Every finding on record at Childrens Specialized Hospital Mountainside

Based on observation, interview, and record review, it was determined that the facility failed to consistently maintain appropriate infection control practices to limit the spread of infection. The deficient practice was observed with 1 (one) staff person and 1 resident (Resident#7) in room [ROOM NUMBER] during the medication pass observation. This deficient practice was evidenced by the following: On 1/21/26 at 9:51 AM, the surveyor observed the Registered Nurse (RN) wearing a pair of gloves. The RN was observed preparing medications using a syringe. After the medication was prepared, she administered all the medication to Resident #7 by G-Tube (Gastrostomy tube, a small tube surgically inserted into the abdomen directly into the stomach to deliver nutrition, fluids, and medication). After administering medications, the RN threw the syringes into the garbage, and then back to the resident without changing the gloves. RN, using the same gloves, took the zinc oxide tube to the medication cart using her right hand and stated to the surveyor that she would be giving the zinc oxide treatment to Resident #7. The surveyor observed the RN holding the tube with the right hand while showing the surveyor, using her left hand, the resident's neck covered with a dressing. RN stated that she is going to do the treatment for the resident later, when the resident was in bed. RN put back the zinc oxide into the cart using the same gloves from preparing medication to administering medications by GT, who touched the resident's neck with a covered dressing. The surveyor interviewed the RN regarding the observation. She stated that she usually changed her gloves between preparing medications and administering them to the resident. The RN revealed that she should change her gloves between preparing medications and administering them and touching the resident's treatment area. The RN added that the medication cart includes all the medications and treatments for 4 residents in room [ROOM NUMBER]. On 1/21/26 at 12:19 PM, the surveyor reviewed the electronic health record of Resident #7, which revealed the following: A review of the patient demographics reflected that Resident #7 was admitted with diagnoses that included but were not limited to anoxic brain injury (a type of brain damage resulting from a total lack of oxygen in the brain), pressure injury neck posterior, gastrostomy tube, and tracheostomy (a surgical procedure that creates an opening to the neck to the trachea to provide an alternative means of breathing) status. A review of the quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) with the date of 10/30/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which stated that the resident had impaired cognition. A review of an active order of medications included, but was not limited to, zinc oxide 20% ointment, administered topically 2 times daily to the neck area, with a start order of 5/29/25. A review of the care plan initiated on 5/14/25 with a problem that includes compromised skin integrity. Interventions included, but were not limited to, applying skin protectant as ordered. On 1/22/2026 at 1:49 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss the above concerns. The DON acknowledged the infection control breach described by the surveyor. A review of the facility policy titled Infection Control Standard and Transmission-Based Precautions Guidelines (Procedure) with an effective date of 1/9/26 stated under II. Fundamentals of Infection Control Precautions A. Standard Precautions: 1. Hand Hygiene . it may be necessary to clean hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. And 4. Use of Personal Protective Equipment (PPE): a. Gloves: wear clean gloves when touching blood, body fluids, secretions, excretions, and patients' skin that may potentially be contaminated and contaminated items, put on clean gloves just before touching mucous membranes and non-intact skin, and remove gloves after contact with a patient and/or surrounding environment (including medical equipment) using proper technique to prevent hand contamination. NJAC 8:39-19.4

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

Based on observation, interview and record review, it was determined that the facility failed to ensure a.) a physician orders for administration was followed, route of administration was clarified (Resident 18), and b.) dosing was clarified for an eye ointment, prior to administration (Resident 44 and Resident #2) in accordance with professional standards of practice and facility policy. The deficient practice was identified for three (3) of seven (7) residents, administered by three (3) of five (5) nurses, observed during the medication administration observation, and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) On 9/25/24 at 7:41 AM, the surveyor observed Licensed Practical Nurse (LPN #1) prepare two (2) medications for Resident #18. The medications orders were: Prograf (Tacrolimus; medication used to prevent rejection of a transplanted organ such as the kidney, liver, heart or lung) 0.5 milligram (mg) capsule, to be administered by mouth (PO) at 6:00 AM. The order was started on 3/17/24. Prograf 5 mg capsule, to be administered PO twice daily (BID) at 6:00 AM and at 6:00 PM. The order was started on 11/14/22. At that time, LPN #1 was observed removing both capsules from a unit dose package, opened the capsules and poured into a medication cup, drew approximately, drew water into a syringe then emptied the water into a medication cup, and opened the Prograf capsules into the water in the medication cup. LPN #1 drew another five (5) milliliters (mls) of water into a syringe. On 9/25/24 at 7:43 AM, the surveyor observed LPN #1 asked Resident #18 if they can administer the medication by mouth. Resident #18 turned their head left and right twice. LPN #1 attached an enteral tube to a port, administered Prograf through the gastronomy tube (g-tube) and was followed with a water flush of the enteral tube. On 9/25/24 at 7:49 AM, during an interview with the surveyor, LPN #1 was asked why she administered Prograf orders via g-tube without a physician's order for another route and was the physician's order for PO appropriate for Resident #18. The LPN stated she would discuss with the medical team and the Charge Nurse. The surveyor reviewed the medical record for Resident #18. A review of the resident's electronic Medical Record reflected Resident #18 was a long-term care resident with diagnoses that included vocal cord paralysis, developmental delay, oral phase dysphagia (problems with using the mouth, lips, and tongue to control food or liquid) and heart transplant. A review of the quarterly Minimum Data Set, an assessment tool, dated 8/8/24 reflected that Resident #18, sometimes able to be understood and sometimes was able to understand others. The Brief Interview for Mental Status (BIMS; an evaluation for aspects of cognition) was not conducted and the resident had short- term and long-term memory problems. Further review of the qMDS reflected the resident had a swallowing problem that involved loss of liquid/solids from the mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals. A review of Resident #18's comprehensive person-centered care plan reflected Resident #18 had impaired swallowing and the interventions included that the resident was in a puree diet again, had a munching pattern that will not efficiently breakdown food, and safely manage solid foods and no liquids. A review of the physician's progress note dated 9/24/24, included that all medications were given through gastronomy button except for Tacrolimus which was taken orally (most of the time). The resident received pureed diet during daytime with GT supplementation. 2. On 9/25/24 at 9:23 AM, the surveyor observed the Registered Nurse (RN) prepare medications for Resident #44 that included Artificial Tears Lubricant Ophthalmic Ointment (mineral oil and petrolatum; to prevent irritation or to relieve dryness if the eyes), One (1) application every three (3) hours (8 applications per day). On 9/25/24 at 9:42 AM, the surveyor observed the RN administer the Artificial Tears Lubricant Ophthalmic Ointment in varying length in the left and right eye. A review of the Resident #44's physician's order for the Artificial Tears Lubricant Ophthalmic Ointment revealed that the order did not indicate a length of measurement to reflect the dose for each administration. The order was started on 7/2/24. 3. On 9/25/24 at 11:36 AM, the surveyor observed LPN #2 prepare medications for Resident #2 that included Artificial Tears Lubricant Ophthalmic Ointment (mineral oil and petrolatum; to prevent irritation or to relieve dryness if the eyes), One (1) application every two (2) hours (12 applications per day). At that time, LPN #2 stated that Resident #2's family member administered the medication to the resident and had been doing so for years. The surveyor observed LPN #2 in the room, near the resident and resident representative during the medication administration. A review of the Resident #2's physician's order for the Artificial Tears Lubricant Ophthalmic Ointment revealed that the order did not indicate a length of measurement to reflect the dose for each administration. The order was started on 3/8/22. On 9/25/24 at 12:35 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns that occurred the medication pass for Resident #18 wherein the physician order for Prograf to be administered orally, was administered via g-tube to Resident #18 without clarification with the physician. The concern with Resident #44 and Resident #2 ophthalmic ointment order that did not include dosing and was also not clarified prior to administration. On 9/25/24 at 12:44 PM, the DON stated that Resident #18 was able to take the medication by mouth and via g-tube, and acknowledged the orders should have been clarified. A review of the provided facility policy, Medication Management, dated 1/9/24 included the following under procedures: B. Ordering and Transcribing 4. Orders for medication and fluids mist contain name and dosage, frequency, route of administration and an indication for use . D. Administration 6. Just prior to administration, compares the medication to the order and adheres to the 5 rights of medication administration rules: a. right patient b. right medication c. right dosage d. right time e. right route NJAC 8:39-27.1(a), 29.2(d)

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

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

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 12 of 21 residents, (Residents #2, #3, #11, #14, #21, #27, #28, #33, #36, #41, #44, and #48) reviewed, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified 12/01/21, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of the source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. All assessments are completed within specific guidelines and time frames. According to CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated October 2019, included the following: SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status . I: Active Diagnoses in the Last 7 Days . Planning for Care This section identifies active diseases and infections that drive the current plan of care. Steps for Assessment There are two look-back periods for this section: Diagnosis identification (Step 1) is a 60-day look-back period. Diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period (except for Item I2300 UTI, which does not use the active 7-day look-back period). 1. Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days. Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available. If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered. Although open communication regarding diagnostic information between the physician and other members of the interdisciplinary team is important, it is also essential that diagnoses communicated verbally be documented in the medical record by the physician to ensure follow-up. Diagnostic information, including past history obtained from family members and close contacts, must also be documented in the medical record by the physician to ensure validity and follow-up. 2. Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period . Check the following information sources in the medical record for the last 7 days to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available . If a disease or condition is not specifically listed, enter the diagnosis and ICD code in item I8000, Additional active diagnosis . SECTION N: MEDICATIONS Intent: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident. In addition, an Antipsychotic Medication Review has been included. Including this information will assist facilities to evaluate the use and management of these medications. Each aspect of antipsychotic medication use and management has important associations with the quality of life and quality of care of residents receiving these medications. 1. On 6/15/23 at 10:44 AM, the surveyor observed Resident #2 lying on the bed supine (facing upward), with a tracheostomy (is an opening surgically created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe), intermittent leg tremors, nonverbal and unable to be interviewed. On 6/15/23 at 10:50 AM, the surveyor observed the Respiratory Therapist enter Resident #2's room. The surveyor reviewed Resident #2's medical record. The resident's Registration Form (RF; or face sheet; an admission summary) reflected that the resident was admitted to the facility and had a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own). The resident's most recent Comprehensive Minimum Data Set (CMDS) with an Assessment Reference Date (ARD) of 6/02/23, revealed a Cognitive Skills for Daily Decision-Making (CSDDM) assessment which indicated the resident's cognition was severely impaired. The CMDS indicated the resident had active diagnoses that included, seizure disorder, or epilepsy, respiratory failure, dysphagia (difficulty swallowing), dependence on a respirator. Section G Functional Status of the CMDS revealed that toilet use were coded as 8/8 (activity did not occur/activity did not occur). The CMDS Section H Bladder and Bowel indicated the resident was receiving intermittent catheterization (removing the urine from the bladder by placing a tube into the bladder). Further review of the resident's MDS reflected a previous quarterly MDS (qMDS) with an ARD of 3/03/23, Section G for toilet use was coded 8/8. On 6/26/23 at 11:48 AM, during an interview with the surveyor, Certified Nursing Assistant #1 (CNA #1) stated she was the aide assigned to Resident #2. CNA #1 informed the surveyor that Resident #2 used a diaper and the output of bowel and bladder was documented by her into the electronic Medical Record (eMR). On 6/27/23 at 9:33 AM, during an interview with the surveyor, Licensed Practical Nurse #1 (LPN #1) stated she was assigned to the team that cared for Resident #2 on that day. LPN #1 informed the surveyor that the resident voided into a diaper and was incontinent of bowel and bladder. The LPN informed the surveyor that the resident also received a bladder massage to encourage voiding. 2. On 6/15/23 at 10:50 AM, the surveyor observed Resident #3 seated in a wheelchair, head tilted to the right with saliva dripping uncontrollably from the right side of the face, fitted with trach collar (a medical device used to secure a tracheostomy/windpipe tube). The surveyor reviewed Resident #3's medical record. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of static encephalopathy (a broad term to describe chronic nonprogressive brain disorder). The resident's most recent CMDS with an ARD of 5/12/23, revealed a CSDDM assessment which indicated the resident's cognition was severely impaired. The CMDS also indicated the resident had active diagnoses that included, seizure disorder, respiratory failure, tracheostomy, respiratory failure, dysphagia, pressure ulcer of other site. Section G of the CMDS revealed that eating and toilet use was coded as 8/8. The CMDS Section H indicated the resident was receiving intermittent catheterization. Further review of the resident's MDS showed that on the following MDS assessments: ARD 8/12/22 qMDS, Section G eating and toilet use was coded 8/8 ARD 11/11/22 qMDS, Section G eating and toilet use was coded 8/8 ARD 02/10/23 qMDS, Section G eating and toilet use was coded 8/8 The resident's Nutritional assessment dated [DATE] reflected the resident was on a G-tube (gastrostomy; a tube inserted through the belly that allows air, fluid to leave the stomach and can be used to administer food, liquid and medications) On 6/22/23 at 12:53 PM, the surveyor and the Dietetic Technician Registered (DTR) reviewed the Nutritional Assessment for Resident #3. The DTR confirmed Resident #3 was NPO (nothing by mouth) and received enteral feeding whose weight was monitored monthly. On 6/26/23 at 11:52 AM, during an interview with the surveyor, CNA #1 stated she was the aide assigned to Resident #3. CNA #1 informed the surveyor that Resident #3 had a G-tube and used a diaper; The output of bowel and bladder was documented by the her into the eMR. 39885 3. On 6/15/23 at 11:11 AM, the surveyor observed Resident #11 lying in bed with the head of the bed elevated. Resident #11 had a tracheostomy that was connected to a ventilator and was receiving nutrition through a tube feeding (TF). On 6/22/23 at 9:52 AM, the surveyor reviewed Resident #11's medical record. Resident #11's AR showed that the resident was admitted to the facility with diagnoses that included but was not limited to; holoproencephaly (holoprosencephaly; a condition that occurs in the first two or three weeks of pregnancy and results in abnormal development of the brain) and panhypopitutrism (panhypopituitarism; a rare condition in which the pituitary gland stops making most or all hormones). The most recent qMDS with an ARD of 5/05/23, showed that Resident #11's CSDDM assessment was severely impaired. The 5/05/23 qMDS showed on Section G, the resident was coded 8/8 on toilet use. The section for toilet use was coded incorrectly. Further review of the MDS showed the following: ARD of 02/03/23 CMDS: Section G toilet use was coded 8/8 ARD of 11/04/22 qMDS: Section G toilet use was coded 8/8 ARD of 8/05/22 qMDS: Section G toilet use was coded 8/8 On 6/26/23 at 11:18 AM, the surveyor interviewed CNA #2 regarding the care of Resident #11. She stated that the resident was incontinent of urine and had to change the resident's diaper often because the resident had bowel movements frequently. On 6/26/23 at 12:21 PM, in the presence of the survey team, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) who confirmed that Section G toilet use was coded incorrectly for Resident #11. On 6/26/23 at 01:40 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director Of Nursing #1 (DON#1), DON#2, MDSC/RN, and Director of Therapy (DoT) the concern regarding the incorrectly coded MDS. 4. On 6/19/23 at 11:17 AM, the surveyor observed Resident #21 ambulating and mopping the floor with a play mop in the resident's room with a staff member present. The surveyor reviewed Resident #21's medical record. Resident #21's AR showed that the resident was admitted to the facility with a diagnosis that included but was not limited to; prematurity (a birth that occurs before 37 completed weeks (less than 259 days) of gestation and is associated with considerable risk of morbidity and mortality) and respiratory failure. Resident #21's Medication Administration Record for June 2023 included the following orders: Aripiprazole (an antipsychotic medication used to treat schizophrenia, bipolar disorder, depression, and Tourette syndrome and it can also be used to treat irritability associated with autism) 1 mg/ml (1 milligram/milliliter) solution (0.25 mg) via G-tube at 7:30 AM. Aripiprazole 1 mg/ml solution (2 mg) via G-tube at 8 PM. A review of Resident #21's developmental pediatric physician's note dated 6/06/23 included the following: Reason for Evaluation: Resident #21 . with retinopathy of prematurity, respiratory failure, tracheostomy, gastrostomy, osteopenia of prematurity, Autism spectrum disorder, who is being seen for initial assessment and assessment of behavior problems. Medications: Abilify (Aripiprazole) 2 mg at night with added 0.5 mg daytime, as tolerated .Plan: A prescription and written order were provided for Abilify to change to 0.25 mg in am (morning) .but keep Abilify 2 mg at bedtime for now . The most recent CMDS with an ARD of 5/19/23, showed that Resident #21's CSDDM assessment was moderately impaired. The CMDS showed on Section N for medications that the resident received an antipsychotic medication 7 (seven) days. Further review of the CMDS indicated that Section I Active Diagnoses did not include Autism Spectrum Disorder which was the diagnosis indicated for the physicians order of Aripiprazole. Further review of the MDS showed the following: ARD of 02/17/23 qMDS: Section N antipsychotic 7 days; Section I did not include diagnosis of autism. ARD of 11/18/22 qMDS: Section N antipsychotic 7 days; Section I did not include diagnosis of autism. ARD of 8/19/22 qMDS: Section N antipsychotic 7 days; Section I did not include diagnosis of autism. On 6/20/23 at 12:35 PM, the surveyor interviewed Registered Nurse #1 (RN #1) who stated that Resident #21 had a diagnosis of autism and that the resident had behavioral issues. On 6/26/23 at 12:16 PM, the surveyor interviewed the MDSC/RN regarding Resident #21's MDS. The MDSC/RN stated that the resident was on an antipsychotic medication and that the reason the resident was on the medication was that the resident had a diagnosis of autism. The surveyor asked the MDSC/RN the reason the diagnosis of autism was not listed on Resident #21's MDS. The MDSC/RN stated that the diagnoses listed on the MDS were the medical diagnoses that were in the resident's chart in the section of diagnoses. The surveyor asked the MDSC/RN if autism was a medical diagnosis. She stated yes, and added that the diagnosis was documented in other sections of the medical chart. On that same date and time, the surveyor then asked the MDSC/RN if the expectation would be to see the diagnosis on the MDS. The MDSC/RN stated yes maybe. She then added that the diagnosis code was pulled directly from eMR, in the diagnosis section. She then stated that if the diagnosis was not coded in the diagnosis section of the eMR, then it would not go over to the MDS. She further stated that she could manually put in the diagnosis but that she was told not to put the diagnoses in. The surveyor then asked the MDSC/RN if Resident #21's autism diagnosis should have been listed in the MDS. She stated yes. On 6/26/23 at 01:40 PM, in the presence of the survey team, the surveyor notified the LNHA, DON #1 and #2, MDSC/RN and DoT the concern regarding the missing diagnosis associated with the use of the antipsychotic medication in the MDS. On 6/27/23 at 12:24 PM, in the presence of the survey team, the LNHA stated that the diagnosis of autism was in Resident #21's neuro developmental notes. The surveyor then asked the LNHA if the diagnosis of autism should have been in Resident #21's MDS. The LNHA stated that he was not a MDS Coordinator and that he would have to look at the manual. 5. On 6/15/23 at 10:42 AM, the surveyor observed Resident #36 sitting up in bed watching television. Resident #36 had a tracheostomy that was connected to a ventilator and was receiving nutrition through a TF. The surveyor reviewed Resident #36's medical record. The AR showed that the resident was admitted to the facility with a diagnosis that included but was not limited to; myopathy (general term referring to any disease that affects the muscles that control voluntary movement in the body). The most recent qMDS with an ARD of 4/17/23, showed that Resident #36's CSDDM assessment was severely impaired. The 4/17/23 qMDS showed on Section G, the resident was coded 8/8 on eating and toilet use. Section K Swallowing/Nutritional Status indicated the resident had a TF. The sections for eating and toilet use were coded incorrectly. Further review of the MDS showed the following: ARD of 01/06/23 qMDS: Section G eating and toilet use was coded 8/8; Section K-TF. ARD of 10/07/22 qMDS: Section G toilet use was coded 8/8 and eating was coded four (4) total dependence and (2) one person physical assist. Section K-TF. ARD of 7/18/22 CMDS: Section G eating and toilet use was coded 4/2 (total dependence/one person physical assist). Section K-TF. The section for toilet use was coded incorrectly for 3 (three) of 4 (four) MDS reviewed. The section for eating was coded incorrectly for 2 (two) of 4 (four) MDS reviewed. On 6/26/23 at 11:21 AM, the surveyor interviewed CNA #2 regarding Resident #36's care. She stated that Resident #36 was incontinent and that she would change the resident's diaper often. She added that the nurse would give the resident a G-tube feeding. On 6/26/23 at 12:21 PM, in the presence of the survey team, the surveyor interviewed the MDSC/RN who confirmed that Section G eating and toilet use was coded incorrectly for Resident #36 when it was coded 8/8. On 6/26/23 at 01:40 PM, in the presence of the survey team, the surveyor notified the LNHA, DON #1 and #2, MDSC/RN and DoT the concern regarding the incorrectly coded MDS. 6. On 6/15/23 at 11:06 AM, the surveyor observed Resident #44 laying in a crib. Resident #44 had a tracheostomy that was connected to a ventilator and had received nutrition through a TF but the feeding was not currently infusing. The surveyor reviewed the medical records of Resident #44. Resident #44's AR showed that the resident was admitted to the facility with a diagnosis that included but was not limited to; congenital anomalies (comprise a wide range of abnormalities of body structure or function that are present at birth) and prematurity. The most recent qMDS with an ARD of 6/02/23, showed that Resident #44's CSDDM was not assessed. The 6/02/23 qMDS showed on Section G, the resident was coded 8/8 on eating and toilet use. Section K indicated the resident had a TF. The sections for eating and toilet use were coded incorrectly. Further review of the MDS showed the following: ARD of 3/03/23 qMDS: Section G toilet use was coded 8/8 and eating was coded 4/2. Section K-TF. ARD of 12/18/22 CMDS: Section G toilet use was coded 8/8 and eating was coded 4/2. Section K-TF. The section for toilet use was coded incorrectly for 3 (three) of 3 (three) MDS reviewed. The section for eating was coded incorrectly for 1 (one) of 3 (three) MDS reviewed. On 6/26/23 at 11:22 AM, the surveyor interviewed CNA #2 regarding Resident #44's care. She stated that Resident #44 was incontinent and that she would change the resident's diaper often. She added that the nurse would give the resident a G-tube feeding and that the resident had a colostomy bag that the nurse changed. On 6/26/23 at 12:21 PM, in the presence of the survey team, the surveyor interviewed the MDSC/RN who confirmed that Section G eating and toilet use was coded incorrectly for Resident #44 when it was coded 8/8. 38327 7. On 6/15/2023 at 11:57 AM, the surveyor observed Resident #41 seated in a recliner wheelchair inside their room with a tracheostomy attached to an oxygen. The resident was none verbal and unable to respond to the surveyor's questions. On 6/19/23 at 11:29 AM, the surveyor observed the three facility staff transfer the resident from bed to a recliner wheelchair with the use of the mechanical mobility tool as a lift. The three staff were the Nurse Extern (NE), RN #2, and CNA #3. On 6/19/23 at 11:37 AM, the surveyor interviewed CNA#3. The CNA informed the surveyor that Resident#41 was cognitively impaired, and required total assistance with ADL, and on tube feeding. She further stated that the resident was incontinent of both bowel and bladder elimination and that incontinence care was provided as needed. She indicated that the resident was NPO (nothing by mouth) and on a TF for nourishment. The surveyor reviewed Resident #41's medical record. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of diffuse TBI (a type of traumatic brain injury). The resident's most recent qMDS with an ARD of 3/30/23 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the qMDS revealed that the eating and toilet use were coded as 8/8. Section O Special Treatments, Procedures, and Programs in the qMDS revealed that the resident had no pneumococcal (pneumonia) vaccine and was not assessed, and no information. Further review of the resident's MDS showed that on the following MDS assessments: ARD 9/26/22 CMDS=toilet use was coded 8/8 and no pneumonia vaccine information ARD 12/16/22 qMDS=toilet use was coded 8/8 and no pneumonia vaccine information On 6/26/23 at 8:55 AM, the AVP of Access Management & Regulatory Affairs (AVPAMRA) in the presence of the LNHA, and the survey team provided a copy of the resident's Immunization Information System and revealed that the resident received the pneumonia vaccines dated 4/18/2006 (dose one), 7/13/2006 (dose two), 9/28/2006 (dose three), and 02/15/2007 (dose four). A review of the resident's electronic medical record revealed that there was no evidence that the resident had been administered the pneumonia vaccination. The provided list of residents with pneumonia vaccine by DON#2 did not include the resident's name. 8. On 6/19/2023 at 11:43 AM, the surveyor observed Resident #14 seated in a recliner wheelchair inside their room with a padded headboard, lap tray, and leg rest. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed Resident #14's medical record. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of respiratory failure. The resident's Progress Note (PN) dated 6/14/23 by the Medical Doctor (MD) with a date of service of 6/05/23 included past medical history diagnoses that were not limited to hypoxic ischemic encephalopathy (type of brain damage), respiratory failure with tracheostomy and ventilator dependence, seizure disorder, GERD (gastroesophageal reflux disease; occurs when stomach acid repeatedly flows back into the tube connecting mouth and stomach), and severe global developmental delay. The resident's most recent CMDS with an ARD of 4/27/23 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the CMDS revealed that the toilet use was coded as 8/8. Further review of the resident's MDS showed that on the following MDS assessments: ARD 7/15/22 qMDS=toilet use was coded 8/8 ARD 10/14/22 qMDS=toilet use was coded 8/8 ARD 01/13/23 qMDS=toilet use was coded 8/8 On 6/21/23 at 9:56 AM, the surveyor interviewed the MDSC/RN in the presence of another surveyor, DON#1 and #2. The MDSC/RN informed the surveyor that there was another per diem RN who does MDS. She further stated that there was no facility policy with regard to MDS and that the facility follows the RAI Manual in doing MDS. The MDSC/RN informed the surveyor that MDS was used for the resident's assessment that will generate CAAs (process and guides how to focus on key issues identified during a comprehensive MDS assessment. The triggered MDS items target care areas for additional assessment and review, as warranted by MDS item responses) triggers, and that was why the MDS should be accurate. She further stated that the MDS information was gathered from my personal assessments, nursing assessments, therapy notes, and assessment, CNA's information for the ADL, nutrition team notes, and diagnosis from the resident's medical chart. On that same date and time, the surveyor asked the MDSC/RN how she code Section G for toilet use. The MDSC/RN stated that it was being coded as 8/8 because all residents were pediatrics and they do not use the toilet like elder residents. The surveyor then asked the MDSC/RN to provide a copy where she got the information in the RAI manual that the Section G for toilet use should be coded as 8/8, and the MDSC/RN stated that she will get back to the surveyor. On 6/22/23 at 12:08 PM, the survey team met with AVPAMRA, DON#1 and #2, Manager of Regulatory Affairs & Accreditation (MRAA), and the DoT, and they were made aware of the above findings. On 6/26/23 at 11:18 AM, the surveyor interviewed CNA#2 who informed the surveyor that she was the assigned aide of the resident, and Resident #14 was cognitively impaired due to a medical condition. CNA#2 stated that the resident required total assistance with activities of daily living (ADL) including toileting and feeding which the nurse does for TF, and that the resident was NPO. She further stated that the resident was provided with incontinence care frequently to make sure that the resident was clean and dry, and to maintain intact skin. On 6/26/23 at 11:35 AM, the surveyor interviewed RN#2 and LPN #2. The RN stated that the resident required total assistance with ADL, including toileting by CNA and TF for the nurse because the resident also was NPO. The RN further stated that the resident was incontinent and care was provided as often as needed to make sure that the resident was dry, skin intact, and not soiled to prevent pressure ulcers and skin irritation. 45208 9. On 6/15/2023 at 9:37 AM, the surveyor observed Resident #27 seated in a recliner stroller inside their room with a tracheostomy attached to a ventilator. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed the medical records of Resident #27. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of seizures. The resident's PN dated 6/23/23 by the MD with a date of service of 6/22/23 included past medical history diagnoses that were not limited to agenesis of corpus callosum (a brain disorder in which the tissue that connects the left and right sides of the brain (its hemispheres) is partially or completely missing), seizure disorder, respiratory failure with tracheostomy and ventilator dependence and severe global developmental delay. The resident's most recent CMDS with an ARD of 5/05/23 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the CMDS revealed that the toilet use was coded as 8/8. On 6/19/23 at 11:22 AM, the surveyor interviewed CNA #4. The CNA informed the surveyor that Resident #27 was cognitively impaired and required total assistance with ADL, and on TF. She further stated that the resident was incontinent of both bowel and bladder elimination and on strict intake and output measurements. Incontinence care was provided as needed and diapers were being weighed for output. She indicated that the resident was NPO and on a TF for nourishment. 10. On 6/20/2023 at 9:23 AM, the surveyor observed Resident #28 seated in a recliner wheelchair inside their room with a tracheostomy attached to a ventilator. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed the medical records of Resident #28. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of anoxic brain injury (anoxic brain injury occurs when the brain is deprived of oxygen) and quadriplegic cerebral palsy (a form of cerebral palsy that affects both arms and legs and often the torso and face). The resident's PN dated 6/09/2023 by the MD with a date of service of 6/06/23 included past medical history diagnoses that were not limited to, seizure disorder, respiratory failure with tracheostomy and ventilator dependence, severe scoliosis, hypertension, feeding intolerance with gastrostomy dependence and anoxic brain injury with neurological impairments. The resident's most recent CMDS with an ARD of 5/05/2023 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the CMDS revealed that the toilet use was coded as 8/8. Section H of the CMDS revealed that the intermittent catheterization was coded as none of the above. A review of resident #28's personalized care plan revealed Bladder Scan assessment to be done by nursing was initiated on 11/8/2022 with start date of 4/27/2023. On 06/26/23 at 11:11 AM, the surveyor interviewed CNA#2. The CNA informed the surveyor that Resident #28 was cognitively impaired and required total assistance with ADL, and on TF. She further stated that the resident was incontinent of both bowel and bladder elimination. Incontinence care was provided as needed and that nursing was doing straight catheterization on the resident every six hours. 11. On 06/15/2023 at 10:29 AM, the surveyor observed Resident #33 seated in a recliner wheelchair inside their room with a tracheostomy attached to a ventilator. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed the medical records of Resident #33. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of [NAME] syndrome (a rare genetic disorder that can cause structural changes of the skull, bones of the face and other skeletal abnormalities). The resident's PN dated 6/23/2023 by the MD with a date of service of 6/23/23 included past medical history diagnoses that were not limited to, [NAME] syndrome with secondary craniofacial malformation/midface hypoplasia, s/p (status post) reconstructive surgical procedures, chronic respiratory failure with tracheostomy dependence and nocturnal ventilation, dysphagia with gastrostomy dependence, scoliosis, and global developmental delay. The resident's most recent CMDS with an ARD of 4/28/2023 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the CMDS revealed that the eating and toilet use were coded as 8/8. A review of Residents #33's nutrition note dated 5/01/2023 revealed the resident is NPO and is gastric TF dependent. On 6/20/23 at 09:43 AM, the surveyor interviewed RN #3. The RN informed the surveyor that Resident #33 was cognitively impaired and required total assistance with ADL. The RN further stated that the resident is on a TF and wears a diaper because of incontinence of both bowel and bladder elimination. 12. On 6/20/2023 at 10:29 AM, the surveyor reviewed the closed record for Resident #48 for hospitalization . The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of tracheostomy dependent long-term care. The resident's PN dated 5/10/2023 by the MD with a date of service of 5/24/23 included past medical history diagnoses that were not limited to, chronic respiratory failure with tracheostomy dependence, dysphagia with gastrostomy dependence, underlying chromosome 3 (three) duplication. The resident's most recent CMDS with an ARD of 5/26/2023 reflected that the CSDDM indicated that the resident's cognition was severely impaired. Section G of the CMDS revealed that the eating and toilet use were coded as 8/8. A review of Residents #48's nutrition note dated 5/30/2023 revealed the resident is NPO and is gastric TF dependent. On 6/26/23 at 12:00 PM, the surveyor in the presence of another surveyor interviewed the MDSC/RN. The MDSC/RN informed the surveyors that Section G in the MDS was the responsibility of the PT and OT. The MDSC/RN stated that the PT was responsible for Section G from A to F (where H is for eating) and the O [TRUNCATED]

Based on the interview, record review, and review of the facility provided documents, it was determined that the facility failed to identify medication irregularity during the monthly MRR (Medication Record Review) of the CP (Consultant Pharmacist) for three (3) of five (5) residents reviewed for unnecessary medications, Residents#14, #24, and #28. This deficient practice was evidenced by the following: According to [NAME]-Drugs (or Lexicomp an evidenced-based drug referential content; that provides evidence and recommendations to help clinicians as they treat and advise patients with complex conditions) included that review of the Erythromycin with pharmacologic category of antibiotic; Gastroparesis (off-label use; gastoparesis is a condition that affects the normal spontaneous movement of the muscles in stomach). There is a Patients refractory/intolerant to other prokinetic agents (eg, metoclopramide, domperidone; type of drug which enhances gastrointestinal motility) to limit the duration of therapy, tachyphylaxis (the appearance of progressive decrease in response to a given dose after repetitive administration of a pharmacologically or physiologically active substance and tachyphylaxis occurs when medications suddenly become less effective) may occur after four (4) weeks. According to The Use of Long-Term, Low Dose Erythromycin in Treating Persistent Gastric Stasis, volume 29; issue 5, P430-433, May 2005 included that Erythromycin also has been used in other conditions that have gastroparesis as a problem. Most studies have had follow-up periods of less than four weeks, but a recent study followed some patients for up to 18 months and suggested that tolerance may develop over time. A major concern that has been raised about using erythromycin in this way is that resistance of pathogens, such as S. pneumoniae (Streptococcus pneumoniae is a gram-positive bacterium and a cause of community-acquired pneumonia), may increase. Although the doses of erythromycin used are smaller doses than those typically used in treating bacterial infections, they may provide almost ideal conditions for the induction of bacterial mutation, and selection and resistance to erythromycin is well recognized. 1. On 6/19/2023 at 11:43 AM, the surveyor observed Resident #14 seated in a recliner wheelchair inside their room with a padded headboard, lap tray, and leg rest. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed Resident #14's medical record. The resident's Registration Form (RF; or facesheet; an admission summary) reflected that the resident was admitted to the facility and had a diagnosis of respiratory failure. The resident's Progress Note (PN) dated 6/14/23 by the Medical Doctor (MD) with a date of service of 6/05/23 included past medical history diagnoses that were not limited to hypoxic ischemic encephalopathy (type of brain damage), respiratory failure with tracheostomy (is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe) and ventilator dependence, seizure disorder, GERD (gastroesophageal reflux disease; occurs when stomach acid repeatedly flows back into the tube connecting mouth and stomach), and severe global developmental delay. The resident's most recent Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 4/27/23 reflected that the cognitive skills for daily decision-making indicated that the resident's cognition was severely impaired. The June 2023 electronic Medication Administration Record (eMAR) revealed a physician order (PO) dated 4/29/23 for Erythromycin Ethylsuccinate (EES; an antibiotic used to treat many different types of infections caused by bacteria) 200 mg/5 ml (200 milligrams/5 milliliters) susp (suspension) (80 mg) via GT (gastrostomy tube) every 6 (six) hours (Q6HR) with a clinical indication for gastric motility. According to the 5/25/23 CP's Monthly Report for Resident#14, the CP did not identify irregularity with the continued use of EES medication. A review of the provided documents of the CP via email showed that the CP included the article about The Use of Long-Term, Low Dose Erythromycin in Treating Persistent Gastric Stasis as a reference. The article provided by the CP did include the whole report that showed the article above regarding a major concern that has been raised about using EES in this way is that resistance of pathogens, such as S. pneumoniae, may increase and although the doses of EES used are smaller doses than those typically used in treating bacterial infections, they may provide almost ideal conditions for the induction of bacterial mutation, and selection and resistance to erythromycin is well recognized. On 6/26/23 at 9:55 AM, the survey team met with the CP. The CP stated that she was responsible for monthly MRR where she reviews residents' medications, identify irregularities, and notify the nursing and the physicians of the recommendations. The surveyor asked the CP if she was familiar with and use Lexicomp for medication reviews, and the tachyphylaxis concern with continued use of EES, and the CP stated Yes. The CP stated that tachyphylaxis does not mean that the medication was not working, but the efficacy was reduced, meaning that there is still a clinical benefit even though the efficacy was reduced over time. On that same date and time, the surveyor asked the CP if she was aware of the tachyphylaxis effect of continued use of EES to Resident #14, why she did not include it in her monthly MRR on 5/25/23, and if she notify the physician about it. The CP stated that I did not inform the doctor about it. The CP further stated that I do not have it, documented, that she discussed the medication with the doctor, but I know the doctor knows about the medication. 45449 2. On 6/19/23 at 11:02 AM, during the initial tour, the surveyor observed Resident #24 from the hallway in a wheelchair with bilateral leg splint, eyes opened and nonverbal. The surveyor reviewed the medical record for Resident #24. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of anoxia (absence or deficiency of oxygen reaching the tissues of the body). The quarterly MDS (qMDS) with an ARD of 4/14/23, reflected that the resident was cognitively impaired. A review of the Advanced Practical Nurse's (APN) Progress Note signed 5/19/23, reflected diagnoses which included, respiratory failure with tracheostomy and ventilator dependence, dysphagia (difficulty swallowing) with G-tube (gastrostomy; a tube inserted through the belly that allows air, fluid to leave the stomach and can be used to administer food, liquid and medications) dependence, spasticity (an abnormal increase in muscle tone or stiffness of muscle, which might interfere with movement, speech, or be associated with discomfort or pain), bilateral sensorineural hearing loss, and severe developmental delay. Further review of the APN progress note, under current medications, reflected an order for Erythromycin Ethylsuccinate (EES) 200 mg/5 ml, 70 mg Q8HRS G-tube with a start date of 4/29/23 and was indicated for improved GI (gastrointestinal) motility. The eMAR dated 6/18/23, confirmed Resident #24 received the EES 70 mg Q8HRS since 4/29/23. A review of the CP's Recommendations report from 01/30/23 through 5/25/23 did not reflect a recommendation to identify the duration of therapy and inform the prescriber of the studies that reflect a rapidly diminishing response to the use of EES that may occur after four (4) weeks of use. 45208 3. On 6/20/2023 at 9:23 AM, the surveyor observed Resident #28 seated in a recliner wheelchair inside their room with a tracheostomy attached to a ventilator. The resident was none verbal and unable to respond to the surveyor's questions. The surveyor reviewed Resident #28's medical record. The resident's RF reflected that the resident was admitted to the facility and had a diagnosis of anoxic brain injury (anoxic brain injury occurs when the brain is deprived of oxygen) and quadriplegic Cerebral Palsy (a form of cerebral palsy that affects both arms and legs and often the torso and face). The resident's PN dated 6/09/2023 by the MD with a date of service of 6/06/23 included past medical history diagnoses that were not limited to, seizure disorder, respiratory failure with tracheostomy and ventilator dependence, severe scoliosis, hypertension, feeding intolerance with gastrostomy dependence and anoxic brain injury with neurological impairments. The resident's most recent CMDS with an ARD of 5/05/23 reflected that the cognitive skills for daily decision-making indicated that the resident's cognition was severely impaired. The June 2023 eMAR revealed a PO dated 4/29/23 for EES 200 mg/5 ml susp via GT Q8HR with a clinical indication for gastric motility. According to the 5/25/23 CP's Monthly Report for Resident #28, the CP did not identify irregularity with the continued use of EES medication. On 6/26/23 at 10:32 AM, the MD (also the Medical Director of the facility) and the Licensed Nursing Home Administrator (LNHA) met with the survey team. The MD presented herself to be interviewed and stated that there was a concern with EES and that the doctor wanted to talk about it. The LNHA then left. On that same date and time, the surveyor in the presence of the survey team notified the MD of the above findings and concerns regarding EES medication that the CP did not identify and notify the MD and the facility of irregularities even though the CP admitted that she knew about the tachyphylaxis issue with continued use of medication for more than 4 (four) weeks. The MD did not disagree with what the CP informed the surveyors that the CP did not notify the MD of the tachyphylaxis irregularity with continued use of EES and that there was no report about it on 5/25/23 MRR. Furthermore, the MD stated that she can not disagree more with the surveyor about the ABT (antibiotic) stewardship regulation and pharmacy review regulation that the facility should follow concerning the review of unnecessary medications should have been followed and that the irregularity should have been reported to the physician during the monthly MRR. At that same time, the MD stated that moving forward she should document the justification for continued use of EES according to the requirement of the regulation. On 6/27/23 at 12:09 PM, the survey team met with the AVP (Assistant [NAME] President) of Access Management & Regulatory Affairs (AVPAMRA), Manager of Regulatory Affairs & Accreditation (MRAA), Director Of Nursing#1 (DON#1), DON#2, and the LNHA. The LNHA stated that there was no further information that the facility can share about the EES medication. A review of the facility's Pharmacy-Pharmacist Consultation LTC Policy that was provided by DON#2 with an effective date of 01/01/23 included that the consulting pharmacist shall review each patient's drug regimen at least monthly. The monthly review of the patient's drug regimen shall include, but not be limited to, laboratory tests, dietary requirements, physician's and nurse's clinical notes, physician's orders, and progress notes. Potential adverse reactions, allergies, drug interactions, contraindications, rationally of therapy, drug therapy evaluation, and laboratory test modifications shall also be monitored. On 6/27/23 at 01:11 PM, the survey team met with the LNHA, DON#1 and #2, Director of Therapy, AVPAMRA, and MRAA. There was no additional information provided by the facility management. NJAC 8:39- 29.1(a), 29.3 (a)(1)

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure a) proper disposal of a controlled substance (narcotic; medications, that due to their high potential for abuse, are tracked with detail) medications, b) medication was crushed, c) proper disposal of non-controlled substance and was identified during the medication administration observation for two of three nurses in accordance to standards of clinical practice and facility policy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. A review of the manufacturer's specification for [brand name redacted] oral/enteral syringe with [brand redacted] connector for pharmacy use, included: Indication for use, the device is indicated for use as a dispenser, a measuring device, and a fluid transfer device. It is used to deliver fluids into the body orally and enterally (administration by mouth or esophagus or artificial opening to the intestine). It is intended to be used in clinical or home care settings by users ranging from clinicians to layperson (under the supervision of a clinician) in all ages. Contraindications included: This device is intended for oral /enteral applications only .5) Do not modify this device as this may lead to leakage, inadequate nutrition delivery or patient harm. 1. On [DATE], at 9:35 AM, the surveyor began the Medication Observation Pass for Resident #40. The surveyor observed Licensed Practical Nurse #1 (LPN#1) and Registered Nurse #1 (RN #1) obtain a 5 ml syringe that contained Phenobarbital (prevents and controls seizures in people with epilepsy) 20 milligram (mg)/5 milliliter (ml) syringe from the electronic back-up machine. At that time, LPN #1 stated that the pharmacy made 5 ml of the Phenobarbital 20 mg/5 ml and that she had to waste 0.6 ml because Resident's order was for 4.4 ml. At that time, the surveyor observed LPN#1 began to run the water from the faucet and wasted 0.6 ml of the Phenobarbital into the sink. The surveyor observed RN#1 and LPN#1 document the disposal into the electronic backup machine and LPN #1 relabeled the syringe for administration. The surveyor reviewed the medical record for Resident #40. The Registration Form (RF; or facesheet; an admission summary) reflected the resident was admitted to the facility with a diagnosis of homocystinuria (a disorder in which the body is unable to break down certain building block proteins (amino acids)). The electronic Medication Administration Report (eMAR) included an order for: Phenobarbital 20 mg/5 ml, dose 17.6 mg (4.4 ml) GT (gastrostomy; a tube inserted through the belly that allows air, fluid to leave the stomach and can be used to administer food, liquid, and medications) BID [twice a day] 10:00 and 22:00 (8 PM), with a start date of [DATE]. A review of the manufacturer specifications revealed Phenobarbital was classified as a scheduled 4 (four) Controlled Substance. On [DATE] at 12:36 PM, during an interview with the surveyor, LPN #1 stated narcotic medications must be wasted within the medication room in a trash can and a second nurse must sign that we are wasting/disposing of the narcotic. We then have to let the pharmacy know that we wasted the medication. LPN#1 also stated non-controlled medications, are disposed in the garbage with the second nurse present. We have additional doses that we can retrieve from the cassettes [in the medication cart]. 2. On [DATE] at 11:19 AM, the surveyor observed LPN #2 prepare medications for Resident #25 in the resident's room. The eMAR included an order for Cortef (Hydrocortisone; is a steroid used to treat many different conditions such as allergic disorders, skin conditions, etc.) 2.5 mg GT schedule for 12:00 PM. At that time, the surveyor observed LPN #2 use an Alcohol based hand rub (ABHR) and donned gloves. At that time, the surveyor observed LPN #2 retrieve the Cortef 2.5 mg tablet from the Resident #25's designated cassette from the medication cart, opened the unit dose of Cortef, leaving the pill within its package and placed it on the medication cart. At that time, LPN #2 retrieved an open system [brand redacted] syringe from the medication cart drawer, pulled the plunger off the syringe and placed the Cortef tablet into the syringe. LPN #2 placed the plunger into the syringe and crushed the tablets that emitted dust particles from the open end of the syringe. The nurse drew water and capped the syringe with her gloved finger and shook the syringe to dissolve its contents. At 11:20 AM, the surveyor observed a [brand redacted] pill crusher on the medication cart and asked the nurse if that was the facility policy to crush the pill in the syringe. LPN #2 stated I was not told I can not crush into a syringe. The surveyor reviewed the medical record for Resident #25. The RF reflected that the resident was admitted to facility with a diagnosis of adenovirus (viruses which are common causes of respiratory illness). A review of the eMAR reflected an order that included: Hydrocortisone 2.5 mg GT scheduled for 6:00 AM, 12:00 PM and 18:00 (6 PM), with a start date of [DATE]. 3. On [DATE] at 11:24 AM, the surveyor observed LPN #2 prepare medications for Resident #1 in the resident's room. The eMAR reflected an order that included Robinul Forte (Glycopyrolate; helps to control conditions such as peptic ulcers that involve excessive stomach acid production) 2 mg GT. At that time, the surveyor observed LPN #2 use an ABHR and donned gloves. At 11:29, the surveyor observed LPN #2 crush the Robinul Forte using the pill crusher, as she was transferring the crushed medication into the syringe, LPN #2 spilled some crushed medication onto the medication cart, and some were in the open system syringe. At that time, the surveyor observed LPN #2 throw the syringe that contained some of the crushed Robinul Forte into the trash bin that was attached to the medication cart. LPN #2 wiped the spilled medication and threw the paper towel into the trash bin. At that time, the surveyor asked LPN #2 what the facility policy for disposal of a non-controlled medication. LPN #2 stated I don't know where else to throw it. LPN #2 could not recall receiving an in-service (education) for medication disposal. The surveyor reviewed the medical record for Resident #1. The RF reflected Resident #1 was admitted with a diagnosis of perinatal asphyxia (failure to establish breathing at birth). On [DATE] at 9:31 AM, during an interview with the surveyors the Pharmacy Director (PD) confirmed that Phenobarbital was a scheduled 4 (four) narcotic medication. The PD stated that the Joint Commission recommended that it can be flushed down the sink. The PD stated liquids were flushed down the sink and that tablets were brought back to the pharmacy; We have proper bins to dispose of those. The PD informed the surveyors that the facility did not have a drug disposal solution (bottle of solution used to disintegrate pills and tablets). The PD was unable to respond when asked where should spilled crushed medications be disposed. The PD stated the policy was appropriate. At that time, during an interview with the surveyors the PD stated medications should not be crushed within a syringe because she can not ensure the medication could be completely crushed but can be dissolved within the syringe. The PD stated that crushing a medication through an open system syringe can result to medication being lost through the opening and did not guarantee 100% delivery of the medication. At that time, the PD confirmed the facility policy should be followed. At that time, the PD also stated that placing a finger over the open system syringe was not a clean process and that was an infection control issue. On [DATE] at 9:55 AM, during an interview with the survey team, the Consultant Pharmacist (CP) stated she was in the facility once a month and conducted medication pass observations. The CP stated she had observed the nurses crush a medication in a syringe and that it was okay to do. The CP informed the surveyors that she did not report any competency issue with crushing a medication in a syringe. The CP stated she would provide information regarding crushing medications using a syringe. No further information was provided. At that time, the CP stated that all medications including crushed medication should be returned to the in-house pharmacy in the building. At that time, the CP stated she would provide an in-service/education to the individual nurse but has not provided the education yet. The CP stated she has not provided in-service on the topic of medication administration and drug disposal. On [DATE] at 01:34 PM, the survey team met with the Minimum Data Set Coordinator, the Director of Nursing (DON #1) and DON #2, the Director of Therapy (DoT), and were made aware of the above findings. On [DATE] at 12:09 PM, the survey team met with the AVP (Assistant [NAME] President) of Access Management & Regulatory Affairs (AVPAMRA), Manager of Regulatory Affairs & Accreditation (MRAA), DON#1, DON#2, and the Licensed Nursing Home Administrator (LNHA). The LNHA stated that there was no further information that the facility can share. At that time, DON #2 stated the facility had a [brand name redacted] pill crusher and we would like to streamline the process. At that time, DON #2 stated she would not recommend the use of a hand in dissolving the medication in the syringe because of infection control. A review of the facility policy provided, Destruction of Medication with an effective date of [DATE], included following: It is the policy of the [facility name redacted] that the pharmacy department shall be responsible for the destruction of outdated, discontinued, contaminated or otherwise unusable medication. Under section, II. Destruction Procedure subsection A. Non-controlled Substance: 1. Individual, small quantities of liquids that are non-poisonous, non- corrosive, non-hazardous or nonflammable will be kept in their container and deposited in the red medical waste receptacle. 2. Small quantities of tablets and capsules that cannot be returned for credit through an authorized drug disposal company will be kept in the container and deposited in the red medical waste receptacle, 3. Hazardous medications will be discarded in the black hazardous medication bin. B) Controlled Substances: 1. Unused or expired controlled substances will be locked in a designated cabinet in the pharmacy department the prior to planned disposition. A review of the facility policy provided, Medication Management with an effective date of [DATE], included following: Purpose: This policy establishes the process for [facility name redacted] for safe medication prescribing, dispensing and administration. Departments Affected: Pharmacy, Nursing, Respiratory, Medical Outpatient Services. Under section D. Administration, subsection 5. Verifies the medication is stable based on visual examination for particulates or discoloration and that the medication has not expired. NJAC 8:39- 19.4(a), 29.7 (c), 29.4(g), 27.1(a),

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

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

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

Based on observation, interview and record review, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous foods in a safe and sanitary environment to address the risk of development of food-borne illness. This deficient practice was evidenced by the following: During a tour of the kitchen with the Assistant Dietary Manager (ADM) on 10/15/19 at 9:29 AM, the surveyor observed the following: 1. There was an opened (product exposed to the air) 20-pound box of lentils observed in the dry storage area. The ADM stated that it should not have been open and exposed and she removed it from the storeroom. 2. There was a 16-ounce clear plastic container of fresh strawberries observed on a shelf in the walk-in refrigerator. Some of the strawberries were observed to have a grayish/white fuzzy substance on them. The ADM stated that they should not be that way and that the product was recently delivered. She removed the strawberries from the refrigerator. 3. There was a case of 15-dozen raw eggs stored on the top shelf of a two tiered stainless steel utility cart. There was a case of unsalted butter next to the raw eggs. A case of heavy cream and a case of American cheese were observed on the shelf underneath the raw eggs. The ADM stated that the products were just delivered but should not have been stored that way. She further stated that raw eggs should always be stored on the bottom shelf. 4. There was a [NAME]o-Coupe (a machine that can mechanically alter a foods consistency or mix foods) observed to have cracks on the inside bottom of the gray plastic bowl (where there would have been food contact) as well as a small piece of plastic missing. The ADM stated the [NAME]o-Coupe was used to prepare mechanically altered food and that the gray bowl should no longer be used. 5. There was a slicer covered with an opaque plastic bag. The ADM stated that if the equipment was covered that it indicated the equipment was cleaned. The ADM removed the bag and red debris was observed on the underside of the slicer where the blade sits. The ADM acknowledged the red debris. 6. There were two ovens that were heavily soiled with a black build up. The ADM could not speak to the last time they were cleaned and stated that the ovens were on a cleaning schedule. 7. There was a grill top that was heavily soiled with a black build up. The ADM could not speak to the last time it was cleaned and stated that the grill top was on a cleaning schedule. 8. There was a sticky build up on the base and in the gear of the table top manual can opener. The ADM stated that the can opener should have been cleaned through the dish machine after each use. She further stated that the base was on a cleaning schedule but could not speak to the last time it was cleaned. The Cook was also present at that time and stated that the can opener was cleaned every other day. During a tour of the kitchen with the ADM on 10/18/19 at 10:45 AM, the surveyor observed the following: 9. There were three light covers underneath the kitchen exhaust hood over the cooking equipment. The light covers were yellowed and there was a heavy build up of debris. The ADM acknowledged the observation. 10. There was a square white ceiling vent over the coffee machine area that was discolored with a brownish/blackish substance. The ADM acknowledged the observation and could not speak to what the substance was. During an interview with the surveyor on 10/15/19 at 9:29 AM, the ADM stated that the kitchen prepared mechanically altered foods for some residents and prepared powdered formula with sterile water for other residents. During an interview with the surveyor on 10/21/19 at 9:17 AM, the Registered Dietitian (RD) stated that two resident's received pureed food from the kitchen, four residents received mechanically ground food from the kitchen, and 13 residents received formula prepared by the kitchen (three of which also received mechanically altered food). Review of the Children's Specialized Hospital Weekly Cleaning Assignment, with a revised date of (YEAR), indicated the following: a. the grill was last cleaned on 10/13/19 from 2:45 to 2:55; b. the oven (#1) was last cleaned on 10/14/19 from 4:32 to 4:50; c. the oven (#2) was last cleaned on 10/9/19 from 3:25 to 3:45; and d. the can opener, scales and food processor were last cleaned on 10/11/19 from 2:15 to 2:52. Review of the facility policy Food and Non Foods Storage, with a revised date of 10/12 and a reviewed date of 04/15, reflected that food and non-food products should be stored in a safe, sanitary and timely manner. It further indicated that plastic containers with tight fitting lids were used to store bulk foods such as grains, rice and beans. Review of the facility policy H.[NAME]C.C.P. (Hazard Analysis Critical Control Point Program), dated 12/16/91, reflected that the Dietary Department would protect residents and staff from food borne illness. It also reflected the identification of hazards which were indicated as situations that would allow for contamination, growth and survival of pathogens. The policy reflected the sources of contamination as naturally occurring, cross contamination, direct contamination and equipment not sanitized. It further reflected that the facility should monitor and verify the application of control methods by having checked for conditions that could lead to contamination. NJAC 8:39-17.2 (g)

Based on observation, interview, and record review, it was determined that the facility failed to follow a physician's order for Head of Bed (HOB) at or equal to 30 degrees and the facility's Ventilator Associated Pneumonia (VAP) protocol. This deficient practice was identified for Resident #33, 1 of 1 resident reviewed with a [MEDICAL CONDITION] (a surgical opening created in the neck to place a tube into the windpipe), and was evidenced by the following: According to the Registration Form, Resident #33 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Annual Minimum Data Set (MDS), an assessment tool dated 08/23/19, revealed that the resident's cognition was severely impaired. The MDS also revealed the resident required oxygen, suctioning, [MEDICAL CONDITION] care, and a respirator. Review of the resident's Care Plan (CP), dated initiated on 01/8/09, revealed the resident was at risk for Ineffective Airway Clearance related to [MEDICAL CONDITION] and ventilator inability to clear own secretions, and effective breathing pattern. The CP indicated, under Additional Interventions, to Elevate HOB>(greater)30 to optimize ventilation with an initiated date of 01/29/16. On 10/17/19 at 9:53 AM, the surveyor observed Resident #33 lying supine (on back facing upward) in bed. The degree indicator on the outside of the right upper side rail of resident's bed showed the HOB was elevated at 10 degrees. The HOB degree indicator revealed black marks drawn to show where the silver ball should be at 30 degrees. The silver ball inside the HOB indicator revealed the HOB was at 10 degrees. Resident #33's [MEDICAL CONDITION] was connected to the ventilator. The resident was on continuous monitoring, which displayed the resident had an oxygen saturation level of 99%. During an interview with the surveyors on 10/17/19 at 9:57 AM, Registered Nurse (RN) #1 stated that Resident #33 was not on VAP precautions and that the resident could lay flat. RN #1 stated there was nothing in the room to indicate that the resident was on VAP precautions. If a resident was on VAP precautions it would have been endorsed between staff members and/or it would be in the computer. On 10/17/19 at 10:01 AM, the surveyor and RN #1 reviewed the resident's medical record which revealed an order to Elevate Head Bed >/= (greater or equal to) 30 degrees that was entered 10/24/18 at 3:03 PM. The surveyor questioned RN #1 about the positioning and HOB of Resident #33. RN #1 stated Resident #33's HOB was at 30 degrees. The surveyor and RN #1 went to the bedside of Resident #33. RN #1 confirmed that the resident's HOB was at 10 degrees and not at 30 degrees. RN #1 elevated the residents HOB to 30 degrees, which was indicated by the silver ball of the HOB indicator and the black marks drawn on the side rail. RN#1 stated the purpose of elevating the HOB was so that the resident did not choke on their secretions. During an interview with the surveyors on 10/17/19 at 10:47 AM, the Respiratory Therapist (RT) #1 stated that according to the facility's protocol for residents that have a [MEDICAL CONDITION] connected to a ventilator, the HOB should be at 30 degrees to prevent aspiration and ventilator pneumonia. RT #1 stated that when a resident with a [MEDICAL CONDITION] lays flat, their secretions could go into their airway. RT #1 stated that Resident #33 needed to be suctioned quite often, every three or four hours. RT #1 stated that Resident #33 was not able to communicate and was not able to move around in the bed. During an interview with the surveyors on 10/17/19 at 11:47 AM, Medical Doctor (MD) #1 stated that any resident that was dependent on a ventilator for 24 hours a day was on VAP precautions. VAP precautions included HOB at 30 degrees. MD #1 stated that the purpose of elevating the HOB to 30 degrees was to prevent VAP and for better aeration to the lung bases. MD #1 confirmed Resident #33 was dependent on the ventilator for 24 hours a day and had VAP precaution orders. During an interview with the surveyors on 10/17/19 at 1:08 PM, the Director of Nursing (DON) stated the VAP Protocol included HOB at 30 degrees and the reason was to prevent pneumonia. The DON stated that if a resident had an order for [REDACTED]. Review of the Care Activity-Interventions, revealed that RN #1 had completed the intervention for Elevate HOB>30 to optimize ventilation on 10/17/19 at 7:30 AM. Review of the facility's Policy#: PC-114, Prevention of Ventilator Associated Pneumonia, with a reviewed date of 06/19, revealed HOB elevation: HOB elevation >30 degrees is the preferred position for ventilated patient. Review of the facility's policy Mechanical Ventilation Protocol, with a revised and reviewed date of 06/19, revealed that the HOB should be elevated between 30 and 45 degrees unless other medical conditions dictated otherwise. Review of the facility's NetLearning on VAP education for RN#1 revealed a completion date of 01/01/10. NJAC 8:39-27.1(a)

C#: NJ 5 Based on observation, interviews and review of facility policy, it was determined that the facility Housekeeping staff failed to implement the standards of infection control in accordance to the facility's policy and accepted standards of infection control practice. The surveyor observed 4 Housekeeping staff perform terminal cleaning in room [ROOM NUMBER] without utilizing Protective Personal Equipment (PPE). This deficient practice was evidenced by: On 2/11/19 at 10:17 AM, the surveyor observed a nurse gave instructions to a Certified Nursing Assistant (CNA) to take the Unsampled Resident A out of room [ROOM NUMBER] because the Medical Doctor (MD) ordered to discontinue contact isolation. The nurse then instructed the housekeeping staff to perform terminal cleaning in the room. On 2/11/19 at 10:30 AM, the surveyor observed 4 Housekeeping staff performing terminal cleaning in room [ROOM NUMBER]. The surveyor observed 2 Housekeeping staff on ladders cleaning the furniture cubicles high above the bed area and 1 Housekeeper cleaning the bed. 1 Housekeeper was on a ladder removing the privacy curtains. The surveyor observed that the staff did wear gloves, however; did not wear PPEs. On 2/11/19 at 10:31 AM, the surveyor questioned why the Housekeeping staff did not wear the PPEs, and if they should wear the PPEs at that time. The Lead Housekeeper stated that there was no sign to indicate contact precaution, so Housekeeping staff did not wear the PPEs. A discussion ensued between the Housekeepers and the surveyor observed the 4 Housekeepers don PPEs and proceeded to continue terminal cleaning of room [ROOM NUMBER]. During an interview on 2/11/19 at 11:07 AM, the Assistant Manager of Environmental Services stated that during terminal cleaning, the Housekeeping staff must wear PPEs. He further explained that because the nurse removed the contact precaution sign and the storage bin from in front of the room, the Housekeeping staff assumed they did not have to apply the PPEs. They did however, wear the PPEs after the surveyor questioned the Lead Housekeeper about the protocol. He also stated that the staff were inserviced in (MONTH) (YEAR) on the proper use of PPEs including when to use them. They are supposed to put on PPEs for terminal cleaning, even though the signs were removed. During an interview with the Lead Housekeeper on 2/11/19 at 12:02 PM, the Lead Housekeeper stated, We did not put PPEs on this morning in room [ROOM NUMBER] because the sign was not on the door, so we thought it was ok. She further stated that the housekeeping staff must put on the PPEs to do cleaning of the rooms. During an interview with the Infection Preventionist on 2/11/19 at 12:45 PM, she stated that the Housekeeping staff should wear PPEs during terminal cleaning. A review of the facility policy entitled, Procedure for Cleaning and Disinfection of Rooms following Discontinuation of Transmission Based Precautions. dated 6/00 and revised on 6/18, included but was not limited to the following: Policy: To maintain a clean environment for patients and minimize the risks of patient and healthcare personnel exposure to potentially infectious organisms. The patient care environment throughout the facility will be maintained in a state of cleanliness that meets professional standards in order to protect patients and healthcare personnel from potentially infectious microorganisms. Personnel responsible for cleaning the environment and equipment will receive education and training on proper environmental cleaning and disinfection methods, agent use and selection, and safety precautions. Purpose: To establish procedures for daily and terminal cleaning of rooms requiring Transmission Based Precaution. Definitions: Environmental Contamination: the presence of an infectious agent on hands or on a surface such as clothes,gowns,gloves, bedding, toys, patient care equipment, dressings or other inanimate objects Personal Protective Equipment (PPE): clothing or equipment worn by staff for protecting against hazards. Terminal Cleaning: the thorough cleaning and disinfection of a patient room following discharge or discontinuation of Transmission Based Precautions in order to remove germs that might be transferred to the next patient in the room. Cleaning and Disinfecting Procedures: Do not begin cleaning room while patient is in room. Use personal protective equipment (PPE) at all times. Gown and gloves required at all times. Signs must remain posted until the terminal cleaning process is complete. Environmental staff will change the sign once room cleaning is complete. NJAC 8:39 - 19.4 (a)

Based on interviews and record review, as well as review of pertinent facility documents on 12/4/18, the facility failed to review the facility's Infection Control Manual (ICM) standards, policies and procedures annually, as evidenced by the following: On 12/4/18 at 3:00 p.m., the Certified Infection Control (CIC) staff provided the facility's Infection Control Manual (ICM). The ICM revealed that the Infection Control-Scope of Service, Mission and Vision, Methods of Surveillance, Exposure Control Plan, and Mgmt (Management) of Exposure to Blood and Other Potentially Infectious Material was last reviewed/revised on 1/2017. The ICM also revealed the Antibiotic Stewardship and the Hand Hygiene policy was reviewed/revised on 7/2018 and 11/2018, respectively. During an interview with the Administrator and the CIC on 12/4/18 at 4:03 p.m., they confirmed the aforementioned dates the last ICM was reviewed. They were aware that the ICM should be reviewed annually. The CIC stated that the ICM will be reviewed before the end of this year (YEAR). Post Survey on 12/6/18, the surveyor received and reviewed the Infection Prevention and Control Committee Meeting Minutes, for (YEAR). This meeting revealed that the Infection Prevention Plan and Risk Assessment were reviewed on 5/14/18, which was four months late for 1/2018 review. NJAC 8:39-19.4 (a)

Based on observation, interview and record review, it was determined that the facility failed to maintain accurate accountability and reconciliation for controlled medications in 2 of 2 Omnicell (automated medication dispensing system) medication storage units located on 2 of 2 facility wings. This deficient practice was evidenced by the following: On 10/25/18 at 8:29 AM, the surveyor inspected the West Wing Omnicell in the presence of the Nurse Manager (NM) and Pharmacist. At that time, the surveyor interviewed the NM. The NM stated, the 11 PM to 7 AM Nursing Supervisors were required to do a cycle count (inventory) every evening of the contents of the Omnicell for accuracy. The NM further stated, the cycle count was completed electronically. On 10/25/18 at 12:35 PM, the NM provided the surveyor with a copy of the Omnicell Specific Criteria Report (Report) dated 10/1/18 through 10/24/18. The surveyor reviewed the Report and observed the Report failed to contain the electronic signatures of two nurses on the daily cycle count for the following days: 10/4/18, 10/5/18, 10/9/18, 10/10/18, 10/11/18, 10/15/18, 10/19/18, 10/23/18, and 10/24/18. On 10/26/18 at 9:14 AM, the surveyor interviewed the Director of Long Term Care (Director). The Director stated that she was unable to provide further documentation of the daily cycle count. The Director confirmed that the counts were not conducted on 10/4/18, 10/5/18, 10/9/18, 10/10/18, 10/11/18, 10/15/18, 10/19/18, 10/23/18, and 10/24/18. On 10/26/18 at 12:40 PM, the surveyor interviewed the NM. The NM stated, per facility policy, the Omnicell Cycle Count was supposed to be completed daily at 7 AM by two night shift nursing supervisors. The UM further stated that the nursing supervisors are responsible for this task without oversight. The surveyor reviewed the facility Policy #MM-24, titled, Omnicell Automated Medication Dispensing Device-Controlled Drug Substances (Revised: 7/18), which revealed the following: A complete cycle count of all controlled drug substances will (sic) performed daily during the 7 am shift change by two members of the outgoing and incoming Nursing and Pharmacy staff. The policy further revealed, The nurse will count and verify quantity with witness of each controlled substance and enter into Omnicell as directed. NJAC 8:39-29.7(c)

Based on observation and interview, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 10/23/18 at 8:52 AM, the surveyor, who was accompanied by the Cook, began the initial tour of the kitchen: 1. In the walk-in refrigerator, an opened half gallon carton of Almond Breeze milk was stored on a shelf. The carton was labeled opened on 09/24/18. The packaging indicated to use within seven days of opening. 2. In the walk-in refrigerator, an opened case of pure lactose free eight-ounce milk containers was stored on a shelf. The surveyor observed four of the 11 containers to be soiled with an unknown brown substance. When interviewed, the Cook stated that something must have dripped on the containers. 3. In the walk-in refrigerator, a case of 18 single serving soy milks was stored on a shelf. The case was soiled with an unknown brown substance. 4. In the walk-in refrigerator, a milk crate containing 41 eight-ounce milk cartons was stored directly on the floor. When interviewed, the Cook said the milk crate was delivered that morning and that the milk crate was always placed on the floor when delivered until someone was able to put the milk cartons onto the shelves. At which time, the Cook confirmed the milk crate, that contained the 41 eight-ounce milk cartons, should not have been stored on the floor because the floor was dirty. 5. In the walk-in refrigerator, a container of Top Banana Muffin Batter with an opened date of 10/23/18 was stored on a shelf. The surveyor observed batter on the outside of the container in three different places. When interviewed, the Cook said one of the containers was busted on delivery and the batter observed on the container was from the busted container. The Cook further stated that the batter on the outside of the container promoted bacterial growth which could contaminate the batter on the inside. 6. In the walk-in refrigerator, a square clear plastic container that contained tuna fish was stored on a shelf. The tuna fish had an opened date of 10/15/18 and a use by date of 10/21/18. 7. In the walk-in refrigerator, a container of pre-made tuna fish salad with an open date of 10/13/18 was stored on a shelf. When interviewed, the Cook said the tuna fish salad should have been discarded seven days after the open date. At 9:32 AM, the Food Service Supervisor (FSS) was present and continued the tour of the kitchen with the surveyor. The surveyor interviewed the FSS about the tuna fish salad. The FSS confirmed the tuna fish salad should have been discarded seven days after it was opened. 8. In reach-in refrigerator five, two packages of twelve-inch Italian rolls had a use by date of 10/17/18. 9. In reach-in refrigerator five, two packages, that contained twelve hoagie rolls each, was undated. When interviewed, the FSS was unsure when the rolls were delivered or when the rolls should be used by. 10. In reach-in refrigerator five, a package, that contained six seeded hamburger rolls, had a use by date of 08/30/18. 11. In reach-in refrigerator five, a package, that contained twelve hot dog rolls, had a use by date of 10/22/18. 12. In reach-in refrigerator five, a package, that contained 16 top slit dinner rolls, was ripped open and exposed to air. The surveyor observed there was no use by date indicated on the package. 13. In reach-in refrigerator five, a package, that contained 10 top slit dinner rolls, was opened and had a use by date 09/11/18. When interviewed, the FSS said the staff should be rotating the products. 14. In reach-in freezer five, the surveyor observed an ambient temperature of thirty-nine degrees Fahrenheit (F) and a package of egg rolls stored inside. When interviewed, the FSS stated the freezer was not functioning properly and maintenance had already been informed. 15. The surveyor observed three plastic cutting boards stored under the preparation table. The cutting boards were warped, discolored, and pitted. When interviewed, the FSS confirmed the surveyor's findings and stated the plastic cutting boards needed to be replaced. 16. The surveyor observed a small plastic container of shredded cheddar cheese stored on the preparation table. The surveyor observed the FSS calibrate a facility thermometer to 32.1 degrees F. The FSS then used the calibrated thermometer and obtained a temperature of 53 degrees F for the shredded cheddar cheese. The FSS stated that cold food should be maintained below 40 degrees F. 17. The surveyor observed two rubber spatulas and one food ladle stored in a drawer under the vegetable sink preparation table. The surveyor observed that the spatulas were discolored and cracked. The surveyor also observed that the ladle had food debris on it. When interviewed, the FSS stated that spatulas should be discarded, and the ladle washed. 18. The surveyor observed a cart next to the slicer that contained one corned beef, one honey ham, one pastrami, and the end of a piece of turkey deli meat. When interviewed, the Cook said he was going to slice the corned beef, honey ham, and pastrami meats. The Cook stated he was going to use the turkey deli meat to prepare both chopped and pureed meals. The surveyor observed the FSS obtain the following temperatures: corned beef 44 degrees F; pastrami 44 degrees F; honey ham 50 degrees F; and turkey 60 degrees F. 19. The surveyor observed a serrated knife, a carving knife, a knife honer (a tool used to sharpen a knife), and two pizza slicers stored in a drawer in the Cook's area. The handles were pitted and discolored. The drawer also contained one metal bench scraper (a tool used to scrape dough from work surface). The scraper was warped, and the plastic handle was melted. 20. The surveyor observed that the fryer back splash was discolored and soiled with build-up. The surveyor also observed the shelf under the fryer contained food debris. When interviewed, the FSS stated that the Cooks were responsible for cleaning the fryer. 21. The surveyor observed a shelf positioned to the left of the oven. The shelf contained a plastic tray and two fryer baskets. The shelf was visibly soiled with a grease-like substance and food debris. 22. The surveyor observed five pot holders on top of the steamer. When interviewed, the FSS informed the surveyor that they (kitchen staff) stored the pot holders on top of the steamer. The surveyor observed the FSS take a clean white disposable towel and wipe the top surface of the steamer. The surveyor observed the white towel to be visibly discolored. The FSS then stated that they should not store the pot holders above the steamer because dust and debris transfers to the pot holders. The FSS further stated that when the pot holders are used, the dirt could transfer to cooking equipment and into the food. 23. In the dry storage room, the surveyor observed dust and debris on top of multiple large cans that included: one ketchup, one chow mien noodles, one nacho cheese sauce, one tomato paste, one sauerkraut, one chili sauce, two banana puddings, one chocolate pudding, and four beef ravioli. The lids were visibly soiled with dust and debris. When interviewed, the FSS stated cans covered in dust and debris could result in the dust and debris being transferred into the product upon opening. 24. In the dry storage room, eight twelve-ounce cans of evaporated milk had a use by date of 10/12/18. 25. In the dry storage room, six cans of chipotle peppers had a use by date of (MONTH) (YEAR). 26. In the dry storage room, 26 chocolate cookies were made on 10/15/18 and had a use by date of 10/21/18. On 10/24/18 at 09:43 AM, the surveyor interviewed the Assistant Dietary Manager (ASM), who acknowledged the surveyor's concerns from the initial kitchen tour and stated the staff would be in-serviced. The ASM said maintenance looked at reach-in freezer five and someone had turned the freezer to defrost mode. The surveyor and ASM observed the dry storage area and observed the large cans with dust and debris. The ASM stated that staff swept and mopped the dry storage floors daily and dusted the cans on a weekly basis. At which time, the ASM confirmed the cans needed to be cleaned. On 10/26/18 at 11:05 AM, the Senior Administrator, in the presence of the survey team, acknowledged the surveyor's findings. The surveyor reviewed the facility's, Food and Non Food Storage policy dated 4/15. The policy indicated that no food or non-food supplies are to be stored on the floor. That policy reflected that products are stored no less than six inches from the floor. The policy further indicated that all stock is rotated at every delivery. The surveyor reviewed the facility's undated, Disposition of Potentially Hazardous Foods policy. The policy indicated products are to be dated and refrigerated after opening and monitored for their expiration date. The policy further revealed that special care would be taken to ensure the outside of these and all other containers will be wiped down after each use. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to perform proper hand washing technique and failed to disinfect medication carts between residents. This deficient practice was observed for 4 of 4 nurses during medication pass and was evidenced by the following: On 10/25/18 at 8:01 AM, the surveyor observed Nurse #1 suction Resident #29's [MEDICAL CONDITION]. The surveyor observed Nurse #1 remove her gloves and wash her hands. Nurse #1 wet her hands, applied soap, and washed her hands with friction for 10 seconds. The surveyor then observed the nurse prepare and administer medications to Resident #29. The surveyor observed that Nurse #1 washed her hands following the same procedure with friction for 10 seconds. The surveyor observed that Nurse #1 cleaned the top portion of the medication cart but did not disinfect the electronic devices attached to the medication cart, which included the computer monitor, keyboard, mouse, and barcode scanner, prior to entering and upon exiting the resident's room. On 10/25/18 at 8:43 AM, the surveyor observed Nurse #1 wash her hands after administering medications to Resident #42. The nurse wet her hands, applied soap to her hands and washed her hands with friction for 10 seconds. The surveyor observed that Nurse #1 cleaned the top portion of the medication cart but did not disinfect the electronic devices attached to the medication cart, which included the computer monitor, keyboard, mouse, and barcode scanner, prior to entering and upon exiting the resident's room. On 10/25/18 at 8:49 AM, the surveyor observed Nurse #1 wash her hands after administering medications to Resident #27. The nurse wet her hands, applied soap to her hands and washed her hands with friction for 12 seconds. The surveyor observed that Nurse #1 cleaned the top portion of the medication cart but did not disinfect the electronic devices attached to the medication cart, which included the computer monitor, keyboard, mouse, and barcode scanner, prior to entering and upon exiting the resident's room. On 10/25/18 at 11:14 AM, the surveyor observed Nurse #2 wash her hands after administering medications to Resident #296. The nurse wet her hands, applied soap to her hands and washed her hands with friction for 5 seconds. The surveyor further observed that the nurse did not disinfect the medication cart, electronic devices attached to the medication cart, which included the computer monitor, keyboard, mouse, and barcode scanner, prior to entering and exiting the resident's room. On 10/25/18 at 11:40 AM, the surveyor observed Nurse #2 wash her hands after administering medications to Resident #8. The nurse wet her hands, applied soap to her hands and washed her hands with friction for 5 seconds. The surveyor further observed that the nurse did not disinfect the medication cart, electronic devices attached to the medication cart, which included the computer monitor, keyboard, mouse, and barcode scanner, prior to entering and exiting the resident's room. On 10/25/18 at 12:09 PM, the surveyor observed that Nurse #3 did not disinfect the medication cart, electronic devices attached to the medication cart, which included the computer monitor, keyboard, mouse, and barcode scanner, prior to entering and exiting the resident's room. On 10/25/18 at 12:21 PM, the surveyor observed Nurse #3 wash her hands after administering medications to Resident #38. The nurse wet her hands, applied soap to her hands and washed her hands with friction for 10 seconds. The surveyor further observed that the nurse did not disinfect the medication cart, electronic devices attached to the medication cart, which included the computer monitor, keyboard, mouse, and barcode scanner, prior to entering and exiting the resident's room. During an interview, Nurse #3 stated, I usually clean the top part of the medication cart, and usually after use. The nurse further stated, I usually wash my hands for approximately 45 seconds and did not realized that I only did it for 10 seconds this time. On 10/26/18 at 7:45 AM, the surveyor observed that Nurse #4 did not disinfect the medication cart, electronic devices attached to the medication cart, which included the computer monitor, keyboard, mouse, and barcode scanner, prior to entering and exiting the resident's room during medication administration to Resident #28. On 10/26/18 at 7:54 AM, the surveyor observed that Nurse #4 did not disinfect the medication cart, electronic devices attached to the medication cart, which included the computer monitor, keyboard, mouse, and barcode scanner, prior to entering and exiting the resident's room during medication administration to Resident #30. On 10/26/18 at 8:02 AM, the surveyor observed that Nurse #4 did not disinfect the medication cart, electronic devices attached to the medication cart, which included the computer monitor, keyboard, mouse, and barcode scanner, prior to entering and exiting the resident's room during medication administration to Resident #23. During an interview at the time, Nurse #4 confirmed that she did not clean the medication cart between residents. The nurse further stated that she usually cleans the medication cart after use. The surveyor reviewed the facility's Hand Hygiene Policy #IC-04 with a revision date of 8/17. The policy revealed that Hand Hygiene is the single most effective way to prevent the spread of infection. The policy further revealed that Hand Hygiene procedures will be consistent with the current Centers for Disease Control and Prevention Guidelines. The policy included in Procedure II. Handwashing with soap and water. Under section B. Method . 3. Lather for at least 20 seconds - thoroughly scrub between fingers and under fingernails. The surveyor reviewed the facility's Disinfection of Equipment, Utensils and Toys Policy # IC-10 with a revision date of 8/18. The policy revealed that the purpose of the policy is to prevent the transmission of infectious organisms from patient to patient and patient to healthcare workers during contact with equipment, toys, and utensils. The Policy included, Procedure: .H. Computer Devices Information technology (IT) devices, including computers, monitors, keyboards, mice, hand held devices, mobile telephone, pagers, etc. can become contaminated with microorganisms when touched with gloves or unwashed hands which have been in contact with a client or surface in the client environment or workplace. The policy further revealed 3. a) Computer equipment that is stored on rolling stands (i.e. WOWs (workstation on wheels)), specifically the keyboard and mouse, should be cleaned with a disinfectant wipe by the user prior to entrance and upon exit of a patient care area/room. On 10/25/18 at 3:21 PM, the survey team interviewed the Director of Nursing (DON). The DON stated that hand hygiene should be performed before donning and after removing gloves. The DON stated that the staff should do at least 20 seconds of scrub time with soap before rinsing hands under running water when performing hand washing. The DON further stated that the medication carts should be cleaned between residents. NJAC 8:39-19.4(a) 1

Based on observation, interview and record review, it was determined that the facility failed to maintain 2 of 2 medication refrigerators on 2 of 2 facility wings in a sanitary manner. This deficient practice was evidenced by the following: On 10/25/18 at 8:29 AM, the surveyor inspected the West Wing medication refrigerator in the presence of the Director of Nursing (DON) and Pharmacist. The surveyor observed a stainless-steel tray stored on the lower shelf of the refrigerator. The surveyor observed that both the stainless-steel tray and the lower shelf of the refrigerator were heavily soiled with a white, flaky substance. On 10/25/18 at approximately 8:50 AM, the surveyor inspected the East Wing medication refrigerator in the presence of the DON and Pharmacist. The surveyor observed a stainless-steel tray stored on the lower shelf of the refrigerator. The surveyor observed that both the stainless-steel tray and the lower shelf of the refrigerator were heavily soiled with a white, flaky substance. When interviewed, neither the DON nor the Pharmacist could identify the white substance. On 10/25/18 at approximately 09:15 AM, the surveyor interviewed the Director of Long-Term Care (Director). The Director stated that the pharmacy was responsible for cleaning the medication refrigerators. The Director further stated, Housekeeping does not have access to the locked refrigerators, only the medication rooms. On 10/25/18 at 10:15 AM, the surveyor interviewed the Pharmacist in Charge (PIC). The PIC stated, Housekeeping was responsible to clean the medication refrigerators and should call the Pharmacy Department to unlock the refrigerators when needed. The PIC was unable to provide documentation to support the frequency when Housekeeping required assistance to gain entry to the medication refrigerators. On 10/25/18 at 10:18 AM, the surveyor interviewed a Housekeeper. The surveyor asked the Housekeeper if the Housekeeping Staff were required to clean the medication refrigerators? The Housekeeper stated, We just found out today that we are responsible to clean them on night shift. On 10/25/18 at 12:58 PM, the surveyor interviewed the Director of Housekeeping (DOH). The DOH stated he was unsure when the medication refrigerators were last cleaned and further stated that they must have fallen through the cracks. The DOH further stated that all facility refrigerators were cleaned on Friday on the 11 PM-7 AM shift. The DOH was unable to provide documented evidence of when the refrigerators were cleaned. The surveyor reviewed the facility policy titled, Environmental Control (Revision Date: 2/17) which revealed, All refrigerators are cleaned every Friday . They are wiped clean with Germicidal and water. NJAC 8:39-29.7(c)

Based on observation, interview and record review, it was determined that the facility failed to provide adequate supervision and staff intervention when a pulse oximetry monitoring device alarmed. This deficient practice was identified for 1 of 5 residents reviewed for Respiratory Care (Resident #42) and was evidenced by the following: On 10/23/18 at 9:47 AM during the initial tour of the facility, the surveyor entered Resident #42's room and observed that the resident was harnessed into a stroller beside the crib, which was not visible from the doorway. The surveyor further observed the resident received 2 liters of oxygen via nasal cannula (tubing used to deliver supplemental oxygen to a person in need of respiratory help). At 9:48 AM, a monitor, located on the wall adjacent to the resident's crib, began to signal that the resident's pulse oximetry level (the oxygen level in the blood) fluctuated from 96% to 88% to 85%. At that time, Resident #42 noted the surveyor's presence and started to cry. The surveyor observed the pulse oximetry levels on the monitor fluctuated and returned to 96% at 9:55 AM. The surveyor further observed that staff members did not respond to the monitor during this time. On 10/24/18 at 12:54 PM, the surveyor interviewed the resident's Certified Nursing Assistant (CNA). The CNA stated that residents were permitted to be left at the bedside if they wore a monitor. The CNA further stated, there is a monitor at the nurses' station that will trigger the nurse's pager if something were wrong with the resident. On 10/25/18 at 9:24 AM, the surveyor interviewed the Director of Long-Term Care (Director). The Director stated, if a resident is left in the room, they must be visible from the doorway or window. The Director stated, the facility utilized a Masimo System (remote monitoring and clinician notification system) to monitor pulse oximetry levels. The Director further stated that the monitor first sends a response to the resident's nurse, then the respiratory therapist and then the supervisor, if no one responded. The Director told the surveyor, a pulse oximetry level between 86% and 88% should be addressed immediately. On 10/25/18 at 11:26 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the Masimo System triggered a signal which escalated first to the respiratory therapist's pager within 15 seconds. The DON told the surveyor, if the respiratory therapist did not respond, a signal would be sent to the medication nurse within one minute. The DON further stated, if the medication nurse did not respond within three minutes, a signal would be sent to anyone with a pager and the supervisor. The DON stated that the Masimo System recorded alarm times that lasted longer than 15 seconds and recorded when the alarm was silenced either when reset by a staff member on the monitor or if the resident went back to normal parameters. On 10/25/18 at 12:10 PM, the Director provided the surveyor with a User Interaction Report, which indicated on 10/23/18 from 9:48 AM to 9:50 AM, Resident #42 had an abnormal pulse oximetry level that triggered the Masimo Remote Monitoring System for 119 seconds. On 10/25/18 at 12:10 PM the surveyor reviewed the facility Policy #PC-102, titled, Physiologic Monitoring (Effective 7/18), which revealed the following: Patient monitoring with alarms is used to provide a warning of changing physiology before a patient safety event occurs. Monitoring is an adjunct to direct nursing and medical assessment. NJAC 8:39-27.1 (a)