will not have fall related injuries falls in the next 30 days, Active 5/12/25; The following Interventions, Active as 5/12/25: Administer psychotropic medications as ordered and monitor for side effects; Assist with transfers and with physical functioning; Ensure a safe and clutter free and well lighted environment; Lower bed to the floor. Provide frequent staff monitoring. Verbal and visual reminder to use call bell for assistance; Place call bell within reach and encourage to call for assistance; Tap call bell. A review of the admission MDS (an assessment tool) dated 4/22/25 revealed a Brief Interview for Mental Status Score of 1 which indicated a severely impaired cognitive status. A review of the physician order sheet for 6/1/25-6/30/25 revealed the following: Divalproex, 125 mg capsule, delayed release sprinkle (1 capsule), three times per day, Order Date: 4/21/2025; Instructions: Diagnoses Bipolar Disorder was administered on 6/2/25 at 13:00 (2:00 PM) for the Behavior Symptom: Paranoia (extremely suspicious of others, believing others are trying to harm you). On 6/23/25 at 2:00 PM, Surveyor #2 requested all investigations for Resident #25. On 6/23/25 at 2:29 PM, the Charge Nurse (CN) provided one investigation for Resident #25, and confirmed it was the only investigation and it was the entirety of the investigation which was dated 6/2/25 at 5:30 PM. The investigation revealed: Type: Fall; Location: Resident Room; Witness/es: None; Cognition prior to occurrence: Confused; Cognition after occurrence: Confused; Injuries: Head Trauma; Location: Center side of Forehead; Details: Head Injury: Hematoma to forehead; Immediate Actions Taken: Pressure dressing applied, Notified immediate supervisor, Fall risk assessment completed, Placed in wheelchair, Pain assessment; Notes: Entered by Registered Nurse (RN #1) at 9:24 PM, Writer was informed by aide about resident on the floor. Writer found resident lying prone in room, head in a pool of blood on the floor. Further assessment revealed a hematoma to the forehead of the resident. Wound was cleansed with [normal saline solution] and pressure dressing was applied. A 911 call was made and resident was transferred to the [emergency room] for further evaluation. Resident statement of what happened written by resident entered by RN on 6/2/25 at 9:24 PM: Resident is confused at baseline but reports [they] were responding to a call by someone who told [them] to get out of [their] chair. Witness statement: N/A; Fall type: Found on floor; Position on Floor: [Left Blank]; Independent for toileting: no; Care prior to fall: visually observed 6/2/25 at 5:15 PM; Preventative measures at time of fall: Call light: off; Conclusion: Completed by the DON on 6/3/25 at 8:13 AM; Nursing supervisor alerted that resident noted on the floor. Nursing supervisor observed resident laying on the floor in prone position with head on the floor in a pool of blood. Resident assessed. Vitals signs [within normal limits]. Full range of motion noted to all extremities. Hematoma noted to forehead with fresh red blood. Area cleansed and pressure dressing applied. [Physician] and family notified. New order to send resident to [emergency room] for evaluation at treatment. Resident transferred via 911 at approximately 5:45 PM. Resident returned to facility at approximately 10:05 PM. All x-rays and scans negative. Physician and family notified of return to facility. Resident encouraged to call for assistance. All safety precautions in place and maintained. Care plan reviewed and updated. Medications reconciled. Root Cause: Factual description of incident added to nurse note, Due to resident action or internal risk factors: N/A; Resident state of motion at time of fall, Transferring; How many staff were in assistance, 2; Staff Interviews: No staff interviews available; Recommendations: none noted. One Individual Statement was attached to the investigation, dated 6/2/25, which revealed: room [ROOM NUMBER] at 5:30 PM, I went into resident's room to leave dinner tray and found resident on the floor. I immediately informed nurse on duty. There was no documentation in the investigation when the resident was last toileted or given fluids as both areas were documented as N/A, in the section Care Plan Prior to Fall although the resident was documented as no for independent with toileting. A review of the facility provided emergency room record dated 6/2/25, revealed CT (Computed Tomography- a detailed picture using scans and computer) of the head revealed There is a large area of left frontal scalp swelling with hematoma measuring approximately 4.5 X 3.7 centimeters. On 06/25/25 at 9:16 AM, Surveyor #2 informed the DON and LNHA of the above findings and asked what was the root cause for the fall that resulted in 911 transfer. The DON reviewed the incident report and statement and stated the Certified Nurse Aide found the resident on the floor when she went to pass the meal tray and the DON stated that the resident was confused. The DON stated the resident told RN #2 that someone told them to get out of the chair, The DON further stated that was the cause of the fall. The facility did not identify the causal factor of the fall. No other information was provided. c. On 06/18/25 at 1:12 PM, Surveyor # 2 reviewed the closed electronic medical record for Resident # 44 which revealed a Care Plan, Effective 9/10/24, with a Problem: Recent fall prior to admission, at risk for further falls due to difficulty with transfers and ambulation, weakness following hospitalization; 11/4/2024, Fall in bathroom skin tear to right elbow. A review of the Face Sheet (an admission summary) revealed the resident had diagnoses which included, but were not limited to; vascular Dementia, altered mental status, repeated falls, cognitive communication deficit, history of falling, and muscle weakness. The Quarterly MDS dated [DATE] revealed the resident was moderately cognitively impaired and required assistance for bed mobility, transfer and toileting. At that time, Surveyor #2 then requested all investigations for Resident #44. On 6/19/25 at 9:00 AM, Surveyor #2 reviewed the electronic medical record, the paper closed medical records along with two investigations provided by the facility which revealed the following: 1. On 11/4/24 at 12:35 AM, Resident #44 was confused and sustained an unwitnessed fall and sustained a skin tear to the right elbow, circular, measuring 1.1 x .5 centimeters (cm). The Nurses Note of what happened was documented by RN # 1 on 11/4/24 at 2:40 AM, which revealed: Aide called writer's attention about resident on the floor. Writer found resident on the floor in [their] bathroom, sitting up with [their] back against the toilet. Resident was confused and could not recollect exactly what happened. Resident was helped back into [their] bed. Resident had a skin tear measuring 1.1 x .5 cm to right elbow. Skin tear was cleaned with normal saline and covered with [gauze]. Resident denied hitting head, denied any other pain apart from the skin tear. Neuro checks initiated . Resident statement of what happened on 11/4/24 at 2:24 AM, Resident stated [they] were trying to go to bathroom. Resident confused, sometimes non-compliant to safety measures. The Conclusion documented by the DON on 11/4/24 at 11:45 AM revealed the CNA alerted the primary nurse that resident noted sitting on the floor. Primary nurse observed resident sitting in an upright position on the bathroom floor with [their] back against the toilet. Resident assessed . Resident denies any pain or discomfort at this time. Resident denies hitting [their] head. Skin tear noted to right elbow with fresh red blood noted. Skin tear cleansed and treatment in place. Resident encouraged to call for assistance. All safety precautions in place and maintained. Care plan reviewed and updated. Medications reconciled. There was one statement attached and signed by the CNA on 11/4/24, which revealed the date and time of incident, Room # 236 on 11/4/24 at 12:35 AM. The section titled to tell us step by step in your own words what happened . revealed: Resident's bathroom call bell was on and I entered the room, and saw blood on the floor next to the bed and then saw resident on bathroom floor sitting up with back against toilet. Resident stated [they] fell when trying to go to bathroom. Resident was bleeding from right elbow area. Nurses and supervisor was made aware. Care Prior to Fall: Visually Observed, 11/4/24 at 12:10 AM; Toileted: NA; Given Fluids: N/A: Repositioned: N/A. Preventable Mesures at time of fall: call light off. 2. On 2/9/25 at 6:45 PM, Resident #44 sustained a skin tear to the left lower leg while an Agency CNA provided care and the Nurse documented on 2/9/25 at 11:31 PM, that This writer was informed by aide that resident had sustained a skin tear during care. Upon arrival resident was bleeding. Site was treated. Measuring 9 x 1 centimeter . Resident statement of what happened, doesn't know. Witness statement of what happened written by CNA, I saw a bleeding from the resident due to skin tear. Conclusion, signed by DON on 2/10/25 at 9:05 AM. Primary nurse alerted by CNA resident noted with skin tear. Primary nurse assessed resident .Skin tear noted to [left] lower leg measuring 9 x 1 cm with fresh red blood. Resident in bathroom by self when skin tear was noted. Skin tear was noted in direct line of door frame .Resident encouraged to call for assistance. One statement was attached from the Agency CNA, dated 2/9/25, which revealed: Resident was in the bathroom by self when I went to provide care. I noticed resident was bleeding due to skin tear on leg. I quickly notified the nurse of the incident around 6:54 PM. I saw bleeding from the resident due to skin tear. The investigation did not address that the CNA reported the resident sustained the skin tear during care to the nurse, and the activity that was documented as occurring was Dressing, or why the resident was found alone in the bathroom. On 06/18/25 at 2:41 PM, the survey team interviewed the Licensed Nursing Home Administrator (LNHA) who stated the DON was responsible to complete all investigations and he was responsible to ensure that an investigation was completed. On 06/19/25 at 9:28 AM, Surveyor #2 interviewed the [NAME] President of Clinical Services (VPC) and the DON, in the presence of the survey team, and inquired regarding the investigative process following an unwitnessed fall. The DON stated, the staff would alert the nurse and the nurse would complete an assessment of the resident. Surveyor #2 then asked who would be responsible to obtain statements. The DON stated the primary nurse was responsible to obtain statements from the CNA and the nurse would obtain resident's statement. According to the DON, the facility did not collect statements from any other staff on duty on the day of the incident. Surveyor #2 then asked the DON what was the purpose of an investigation? The DON replied, to investigate what happened. On 06/19/25 at 9:47 AM, Surveyor #2 read the CNA's statement regarding the incident and asked the DON if there was an investigation regarding the blood that was observed next to the resident's bed? The DON stated when she completed her investigation the following morning that she did not see the blood by the bed, and stated it was an Agency CNA. Surveyor #2 asked if the blood next to the bed was important to review and to determine what was the causal factor? The DON did not respond. Surveyor #2 then asked about the skin tear documented as happening during care, and what was determined as the causal factor of the skin tear, and what specific interventions were implemented as a result? The VPC requested to further review both investigations prior to proceeding with the surveyor inquiries. On 06/19/25 at 9:57 AM, Surveyor #3 asked the VPC when an injury of unknown origin occurs, who do you collect statements from? The VPC stated, we usually do a 24-hour look back and collect statements. On 06/25/25 at 11:54 AM, during a meeting with the LNHA and the DON, in the presence of the survey team, they did not have any additional information to provide regarding the causal factor for Resident #25 and #44's unwitnessed falls with injury, and for Resident #147's Stage 3 PU that was identified during an outpatient visit, to determine if the injuries were not related to neglect. The Incident Reporting Policy Revised 9/16/24 revealed: Purpose: Incidents are defined as any event, occurrence, situation or circumstance, which is unusual or inconsistent with the policies, practices and routine operation of the community. It may be an accident or situation which may or may not result in bodily injury and/or property damage. Policy: It is the policy of the community that all incidents are properly reported, recorded and analyzed for causative factors and trends. Corrective and/or preventative measures shall be implemented as indicated. 2. Assure incidents are recorded and reported to the proper agencies and internal departments. 3. Analyze all incidents for risk potential implementing corrective and/or preventative actions as required. Procedure: Significant Event/Injury: A resident transported to a local medical facility for treatment related to the injury event. A fall that results in a fracture and or/multiple contusions. Event/injury related death. Incident Report Investigation Forms: 1. An investigation shall be initiated on all reported incidents. An incident investigation shall be completed at the time of the incident. 2. Document in the investigation section if facts relating the cause of the incident are known. Possible causes may be investigated but not documented until substantiated by facts. 3. All staff members assigned to the unit/area on the shift the incident occurred having knowledge of the incident should completed written statements. It is not necessary to obtain written statements from everyone, only those individuals with knowledge of the incident. Written statements should document the facts surrounding the incident. All statements must be signed by the authors/writers, including any statements obtained from residents. 4. All injuries of unknown origin, including skin tears and bruising, must be investigated immediately. All staff caring for the injured resident for the past 24 hours shall be interviewed and write and sign a statement regarding their knowledge of the injury and/or whether it was present during their shift. Further investigation and statements may be necessary based on findings and analysis of information obtained. Abuse Investigation. 1. An investigation shall be initiated by the community/ facility within twenty-four hours of the discovery of a resident with any injury of a suspicious or unknown origin or receipt of an allegation of abuse . NJAC 8:39-4.1(a)(5)

Based on observations, interviews and review of facility documentation it was determined that the facility failed to a.) label, date, and store potentially hazardous foods appropriately to prevent food borne illness; b.) maintain kitchen equipment in a manner to prevent microbial growth, and c.) maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 1/30/24 at 9:54 AM, the surveyor, in the presence of a second surveyor and the Director of Dining services (DDS) toured the kitchen, and observed the following: In walk-in freezer #1: 1. A 22-quart plastic food storage container containing, what was identified by the DDS as, rice soup. The container was not labeled or dated. At this time the DDS stated, that should have been labeled. 2. One (1) opened 20-pound (lb) box of wax beans labeled with a received date of 1/15/24, containing a plastic bag of wax beans which was opened to air, to which the DDS stated it should not be opened to air like that. On a drying rack adjacent to the dish washing area were two large stainless steel mixing bowls and two clear plastic food storage containers all wet nested (stacked on top of each other while still wet). At that time, the DDS stated these should not be stored like that. On a storage rack adjacent to the three-compartment sink were four cutting boards with scrapes, gouges, and black discoloration. The DDS stated there were new cutting boards on order and had a kitchen staff member remove these cutting boards from use. On 2/2/24 at 10:10 AM, the surveyor in the presence of a second surveyor and the ADDS, observed in the emergency food supply room a one-pound bag of cereal which was not in it's original shipping box and not labeled or dated. At this point the ADDS stated it should be labeled. On 2/6/24 at 10:01 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) stated they had a new dining company and are still working out the kinks. Review of the facility's policy titled Food and Supply Storage with revised date 1/22 included but was not limited to, all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . cover, label and date unused portions and open packages. Review of the facility's policy titled Storage of Pots, Dishes, Flatware, Utensils with revised date 1/22 included but was not limited to, air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet. Review of the facility's policy titled Cutting Boards with revised date 1/22 included but was not limited to, replace all cutting boards with grooves and pits 1/8-inch or deeper that cannot be cleaned and sanitized using routine cleaning and sanitizing procedures. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to complete a thorough investigation related to an injury of unknown origin for 1 of 3 residents reviewed for accidents and incidents, (Resident #14). This deficient practice was identified by the following: On 9/01/21 at 10:11 AM, the surveyor observed Resident #14 seated in a wheelchair at the bedside. The resident had a fabric transfer sling (a device that is used in conjunction with a mechanical lift to transfer a patient between various surfaces such as a bed to chair) placed beneath his/her back and lower body in the wheelchair. The resident was very hard of hearing and was unable to be interviewed. According to Resident #14's Face Sheet (an admission summary) the resident was initially admitted to the facility in 11/2016 and had diagnoses which included but were not limited to: Alzheimer's Disease with late onset, generalized anxiety disorder, and muscle weakness. According to the Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 7/12/21, Resident #14 was readmitted to the facility on [DATE] from an acute hospital. Further review of the MDS revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 which indicated that the resident was severely, cognitively impaired and had behaviors which included rejection of care. Review of the Functional Status portion of the MDS indicated that the resident was totally dependent for transfers and required two-person assistance to transfer from the bed to wheelchair. A review of the Care Plan Report effective 7/14/21 to present, revealed that Resident #14 required help with activities of daily living (ADLs) due to cognitive deficits related to Alzheimer's diagnosis. An intervention was added to the entry on 5/13/21 for two-person assistance with transfers via Hoyer Lift. Further review of the Care Plan Report included another entry which specified that the resident was at risk for alteration in skin integrity secondary to needing assistance with ADLs, incontinence of bowel and bladder, and was on medications which may cause bruising. The entry included: 6/23/21-bruise to left great toe: x-ray negative and 6/25/21-bruise to left breast/axillary area. Goals included: Bruises to the resident's left great toe and left breast area will resolve without any complications and resident will not have a skin impairment x 90 days through 10/31/21. Interventions included: During the shower times the resident's CNA would use 2 assist to move the resident with the Hoyer lift to carry me from one place to another. The surveyor reviewed three incident investigations that pertained to Resident #14. One of which was dated 6/23/21 at 6:00 PM, which pertained to an Injury of Unknown Origin. The Registered Nurse (RN) documented that the CNA (Certified Nursing Assistant) reported a bruise on the resident's left great toe. On assessment, the nurse documented that she noted purple discoloration and swelling with resident complaint of pain with both touch and movement. The RN documented that the resident was unable to verbalize what happened and that there were no witnesses to explain the bruising. The RN documented that she notified the physician who ordered an x-ray of the resident's left foot and great toe to rule out fracture. Further review of the investigation revealed that the resident's last skin check was conducted on 6/23/21 at 8:00 AM and illustrated that the resident's skin was intact. A review of the Conclusion portion of the investigation contained in the attached Follow up Report, revealed that on 6/24/21 at 2:02 PM, the Director of Nursing (DON) documented that resident looked like he/she was going through an infection. The Root Cause was documented as no fault. In the area provided if abuse was suspected, the DON documented no. There were no staff interviews available according to the documentation reviewed. During a later interview with the surveyor on 9/07/21 at 3:19 PM, the Administrator stated on 6/23/21 the staff should have provided statements with in the past 24 hours according to facility policy to determine if there were any changes or if something occurred that caused the injury. The DON, who was present during the interview, stated that an x-ray was done of Resident #14's left foot which was negative. She stated that she concluded that the bruise that was reported on the resident's left foot was related to a history of gout (a disease in which defective metabolism of uric acid causes arthritis in the smaller bones of the feet). She stated that she thought that maybe it was an infection in that toe. She further stated that the staff should have been interviewed and thought that maybe the resident kicked somebody or something because the resident kicked a lot. She concluded by stating that if she had viewed the proper description of the affected area then she would have interviewed the staff as required. The DON could not provide documented evidence of infection when requested. The surveyor reviewed the facility policy, Abuse (Elder Abuse) (Revised 10/12/2020) which revealed the following: Guidelines for recognizing an Abused Elder: Unexplained bruises. A written report will be submitted to: New Jersey-the Office of the Ombudsman and the State Department of Health within 72 hours. The Administrator and/or a nursing supervisor will conduct a thorough investigation. The investigation will include but not be limited to, .interviewing all staff, elders and visitors who are believed to have knowledge of the event .Also, a review of any past allegations, patterns of unexplained injuries, or unusual events will be conducted if appropriate. All bruising or injuries of unknown etiology will be investigated in a manner similar to patient/elder abuse or neglect. The surveyor reviewed the facility policy, Incident Reporting (Revised 02/01/21) which revealed the following: Policy: It is the policy of the community that all incidents are properly reported, recorded and analyzed for causative factors and trends. Corrective and/or preventative measures shall be implemented as indicated. Assure incidents are recorded and reported to the proper agencies and internal departments. Procedure: Incident Documentation: All sections of the form must be completed. State Notification: Unexplained injury. Significant Event/Injury: A resident transported to a local medical facility for treatment related to the injury event. NJAC 8:39-4.1(a)5

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to perform a wound treatment in a safe and sanitary manner for 1 of 1 nurse observed providing a wound care treatment to 1 of 1 resident, (Resident #2). This deficient practice was evidenced by the following: On 8/31/21 at 11:39 AM, the surveyor observed Resident #2, nonverbal, seated in a recliner chair in his/her room, with a dressing to the left elbow and left wrist. According to the Face Sheet, Resident #2 was admitted to the facility in 09/2019 with diagnoses that included but were not limited to: Parkinson's Disease (a progressive disease of the nervous system), dysphagia (difficulty swallowing) and Transient Cerebral Ischemic Attack (temporary blockage of blood flow to the brain). A review of Resident #2 Quarterly Minimum Data Set (MDS), an assessment tool, dated 5/20/21, revealed that the resident's Brief Interview for Mental Status (BIMS) score of 8 indicated that the resident had moderate cognitive impairment. A review of the skin portion of the MDS indicated that the resident had skin tears. Further review revealed the resident required extensive to total dependency for bed mobility, dressing, toilet use and personal hygiene. On 9/07/21 at 09:46 AM, the surveyor observed the Registered Nurse (RN) perform wound treatments on Resident #2 and observed the following: The surveyor observed the RN remove a pair of metal scissors from her pocket. She then applied alcohol-based hand rub (ABHR) on a piece of gauze, cleaned the scissors and placed them on the over bed table. She then donned gloves and used the scissors to remove the dressing from Resident #2's left elbow. The RN removed her gloves, without performing hand hygiene, walked to the treatment cart, reached into her pockets for the keys to open the cart, and removed a roll of one inch tape. She placed the tape on the overbed table with the other wound care supplies. She then performed hand hygiene and donned gloves. The RN, with gloved hands, used the bed controller to elevate the resident's head. She picked up the plastic garbage bag, that had fallen on the floor. The RN, without changing gloves or performing hand hygiene, removed a piece of 4 x 4 gauze from a cup that contained normal saline solution and several other 4 x 4 gauze in it. Wearing the same gloves, the RN removed the gauze from the cup and separated one piece of gauze. She then returned the remaining gauze to the cup and cleansed the skin tear on the left elbow. She removed the gloves and performed hand hygiene. She donned gloves, then removed a piece of gauze from the same cup and cleansed the skin tear on the left wrist. She removed the gloves and performed hand hygiene. She opened a bacitracin packet and squeezed the bacitracin on a piece of folded gauze. The RN did not apply gloves before applying the gauze to Resident #2's skin tear and covering the skin tear with a non-adherent dressing. When interviewed that day, the RN stated she usually used disinfectant wipes to clean the scissors and did not know why she used the ABHR. When asked about not wearing gloves and cross contamination during the wound care, she stated she did not remember doing those things and she was nervous. She stated she would normally wear gloves and should have worn gloves during the wound care. During an interview with the surveyor on 9/07/21 at 1:55 PM, the Director of Nursing (DON) stated the RN should not have used ABHR to clean the scissors and she should never perform treatments with bare hands. On 09/07/21 at 03:30 PM, the surveyor informed the Administrator of the findings. The surveyor reviewed the facilities policy titled, General Guidelines Wound and Skin Care dated 07/22/21, which revealed the facility would use clean technique when performing dressing change. The surveyor reviewed a Clean Dressing Competency used by the facility which revealed a clean pair of gloves should be used when cleaning wound, performing treatment, and redress wounds. Further review revealed the overbed table should be cleaned with germicidal wipes. NJAC 8:39-19.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to report three injuries of unknown origin to the New Jersey Department of Health (NJDOH) for 1 of 3 residents reviewed for accident and incidents (Resident #14). This deficient practice was evidenced by the following: On 9/01/21 at 10:11 AM, the surveyor observed Resident #14 seated in a wheelchair at the bedside. The resident had a fabric transfer sling (a device that is used in conjunction with a mechanical lift to transfer a patient between various surfaces such as a bed to chair) placed beneath his/her back and lower body in the wheelchair. The resident was very hard of hearing and was unable to be interviewed. According to Resident #14's Face Sheet (an admission summary), the resident was initially admitted to the facility in 11/2016 and had diagnoses which included but were not limited to: Alzheimer's Disease with late onset, generalized anxiety disorder, and muscle weakness. According to the Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 7/12/21, Resident #14 was readmitted to the facility on [DATE] from an acute hospital. Further review of the MDS revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 which indicated that the resident was severely, cognitively impaired and had behaviors which included rejection of care. Review of the Functional Status portion of the MDS indicated that the resident was totally dependent for transfers and required two-person assistance to transfer from the bed to wheelchair. A review of the Care Plan Report effective 7/14/21 to present, revealed that Resident #14 required help with activities of daily living (ADLs) due to cognitive deficits related to Alzheimer's diagnosis. An intervention was added to the entry on 5/13/21 for two-person assistance with transfers via Hoyer Lift. Further review of the Care Plan Report included another entry which specified that the resident was at risk for alteration in skin integrity secondary to needing assistance with ADLs, incontinence of bowel and bladder, and was on medications which may cause bruising. The entry included: 6/23/21-bruise to left great toe: x-ray negative and 6/25/21-bruise to left breast/axillary area. Goals included: Bruises to the resident's left great toe and left breast area will resolve without any complications and resident will not have a skin impairment x 90 days through 10/31/21. Interventions included: During the shower times the resident's CNA (Certified Nursing Assistant) would use 2 assist to move the resident with the Hoyer lift to carry me from one place to another. The surveyor reviewed an incident investigation dated 3/16/21 at 8:00 AM, which detailed that it was related to a Skin Issue that was described as a bruise on Resident #14's left side of chest and further detailed that there was a reddish purple bruise to the left lateral breast and axilla that measured 12 x 7 x 0 cm. Immediate Actions Taken included pain and skin assessment. The Nurse's Note of what happened portion of the form detailed that the CNA who provided morning care to the resident called the nurse to inspect the resident's skin and a bruise to the left lateral side of the breast and axilla which had discoloration described as reddish purple with yellowing to the outer perimeter with no mass noted under the discoloration upon palpation (when pressed upon). Further review of the document revealed that there were no witnesses to the event and the resident was unable to explain what happened. The nurse documented that the resident demonstrated no sign of discomfort at that time and both the resident's family member and physician were notified. Review of the Conclusion portion of the form revealed that Resident #14 was alert and able to make his/her needs known and denied any trauma when interviewed. Through investigation, it was identified that some staff used the Sit to Stand in which the straps fit underneath bilateral armpit and hoyerlift device in which resident was positioned on a sling device and mechanically lifted and applied no contact to the armpit. The resident was assessed by PT (Physical Therapy) and identified to be a Hoyerlift only for safety on an unspecified date. All staff were in-serviced on the preferred technique for transfer. The resident was noted to have been on aspirin therapy. The surveyor reviewed a second incident investigation dated 6/23/21 at 6:00 PM, which detailed that it was related to an Injury of Unknown Origin, that was described as a bruise on Resident #14's left great which further detailed a purple bruise and swelling. Immediate Actions Taken included the following: Pain when ROM (range of motion) performed, pain and skin assessment, physician notified and an x-ray was ordered to rule out fracture of the left foot and great toe, and the Administrator was notified. The Nurse's Note of what happened portion of the form detailed that the CNA reported a bruise on the resident's left great toe. On assessment, the nurse noted purple discoloration and swelling. Resident complained of pain to touch and movement. Physician was notified, a new order for x-ray of left foot was obtained and the resident's family was notified. Further review of the form revealed that the resident was unable to verbalize what happened and that there were no witnesses to the event. Review of the Conclusion portion of the form revealed that the resident looked like he/she was, going through an infection. The surveyor reviewed a third incident investigation dated 6/25/21 at 6:20 PM, which detailed that it was related to a Skin Issue that was described as a bruise on Resident #14's left upper arm. The Nurse's Note of what happened portion of the form detailed that the assigned aide requested that the nurse assess the resident's left arm in the axillary region (armpit). The nurse documented that that the resident had a bruise to the left axillary, left breast was swollen with discoloration, lump on top of left breast, tender to touch and warm and the resident screamed when the nurse assessed the area. Further review of the entry, revealed that the resident was disoriented and not able to explain how the bruise occurred. The nurse documented that the physician was called and ordered to transfer the resident to the hospital for further evaluation. She documented that the DON (Director of Nursing) was notified. Further review of the document revealed that there were no witnesses to the event. During an interview with the surveyor on 9/07/21 at 10:54 AM, the surveyor asked the DON if the facility reported the injuries that were detailed in the incident investigations that pertained to Resident #14 which were dated 3/16/21, 6/23/21 and 6/25/21 to the NJDOH or Office of the Ombudsman for the Institutionalized Elderly. The DON then asked the LNHA in the presence of the surveyor if the aforementioned incidents were reported and he stated that he had not reported any reportable events to the NJDOH since November 2020. The DON further stated that when Resident #14 was sent to the hospital for swelling and bruising, initially, we thought that it was a fall, then we thought someone fought her. She stated that the facility did not immediately know that it was not abuse until after the hospital was called and reported that the resident was being observed for a mass, then the facility decided to view the cameras. She stated that she might have reported the incident. She further stated that the Administrator was responsible for reporting, but stated, I can too. During an interview with the surveyor on 9/07/21 at 11:50 AM, the Administrator stated that on 6/25/21 he was informed by the Registered Nurse (RN) when he phoned the facility to check on staffing, that Resident #14 had a bruise and the physician wanted to send the resident out to the hospital to evaluate a mass. He stated that he needed to do an investigation. He stated that he was able to see the hospital documentation in real time and saw that that the resident had a mass. He stated that he did not suspect abuse, so he did not call the DOH to report suspected abuse. He stated that he based his decision according to the information that was provided to him. The surveyor asked the Administrator why he reviewed the camera footage if abuse was not suspected? He stated that he viewed the camera to determine the cause of the mass and bruising. The surveyor reviewed the facility policy, Abuse (Elder Abuse) (Revised 10/12/2020) which revealed the following: Guidelines for recognizing an Abused Elder: Unexplained bruises. A written report will be submitted to: New Jersey-the Office of the Ombudsman and the State Department of Health within 72 hours. The surveyor reviewed the facility policy, Incident Reporting (Revised 02/01/21) which revealed the following: A completed Reportable Event Form, Incident Investigation Form and any collaborating statements shall be sent to the NJHHSS and the Office of the Ombudsman for the Institutionalized Elderly within 72 hours. NJAC 8:39-9.4(f)

Based on observation, interview and review of facility documentation it was determined that the facility failed to: a) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses; and, b) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 8/31/21 from 9:42 AM until 10:46 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. In the freezer there was one 18.75 pound unsealed, opened box of cinnamon roll dough with the inner clear plastic bag opened with the rolls visible and exposed to air and no opened date. There was one 20 pound unsealed, opened box of oatmeal raisin cookies that were dated opened 8/16 with the inner clear plastic bag opened and the rolls visible and exposed to air. There was one 18 pound unsealed, opened box of Italian loaf rolls with the inner clear plastic bag opened with the rolls visible and exposed to air and no opened date. There was one opened, unsealed brown bag that the FSD identified as French fries that were not labeled or dated. There was one clear plastic bag of French fries wrapped in clear plastic wrap that had no open date. During an interview at that time, the FSD acknowledged the boxes should have opened dates so they know the food items are not old. 2. In the dry storage area on a metal rack, there were two 6 pound 10 ounce cans of mandarin oranges that were dented. The FSD acknowledged they were dented and moved them to the dented can section. On another metal rack, there were six tied clear plastic bags the FSD identified as cranberries with no label or dates. There was one untied clear plastic bag with contents that fell to the floor, with no label or date which the FSD identified as cranberries. On a metal rack was one opened bag of linguine wrapped in clear plastic wrap with no opened date. During an interview at that time the FSD stated the cranberries should have been sealed to keep them safe from bacteria. The FSD further stated that the cranberries and the linguini should have had an open and use by date. 3. On the spice rack there was: one opened 12 ounce jar of gumbo file spice with no open date, one opened 18 ounce jar of mild chili powder with no open date, one opened 17 ounce jar of smoked paprika with no open date, one 14 ounce jar of ground cumin with no open date, one 14 ounce jar of whole fennel seeds with no open date, and one 16 ounce jar of whole caraway seeds with no open date. The FSD acknowledged the spices did not have open dates and stated they should have been dated when opened. 4. In the free-standing ice cream freezer there was one opened 3 gallon covered container of chocolate ice cream with no open date. There was one opened 3 gallon covered container of vanilla ice cream with no open date. There was one opened 3 gallon covered container of moose tracks ice cream with no open date. The FSD stated he was unsure when they were opened and they would be discarded. 5. On the top convection oven there was a brown sticky substance on the outer panel of the right door, a brown substance on both inner glass doors and a brown substance on the surrounding trim. On the lower convection oven there was a brown substance on both inner glass doors and a brown substance on the surrounding trim. The FSD acknowledged they were dirty and stated they were cleaned weekly. 6. On the top rack of the drying rack was one third pan that was nestled on top of another pan. The FSD separated the two nesting pans where the surveyor observed moisture between the pans. The FSD acknowledged they were wet with water, stated it should be dry and removed the pan to the dishwashing area. 7. There was one large white cutting board with several thin brown lines and one large yellow cutting board with a few thin brown lines and two black smudges. The FSD acknowledged they were dirty, stated they would be cleaned, and removed them to the sanitizing sink. 8. At the cook's station was: one 6 ounce jar of rubbed sage with no opened date, one 18 ounce jar of ground cinnamon with no opened date, one 12 ounce jar of crushed red pepper with no opened date, one 18 ounce jar of mild chili powder with no opened date, and one 18 ounce jar of cajun seasoning with no opened date. 9. There was black debris on the can opener and black debris on the base connected to the counter. The FSD stated it was not clean and it should be cleaned after every use so you don't cross contaminate. 10. There was a clear plastic bag covering the meat slicer. The FSD removed the bag and the surveyor observed red and brown debris on the blade and on the food tray. During an interview at that time, the FSD acknowledged the slicer had debris and it was not clean. He stated it was important to clean and bag the slicer after use so no one gets sick. On 9/01/21 from 12:02 PM until 12:24 PM, the surveyor toured the kitchen in the presence of the Executive Chef (EC) and observed the following: 1. In the freezer was one metal dessert rack with two metal trays each containing 15 individual clear plastic containers that the EC identified as containing one sticky bun and one muffin, all with no label or date. There was one metal tray containing 10 individual clear plastic containers that the EC identified as containing assorted desserts, all with no label or date. There was one metal tray containing 5 individual clear plastic containers that the EC identified as containing assorted desserts, all with no label or date. The EC stated that the containers would be disposed of. There was one 4 inch half pan containing 15 meat patties individually wrapped in clear plastic that the EC identified as Canadian bacon, with no label and no dates. The EC threw the patties in the garbage. During an interview at that time the EC acknowledged there were no tags and stated it was important to label items correctly so everyone would know if it was good or bad, to prevent freezer burn, and so it would have an expiration date. 2. In the walk-in refrigerator there was one 4 inch six pan containing a thick red gelatinous material that the EC identified as pureed tomato with no label and no date. The EC stated it should be labeled and dated and threw it away. A review of the facility's policy General Food Preparation and Handling, with a revision date of 5/23/2018, revealed Procedure: 1.a. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. 3. Food preparation: e. cutting boards will be cleaned and sanitized after each use, following the dish machine or 3 compartment sink method, and will be air dried before storing. k. The can opener will be cleaned and sanitized daily and/or as needed. 5. Equipment: a. All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. A review of the facility's policy Food Safety and Sanitation, with a revision date of 5/30/2018, revealed 3. Bulging or leaking cans, cans with severe dents on the seams, or broken containers of food will not be used. They will be returned to the vendor or discarded. 4. Food storage: when a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. A review of the facility's policy Cleaning Dishes/Dish Machine, with a revision date of 5/30/2018, revealed Procedure: 11. Dishes should not be nested unless they are completely dry. A review of the facility's policy Cleaning Instructions: Slicers, with a revision date of 5/24/2019, revealed Policy: the slicer will be cleaned and sanitized after each use. Review of the facility's policy Accepting Food Deliveries, with a revision date of 5/23/2018, revealed Procedure: 4. Perishable foods will be properly covered, labeled and dated and promptly stored in the refrigerator or freezer as appropriate. A review of the facility's policy Food Storage, with a revision date of 5/24/2019, revealed Procedure: 3. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetable, and various bulk foods. All containers must be legible and accurately labeled and dated. 6.b. Food should be dated as it is placed on the shelves. 6.c. Food should be dated when the original container or packaging is opened. 6.d. Date marking to indicate the date or day by which a ready-to-eat, time/temperature control for safety food should be used will be visible on all high-risk food. 10.d. Refrigerated foods will be dated and stored upon delivery. 10.g. All foods should be covered, labeled, and dated. 11.c. Frozen foods will be dated upon delivery. 11.d. All foods should be covered, labeled and dated. NJAC 8:39-17.2(g)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure that staff interact with residents in a dignified and respectful manner for 2 of 14 residents reviewed, Resident #6, and an anonymous resident. This deficient practice was evidenced by the following: On 10/15/19 at 8:56 PM, the surveyor entered the room of a resident that chose to remain anonymous. The resident was sitting in bed; the head of the bed was in an upright position. The resident asked if the surveyor could hand over the large Styrofoam cup filled with water that was on the overbed table on the resident's right side. The resident tried to reach the water but was unable to grasp the cup. The surveyor asked the resident if they could reach it. The resident replied, I don't want to spill it. The surveyor suggested the resident ring the call bell. The resident said, No, Please, I already called twice from my phone. I don't want them to get mad or holler. The surveyor asked if the staff yelled at him/her. The resident then said that they didn't want to get anyone in trouble. The resident could not give names, or times of day, but added that the staff got mad at them if the resident called too much. The surveyor asked for details, but the resident was unable to provide any. The resident said that they didn't blame them, they're always very busy. The resident denied feeling afraid or intimidated. The resident said they didn't want to bother anyone. This resident, who wished to remain anonymous, did not want the surveyor to talk to anyone about what was said. On 10/17/19 at 11:00 AM, the surveyor asked the Registered Nurse (RN) at the nurse's station desk for the unit assignment. The surveyor found the anonymous resident's name on the day shift assignment sheet. The surveyor asked the RN which residents in the list of residents besides the anonymous resident were alert and oriented and able to be interviewed. The RN stated only [Resident #6]. On 10/17/19 at 11:45 AM, the surveyor interviewed Resident #6. Upon entering the resident's room, Resident #6 stated that some of the aides were nasty. The resident spoke of a Certified Nursing Assistant (CNA), that was also assigned to the anonymous resident before the surveyor asked about the attitude of the staff. The resident explained that they recently reported an incident to the Social Worker (SW). The resident explained that a few days before, they were in the bathroom and that they rang their call bell. The resident got tired of waiting, so the resident stated that he/she, Got myself, to the recliner in the resident's room. The resident reported that when the CNA came in she yelled at them and said, What are you doing with your feet up with the call bell on in the bathroom, then she walked out with her hand on her hip. As the surveyor was speaking with Resident #6, the Social Worker (SW) knocked on the door. The resident asked her to come back later. The resident stated, I asked her to come because I wanted to report something that happened last night. I was sleeping, and the CNA put my dinner on the table and walked out. She didn't even wake me up. When I woke up, my dinner was cold. I called the Registered Nurse and asked him to heat my dinner. He reamed me out, yelling that I always eat late. I don't always eat late, I was asleep when she brought my tray in, and no one woke me up. The resident added that that was the first time the RN had treated them in that way. The surveyor then asked the resident if they were afraid or intimidated by the CNA or the RN, or if the resident felt abused. The resident replied, I wouldn't describe it as abusive. The few are discourteous. They make judgments and comments that aren't nice. I'm not frightened. I don't like being angry, because I don't feel well when I'm angry. The resident explained that most of the staff were friendly, but that a couple of people were not always nice. On 10/18/19 at 9:00 AM, the surveyor reviewed the personnel files for the CNA, and the RN identified above. There were no similar incidences documented in the personnel files of the CNA or the RN. On the same day at 10:18 AM, the surveyor interviewed the SW and asked if she had an investigation of the CNA incident that had occurred a few days previously, as revealed by Resident #6. The SW stated that she wasn't aware of any incident involving that CNA other than a schedule request. The surveyor asked if she went back and spoke with Resident #6. The SW confirmed that she had followed up with the resident and provided a statement and that the resident spoke of a different CNA. According to the statement, Resident #6 requested to have the CNA in the morning, and not in the evening, because he/she felt that the CNA was less efficient in the evening. The surveyor also asked the SW if Resident #6 mentioned the incident about the RN. The SW stated, I have a voicemail from last night about how he made a face at [ Resident #6 ] when the resident was being transferred to the hospital for abdominal pain last night. The surveyor asked the SW if they could listen to the voicemail together. According to the message, Resident # 6 explained to the SW, while he/she was leaving to go to the hospital, the RN came up to the [resident], and that his eyes were very dark. Resident #6 further explained to the SW about how [the resident] told [the surveyor] about the way the RN had treated them the night before. And also, that the resident felt bad about telling the surveyor about this. Resident #6 also said that the RN had never acted this way before and that he had always been courteous. Resident #6 further stated that they had mentioned the incident involving the CNA. Resident #6 was apologetic to the SW and felt remorse for telling the [surveyor]state. After listening to the voicemail, the SW told the surveyor that Resident #6 was very rational and very sensitive to the feelings of others, so she understood that the resident was probably worried. The SW added that the resident was alert and oriented and able to express themselves. At 11:15 AM, the surveyor interviewed the RN that had been reported as being discourteous. The RN stated, [The Resident] said [the resident] wanted to change [the resident's] dinner order to scrambled eggs, mashed potatoes and butter. I went directly to the kitchen to order the food. When the food came, one of the aides took it to [the resident's] room. Later when we finished with dinner, [The resident] rang the call bell, I went there and [the resident] asked me to heat up [the resident's] food. I said [Resident # 6], you got a total of 11 units of insulin and you are not eating yet? I took the food to the microwave right away and I heat it up. It was almost an hour after [the resident] received the insulin. I said [Resident # 6] you better eat now, there is a lot of insulin in your body right now, you're going to bottom out, and I left the room. I didn't ask [the resident] no questions. The surveyor asked the RN what was the resident's response to him and he stated, [The resident] said they brought the food and [the resident] didn't know that. My thing was eat now, that's a lot of insulin, so eat now. The surveyor asked the RN if it was possible that the resident was offended by the way he spoke to them and the RN stated, No, [The resident] said [the resident] didn't know the tray was there, but at that point I wasn't even listening, I was concerned about the insulin. At 11:47 AM, the surveyor interviewed the CNA on a speaker phone, in the presence of other surveyors, about the incident reported by Resident #6. The CNA had an angry tone in her voice and stated,I don't have issues with the residents. I am there to help the resident and to give them what they need. I do not have issues with the residents. At 2:00 PM, the surveyor met with the Administrative staff and expressed the concern identified by the aforementioned residents. The surveyor then asked for any training that had been done with the RN and the CNA on Abuse, Sensitivity, Customer Service, and Dignity. On 10/18/19 at 5:00 PM, the Director of Nursing (DON) provided abuse training that the RN completed on 9/30/19, and abuse and resident rights training completed by the CNA on 7/12/19. The facility also provided a copy of a presentation that was given dated 9/3/15 and titled, Session 3, Resident Rights. Line one read: All residents are entitled to be treated with respect, courtesy, and consideration as an individual. A second presentation dated 9/3/15 and titled, Customer Satisfaction, line two under Customer Service Basics read: Treat people with courtesy and respect. Remember that every contact with a resident, family member, or visitor-whether it's by email, phone, written correspondence, or face to face meeting leaves and impression. Use the resident's proper name unless you have been given permission to use their first name. Use phrases like sorry to keep you waiting, thank you, it's been a pleasure helping you. Number four read: Never argue with a resident. You know that residents aren't always right, but instead of focusing on what went wrong, concentrate on how to fix it, and don't take it personally. There were no sign in sheets provided for these presentations. N.J.A.C. 8:39-4.1, 12

Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to provide resident privacy during a wound treatment for 1 of 2 wound treatments observed (Resident #3). This deficient practice was evidenced by the following: On 10/17/19, at approximately 10:39 AM, the surveyor observed the completion of three prior wound treatments for Resident #3. In the middle of the fourth wound treatment to the left shin of Resident #3, the Licensed Practical Nurse (LPN) medicated the resident with pain medication and then proceeded to finish the wound treatment to the left shin without closing the resident's door to provide the resident with privacy. The resident's doorway opened to the unit's hallway. After finishing the fourth wound treatment, the LPN proceeded to perform the fifth wound treatment to the left elbow of Resident #3. During the treatment to the left elbow, the LPN went to the treatment cart to obtain a border gauze dressing. The LPN then returned to Resident #3 to finish the wound treatment to the left elbow without closing the resident's door to provide the resident with privacy. On 10/18/19 at 9:46 AM, during surveyor interview, the LPN stated that it was the first time she was being watched and that she was nervous and forgot to close the door. On the same day at 1:20 PM, the surveyor reviewed the facility policy titled, Elder Rights, with a revised date of 11/28/17, which read: under Procedure: d. Privacy and Confidential Treatment, 1) To have physical privacy. You must be allowed, for example, to maintain privacy of your body during medical treatment . N.J.A.C. 8:39-4.1(a)16

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/17/19 at 9:55 AM, the surveyor observed a wound treatment for Resident #3. During the handwashing observation of the Licensed Practical Nurse (LPN), the surveyor noted the bathroom call bell, which was draped over the towel bar. On 10/18/19 at 9:25 AM, the surveyor entered Resident #3's bathroom and observed the call bell cord was again draped over the towel bar. At 9:30 AM, the surveyor showed the LPN the call bell, and the LPN stated that housekeeping probably put it there when they were changing the toilet paper roll and that they forgot to put it down. At 9:45 AM, the surveyor reviewed the most recent quarterly Minimum Data Set, an assessment tool, dated 10/17/19, which revealed the resident required two people to extensively assist him/her when toileting. At 12:36 PM, during the surveyor interview, the DON confirmed that the call bell cord should not be draped over anything and that it should be hanging straight down. The surveyor then requested a facility policy for the bathroom call bells. The facility did not provide a policy at the time of the survey exit. N.J.A.C. 8:39-27.1 (a) Based on observation, interview, and record review, it was determined that the facility failed to a.) determine a causative factor for a resident who experienced a fall for 1 of 3 residents reviewed for falls, Resident # 7; and b.) failed to ensure that the pull cord in the bathroom of a resident was accessible at all times for 1 of 14 residents reviewed for hazards, Resident # 3. This deficient practice was evidenced by the following: 1. On 10/15/19 at 8:46 AM, the surveyor observed the resident in the resident's room. The resident was in a low bed with half side rails up. The resident reported that they had a fall not too long ago and cut their finger. The resident didn't remember the details of the fall. On 10/17/19 at 10:31 AM, the surveyor spoke with the spouse of Resident #7. The spouse repeated the same event of the resident falling not too long ago when trying to get out of bed. On the same day at 10:45 AM, the surveyor reviewed the resident's record, which revealed a facesheet which indicated that the resident was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure, Weakness, Atrial Fibrillation, Anemia, Unspecified Dementia without Behavioral Disturbances, and Difficulty in Walking. The Residents most recent Brief Interview of Mental Status Assessment, dated 8/1/19, indicated that the resident scored a 10 of a possible 15, which identified that the resident had moderate cognitive impairment. The surveyor then reviewed the two fall care plans for Resident #7. One with an effective date of 7/29/19 and one with a change date of 9/16/19 that read the same and as follows: I am at risk for falls related to my needing assistance with transfer and my decline in my balance. After the 8/15/19 fall, the new intervention listed on the care plan that was dated 9/16/19 read: Maintain frequent rounding and anticipate resident's needs. The surveyor then reviewed a third care plan which read: I am at risk for falls related to my needing assistance with transfer and my decline in my balance. There was a new intervention dated 10/10/19, which read: Maintain frequent rounding and anticipate resident's needs. That was the same intervention that was initiated a month after the 8/15/19 fall. On 10/17/19 at 12:00 PM, the surveyor reviewed the fall investigation for Resident #7. The investigation indicated that the resident fell on 8/15/19 at 8:35 PM. There were no injuries identified. The nurses note on the investigation read: Writer called to resident's room [the resident] was on the floor. Upon arriving, the resident was lying supine on the floor. Vitals assessed when asked about pain, [the resident] stated that [the resident] feels pain on the buttocks, but nowhere else hurts. Further review of the investigation revealed that the fall was unwitnessed. Facility nursing staff were unsure if the resident hit their head, so 911 was called, and the resident taken to hospital for an evaluation. Under Conclusion, it read: N/A. The surveyor then reviewed a second fall investigation for Resident #7. The investigation indicated that the resident fell on [DATE] at 5:45 AM. The resident sustained a skin tear on the resident's left, 3rd finger. The nurses's note on the investigation read: Assigned CNA reported to this writer at 5:45 AM, that resident was on a floor, noted lying supine on a floor by [the resident's] bedside, surrounding assess, bed in lower position, half bilateral side rails up, call light within reach but not in use, no wet floor, no clutter. When asked how [the resident] ended up on the floor, stated, I was trying to get something. Told to remain on floor, body assessment done noted a skin tear on left hand, 3rd finger, stated, I hit my head on a floor, no swelling or hematoma noted at this time, move all extremities on commands, pupil equal and reactive to light, verbalized no pain when asked, remained in the same position, MD made aware, order to transfer resident by 911 to [the hospital] for further evaluation. [Residents spouse] made aware. 911 dispatched took resident [to hospital] at 6:15 AM. Under Conclusion, it read: N/A. On 10/18/19 at 5:00 PM, the surveyor interviewed the Director of Nursing (DON) about the conclusion related to the 8/15/19 fall. The DON stated that she was still working on it, that other falls with injuries took precedence over this resident's investigation. On the same day at 6:00 PM, the surveyor reviewed the facility's Policy and procedure titled, Incident Reporting, under Policy it read: It is the policy of the community that all incidents are properly reported, recorded and analyzed for causative factors and trends. Corrective and/or preventative measures shall be implemented as indicated: 1. Reduce risk to residents, visitors, and employees. 2. Assure incidents are recorded and reported to the proper agencies and internal departments. 3. Analyze all incidents for risk potential implementing corrective and/or preventative actions as required.

Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to identify and provide pain management for a resident that exhibited signs of pain, during a wound treatment, consistent with professional standards of practice, for 1 of 2 residents observed during wound treatments (Resident #3). This deficient practice was evidenced by the following: On 10/17/19, at approximately 10:30 AM, the surveyor observed the completion of three wound treatments to the shin, heel, and big toe of Resident #3's right leg. The resident had not complained of pain during the previous treatments. While the Licensed Practical Nurse (LPN) performed hand washing, Resident #3 stated that their leg was throbbing. The LPN said that she was sorry and that when she was done, she would give Resident #3 pain medicine. The LPN then started to remove the dressing from Resident #3's left shin. The resident was observed to make a face suggesting pain. The LPN was trying to remove the dressing, but the dressing was stuck to the resident's wound. Resident #3 stated that the nurse should stop and that the resident was done [with the treatment]. After a failed attempt to remove the dressing, the LPN poured the normal saline solution onto the dressing to help ease the removal of the dressing from the resident skin. The LPN went to try and remove the dressing when the surveyor intervened and asked the LPN if there was anything else she could do for the resident at this time. The LPN asked the resident to rate the pain at that time, in which, Resident #3 said it was a ten on a pain scale of 1 to 10, with each pain level being increasingly more painful. On the same day, at approximately 10:39 AM, the surveyor observed the LPN medicate Resident #3 with an Oxycodone 5 milligram tablet (a medication used to treat pain). The LPN then asked Resident #3 if she could finish the treatment to the left shin, and Resident #3 agreed. The LPN then finished the treatment to Resident #3's left shin. Resident #3 appeared to be asleep when the LPN placed the dressing on the resident's shin. At approximately 10:51 AM, the LPN asked Resident #3 about the pain in which the resident did not respond. The surveyor then observed the LPN start the treatment to the fifth wound, which was on Resident #3's left elbow. At approximately 10:56 AM, after finishing the treatment to the left elbow, the LPN asked Resident #3 if they were in pain. Resident #3 stated that there was discomfort, but no pain. On the same day at approximately 11:08 AM, after cleaning up the supplies from the wound treatment, the LPN again asked Resident #3 if they were in pain. Resident #3 stated that the LPN did a fantastic job. Later that same day at 1:43 PM, during the surveyor interview, the LPN stated that today was the first time that the resident had complained of pain. The LPN further stated that she never had to stop the treatment or medicate the resident for pain in the past. On 10/18/19 at 12:16 PM, during the surveyor interview, the Director of Nursing (DON) confirmed that the LPN should have stopped the treatment, covered the wound with a dressing, and medicated the resident for pain. The DON further confirmed that the LPN should have waited 30 minutes before continuing the treatment. At 2:00 PM, the surveyor reviewed the facility policy titled, Pain Management, with a revised date of 5/18/12, which read: Under Philosophy: Experiencing pain is not a natural effect of growing old. The resident's perception of and or sensitivity to pain does not decrease with age. The elderly have developed coping mechanisms to deal with pain. Therefore, even if a resident appears to be occupied, asleep, or otherwise distracted, this does not mean he/she is not experiencing pain. The nurse must use his/her assessment skills to evaluate the non-verbal cues of each resident, such as restlessness, grimacing, etc. The nurse must accept and respect the resident's reports of pain, and its severity, as the guide to Pain management. The resident is the authority on his/her pain. At 2:10 PM, the surveyor reviewed the facility policy titled, Wound and Skin Care, with a revised date of 5/4/18, which read: Under General Policy: Pain assessment is conducted during the initial assessment and is an ongoing process (i.e. prior to wound care) to ensure pain management strategies are effective. NJAC 8:39-27.1(a) N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure that Certified Nursing Aides (CNA) received 12 hours of mandatory in-service training that included dementia and abuse training for 1 of 5 CNA files reviewed (CNA #1). This deficient practice was evidenced by the following: On 10/18/19 at 11:30 AM, the surveyor reviewed the in-service education hours for five randomly selected CNA files, which were provided by the facility. The Staff In-service Logs showed the following: CNA #1 had a hire date of 4/27/18. According to the Staff In-service Log, CNA #1 had completed 6.25 hours of in-service education training in the year after her date of hire. On 10/18/19 at 11:40 AM, during the surveyor interview, the Administrator confirmed that the 1 of 5 CNA's reviewed did not have the required 12 hours in the annual period reviewed based on their hire date. N.J.A.C. 8:39-43.17 (b)

Based on observation, interview and review of facility documentation, it was determined that the facility failed to a.) properly store refrigerated controlled medications (a federally regulated drug), and b.) remove expired medication from active inventory for 1 of 3 medication carts inspected, and was evidenced by the following: 1. On 10/15/19 at 6:37 PM, the surveyor, in the presence of the Licensed Practical Nurse (LPN) #1 inspected the low side cart and found an opened bottle of liquid lorazepam (a federally regulated medication used to treat anxiety) that had been removed from the refrigerator and was improperly stored in the locked medication cart. On the same day at 6:44 PM, LPN #1 stated to the surveyor that she had not administered any lorazepam that day and that the medication must have been left in the medication cart since the administration of the morning dose. LPN #1 then stated the medication should have been stored in the medication room in the locked refrigerator and later confirmed that the lorazepam was not cold to the touch. LPN #1 also confirmed that the last dose of lorazepam was given on that morning at 7:30 AM. LPN #1 stated that the process was to remove the lorazepam from the refrigerator right before it was to be administered, and when the administration was completed, the lorazepam was to be returned and locked in the refrigerator. LPN #1 further stated that at the change of shift, the controlled medications were counted for accuracy, and she, nor the outgoing nurse, had not noticed that the lorazepam had been left in the medication cart. At 7:21 PM, the Registered Nurse/Evening Supervisor (RN/ES) stated that the lorazepam should not have been stored in the mediation cart, but that it should have been stored in the refrigerator. The RN/ES further stated that the change of shift process was the outgoing nurse and incoming nurse together counted the narcotics on the medication cart, once the count was verified the nurse handed off the medication cart key to the incoming nurse. The RN/ES stated that the nurses should have noticed that the bottle was not in the refrigerator and tried to locate it. On 10/18/19 at 10:29 AM, the surveyor interviewed LPN #2, who was the outgoing nurse assigned to the low side cart on the 10/15/19 day shift. LPN #2 stated that 10/15/19 was a very busy day and that she had taken the lorazepam out of the refrigerator around 2:00 in the afternoon, in anticipation of the controlled medication count at shift change. LPN #2 stated that she had a lot going on and had forgotten to return the lorazepam to the refrigerator. The surveyor then reviewed the manufacturer recommendations for Lorazepam Oral Concentrate, which revealed that it should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and that an opened bottle should be discarded after 90 days. 2. On 10/15/19 at 8:12 PM, the surveyor, in the presence of LPN #3, inspected the middle cart. In a medication drawer, the surveyor located an opened foil wrapper on which was written 9/25/19 and contained three single-use vials of Dorzolamide/Timolol 2%/0.5% (two medications used to treat high pressure inside the eye) eye drops. Manufacturer recommendations on the container read: After pouch opened, throw away any unused single-use containers 15 days after the first opening. At that time, LPN #3 stated that the date on the pouch indicated the date the pouch was opened and that the eye drop vials were expired and should have been removed from the cart. On 10/18/19 at 1:00 PM, the survey team met with the Director of Nursing (DON) and the Administrator. The DON confirmed that the lorazepam should have been secured in the refrigerator in the medication storage room and not in the locked medication cart. The DON further stated that LPN #1 and LPN #2 required re-education. At that same time, the DON confirmed that expired medications should have been removed from active inventory on the medication cart. At 1:10 PM, the surveyor reviewed the facility policy titled, Controlled Substances, revised 2/6/18, which read under #6: Controlled substances must be stored in the medication room or medication cart in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for elders. N.J.A.C. 8:39-29.4 (h)

Based on observation, interview, and review of the medical record and of other facility documentation, it was determined that the facility failed to clarify if a resident had an intolerance and/or, an allergy to Lactose; and, failed to communicate the intolerance/allergy to the Dietary department for 1 of 14 residents reviewed (Resident #21). This deficient practice was evidenced by the following: On 10/15/19 at 7:55 PM, the surveyor observed Resident #21 sitting up in bed watching television. During the surveyor interview, Resident #21 stated that they had a lactose intolerance and that they were not sure if the facility knew because they received cheese for a lot of their meals. Resident #21 confirmed that they chose their meals. On 10/17/19 at 8:27 AM, the surveyor observed Resident #21 sitting up in bed eating breakfast. The surveyor found Resident #21's meal ticket located on the resident's breakfast tray, which did not reveal any indication that the resident had an intolerance to Lactose. The breakfast tray contained a danish, bacon, and fresh fruit. The tray also included hot tea. During the surveyor interview, Resident #21 stated that they did not tell anyone about the intolerance to Lactose but that they thought it should be listed on their medical record from when he/she was in the hospital. On the same day at 12:03 PM, the surveyor observed Resident #21's lunch tray, which included shrimp creole soup, fruit salad, and tomato salad. The meal ticket had no yogurt handwritten on it by the resident. On the same day at 1:10 PM, the surveyor reviewed the Face sheet of Resident #21, which revealed Lactose under allergy. The surveyor then reviewed the computer system, which contained the medical record of Resident #21, which revealed Lactose listed as an allergy. The surveyor then reviewed Resident #21's most recent Minimum Date Set (MDS), an assessment tool, dated 9/4/19 that revealed the resident's brief Interview of Mental status was scored a 12 out of 15, which indicated the resident moderately cognitively impaired. On the same day at 2:23 PM, during the surveyor interview, the facility's Registered Dietician (RD) stated that no residents were currently on a Lactose-free diet. On 10/18/19 at 9:58 AM, during the surveyor interview, the Registered Nurse (RN) confirmed that the two Diet Order and Communication forms, dated 8/28/19 and 8/29/19 that were given to the dietary department did not contain information about Resident #21's lactose intolerance. The RN further confirmed that the dietary department was not notified of Resident #21's lactose intolerance. At 10:17 AM, during the surveyor interview, the Food Service Director (FSD) stated that the Nursing staff fill out the Diet Order and Communication forms and send it to the Dietary department when a resident has a lactose intolerance. The FSD further stated that there were no residents currently on a Lactose-free diet and confirmed that the Dietary department was not notified of Resident #21's lactose intolerance. On the same day at 12:15 PM, during the surveyor interview, the Director of Nursing (DON) confirmed that the staff should have clarified if Resident #21 had an allergy or intolerance to Lactose. The DON further confirmed that any allergy or intolerance should have been communicated to the dietary department. The surveyor requested a facility policy for food allergy or food intolerance. The facility did not provide a policy at the time of the survey exit. N.J.A.C. 8:39-17.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/17/19 at 9:04 AM, the surveyor observed Licensed Practical Nurse (LPN #1) prepare medications for Resident #28. LPN #1 washed her hands, outside the flow of water for greater than 20 seconds, used paper towels to dry her hands, and then used those same paper towels to turn off the water faucet tap. On the same day at 9:37 AM, the surveyor observed LPN #1 prepare medication for Resident #14. LPN #1 washed her hands outside the flow of water for greater than 20 seconds, used paper towels to dry her hands, and then used those same paper towels to turn off the water faucet tap. At 2:29 PM, the surveyor interviewed LPN #1, who stated that she had worked at the facility for seven months and was taught to use the same towel she dried her hands with to close the faucet tap. LPN #1 further stated that she had been in-serviced at least twice for the appropriate hand washing technique. At 2:38 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated that during in-services, she encouraged the staff to wash their hands for more than 20 seconds to wash in between residents, and encouraged staff to use hand sanitizer. The RN/UM further stated that in-services were performed monthly to remind the staff of proper handwashing. The RN/UM confirmed that LPN #1 should have used a clean paper towel to close the faucet because the faucet was considered contaminated. At 4:53 PM, the survey team met with the Director of Nursing (DON) and the Administrator for the facility. The DON stated the proper procedure for performing hand hygiene was to use a separate paper towel for drying hands and closing the water faucet tap. At that same time, the facility Administrator confirmed the DON's statement. Surveyor: [NAME], [NAME] Surveyor: [NAME], [NAME] 3. On 10/17/19 at 9:55 AM, the surveyor observed the following during the wound treatment to the five wounds of Resident #3: LPN #2 performed handwashing for 18 seconds in Resident #3's bathroom sink. The surveyor observed that the sink was not draining well, and the bubbles from the soap were accumulating in the sink, and the soap bubbles were rising above the sink basin and toward the faucet. LPN #2 was unable to perform proper rinsing of her hands without her hands being contaminated from the dirty soap bubbles in the sink. LPN #2 then put a barrier sheet on the already wiped bedside table and placed the supplies for the treatment on the barrier sheet. LPN #2 then performed handwashing for 20 seconds with the soap bubbles rising out of the sink and touching her hands. After putting on a pair of gloves, LPN #2 removed the non-adherent dressing on the resident's right shin. LPN #2 sprayed a 4 X 4 gauze dressing with normal saline solution and wiped the wound on the right shin. LPN #2 then grabbed the entire stack of 4 X 4 gauze dressings and moved them closer to her on the bedside table. LPN #2 sprayed another 4 X 4 gauze dressing with normal saline solution and wiped the wound on the right shin. The spray bottle of normal saline solution then fell to the floor, and LPN #2 left the bottle on the floor. LPN #2 then placed bacitracin ointment (used to prevent infection) onto her gloved finger and applied the ointment to the resident's right shin. LPN #2 did not change her gloves or use an appropriate transfer method to apply the medication. After removing her gloves, LPN #2 performed handwashing for 13 seconds in the non-draining sink with rising soap bubbles. After putting on a pair of gloves, LPN #2 placed a non-adherent dressing on the right shin. After removing her gloves, LPN #2 performed handwashing for 12 seconds in the non-draining sink with rising soap bubbles. LPN #2 then went to the computer to check the order for the next wound and put on a pair of gloves. LPN #2 removed the dressing from the resident's right heel and put dakol's solution (an antiseptic used to cleanse wounds) on a 4 X 4 gauze dressing and wiped the heel with the moistened 4 X 4 gauze dressing. LPN #2 then took a dry 4 X 4 gauze dressing and wiped the resident's right heel. After removing her gloves, LPN #2 performed handwashing for 14 seconds in the non-draining sink with rising soap bubbles. While LPN #2 had performed the handwashing, Resident #3 had placed her heel on the bedsheet. After putting on gloves, LPN #2 applied santyl ointment with a tongue depressor to the resident's right heel. LPN #2 then applied a dry 4 X 4 gauze dressing, thick absorbent pad dressing, and wrapped the right foot with an absorbent gauze roll dressing. LPN #2 then performed the wound treatment to the right great toe of Resident #3. LPN #2 performed handwashing for 15 seconds in the non-draining sink with rising soap bubbles and put on a pair of gloves. LPN #2 then picked up the spray bottle of normal saline solution from the floor and sprayed the normal saline solution on the right great toe without wiping the spray bottle with a disinfectant. LPN #2 then changed her gloves without performing hand hygiene and completed the wound treatment to the right great toe. LPN #2 then performed handwashing for 13 seconds in the non-draining sink with rising soap bubbles. After putting on a pair of gloves, LPN #2 started to perform the treatment to the left shin of Resident #3. During the removal of the dressing to the left shin, LPN #2 gave Resident #3 pain medication. After asking the resident if she could continue, LPN #2 performed handwashing for 10 seconds in the non-draining sink with rising soap bubbles. After putting on a pair of gloves, LPN #2 placed santyl ointment on her gloved finger and placed it on the resident's left shin. LPN #2 then changed her gloves without performing hand hygiene. LPN #2 then placed a small piece of calcium alginate dressing (used to promote healing) and a bordered gauze dressing on the left shin. After removing her gloves, LPN #2 performed handwashing for less than 20 seconds in the non-draining sink with rising soap bubbles. LPN #2 then performed the treatment to the wound of the left elbow of Resident #3. On 10/18/19 at 12:16 PM, during the surveyor interview, the DON confirmed that LPN #2 should not have washed her hands in a clogged sink and that she should have performed handwashing for 20 seconds outside the flow of water. The DON also confirmed that LPN #2 should have changed her gloves after cleaning a wound before placing medication on the wound and that placing medication should not be done with a gloved finger. On 10/22/19 at 8:30 AM, the surveyor reviewed the facility policy titled, Wound and Skin Care, with a revised date of 5/4/18, which did not contain information on how to perform the wound treatment correctly. On 10/22/19 at 8:45 AM, the surveyor reviewed the facility policy titled, Handwashing/Hand Hygiene, with a revised date of 7/18/18, which read: Under Procedure: 7. Use an alcohol-based hand rub .or alternatively, soap and water for the following situations: f. Before donning gloves; g. Before handling clean or soiled dressings, gauze pads, etc.; Under Washing Hands: 2.Wet your hands and wrists. 3. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) away from the stream of water. 4. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink. N.J.A.C. 8:39- 19.4 (a) Based on observation, interview, and review of facility documents, it was determined that the facility failed to a.) conduct an annual review of the Infection Prevention and Control Policy (IPCP); and, b.) perform proper handwashing to reduce the risk of the spread of infection. This deficient practice was evidenced by the following: 1. On 10/18/19 at 10:30 AM, the surveyor reviewed the facility's IPCP titled, Health Services-Infection Control, which contained sixty-one policies and procedures (P&P). Fifty-Four of the sixty-one P&P's had effective dates of 3/1/17. The following seven remaining P&P's had more recent revision dates: Antibiotic Stewardship-Orders for Antibiotics revised 11/22/17 Antibiotic Stewardship 11/21/17 Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes 11/28/17 Antibiotic Stewardship-Staff and Clinician Training and Roles 11/28/17 Infection Prevention and Control Committee 11/28/17 Infection Preventionist 11/28/17 Policy Review and Updating 11/28/17 The front page of the manual had a sheet which read: In-Service Sign-off Sheet-By signing below, you acknowledge that you have read and understand the policy below. The policy was listed as Infection Control. Presented by the Director of Nursing (DON) and dated 4/30/19. There were signatures on the page of the Administrator, DON, Medical Director, Infection Preventionist, and five members of the Infection Control Committee. On 10/18/19 at 5:00 PM, the surveyor met with the Administrative team and expressed the concern of the facility's IPCP not being reviewed or approved since 2017. The DON stated that the signature page that read: In-Service Sign-off Sheet on the front of the manual dated 4/30/19 was evidence that the IPCP was reviewed and approved this year. The surveyor explained that it had been 21 months between the most recent review date listed and the date on the sign off sheet. The surveyor then reviewed the facility's policy and procedure titled, Policy Review and Updating, under Purpose read: The facility's infection control policies and procedures shall be reviewed and revised or updated as needed. Number two under procedure read: Infection control policies, procedures, practices, etc., shall be reviewed, revised, and updated whenever necessary to reflect: a. New or modified tasks and procedures that affect our infection control program and practices; b. New or revised policies; c. Changes in regulatory guidelines and recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. On 10/17/19 at 9:33 AM, the surveyor observed the Registered Nurse (RN) prepare medication for Resident #241 for morning medication pass. The medication included; ferrous sulfate (a type of iron, used to treat a lack of red blood cells), cephalexin (an antibiotic), losartan (used to treat high blood pressure), enoxaparin (used to prevent the formation of blood clots), Magnesium oxide (a mineral used in the body for muscles and nerves), a probiotic (a beneficial bacteria), moxifloxacin eye drops (used to treat bacterial infections in the eye), Vitamin D (used to treat hypoparathyroidism, decreased functioning of the parathyroid glands), and sertraline (an anti-depressant). At that time, the RN walked into Resident #241's room and placed their medications on the resident's overbed table, located away from the resident's bedside. The RN then walked into the resident's bathroom to wash her hands, leaving the medications unattended and not within the nurse's line of sight. The nurse then returned to the resident's bedside and administered their medications as ordered by the physician and completed the medication pass. At 10:29 AM, the surveyor interviewed the RN and asked if it was appropriate for her to leave medications on the overbed table and go into the bathroom to wash her hands. The RN confirmed that she should not leave medications on the overbed table and out of her line of sight. At 11:00 AM, the surveyor reviewed Resident #241's facesheet, which revealed, the resident was admitted to the facility on [DATE] with diagnoses which included; abnormalities of gait and mobility, need for assistance with personal care, hypertension, cognitive communication deficit, Aphasia (an inability to communicate), Benign Prostatic Hypertrophy ( an enlarged prostate gland) and Dementia. The surveyor then reviewed the current Physician's Order Sheet (POS) which read: Vitamin D 3 400 units one tablet one time daily, Lovenox (enoxaparin) 40 milligrams (mgs) subcutaneous one time daily, ferrous sulfate 325 mg one tablet one time daily, magnesium oxide 400mg tablet one tablet one time daily, Zoloft (sertraline) 25 mg tablet one tablet one time daily, losartan 100 mg one tablet one time daily, Vigamox 0.5% (moxifloxacin) one drop left eye three times a day, Risaquad 8 billion cell capsule one capsule one time daily, Keflex (cephalexin) one capsule two times a day. A review of the resident's most recent admission MDS (an assessment tool used to facilitate the management of care), reflected that the MDS assessment was still in progress, as the resident was admitted to the facility less than 14 days earlier. On 10/17/19 at 9:58 AM, the surveyor observed the RN prepare medication for Resident #32's morning medication pass. The medications included; fortified health shake, allopurinol (used to treat gout), aspirin (used to treat pain, and reduce fever or inflammation), atenolol (used to treat high blood pressure), doxazosin (used to treat high blood pressure), fluticasone (used to prevent asthma) nasal spray, loratadine (used to help decrease allergy symptoms) and losartan (used to treat high blood pressure). At that time, the RN walked into the resident's room. Resident #32 was sitting upright in bed, and the resident's private aide was sitting in a chair opposite the resident's foot of the bed. The RN placed the resident's medications on the resident's overbed table and walked into the resident's bathroom to wash her hands, leaving the medications unattended and not within the nurse's line of sight. At 10:29 AM, the surveyor interviewed the RN and asked if it was appropriate for the nurse to leave medications on the overbed table and go into the bathroom to wash her hands. The RN stated she should not leave medications on the overbed table and out of her line of sight. At 11:30 AM, the surveyor reviewed the resident's facesheet, which revealed that Resident #32 was admitted to the facility on [DATE] with diagnoses which included; chronic kidney disease, hypertension, heart failure, and atrial fibrillation (an irregular heart rate). The surveyor then reviewed the current Physician's order sheet (POS) which read: House Two Cal 120 milliliters (mls) orally two times daily, doxazosin ( a medication used to treat high blood pressure) 2 mg tablet one tablet one time daily, allopurinol (a medication used to treat gout) 100 mg tablet one tablet one time daily, Aspirin ( a medication used to treat pain or as a blood thinner) 325 mg one tablet one time daily, atenolol (a medication used to treat chest pain and hypertension)100 mg tablet one tablet two times daily, fluticasone (a medication used to relieve seasonal allergies) 50 micrograms (mcg)/actuation nasal spray, suspension two sprays into both nostrils one time daily, loratadine (a medication used to treat allergies) 10 mg tablet one tablet one time daily. The surveyor then reviewed Resident #32's BIMS on the most recent MDS, dated [DATE], which recorded that the resident scored a 13 out of a possible 15, which established the resident was cognitively intact. 2. On 10/17/19 at 12:10 PM, the surveyor interviewed the Consultant Pharmacist (CP) and asked if she did any medication pass training with the nurses. The CP confirmed that she did. The surveyor asked the CP what the nurses were told about leaving the medication at the bedside for the resident to take later. The CP stated, Absolutely, we tell the nurse to stay at the bedside to watch the resident take the medicine. If the nurse leaves it there to get gloves even, we count that as an error. If we leave an open cup in the room, we don't know what happens to it or where it goes. You can't sign off that it's been administered if you didn't observe it. The surveyor asked if there was a process for residents who wanted to self administer medication, and the CP stated, I don't think there are any residents here who do that. I don't know if that's possible. I would have to check. The surveyor asked the CP what she would suggest if the nurse went to give the resident the medication, and the resident said to leave it. They would take it later. The CP further stated, I would tell the nurse to stay with and ask the resident to take it or to call the doctor. The surveyor asked if, as a last resort, should the nurse leave the medication with the resident. The CP stated, No. At 12:25 PM, the surveyor interviewed the Director of Nursing (DON) and asked if it was appropriate for a nurse to leave pills with a resident to take later. The DON stated, Only one resident is care planned for that, and I believe it's [Resident #6] because it will take an hour for the resident to take the medicine. [The resident] wants to drink this and take a bite of that. It's very time-consuming. On the same day at 2:00 PM, the survey team met with the Administrator, the DON, the Regional Registered Nurse (RN) Consultant, the Executive [NAME] President of Health Services, and the Executive Director. The survey team shared the concern of the nurse leaving the resident's medication in the resident's room and not remaining with the resident until the medication was observed as taken. On 10/18/19 at 12:55 PM, the DON stated the nurses must have sight of medications at all times and that all the nurses would be in-serviced and re-educated. At 1:00 PM, the surveyor reviewed the facility's policy and procedure titled; Administering medication with an effective date of 4/1/01 and a revised date of 2/6/18. The policy did not address the issue of leaving medication at the bedside unattended. 3. On 10/17/19 at 8:52 AM, the surveyor observed LPN #2 prepare medications for Resident #28 for medication pass observation. One of the medications LPN #2 prepared for the resident was two menthol 5% topical patches (used to ease muscle and joint aches and pain); one patch to be applied to the resident's left shoulder and a second patch to be applied to the resident's right shoulder. LPN #2 then proceeded into the resident's room to administer the resident's morning medications. At 9:05 AM, the surveyor observed LPN #2 remove a topical patch from the resident's right shoulder, and then shaking her head, applied a new topical menthol patch to the right shoulder. Then LPN #2 continued to the resident's left shoulder. At 9:07 AM, the surveyor observed LPN #2 remove a topical patch from the resident's left shoulder, this time sighing and shaking her head. She then proceeded to apply a new topical menthol patch to the resident's left shoulder. On 10/17/19 at 2:00 PM, the survey team met with the Administrator, the DON, the Regional Registered Nurse (RN) Consultant, the Executive [NAME] President of Health Services, and the Executive Director. The survey team shared the concern of the nurse not removing the resident's medication patches per physician's order. On the same day at 2:29 PM, the surveyor interviewed LPN #2 and asked her if she had expected the resident to have menthol patches in place when she attempted to place new patches that morning during morning medication pass. LPN #2 stated the resident had a physician's order to have the menthol patches applied to each shoulder in the morning and a physician order to remove the patches in the evening. LPN #2 stated that the patches should have been removed the evening before and that physician's orders were not followed. At 2:45 PM, the surveyor reviewed Resident #28's facesheet, which revealed that the resident was admitted to the facility on [DATE] with diagnoses which included; Hypertension, Heart Failure, and Dementia without behavioral disturbance. The surveyor then reviewed the current Physician's Order Sheet (POS) which read: BenGay Ultra Strength (menthol) 5% topical patch apply 1 patch to LEFT shoulder once daily, ON at 9:00 AM, OFF at 5:00 PM, BenGay Ultra Strength (menthol) 5% topical patch apply 1 patch to RIGHT shoulder once daily, ON at 9:00 AM, OFF at 5:00 PM. The surveyor then reviewed the BIMS on the most recent MDS, dated [DATE], which recorded that Resident #28 scored a 13 out of a possible 15, which established the resident was cognitively intact. On 10/18/19 at 12:55 PM, the DON stated that the nurse who did not remove the topical menthol patches per physician's orders, was an omission of treatment and that the nurse had been re-educated. 4. On 10/17/19 at 9:58 AM, the surveyor observed the RN prepare medication for Resident #32's morning medication pass. The medications included fortified health shake. At that time, the RN walked into the resident's room where the resident was sitting upright in bed, and the resident's private aide was sitting in a chair opposite the resident's foot of the bed. After the RN washed her hands, she attempted to administer the resident medications, which included placing a straw into the resident's fortified health shake. Located above the resident, attached to the wall, was a laminated sign indicating, No Straws. At 10:10 AM, the surveyor intervened before the RN could give the resident the straw to aid in administering the fortified health shake. The RN, accompanied by the surveyor, stepped outside with the medications and fortified health drink. The surveyor then pointed out the sign above the bed, as well as an additional sign located on the side of the resident's wardrobe, indicating No Straws. The surveyor asked why the resident could not use straws, and the RN stated that they could aspirate or choke. The RN then removed the straw from the fortified health shake and proceeded to administer the medications to the resident without difficulty. At 10:29 AM, the surveyor interviewed the RN and asked if it was appropriate to use a straw to administer the medications to Resident #32. The RN stated it was not appropriate and that she should have checked the Medication Administration Record (MAR), where it would indicate the resident's diet and any instructions for administering the resident's medications. At 11:30 AM, the surveyor reviewed the resident's face sheet, which revealed that they were admitted to the facility on [DATE] with diagnoses which included; chronic kidney disease, hypertension, heart failure, and atrial fibrillation (irregular heart rate). The surveyor reviewed the current Physician's order sheet (POS), which read: House Two Cal 120 milliliters (mls) (fortified health shake) orally two times daily, doxazosin 2 mg tablet one tablet one time daily, allopurinol 100 mg tablet one tablet one time daily, Aspirin 325 mg one tablet one time daily, atenolol 100 mg tablet one tablet two times daily, fluticasone 50 micrograms (mcg)/ actuation nasal spray, suspension two sprays into both nostrils one time daily, loratadine 10 mg tablet one tablet one time daily. Diet orders: Thin liquids, Diet Consistency Mechanical Soft, Regular Diet. A review of the Physician's written orders dated 10/1/19 revealed a change of diet order to mechanical soft with puree soup/thin liquid (no straws). At 2:00 PM, the survey team met with the Administrator, the DON, the Regional Registered Nurse Consultant, the Executive [NAME] President of Health Services, and the Executive Director. The survey team shared the concern of the RN attempting to use a straw to administer medications to a resident with a diet order that stated, No straws. On 10/18/19 at 11:04 AM, the surveyor interviewed the Speech-Language Pathologist (SLP) who stated that she had been working with the resident for quite some time for dysphagia oral phase moderate and mild pharyngeal phase. The SLP stated the resident was most recently evaluated on 10/2/19, for not responding to cues to eat as they had in the past, as well as taking an extended amount of time to chew their food. The SLP stated the resident's liquid consumption was a thin consistency. The SLP explained the reason the resident had a No Straws order was that the resident tended to take too big of a sip of thin liquids when using the straw and would cough. The SLP stated the House 2 Cal was thicker than thin liquids and would take longer to swallow. The SLP said she believed the resident could tolerate the thicker consistency fortified health shake via straw if the resident took small sips, and someone was there to cue them to drink slowly. The SLP stated she had considered trying to reintroduce the straw back, but her main goal was nutrition. The SLP stated the resident was doing well with the current diet and expected he/she would be discharged from speech therapy soon. At 12:00 PM, the surveyor reviewed the most recent SLP treatment note dated 10/15/19, which revealed, as of now, current PO (by mouth) diet (mechanical soft with a big portion of puree' soup with thin liquid no straws) is judged to be least restrictive at this time. At 1:04 PM, the DON stated the nurse should have reviewed the resident's eMAR before preparing the resident's medications and confirmed that the RN did not follow the Physician's diet order. At 1:15 PM, the surveyor reviewed the facility's policy titled; Administering Medication under Number 3 it read: Medications must be administered in a timely manner and in accordance with the attending Physician's written/verbal orders. 5. On 10/17/19, beginning at 9:55 AM, the surveyor observed the wound treatment to the five wounds of Resident #3. LPN #3 put a barrier sheet on the already wiped bedside table and placed the supplies for the treatment on the barrier sheet. LPN #3 then performed handwashing for 20 seconds with the soap bubbles rising out of the sink and touching her hands. After putting on a pair of gloves, LPN #3 removed the non-adherent dressing on the resident's right shin. LPN #3 sprayed a 4 X 4 gauze dressing with normal saline solution and wiped the wound on the right shin. LPN #3 then grabbed the entire stack of 4 X 4 gauze dressings and moved them closer to her on the bedside table. LPN #3 sprayed another 4 X 4 gauze dressing with normal saline solution and wiped the wound on the right shin. The spray bottle of normal saline solution then fell to the floor, and LPN #3 left the bottle on the floor. LPN #3 then placed bacitracin ointment (used to prevent infection) onto her gloved finger and applied the ointment to the resident's right shin. LPN #3 did not change her gloves or use an appropriate transfer method to apply the medication. After removing her gloves, LPN #3 performed handwashing for 13 seconds in the non-draining sink with rising soap bubbles. After putting on a pair of gloves, LPN #3 placed a non-adherent dressing on the right shin. After removing her gloves, LPN #3 performed handwashing for 12 seconds in the non-draining sink with rising soap bubbles. LPN #3 then went to the computer to check the order for the next wound and put on a pair of gloves. LPN #3 removed the dressing from the resident's right heel and put Dakin's solution (an antiseptic used to cleanse wounds) on a 4 X 4 gauze dressing and wiped the heel with the moistened 4 X 4 gauze dressing. LPN #3 then took a dry 4 X 4 gauze dressing and wiped the resident's right heel. After removing her gloves, LPN #3 performed handwashing for 14 seconds in the non-draining sink with rising soap bubbles. While LPN #3 had performed the handwashing, Resident #3 had placed her heel on the bedsheet. After putting on gloves, LPN #3 applied santyl ointment with a tongue depressor to the resident's right heel. LPN #3 then applied a dry 4 X 4 gauze dressing, thick absorbent pad dressing, and wrapped the right foot with an absorbent gauze roll dressing. LPN #3 then performed the wound treatment to the right great toe of Resident #3. LPN #3 then performed handwashing for 13 seconds in the non-draining sink with rising soap bubbles. After putting on a pair of gloves, LPN #3 started to perform the treatment to the left shin of Resident #3. During the removal of the dressing to the left shin, the surveyor had to intervene, and LPN #3 stopped the treatment to give Resident #3 pain medication. After asking the resident if she could continue, LPN #3 performed handwashing for 10 seconds in the non-draining sink with rising soap bubbles. After putting on a pair of gloves, LPN #3 placed santyl ointment on her gloved finger and placed it on the resident's left shin. LPN #3 then changed her gloves without performing hand hygiene. LPN #3 then placed a small piece of calcium alginate dressing (used to promote healing) and a bordered gauze dressing on the left shin. After removing her gloves, LPN #3 performed handwashing for less than 20 seconds in the non-draining sink with rising soap bubbles. LPN #3 then performed the treatment to the wound of the left elbow of Resident #3. On 10/17/19 at the surveyor reviewed the medical record of Resident #3, which revealed the following physician orders: 1. Cleanse right shin wound with NSS apply santyl followed by calcium alginate and cover with dry dressing daily. 2. Cleanse right heel ulcer with NSS. Skin prep to peri-wound. Apply santyl followed by gauze lightly moistened with 0.125% Dakin's solution BID (twice daily) and PRN (as needed). Cover with bordered gauze dressing. 3. Cleanse left shin with NSS apply xeroform (a non-adherent sterile dressing) and cover with telfa (a non-adherent dressing) daily. On 10/18/19 at 9:46 AM, during the surveyor interview, LPN #3 stated that she kept going back to the computer to make sure she was doing the correct treatment, but that there were so many wounds and that she was nervous since she was being observed. On the same day at 12:16 PM, during the surveyor interview, the DON confirmed that LPN #3 should have performed the correct physician's ordered treatment to the corresponding wound for which it was ordered. The surveyor requested a facility policy for following physician's orders. The facility did not provide a policy at the time of the survey exit. N.J.A.C. 8:39 - 29.2 (d) Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards of clinical practice with respect to a.) maintain full view of medication at all times; and b.) follow physician's orders. This deficient practice was observed for 4 of 14 residents reviewed for professional standards of practice (Resident's #3, #28, #32 and #241) and was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing a 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 with in 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.

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: 1. On 10/16/19 at 12:01 PM, in the presence of another surveyor, the surveyor observed Food Service Worker (FSW) #1 enter the second-floor pantry/kitchen and put on a pair of gloves. FSW #1 then proceeded to take the temperatures of the food. FSW #1 had not conducted hand hygiene before putting on a pair of gloves. FSW #1 wiped the thermometer with a sanitizing wipe before taking the temperature of the first food tray but did not clean the thermometer in between taking the temperatures of the five other food trays. FSW #1 then plated soup into soup cups and then scooped dressings into small black plastic containers. FSW #1 did not change her gloves. FSW #1 was then observed opening the refrigerator and opening the door of the food transport cart and then would proceed to plate more soup into soup cups without changing her gloves. On the same date at approximately 12:20 PM, FSW #1 was observed to put on an oven mitt over her gloved hands and removed a stack of plates from the warmer. FSW #1 then placed the plates on the counter and removed the oven mitt from her gloved hands and proceeded to plate entrees. FSW #1 did not change her gloves. At approximately 12:30 PM, FSW #1 was observed to scoop the pureed meat on to a plate and then scooped a white-colored pureed substance on top of the pureed meat. The white pureed substance started to fall off the pureed meat, and FSW #1 was observed to push the white pureed substance [that was falling off ] back on top of the pureed meat with her gloved finger. FSW #1 was later observed to use her left gloved hand to hold food that she was cutting with a serrated knife that was in her right hand. At approximately 12:42 PM, the surveyor observed FSW #1 removed her gloves and did not perform hand hygiene. FSW #1 walked to the cabinet located just outside of the pantry/kitchen, removed a stack of paper plates from the cabinet, and placed them on the counter in the pantry/kitchen. FSW #1 then put on a new pair of gloves without performing hand hygiene. At approximately 12:50 PM, the surveyor observed FSW #1 take the trays of the remaining food from the steam table and placed them back in the food transport cart. FSW #1 then put the metal lids on the steam table. FSW #1 did not change her gloves or perform hand hygiene. At approximately 12:55 PM, the surveyor observed FSW #1 move the garbage can with her gloved hand and then moved a black cart and proceeded to place the dirty dishes into the sink. FSW #1 then removed her gloves and took the food transport cart onto the elevator. FSW #1 did not perform hand hygiene. At approximately 1:08 PM, the surveyor observed FSW #1 come out of the elevator and put on two pairs of gloves. FSW #1 then loaded dirty dishes that she had rinsed in the sink onto a tray. FSW #1 then loaded the tray into the dishwasher, closed the door, and pushed the start button. FSW #1, after the dishwasher, was finished and without changing her gloves, removed the clean tray from the dishwasher. The surveyor observed that two white scalloped dishes had dishwasher fluid inside them. FSW #1 then dumped the fluid out of the two cups into the sink and stacked them on the counter. The surveyor observed FSW #1 stack the rest of the dishes and cups on the counter, which were still wet evidenced by occasional dripping of liquid from the items. The surveyor then observed FSW #1 place another tray of dirty items into the dishwasher. FSW #1 then loaded dirty dishes from the sink into another tray. After the dishwasher was finished, FSW #1 again removed the clean tray from the dishwasher without changing her soiled gloves and placed another tray of dirty dishes into the dishwasher. The surveyor then observed FSW #1 remove the outer pair of gloves she had on. FSW #1 then put away more cleaned, wet dishes and cups onto trays on the counter. At approximately 1:20 PM, the surveyor observed FSW #1 put a pair of gloves on over the gloves that she already had on. FSW #1 then placed the dirty silverware that she rinsed in the sink into a tray and put the tray in the dishwasher. FSW #1 then loaded another tray with dirty dishes and cups that she rinsed in the sink. When the dishwasher was finished, FSW #1 then removed the clean tray from the dishwasher without changing her dirty gloves. On 10/17/19 at 8:19 AM, the surveyor observed FSW #1 walk into the pantry/kitchen on the second floor and put on a pair of gloves without performing hand hygiene. On the same day at 9:38 AM, the surveyor observed FSW #1 taking dirty dishes from the black cart and placed them in the sink. FSW #1 was then observed, opening the finished dishwasher and removed a clean tray of dishes without changing her dirty gloves. FSW #1 then placed a tray of dirty dishes into the dishwasher. FSW #1 then rinsed dishes from the sink and loaded another tray of dirty dishes. After the dishwasher was finished, FSW #1 again removed a clean tray from the dishwasher, without changing gloves, and put a tray of dirty dishes into the dishwasher. FSW #1 then removed her gloves and put on a new pair of gloves without performing hand hygiene. 2. On 10/16/19 at 12:34 PM, the surveyor observed FSW #2 perform handwashing for 10 seconds. 3. On 10/16/19 at 12:39 PM, the surveyor observed FSW #3 put on a pair of gloves without performing hand hygiene to collect the used dishes from the tables. FSW #3 placed the dishes on the black cart and then removed her gloves. FSW #3 then put on a new pair of gloves without performing hand hygiene. 4. On 10/16/19 at 12:01 PM, the surveyor observed FSW #4 in the pantry/kitchen with a pair of gloves. During the entire lunch observation, the surveyor did not see FSW #4 change her gloves or perform hand hygiene. At approximately 1:26 PM, the surveyor observed FSW #4 remove her gloves and perform appropriate handwashing. On 10/18/19 at 12:11 PM, during surveyor interview, the Administrator (ADM) confirmed that the FSW's gloves should have been changed more often, and that hand hygiene should be performed after removing gloves. The ADM also confirmed that gloves should be changed and hand hygiene performed before removing clean dishes from the dishwasher. Lastly, the ADM confirmed that handwashing should be performed for 20 seconds outside the flow of water. On 10/21/19 at 10:50 AM, the surveyor reviewed the facility policy titled, Cleaning Dishes/Dish Machine, with an updated date of 5/20/18 which read: under Procedure: 2. The person loading dirty dishes will not handle the clean dishes unless they wash their hands thoroughly and put on clean gloves before moving from dirty to clean dishes. 10. Inspect for cleanliness and dryness, and put dishes away if clean (be sure clean hands or gloves used). 11. Dishes should not be nested unless they are completely dry. On the same day at 11:00 AM, the surveyor reviewed the facility policy titled, General Good Preparation and Handling, with an updated date of 5/23/18 which read: under Procedure: 3.h. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact of prepared foods. At 11:10 AM, the surveyor reviewed the facility policy titled, handwashing, with an updated date of 1/8/19 which read: under Procedure: Clean hands and exposed portions of arms immediately before engaging in food preparation. 1. When to wash hands: a. When entering the kitchen at the start of a shift. f. After handling soiled equipment or utensils. g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross-contamination when changing tasks. i. Before donning gloves for working with food. j. After engaging in other activities that contaminate the hands. 2. How to wash hands: b. Wet hands and forearms with warm water and apply an adequate amount of soap. c. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds. N.J.A.C. 8:39-17.2 (g)

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) Committee develop and implement appropriate plans of action to correct identified quality deficiencies found in the kitchen in accordance with the facility's Plan of Correction (POC) from the last certification period. This deficient practice was evidenced by the following: On 10/16/19 at 12:01 PM, the surveyor observed the second-floor pantry/kitchen and noted repeated deficiencies identified from the last survey. Refer to F812 A review of the facility's POC submitted and electronically signed on 10/04/18 from the last survey included the following systematic changes: * In-service activity and dietary staff on the Hand Washing Policy and Procedure. Give a competency test to all staff and have them demonstrate proper handwashing to pass the test. * Implement a (Continuous Quality Improvement) CQI checklist that monitors all areas of the kitchen sanitation and dining standards to maintain standards of practice. Audits will be done daily, weekly, and monthly and will be reported to the Director of Food Services/Designee and reported at the monthly (Quality Assurance) QA meetings. * If CQI Plan of Correction (POC) is needed for an audit, it will be initiated immediately by the Food Service Director/Designee and include any other Interdisciplinary Team (IDT) members. The Administrator will review the POC and report at the monthly QA Meetings. On 10/18/19 at noon, in response to dietary concerns observed during the survey, the surveyor was provided with documents that included: 1) Hand Washing Policy and Procedure updated 1/08/19, 2) Employee handwashing in-service record for two employees on 2/20/19, 3) Training/In-Service Attendance Sheet on Working Together, Regulatory Compliance, Handwashing, Taking Temperatures, and Food Handling for 10 employees on 5/07/19 and 5/11/19, 4) Training/In-Service Attendance Sheet on Personal Hygiene for nine employees on 7/17/19 and 7/18/19, 5) Employee handwashing in-service record for one employee on 7/19/19, and 6) Employee handwashing in-service record for three employees on 10/17/19. On the same day at 3:15 PM, the surveyor interviewed the Administrator. The Administrator confirmed she oversaw the Quality Assurance (QA) Committee, and she stated that the QAPI process worked by her asking all of the managers of every department in the facility to identify a problem and develop a plan to correct it and then it was reviewed at the monthly QA meetings. The surveyor then asked the Administrator about the QAPI plan with the Dining Services Department Quality Improvement (QI) Projects of: 1) Daily and Weekly audits of the kitchen and pantries and 2) Compliance with State Requirements for Food as to how it was determined that the Threshold Desired was set at 95 % and what that meant. The Administrator stated they did not want to set it at 100% because they wanted the department to have something to work toward. The surveyor asked about the follow-up for when the Performance Achieved was less than the Threshold of 95%, such as in March 2019 when it was 93 %, and the Administrator stated she was not sure how it was calculated or how it was addressed. The surveyor then asked the Administrator how follow-up action was measured and evaluated for the January 2019 QAPI report, which noted: 1) Maintain a proactive approach in order to comply with all standards and regulations, 2) Expanded Dining CQI audit has been implemented and tracked monthly and 3) Inservices scheduled on 1/16/19, 1/18/19, and 1/27/19 with entire staff, competency tests will be given every quarter, and the next test scheduled for February, for handwashing and taking temperatures. The surveyor asked the Administrator how the Committee measured number one, and she stated she was not sure. For number two, the Administrator showed the surveyor an audit form, but was unable to explain what the numbers meant, what action had been taken for measurements that were less than determined thresholds, why data was incomplete in some of the areas being tracked, and why data was not reported for the months of August and September 2019. The surveyor asked the Administrator what the follow-up was for in-service and competency tests not completed and she stated she did not know but confirmed that competency tests for all handwashing had not been completed quarterly for all Dining employees. The Administrator stated that she thought the Director of Dietary Services might have a better understanding of the data and asked if he could speak to the surveyors' specific questions. On 10/18/19, at 3:45 PM, the surveyor interviewed the Administrator, the Director of Dietary Services, and the Corporate Dietician. When questioned about Thresholds (defined as the magnitude or intensity that must be exceeded for a certain result to occur) set by the facility and data measurement, the Corporate dietician stated that if something needs to be set at 100% like Infection Control, it is set at 100%. She said many things go into the data to establish the Threshold and how it was measured. The surveyor asked the Administrator if she understood what was measured and if she knew what went into the calculation, and she stated, No. At that time, the surveyor asked when Infection Control was 81% in January, 90% in February, and 91% in June, if there was any follow-up, the Corporate Dietician stated sometimes in-services are given to the staff as needed. The surveyor reviewed with the Administrator, the Director of Dietary Services, and the Corporate Dietician the documents provided for in-services that had been completed. No additional documents were presented to the surveyor. The surveyor asked if it was important for the Administrator, as head of the QA, to understand the data in order to oversee the Committee and QAPI plan, to monitor system issues, to take corrective action as needed and to resolve areas of concern and the Administrator stated, Yes. The Administrator also added that it looked like the facility QAPI plan required specific interventions and that they needed to document an evaluation of the progress and updates to the problem as part of the monthly report. N.J.A.C. 8:39-33.1; 33.2