Every finding on record at Community Medical Center Tcu

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to develop and implement care plans that are comprehensive and individualized for a.) residents who were placed on Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in skilled nursing facilities) and b.) residents who received antianxiety medications. This deficient practice was identified for 4 of 16 residents reviewed (Resident #157, Resident #158, Resident #163, and Resident #166) and was evidenced by the following: 1.) On 6/27/2025 at 10:55 AM, the surveyor observed Resident #157 sitting in room with their shirt half-covering a urostomy bag (a bag used to collect urine after an opening is created in the abdomen to divert urine) filled with reddish colored liquid. A urinary drainage bag was observed anchored to the resident's bedframe filled with reddish colored liquid and tubing exposed to air. The resident stated that they drain the urine from the urostomy bag to the urine bag by themselves. Inside the door of the resident's room was signage posted for EBP. Outside the resident's door was a green star sign with a round orange magnet on the wall next to the doorframe. The surveyor reviewed the electronic medical record (EMR) for Resident #157. A review of the face sheet revealed that Resident #157 was admitted to the facility with diagnoses including but not limited to malignant neoplasm of the lung (cancer of the lung) and carcinoma in situ, bladder (pre-cancerous condition in urinary bladder). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/27/2025, indicated that it was still in progress. A review of the physician orders as of 6/30/2025 revealed there was no order for the care of urostomy including the resident's management of their own urostomy bag. There was also no physician order for EBP. A review of the resident's care plan with focuses on infection and urinary incontinence did not address the resident's management of their own urostomy bag. The interventions did not specify the use of EBP. On 6/30/2025 at 11:01 AM, during an interview with the surveyor, the Director of Patient Care Services (DPCS) stated that the EBP practice needs to be in the care plan. The DPCS also stated that Resident #157's self-management of urostomy bag should be part of the care plan. On 7/1/2025 at 10:30 AM, during an interview with the survey team, the DPCS confirmed that the resident was on EBP for urostomy. 2.) On 6/27/2025 at 11:07 AM, the surveyor observed Resident #158 sitting in a recliner in their room. A urinary drainage bag was observed attached to the recliner inside a privacy bag. Inside the door of the resident's room was a signage for EBP. Outside the resident's door was a green star sign with a round orange magnet posted on the wall. On 6/27/2025 at 11:25 AM, the surveyor reviewed the resident's EMR which revealed the following: A review of the face sheet indicated that the resident was admitted to the facility with diagnoses including but not limited to iron deficiency anemia and chronic urinary retention/ obstruction. A review of the most comprehensive Minimum Data Set (MDS), an assessment tool dated 6/30/2025, indicated that it was still in progress. A review of the physician orders as of 6/27/2025 included insertion and maintenance of foley catheter for chronic urinary retention/ obstruction started on 6/23/2025. A review of the resident's care plan included a focus for indwelling catheter maintenance. The care plan did not specify the use of EBP. On 6/30/2025 at 11:01 AM, during an interview with the surveyor, the Director of Patient Care Services (DPCS) stated that EBP practice needs to be in the care plan. On 7/1/2025 at 10:30 AM, during an interview with the survey team, the DPCS confirmed that the resident was on EBP for indwelling foley catheter. 3.) On 6/26/2025 at 10:46 AM, the surveyor observed Resident #166 in bed. The resident showed the surveyor their wound dressing along the upper right quadrant of the abdomen and stated that they had surgery in the area. Inside the door of the resident's room was a signage for EBP. Outside the resident's door was a green star sign with a round orange magnet posted on the wall. On 6/27/2025 at 10:36 AM, the surveyor reviewed the resident's EMR which revealed the following: A review of the face sheet indicated that the resident was admitted to the facility with diagnosis that included but not limited to malignant neoplasm of the right breast (cancer of the breast). A review of the most comprehensive MDS dated [DATE], indicated that it was still in progress. A review of the admission assessment dated [DATE] indicated the resident had surgical wound on the medial right upper abdominal area. A review of the physician orders as of 6/30/2025 did not include an order for EBP. A review of the resident's care plan included a focus for infection related to problem list condition but did not specify the practice of EBP. On 6/30/2025 at 11:01 AM, during an interview with the surveyor, the Director of Patient Care Services (DPCS) stated that EBP practice needs to be in the care plan. On 7/1/2025 at 10:30 AM, during an interview with the survey team, the DPCS confirmed that the resident was on EBP for surgical wound. 4.) On 6/26/2025 at 10:21 AM, the surveyor observed Resident #158 sitting in a recliner inside their room. On 6/27/2025 at 10:45 AM, the surveyor reviewed the resident's EMR which revealed the following: A review of the face sheet indicated that the resident was admitted to the facility with diagnosis including but not limited to iron-deficiency anemia. A review of the most comprehensive MDS dated [DATE], indicated that it was still in progress. A review of the physician orders as of 6/27/2025 included an order for alprazolam tablet 0.25 mg nightly as needed for anxiety which was started on 6/23/2025. A review of the Medication Administration Record (MAR) revealed that the resident received alprazolam tablet 0.25 mg on 6/24/2025 at 8:32 PM, and on 6/28/2025 at 8:17 PM. A review of the resident's care plan did not address the potential adverse effects of anti-anxiety medication use. On 7/1/2025 at 10:30 AM, during an interview with the survey team, the Director of Patient Care Services (DPCS) stated that unless the resident had adverse effect from psychotropic medications (medications that affect the mind and nervous system including anti-anxiety medications), the psychotropic medication use does not need to be care planned. 5.) On 6/26/2025 at 10:45 AM, the surveyor observed Resident #163 in bed. The resident stated that they were fine. On 6/27/2025 at 10:30 AM, the surveyor reviewed the resident's EMR which revealed the following: A review of the face sheet indicated that the resident was admitted to the facility with diagnosis including but not limited to atrial fibrillation (a heart condition where the heart beats irregularly and rapidly). A review of the most comprehensive MDS dated [DATE], indicated that it was still in progress. A review of the physician orders as of 6/30/2025 included an order for alprazolam tablet 0.25 mg nightly as needed for anxiety which was started on 6/21/2025. A review of the MAR revealed that the resident received alprazolam tablet 0.25 mg on the following dates: 6/20/2025 at 8:54 PM, 6/21/2025 at 9:21 PM, 6/22/2025 at 9:04 PM, 6/23/2025 at 11:06 PM, 6/25/2025 at 10:12 PM, and 6/26/2025 at 9:39 PM. A review of the resident's care plan did not address the potential adverse effects of anti-anxiety medication use. On 7/1/2025 at 10:30 AM, during an interview with the survey team, the Director of Patient Care Services (DPCS) stated that unless the resident had adverse effect from psychotropic medications (medications that affect the mind and nervous system including anti-anxiety medications), the psychotropic medication use does not need to be care planned. A review of the facility-provided policy and procedures titled Initial Assessment of Resident included under Care Plan Preparation, Long-Term Care Introduction the following: A care plan is an individualized, written action plan for a resident's care, treatment, and services that is based on the resident's medical, nursing, physical, mental, and psychosocial needs and preferences. The care plan must be person-specific and include measurable objectives and time frames in order to reflect the resident's progress toward goals. Under the Elements of a Care Plan, the following are included: .Per CMS, each care plan should: . organize information to identify potential issues or conditions, such as triggers, for the resident .clarify potential issues by looking at causes and risks using the care area assessment process .include information regarding ways to address causes and risks associated with issues and conditions to allow for the resident's highest level of well-being . Under Special Considerations, the following is included: Customize a standardized care plan to avoid 'standardizing' the resident's care and to enable you to address individual resident concerns. N.J.A.C. 8:39 - 27.1 (a)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to follow policy and procedure to provide a rationale for rejection of consultant pharmacist recommendations. This deficient practice was observed for 1 of 5 residents (Resident #105) reviewed for unnecessary medications and was evidenced by the following: On 06/27/2025 at 09:41 AM the surveyor observed Resident #105 lying in bed. Resident #105 offered no complaints and did not display any maladaptive behaviors. According to the admission record/face sheet, Resident #105 was admitted to the facility with a diagnosis of acute kidney injury. A review of the Admission, Transfer, Discharge Orders (From admission on ward) revealed the following physician orders: Metoprolol succinate XL (Toprol XL) 24 hr (hour) tablet 75 mg (milligrams) Freq: 2 times daily with meals Route: Oral Start: 06/27/2025 0800 End: 06/29/2025 2059. Reason to hold? HR (heart rate) < 55 BPM (beats per minute). Tamsulosin (Flomax) 24 hr capsule 0.4mg Freq: Nightly Route: Oral Start: 06/27/2025 End: 06/29/2025 1854 (12:54 PM). On 06/27/2025 at 12:55 PM the facility Director of Nursing (DON) alerted the surveyor that consultant pharmacist (CP) had been in the facility yesterday (06/26/2025) and completed an EPIC for Resident #105 and had also made (3) physician recommendations to be addressed. The surveyor reviewed the documents, and the physician had not had an opportunity to respond as of that time. The surveyor told the DON that he would follow up on 6/30/2025 (Monday) after the physician had the opportunity to address the CP recommendations for Resident #105. On 06/30/2025 at 09:41 AM the surveyor reviewed the 6/26/2025 EPIC (Electronic Pharmacist Information Consultant) review for Resident #105. The following recommendations were made for the physician: 1. Tamsulosin is being administered for an off-label use. Please review risk/benefit and if continued, please document clinical effectiveness. The physician responded on 6/29/2025 and checked the box Not Accepted. The form included a space for Comment or Reason for not accepting. This area was blank, and no comment or reason was provided for not accepting the CP recommendation concerning the use of Tamsulosin. 2. Toprol XL is recommended once daily per manufacturer. Consider changing Toprol XL 75 mg twice daily to 150 mg once daily which would result in drug cost savings, nursing time savings, and possibly medication compliance. The physician responded and checked the box Not accepted on 6/29/2025. No comment or reason for not accepting was provided. The surveyor then reviewed the electronic medical record (EMR) for Resident #105. Review of the EMR did not reveal any rationale provided by the attending physician for not accepting the EPIC/physician recommendations by the CP. On 7/1/2025 the surveyor reviewed the E.P.I.C. New Admissions Policy and Procedure, dated 2020, provided by the facility DON. The following was revealed under POLICY: All newly admitted residents will have their Physician Orders (POS) evaluated by the pharmacy consultant upon admission to the facility. The MAR (medication administration record) and Hospital Discharge Medications will also be evaluated if reasonably provided. In addition, the following was revealed under PROCEDURE: G. When a response is requested from the attending physician, the facility will contact the attending physician in a timely manner, per facility policy, unless it is a Clinically Significant irregularity which needs to be addressed by the midnight of the next calendar day (24 hours). The physician's response needs to be noted on the E.P.I.C. consult sheet. If the response is in the negative, the attending physician will indicate a short statement of the rationale for rejecting the recommendation. N.J.A.C. 18:39-29.3(a)(1)

Based on observation, interviews, record reviews and reviews of facility provided documents, it was determined that the facility failed to obtain a physician order for supplemental oxygen. This deficient practice occurred for 1 of 1 resident (Resident #110) reviewed for respiratory care. The deficient practice was evidenced by the following: On 06/27/2025 at 09:12 AM Resident #110 was observed to be seated in a chair next to the bed. Resident #110 was observed to actively receive oxygen via nasal cannula (a medical device used to deliver medical-grade supplemental oxygen to a user who requires oxygen therapy). Resident #110 did not have any complaints and was not in any respiratory distress. According to the admission record/face sheet Resident #110 was admitted to the facility with congestive heart failure (occurs when the heart can't pump enough blood to meet the body's needs, often leading to fluid buildup int the lungs and other tissues). A review of the Active Order Sets/Admission, Transfer, Discharge orders, Resident #110 had the following physician order: 06/27/2025 Start 1015 (10:15 AM) Oxygen Therapy - Device: Nasal Cannula Continuous PRN (as needed) 2 liters/minute titrate by 0.5 liter/minute. Keep O2 (oxygen) Sat (saturation) between 92% and 100%. Up to every 15 minutes. Notify physician/APP (advanced practice nurse) if oxygen requirement greater than 2 liters/minute. A review of the Plan of Care - Baseline, dated 6/25/25 and effective from 6/25/2025 to 7/3/2025 did not address the use of supplemental oxygen via nasal cannula. On 06/27/2025 at 10:09 AM the facility Director of Nursing (DON) was asked to assist the surveyor in finding a physician order for supplemental oxygen for Resident #1110 because the surveyor could not find one in the electronic medical record (EMR). The DON stated that it should be in orders. the DON then proceeded to review Resident #110's orders via the EMR. The DON stated, I don't see it at the moment, but I remember at report they told me that some orders needed to be updated. The DON further stated that there was no oxygen order at the moment and that she would check with the nurse and see if we need to order it continuous or prn. Resident #110 had been in the facility for approximately 48 hours at that time. On 06/27/2025 at 10:13 AM the DON responded to the surveyor and stated, They have a call out to the doctor to get an order for the oxygen right now. On 06/27/2025 at 11:28 AM the DON provided the surveyor with a copy of Resident #110's oxygen order and stated that it was a prn order because we are in the process of weaning the patient. On 06/30/2025 at 09:04 AM Resident #110 was observed lying in bed with oxygen via nasal cannula at 2 liters/minute. On 06/30/2025 at 11:08 AM the surveyor interviewed the Registered Nurse (RN #) assigned to Resident #110's unit. The surveyor asked RN # if a physician order was required for a resident to receive supplemental oxygen. RN # told the surveyor, Correct, yes. A physician order is required for a patient receiving oxygen. On 07/01/2025 at 10:31 AM during a meeting with the facility administration the surveyor asked the facility DON if a physician order was needed to provide supplemental oxygen to a resident. The DON replied, Yes. A resident receiving supplemental oxygen should have a physician order. A review of the facility provided policy and procedure titled [facility name] Oxygen administration, long term care. Revised: November 18, 2024. The following was revealed under the heading Implementation: Verify the practitioner's order. N.J.A.C. 18:39-27.1(a) .

Based on observation and interview it was determined that the facility failed to: a.) maintain sanitation in cooking areas in a safe consistent manner; b.) label, date, and store potentially hazardous foods appropriately to prevent food borne illness; c.)maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth; and d.) maintain kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On [DATE] at 11:05 AM, the surveyor in the presence of the Administrative Director Hospitality Services (ADHS) and Quality Coordinator (QC), toured the kitchen and observed the following: 1. On a preparation table, one large light blue cutting board that was deeply pitted and discolored black. The ADHS confirmed the facility should not be using that cutting board. 2. On a rack, two small light blue, two large tan, one large red, and one large yellow cutting boards all pitted and discolored black. The ADHS acknowledged the cutting boards needed to be changed; that bacteria could grow in the grooves. 3. On a drying rack adjacent to the pot washing room, four full six-inch pans, three four-inch plastic pans, and three large plastic full lids all wet nested (stacked on top of each other while still wet). The ADHS stated that wet nesting could harbor bacterial growth. 4. On a drying rack adjacent to the pot washing room, three six-inch full deep pans with a yellowish debris caked on. The ADHS confirmed the pans should not have debris on it. 5. In reach-in nourishment refrigerator RU 56, the surveyor observed the following: one half-gallon of fat-free milk dated expired [DATE], was opened with no date of when opened. The ADHS stated it was facility policy to use the manufacturer's expiration date on all products even after opened. One opened half-gallon fat-free lactose milk with a manufacturer's expiration date of [DATE], there was no date of when opened; the packaging indicated to use within seven days of opening. One opened gallon of 2% milk with an expiration date of [DATE], with no date of when opened. Two quart containers of heavy cream with an expiration date of [DATE], opened with no date of when opened. The packaging indicated to use within seven days of opening. The tray that held the milk containers as well as portioned containers of milk had a white liquid puddle. The ADHS acknowledged the tray should not have spilled liquid on it. 6. On the spice rack, one opened forty-eight ounce lemon juice with no date of when opened. The packaging indicated to refrigerate after opening. The ADHS confirmed it should have been refrigerated. 7. In the cook's preparation area, one large yellow cutting board that was deeply pitted and discolored black. 8. The steam table contained a white cutting board that was deeply pitted and discolored black/yellow/reddish colors. 9. In the reach-in refrigerator RU 63, sixteen vanilla and ten chocolate health shakes that were thawed. The packaging indicated to use within fourteen days of thawed. There was no date when the health shakes were thawed or when to use by. The ADHS acknowledged the health shakes were thawed and only had a fourteen day period they could be served within. On [DATE] at 11:09 AM, the ADHS in the presence of the Licensed Nursing Home Administrator (LNHA), Manager Quality Resource Services, and survey team acknowledged the above findings. The ADHS stated milk should be used within seven days of opening. A review of the facility's Food Labeling and Dating policy dated [DATE], included health shakes will be postdated for fourteen days and discarded on the expiration date . A review of the facility's Dietary Department Safety and Sanitation policy dated [DATE], included the Nutrition and Food Service Department will comply with all State, Federal and Local Health Codes; sanitary food handling procedures will be practiced in the preparation, storage and serving of food according to Dietary Department policies .clean pots and pans will be stored in a manner to promote air drying of equipment and prevent wet nesting of pots and pans . A review of the facility's Food and Nutrition Equipment policy dated [DATE], included cutting boards .all cutting boards wear out over time. After cutting boards become excessively worn or develop hard-to-clean grooves, they should be discarded . NJAC 8:,d+[DATE].2(g)

Based on observation, interview and review of documentation, it was determined that the facility failed to a.) properly clean and store dishes and food service equipment and b.) label and date food in a manner to prevent food-borne illness and cross contamination. This deficient practice was evidenced by the following: On [DATE] at 9:58 AM, during the initial tour of the kitchen in the presence of the Hospitality Services Administrative Director (HSAD) and the Quality Resource Services Outcomes Coordinator, the surveyor observed the following: 1. There was a two-compartment plastic [NAME] holding disposable resident meal trays in one of the compartments. The empty compartment adjacent to the clean trays was visibly soiled with dust and debris. 2. There was a three-compartment, heated plate lowerator that was plugged in and turned on with two of the compartments heating clean dishes. The stainless-steel surface of the empty compartment had visible food particles and appeared greasy. 3. In the dry storeroom, there were three gallons of Honey Mustard dressing, two gallons of Golden Italian dressing, one gallon of Creamy French dressing, one gallon of Creamy Caesar dressing, one gallon of Yasou Feta Cheese Vinaigrette and one gallon of South West Cilantro Lime Vinaigrette. None of these unopened gallons of salad dressing were labeled with a date of any type. The HSAD stated that the cases they were delivered in would have had dates. However, there were no dates on the individual gallon jugs. The HSAD stated that there were codes on each container, and he could find out the dates. In addition, there were two gallons of mayonnaise that were not dated. The [CONDITION(S)] stated that they came in on [DATE] and that the facility used six gallons of mayonnaise a week. The [CONDITION(S)] further explained that they rotated the stock. Once a product was taken out of the container it was delivered in, the facility would use it first. Once they opened the food containers, they would date that item. 4. In one of the walk-in refrigerators, there was an unopened five-pound container of potato salad with a manufacturer's Use by date of [DATE] printed on the rim. The [CONDITION(S)] discarded the salad and stated, that's out of date. We'll bring it up in our huddle. 5. In another walk-in refrigerator, there were two plastic dish dollies that could accommodate five stacks of plates. One [NAME] had a torn plastic cover protecting the plates. The second [NAME] had two stacks of plates, was uncovered and the top plate on each stack was not turned over to protect the other plates from dust. There was visible dirt and debris in the three sections of this [NAME] that were not in use. The [CONDITION(S)] stated that the covers were very brittle, and he had ordered new covers. 6. In one reach-in freezer, there were approximately 31 cases of frozen Kosher dinners and some baked goods that were not labeled with any type of a date. The [CONDITION(S)] stated that he ordered the Kosher meals twice a week. He would have to contact the distributor to determine a packing or expiration date. 7. The can opener blade was visibly worn and sticky. The [CONDITION(S)] immediately replaced the dirty can opener along with its tabletop holder, which was also visibly soiled. 8. The wire rack on the conveyer toaster was soiled with baked on food debris according to the [CONDITION(S)]. 9. The rack of clean cutting boards contained two that were visibly soiled with food particles. Five additional cutting boards had black stains on their surfaces. The [CONDITION(S)] stated that the black stains resulted from pots resting on them. The [CONDITION(S)] also stated that he would replace all of the cutting boards. 10. There was a large trash can and lid that were heavily soiled. The [CONDITION(S)] stated that the can was used for soiled linen but, it needs to be cleaned. 11. There was one ice scoop resting on a black plastic surface on a shelf on the side of the ice machine. There was a second scoop held in a non-draining container on the wall next to the machine. The clear plastic container was visibly soiled with dust and debris. 12. The rack holding clean pots and steam table pans was visibly soiled and greasy and sticky to the touch. The [CONDITION(S)] agreed that it felt sticky. On [DATE] at 10:43 AM, in the presence of the [CONDITION(S)] and the Administrative Director for Ancillary Services, the surveyor observed the following: In the dry storage room, the [CONDITION(S)] explained the codes that were stamped on the bottles of dressing and mayonnaise corresponded to a production date. He stated that the [NAME] dressings were good for 180 days from the production date. The bottles of [NAME] mayonnaise were within their 180-day shelf-life. The [CONDITION(S)] stated that the dressing produced by Sysco had a shelf life of 240 days and then he added, I did not know that. Neither the [CONDITION(S)] nor the surveyor were able to read the code printed on the bottle of the Sysco Feta Cheese dressing, therefore an expiration date could not be determined. The codes indicated that the gallon of Creamy French dressing was produced in 2019. The [CONDITION(S)] stated that would be expired. I don't use those. I didn't know how to read the codes until today, so those would be expired. The [CONDITION(S)] acknowledged that four gallons of Honey Mustard dressing were also expired. He stated that the facility had not used those gallons of dressing since they closed the salad bar before the Covid -19 pandemic. After surveyor inquiry, the [CONDITION(S)] stated they had one employee to stock shelves who came in twice a week on delivery days. He also stated that most equipment in the kitchen was cleaned on the weekends. A review of the facility's Food Labeling and Dating policy dated approved [DATE], included: Bulk condiments and dressings will be dated on the date on which they were opened and discarded after 30 days or 1 month. The policy did not include labeling and dating of foods upon delivery or when taken out of the original case and placed on a storeroom shelf. A review of the facility's undated Cleaning Procedures for Kitchen Equipment policy included the following procedures: Conveyor Toaster .Using a damp cloth wipe the wire conveyor from the outside to the center .Clean the crumb tray, wire feeder rack, and the return chute with mild soap and warm water .Rinse when clean. Can Opener .Scrub shank, paying special attention to blade and moving parts. Use sanitizing solution and brush or run through dish machine .Inspect blade and replace if notched .Scrub base plate (attached to table). Tray Carts, Dish Carts, Utility Carts .After each meal to .Wash inside; rinse . allow to air dry .Weekly .Follow steps ,d+[DATE] above or take to cart wash area (and) wash wheels and castors with sanitizing solution. Cabinets and Drawer .Weekly .Use a mild detergent and water .Rinse shelves and drawers with a clean sponge and dry. A review of the facility's Main Kitchen: Saturday Cleaning Sheet and Sunday Cleaning Schedule indicated that the following items had been cleaned on ,d+[DATE] and [DATE]: garbage cans, lowerators, all carts and racks, dish dollies, toaster and the pot shelves. A review of the facility's monthly Safety and Sanitation Inspection dated [DATE], reflected the following: Lowerators clean and in good repair. This section had the following comment written beside it: Need (unintelligible word) cleaning when not hot. Cutting boards clean and allowed to air dry. This area was not checked at all. Freezers: Foods are properly wrapped and labeled and dated. This area was checked Yes. Food Preparation Area: Toaster was checked as clean. Pot Room: Walls, racks and floors are clean. This section was checked Yes. NJAC 8:39 17.2 (g)

Based on interview and record review, it was determined that the facility failed to perform weekly COVID-19 testing for 1 of 3 staff members reviewed for testing (contracted Recreational Activities Tech) who made enrichment visits to 10 of 10 residents on the unit. This deficient practice was identified during a COVID-19 focus infection control survey conducted on 10/27/20, and was evidenced by the following: On 10/27/2020 at 10:45 AM, the surveyor interviewed the Director of Nursing (DON), in the presence of the survey team. The DON stated that the facility currently had no staff that were confirmed positive for COVID-19 in the facility. The DON informed the surveyors that the facility conducts COVID-19 testing for all staff on a weekly basis. The surveyor requested a copy of the facility's tracking sheets for staff testing. The surveyor reviewed the facility's current Transitional Care Unit (TCU) Staff list provided by the DON, which included the name and phone number of a Recreational Activity Tech. A review of the October 2020 schedule for the Recreational Activity Tech reflected that she was scheduled for visits in the TCU four days a week. A review of the staff tracking for COVID-19 testing for October 2020 did not include the name or COVID-19 testing results of the Recreational Activity Tech. A review of the TCU Daily COVID-19 Screening Log for October 2020 reflected that the Recreational Activity Tech was screened for signs and symptoms of COVID-19, including a temperature check during her daily visits to the facility, and she had no signs or symptoms of COVID-19 including no fevers. At 12:45 PM, the surveyor interviewed the DON in the presence of the survey team. The DON stated that the Recreational Activity Tech visited the residents on the TCU approximately four (4) hours a week and she spends about 30 minutes to one hour a day on the unit going room to room visiting all the residents, offering magazines and one-to-one visits. The DON added that the Recreational Activity Tech was a vendor/contracted staff and she did not consider a vendor, an employee that the facility had to perform weekly testing for COVID-19. The DON acknowledged that the Recreational Activity Tech was not being tracked for COVID-19 testing and confirmed that the Recreational Activity Tech had not been tested for COVID-19 that she can recall. At 1:00 PM, the surveyor conducted a phone interview with the Recreational Activity Tech, who stated that she was a vender and performs enrichment activities for the residents for their short stay and was contracted for four hours a week spread throughout four days a week. She stated that that she spends 30 minutes to one hour a day on the unit and spends approximately ten minutes with each resident at a time and wears a mask while on the unit. She stated that she gets screened for COVID-19 when she enters the room, but that she had not been tested for COVID-19 since June 2020. She stated that she was told because she was a vendor that she did not need weekly testing for COVID-19. The Recreational Activity Tech informed the surveyor that she had never tested positive for COVID-19 and had no signs and symptoms of [MEDICAL CONDITION]. At approximately 1:50 PM, the surveyor discussed the findings with the DON, Licensed Nursing Home Administrator (LNHA) and the Quality Manager who acknowledged that vendors had not previously been tested but that they would start weekly testing on them as well. A review of the facility's [DIAGNOSES REDACTED]-CoV-2 (COVID-19) Pandemic Plan Long-Term Care updated 9/21/20 including that Ongoing weekly testing of all staff until guidance from the NJDOH (New Jersey Department of Health) changes based on epidemiology and data about the circulation of virus in the community. The Pandemic Plan did not address including or excluding vendors from the weekly testing of all staff. NJAC 8:39-27.1

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a.) implement Transmission Based Precautions for 10 of 10 newly admitted residents as persons under investigation for COVID-19 in accordance with the U.S. Centers for Disease Control and Prevention (CDC) guidelines, b.) offer hand hygiene to residents before a lunch meal, and c.) ensure an effective strategy for contract tracing in the event a staff member tests positive for COVID-19. This deficient practice was identified during the COVID-19 Focused Infection Control survey conducted on 10/27/2020, and was evidenced by the following: 1. According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Responding to Coronavirus (COVID-19) in Nursing Homes updated 4/30/20 included, Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown .All recommended COVID-19 PPE (personal protective equipment) should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e. goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement . However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. On 10/27/2020 at approximately 9:05 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON informed the survey team that the facility had a current census of 10 residents, and acknowledged that all 10 of 10 residents were admitted less than 14 days ago and were assigned private rooms. She stated that the facility did not currently have a COVID-19 outbreak, but recently on 10/10/20 one resident had tested positive for COVID-19 two days upon admission to the facility and had no signs and symptoms of COVID-19. She added that the resident who had tested positive for COVID-19 (Resident #11) had already been discharged back to the community and was not a current resident in the facility. The DON stated that no staff had tested positive for COVID-19 during the weekly testing in the last few months. The DON provided the surveyor a copy of the facility Census Report dated 10/27/20. The Census Report reflected that 10 of 10 residents were admitted to the facility less than nine (9) days. At 9:30 AM, two surveyors observed a Certified Nursing Aide (CNA) inside the private room of Resident #10 with the door open. The resident was sitting upright in a chair. There was no PPE cart in proximity to the resident's room and there was no signage to indicate that the resident was on transmission-based precautions (TBP). The CNA was wearing gloves and a surgical mask (without the use of a gown or eye protection) and assisted the resident by placing his/her jacket on the resident's bed within reach of the resident, provided the resident his/her assistive device (a reacher), placed a pillow behind the resident's back for support and repositioned the resident's bedside table in front of the resident. The surveyor then observed the CNA doff the gloves and perform hand hygiene using alcohol-based hand gel (ABHG) and exit the resident's room. At 9:35 AM, the surveyor observed a Physical Therapy Assistant (PTA) wearing a surgical mask standing outside the room of Resident #9. The surveyor observed Resident #9 in a wheelchair wearing a surgical mask and the resident began self-propelling down the hallway toward the rehab gym located on the unit and across the hallway. The PTA was less than six feet from the resident and was not wearing a gown, gloves or form of appropriate eye protection. There was no sign posted outside the resident's room that indicated the resident was on transmission-based precautions or a PPE cart within close proximity of the resident's room. At 9:39 AM, the surveyor interviewed the CNA. The CNA stated that he was the only assigned CNA for all 10 of 10 residents on the unit that day. He stated that all the residents are newly admitted to the facility within eight (8) days, they were all tested upon admission to the facility, and all 10 residents had tested negative for COVID-19 upon admission. The surveyor asked if any residents on the unit were on transmission-based precautions, and the CNA stated, No adding that since all residents were tested negative for COVID-19 on admission and none of them have signs or symptoms of COVID-19, or a multi-drug resistant organism (MDRO), therefore staff were not required to wear PPE upon entering the resident rooms. The CNA stated that he only had to follow standard precautions which included wearing gloves when entering each resident room. He added that in addition, all staff were mandated to wear surgical masks at all times while in the facility as and added precaution. The surveyor continued to interview the CNA who stated that if a resident was under investigation for COVID-19, staff would have to wear a gown, gloves, an N95 respirator mask and a face shield upon entering the room and that it would get discarded after each use. He confirmed a second time that there were no residents under investigation for COVID-19 and no residents on TBP. At 9:45 AM, the surveyor observed an Environmental employee entering each resident room to replace the red biohazard sharps containers. Each sharps container was located in the middle half of each resident room and secured to the wall. The surveyor observed him enter the rooms, replace the filled sharps containers and place the filled containers on a cart for transport and disposal. He was wearing a surgical mask and gloves upon entering the resident room. During a brief initial tour of the unit, two surveyors observed that the resident room doors were kept open, while the resident's remained in their rooms. At 10:12 AM, the surveyor interviewed the DON, the Licensed Nursing Home Administrator (LNHA) and the Quality Manager in the presence of the survey team. The DON stated that all the resident rooms are negative pressure rooms (Airborne Infection Isolation Rooms (AIIR)). According to the U.S. CDC guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 7/15/20 included that, Airborne Infection Isolation Rooms (AIIRs) are single-patient rooms at negative pressure relative to the surrounding areas, and with a minimum of 6 air changes per hour (12 air changes per hour are recommended for new construction or renovation) .Room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized. The DON continued to inform the surveyors that the facility currently had no residents that were considered persons under investigation (PUI) for COVID-19. She stated that the average length of stay for residents was 6.7 days, and the LNHA added that all residents must be discharged within eight days (or nine days for special circumstances), so therefore all residents are always admitted for less than 14 days. The DON stated that if the facility had a resident that was a PUI, full PPE would be worn if the resident was symptomatic, including fever greater than 100.4 degrees Fahrenheit, coughing, shortness of breath, diarrhea, loss of taste/smell, or a change in baseline. The DON stated that a PUI would include a resident that had signs or symptoms of COVID-19, a known exposure to COVID-19, and residents that refuse testing. She stated that a resident that had to leave the unit and return to the unit for any length of time would not routinely be considered a PUI. She also added that new admissions were not considered PUI and that all new admissions were placed on standard precautions and only placed on TBP if the resident developed symptoms of COVID-19. She confirmed that the 10 residents on the census were not on TBP. The DON acknowledged that residents can be asymptomatic and test positive for COVID-19. The DON stated that the staff wear a surgical mask at all times and that residents are encouraged to wear surgical masks as well during care, and all residents are in private rooms with negative pressure. At 11:30 AM, two surveyors continued to tour the unit. The surveyors observed that the doors remained opened with the residents in them, and that none of the resident rooms had signage for TBP or a PPE cart within close proximity. The surveyor observed a Housekeeper preparing to clean the room of Resident #6. The Housekeeper was wearing surgical mask and gloves. At that time, the surveyor interviewed the Housekeeper who confirmed none of the residents were on TBP and that she didn't have to don a gown or eye protection unless there was a sign on the door to indicate TBP. At 11:40 AM, two surveyors observed the CNA obtain a lunch tray from the dietary cart. The CNA showed the surveyor what was provided on the tray, including a pre-packaged supply of silverware and a hand wipe. The surveyor observed the CNA pass the lunch tray to Resident #8 and repositioned the resident's bedside table. The CNA was wearing gloves and a surgical mask. The CNA did not offer or encourage the resident to perform hand hygiene before the lunch meal. At 11:44 AM, two surveyors observed the Registered Nurse (RN) provide a lunch tray to Resident #2. The RN placed the tray on the resident's bedside table, and adjusted the table in front of the resident. The RN was wearing a surgical mask, but not wearing gloves, a gown, or eye protection. The RN did not offer or encourage the resident to perform hand hygiene before the lunch meal. At 11:50 AM, the surveyor interviewed the RN who confirmed that all 10 residents were new admissions to the facility and that none of them were on TBP. He stated that the facility followed standard precautions for the new admissions. He stated that if a resident developed signs or symptoms of COVID-19, then they would immediately place the resident on TBP and that staff would have to wear the appropriate PPE upon entering the room. The surveyor continued to interview the RN regarding hand hygiene for resident's before the lunch meal. The RN stated that the residents are given a packet of wet wipes and that they should use it before they eat. The RN acknowledged that he did not offer the residents to wash the hands before the lunch meal. At 11:53 AM, the RN brought the two surveyors to the room of Resident #3. The surveyor observed the resident's lunch tray which still had some pieces of lettuce on the plate. The RN asked the resident if he/she had washed his/her hands before lunch, and Resident #3 replied No. The RN proceeded to show the resident how to open the packet of hand wipes on the resident's bedside table for the resident to wipe his/her hands with, and the resident stated that he/she was already done eating the lunch meal. Upon exiting the room, the RN confirmed that the resident had not been offered or encouraged to perform hand hygiene prior to the lunch meal, but that sanitizer wipes were provided to the resident. At 11:55 AM, the surveyors interviewed the PTA who stated that she assists residents with their rehab program in the rehab gym area on the unit. She stated that there were allowed to be two residents at a time in the gym on either side of the wall greater than 12 feet apart. She stated that she would only have to wear her surgical mask and gloves when working with the residents and that all equipment was wiped down with an Environmental Protection Agency (EPA)-registered disinfectant wipe. She stated that all residents were provided therapy in their rooms for the first day or two of admission, and once they get a negative test result for COVID-19, then the resident can come out of the room to attend rehab in the gym area. She confirmed she assisted Resident #9 that morning with exercises in the rehab gym. At 12:01 PM, the two surveyors interviewed the Director of Therapy/Physical Therapist (PT). The PT stated that a max of two residents were allowed in the rehab gym at a time, and that all equipment was cleaned with a disinfectant wipe after use. She stated that all staff get tested for COVID-19 on a weekly basis, and that none of the residents were currently on TBP because they had all tested negative for COVID-19 upon admission. At approximately 1:45 PM, the surveyor interviewed the DON, LNHA and the Quality Manager in the presence of the survey team, who acknowledged that the facility had not implemented TBP for their newly admitted residents in accordance with U.S. CDC guidelines. The surveyor discussed the findings of the CNA and RN not offering the resident's hand hygiene before the lunch meal, and the DON acknowledged the surveyors findings and confirmed that while residents were provided sanitizer wipes to use, the residents should be afforded the opportunity from staff to perform hand hygiene before meals. 2. According to the U.S. CDC guidelines, Investigating a COVID-19 Case updated 10/21/2020 included that when interviewing a symptomatic client, a case investigator should elicit all close contacts from two days prior to onset of any symptoms through the beginning of isolation. Start date: 2 days before symptom onset; end date: beginning of isolation period OR until discontinuation of home isolation. On 10/27/2020 at 10:45 AM, the surveyor interviewed the DON, LNHA and the Quality Manager regarding the process for contact tracing in the event a staff member tested positive for COVID-19. The DON stated that if a staff member tested positive for COVID-19 they would be taken off the assignment and sent home immediately, and that the facility would look back 14 days to determine the origin of infection. The surveyor asked who was responsible for contact tracing and the DON stated that they would reach out to the Infection Preventionist (IP) regarding that question. She confirmed she did not do the contact tracing. The administrative team stated that they would have the IP speak to the survey team regarding regarding how contract tracing was conducted in the event a staff member tested positive. At 11:03 AM, the surveyor interviewed the IP in the presence of the survey team regarding how contact tracing was conducted in the event a CNA was to test positive for COVID-19. The IP stated that if a CNA tested positive for COVID-19, that it would be handled through their employee health system and they would look back on what unit they were assigned to and determine what staff members they had contact with and seek to determine the origin of the CNA's infection. The IP stated that they weren't really involved in that process. The surveyor provided a scenario that if a CNA became symptomatic and tested positive for COVID-19 today, what would be the look-back period to determine what residents the CNA had exposure to and who would be responsible to notify and track the residents that were exposed to COVID-19 from the positive staff? The IP stated that she believed she would use the same day that the CNA developed symptoms to determine contact tracing. The surveyor asked if they had a system or policy to track resident names and exposure risk in the event a staff member tested positive, and the IP stated that she would provide the surveyor with the CDC guidelines for contact tracing. At approximately 12:05 PM, the DON showed the surveyor the New Jersey Department of Health (NJDOH) algorithm to determine exposure risk and she stated that the facility would utilize that as a guide to assess exposure risk but couldn't speak to who was responsible for determining what residents were exposed to a positive employee or determining the potential exposure risk, and under what timeframe's it would be conducted based on an employees positive results. At approximately 1:50 PM, the surveyor discussed the findings with the DON, LNHA, and the Quality Manager, and the Quality Manager acknowledged that there should be a two day look-back period prior to symptom onset to determine who the staff member came into contact with and under what circumstances and period of time. The DON was unable to speak to who was responsible for determining resident exposure from a staff member in the event a staff member were to test positive for COVID-19, and who was responsible to notify that resident in the event of designated level of exposure from a positive staff member. A review of the facility's [DIAGNOSES REDACTED]-CoV-2 (COVID-19) Pandemic Plan Long-Term Care updated 9/21/20 including that patients/residents who test negative for COVID-19 could be incubating and later test positive. Cohort 4-New or Re-admissions: Special Droplet/Contact Precautions: This cohort consists of all persons from the community or other healthcare facilities who are newly or readmitted .Cohort 4 residents are placed in a single room and quarantined for 14 days to monitor for symptoms that may be compatible with COVID-19 (day of admission or re-admission is considered day 0) After 14 days without signs or symptoms of COVID-19 resident can be removed from Cohort. The Plan further included that, If staff develop even mild symptoms consistent with COVID-19, they are expected to: cease resident care activities, leave the work area immediately and notify their supervisor; Supervisor informs the facility's Infection Preventionist and include information on individuals, equipment, and locations the person came in contact with; contact their health care provider. The plan for tracing did not address the look-back time period when performing the contact tracing. NJAC 8:39-19.1, 19.2; 19.4; 19.5; 12.1

Based on staff interview and record review, it was determined that the facility failed to develop a process for providing weekly cumulative updates on COVID-19 cases or cluster of respiratory symptoms to residents, resident representatives, and families. The deficiency occurred during the COVID-19 pandemic. This deficient practice was evidenced by the following: On 07/07/2020 at 9:00 AM, an interview was completed with the Director of Nursing (DON). The DON reported that COVID-19 notifications were sent out only if there was a new positive case or there were new symptomatic staff or residents. If there were no changes, weekly updates were not being sent out. A review of the facility's policy on the COVID-19 outbreak did not address requirements to notify residents, resident representatives and families about COVID-19 cases or cluster of respiratory symptoms. NJAC: 8:39-13.1 (c)

Based on staff interviews and record review, it was determined that the facility failed to adequately monitor residents, staff and visitors for signs and symptoms of COVID-19, and failed to restrict visitation of all visitors. This affected 14 of 14 residents in the facility during the COVID-19 pandemic. This deficient practice was evidenced by the following: 1. A review of the Centers for Disease Control's (CDC) guidelines titled, Preparing for COVID-19 in Nursing Homes, last updated 06/25/2020, indicated, Actively monitor all residents upon admission and at least daily for fever (T (temperature) (greater than/equal to) 100.0 (degrees) (Fahrenheit)) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. According to the CDC, symptoms of COVID-19 include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. On entering the facility on 07/07/2020 at 8:35 AM, this surveyor was admitted without being asked any screening questions. A physician was then observed entering the facility without being asked any screening questions. On 07/07/2020 at 8:45 AM, an interview was completed with the Chief Nursing Officer (CNO). The CNO stated, Anyone who is not an employee should be screened with questions. She confirmed that employees were not being asked screening questions. An interview was completed with the Director of Nursing (DON) on 07/07/2020 at 9:00 AM. The DON said that staff were not being asked screening questions when they arrived for work. Staff know if they have any symptoms, they don't come to work. The DON also reported that residents were asked screening questions about symptoms at the time of admission, but not on an ongoing basis. On 07/07/2020 at 10:35 AM, an interview was completed with Nurse #1. Nurse #1 said at the time of admission, residents were asked about COVID-19 symptoms, but residents were not asked screening questions routinely. On 07/07/2020 at 10:45 AM, an interview was completed with Nursing Assistant #1 (NA #1). NA #1 reported that she was not asked any screening questions as she came to work. A review of the COVID-19 Outbreak policy did not note a process for asking staff, visitors or residents screening questions for COVID-19. A review of Resident #1's medical record revealed no screening questions related to COVID-19. 2. A review of the New Jersey Department of Health, Recommendations for Long-Term Care Facilities during COVID-19 Pandemic, updated 5/11/2020, indicated, On March 13, 2020 the Center's for Medicare & Medicaid Services (CMS) instructed that facilities should restrict visitation of all visitors and non-essential HCP (healthcare personnel), except for certain [MEDICATION NAME] care situations, such as an end-of-life situation. On 07/07/2020 at 10:00 AM, an interview was completed with the Therapeutic Recreation Director (TRD, activities director). The TRD reported the center had started allowing families to visit face to face with residents. We have started visitation back. They can have one visitor a day for an hour. They come up to the rooms. During an interview on 07/07/2020 at 10:35 AM, Nurse #1 said, We follow the hospital policy for visitors. Right now, visiting hours are 12 (PM) - 8 (PM), they can visit for an hour, one person at time. On 07/07/2020 at 11:48 AM, an interview was completed with the DON. The DON said, For family visits, the Medical Center has a visitation policy. The residents can have one visitor at a time, and they stay in the room. Hours are 12 (PM) to 8 PM. The DON reported that there had been two to three visitors in the center in the last week. NJAC: 8:39-13.1 (c)

Based on observation, interview, and record review, it was determined that the facility failed to maintain medication under direct supervision during the administration process. This was found with 2 of 2 nurses observed during the medication pass on 10/30/17 and after a wound treatment observation of 1 of 1 resident (Resident #6) reviewed with a wound. This deficient practice was evidenced by the following: On 10/30/17 at 8:30 a.m., the surveyor observed Registered Nurse (RN) #1 outside of a resident room with a Work Station on Wheels (WOW) used during the administration of medications that contained a flat surface and a computer. The RN went into the resident's room with a cup of medication. The nurse left an unopened 30 milliliter container of Mag-Al plus (an antacid/antiflatulant medication) on top of the WOW. The nurse was behind the privacy curtain. The WOW was not in the nurse's view. There was no one in the vicinity of the WOW. On 10/30/17 at 8:52 a.m., the surveyor observed RN #2 preparing to administer medication to Resident #11. The WOW the nurse was using had a flat tray top with no drawers and a movable metal arm that held the computer screen above the tray. On top of the flat tray top, there was a pink plastic mesh basket. The nurse confirmed that the basket contained the individual doses of medication for multiple residents. The medications inside of the basket were: Clonidine (a sedative/anti hypertensive), Ferrous Sulfate (an iron supplement), Lasix (a diuretic), four bottles of prescription eye drops, Dilantin (an anti-seizure medication), Inderal (an anti-hypertensive/anti-arrhythmic), Primidone (an anti-convulsant), Thorazine (an anti-psychotic), and Norpace (an anti-arrhythmic). RN #2 left the basket which contained the medication on top of the WOW cart outside of the residents' room from 8:52 a.m. to 8:55 a.m., when she briefly returned, and then again from 8:55 a.m. to 8:57 a.m. while she went to the other side of the unit. There was no one in the area of the WOW. At 9:02 a.m., the nurse left the WOW in the residents' room with the basket which contained the medication on top while she went to the medication room to get pain medication for Resident #11. The roommate of Resident #11, Resident # 3, was also in the room. Both residents were alert and oriented. On 10/30/17 at 9:16 a.m., RN #2 was in the room of Resident #12 with the WOW and the plastic mesh basket which contained the above mentioned medication. RN #2 left the WOW with the plastic mesh basket which contained the medication in the residents room while she went to the pantry to get an orange juice for the resident. Resident #12 was alert and oriented. On 10/30/17 at 9:28 a.m., the surveyor observed RN #1 preparing to administer medication to Resident #13. RN #1 left the following medications in two clear plastic drinking cups on top of the medication cart outside of the residents' room from 9:28 a.m. to 9:29 a.m., while she went to the other side of the unit: Cup #1 held a Dulcolax suppository (a laxative), Aspirin, Multivitamin with Minerals, Calcium plus Vitamin D, Zetia (a drug to treat high cholesterol), and Colace (a stool softener). Cup #2 held Amlodipine (an anti-hypertensive), Sinemet (a drug to treat Parkinson's Disease), a Multivitamin, Vitamin B12, a 3 cc syringe with a needle, Vitamin D3, and a one milliliter vial of injectable Vitamin B12. There was no one in the vicinity of the WOW. RN #1 entered the room of Resident #13 at 9:32 a.m., leaving the WOW outside the doorway. Cup #2 fell over spilling the medication onto the top of the WOW. There were no residents in the hallway. RN #1 administered the medication in Cup #1 to Resident #13. RN #1 then assisted the resident's roommate from the bathroom into their bed, performed handwashing for 25 seconds in the bathroom, and then supervised Resident #13 in the bathroom self insert a rectal suppository. Resident # 13 was alert and oriented. RN #1 returned to the WOW in the hallway outside of the residents doorway at 9:44 a.m. On 10/30/17 at 9:45 a.m., the surveyor asked RN #1 if he/she realized that he/she shouldn't leave medication unattended, unsecured, and unsupervised on top of the cart. RN #1 stated, Well I was right there and they are right here referring to the medications on the WOW. On 10/30/17 at 12:57 p.m., the surveyor observed RN #1 complete the wound treatment with Resident #6 who was awake, alert, and oriented to person, place, and time. When the treatment was completed, RN #1 left a tube of Santyl (a product used to help the healing of burns and skin ulcers) and a bottle of Hycept (a topical used to treat or prevent infections caused by cuts or abrasions, skin ulcers, pressure ulcers, diabetic foot ulcers, or surgery) on the overbed table in Resident #6's room. The surveyor interviewed RN #1 at 1:02 p.m. about the tube of Santyl and the bottle of Hysept left at the bedside of Resident #6. RN #1 stated that, We usually put it in the med room. I will do that. On 11/1/17 at 11:00 a.m., the surveyor reviewed the facility's Policy and Procedure titled, Storage of Medication. The review date of the Policy and Procedure was 09/10 and the revised dates were 09/10; 7/14. Number 6 under the heading: Procedure read, Medications in patient care areas must be under the direct control of authorized personnel at all times. N.J.A.C. 8:39-29.4 (h)

Based on interview and review of the medical record, it was determined that the facility failed to fully investigate an allegation of abuse for 1 of 1 resident reviewed, Resident #9, and/or, report alleged abuse timely to governing agencies as required and per policy and from April - August 2016 (4 months). This deficient was evidenced by the following: According to data provided by the facility for the Abuse Prohibition Protocol, the caregiver of Resident #9 reported to the Transitional Care Unit (TCU) Director on 4/12/16 at 2:20 p.m. that the resident had told her that a male Certified Nursing Assistant (CNA) sexually abused him/her. The caregiver told the TCU Director how the resident described the CNA by race and name and also the sexual act that was allegedly perpetrated. The data indicated that the TCU Director spoke with the identified CNA at 3:00 p.m., forty (40) minutes after the allegation was reported. As a result, this CNA was permitted to continue providing care and services to residents for the 40 minute period of time. The investigative documentation from the TCU Director, who was a Registered Nurse (RN), indicated that there were statements obtained from the accused CNA, the Physical Therapy Manager for the TCU and the Registered Nurse Case Manager. The TCU Director also spoke with Resident #9 on 4/13/16 at 10:30 a.m. There was no documentation indicating that other male employees were interviewed as a part of this investigation. On 4/13/16 at 5:01 p.m., the TCU Director wrote a correspondence revealing that there were inconsistencies with Resident #9's versions of the incident and that the accusation was unsubstantiated. The TCU Director also wrote that because the accusation was unsubstantiated so it was not reportable to the Office of the Ombudsman and the New Jersey Department of Health (NJDOH). According to the facility's administrative policy and procedure titled, Suspected Victim Abuse and/or Neglect, all incidents of suspected abuse will be thoroughly investigated and reported by law. The investigating and reporting was the responsibility of the Administrator (LNHA). The LNHA was to report the accusation immediately to both the NJDOH and Office of the Ombudsman. This policy also indicated that measures would be put into place to safe guard the resident from further abuse but it does not address how other residents would be protect during the investigation of the accusation. There was no documentation in this policy specifically identifying the criteria for obtaining statements from employees and the specific timeframe for obtaining these statements. When interviewed by the surveyor on 8/24/16 at approximately 10:00 a.m., the TCU director stated that she was the administrative staff member who conducted the investigation, not the facility's LNHA. The TCU Director also stated that, based on the inconsistencies in Resident #9's statements, the sexual abuse was unsubstantiated and did not have to be reported to the appropriate agencies. The TCU Director stated that there were no male employees working on the TCU that match the description of the perpetrator so no other statements were obtain from any other male employees that had access to the TCU unit and the resident. NJAC 8:39-4.1(a)(5)

Based on interview and record review, it was determined that the facility failed to conduct a thorough investigation into a resident report of being sexually abused by a staff member. In addition, the facility staff failed to report and immediately protect other residents on the unit. This deficient practice was identified for 1 of 1 resident reviewed for abuse (Residents #9), and was evidenced by the following: According to data provided by the facility for the Abuse Prohibition Protocol, the caregiver of Resident #9 reported to the Transitional Care Unit (TCU) Director on 4/12/16 at 2:20 p.m., that the resident had told her that a male Certified Nursing Assistant (CNA) sexually abused him/her. The caregiver told the TCU Director how the resident described the CNA by race and name and also the sexual act that was allegedly perpetrated. The data indicated that the TCU Director spoke with the identified CNA at 3:00 p.m., forty (40) minutes after the allegation was reported. As a result, this CNA was permitted to continue providing care and services to residents for the 40 minute period of time. The investigative documentation from the TCU Director, who was a Registered Nurse (RN), indicated that there were statements obtained from the accused CNA, the Physical Therapy Manager for the TCU and the Registered Nurse Case Manager. The TCU Director also spoke with Resident #9 on 4/13/16 at 10:30 a.m. There was no documentation indicating that other male employees were interviewed as a part of this investigation. On 4/13/16 at 5:01 p.m., the TCU Director wrote a correspondence revealing that there were inconsistencies with Resident #9's versions of the incident and that the accusation was unsubstantiated. The TCU Director also wrote that because the accusation was unsubstantiated so it was not reportable to the Office of the Ombudsman and the New Jersey Department of Health (NJDOH). According to the medical record, Resident #9, who was [AGE] years old, resided at the TCU from 4/8/16 to 4/16/16. The medical record also revealed that the resident had long term and short term memory deficits and had difficulty with decision making. A review of the personnel file for accused CNA indicated that abuse inservice training was provided to this employee on 10/23/16, and Resident Rights inservice training was provided on 10/25/15. The CNA's most recent annual evaluation revealed satisfactory performance and there had been no disciplinary action against this employee. When interviewed by the surveyor on 8/24/16 at approximately 10:00 a.m., the TCU director stated that she had done an investigation into the accusation but had not obtained statements from any other male employees, aside from the accused CNA, that would have had access to the TCU and/or the resident. The TCU Director was not aware that all accusations must be reported to Office of the Ombudsman and the NJDOH immediately after the facility administration has knowledge of the accusation. The TCU Director stated that she had spoken to the accused CNA at the end of his shift on 4/12/16, and the CNA was scheduled to be off for the following two days (4/13/16 and 4/14/16) so suspension pending investigation was not necessary. NJAC 8:39-4.1(a)(12)

Based on observation, interview and record review, it was determined that the facility failed to provide a sanitary environment during the medication pass with respect to hand washing and while taking residents' blood pressures. This deficient practice was observed for 1 of 2 nurses during the morning medication pass of 8/27/15. The evidence was as follows: 1 On 8/27/15 at 9:10 a.m., during the medication pass, the surveyor observed Nurse #1 wearing a gown, mask and gloves to administer medications, by mouth, to Resident #4 in the resident's room. There was a sign outside Resident #4's room that cautioned to see nurse before entering. When finished with the medication administration, Nurse #1 removed the mask, gown and gloves and washed his hands with soap and water. He wet his hands, applied soap and rubbed his hands together outside of the flow of water for 10 seconds. After 10 seconds, Nurse #1 continued to rub his hands together under the stream of running water. At that time, Nurse #1 stated that Resident #4 was under isolation precautions because of clostridium difficile infection. On 8/27/15 at 12:52 p.m., the surveyor interviewed Nurse #1 who stated that the correct method to wash hands with soap and water was to wet hands, apply soap and rub hands together for two to three minutes away from the stream of running water before rinsing under running water. He then stated that he understood the surveyor's above observation that washing his hands away from the stream of running water for only 10 seconds was inadequate. On 8/27/15 at 1:30 p.m., the surveyor reviewed the facility policy titled Epidemiology/ Infection Control Department Policy and Procedures which indicated the appropriate technique to wash hands with soap and water. This technique included to wet hands with water, apply soap, rub hands vigorously for at least 15 seconds then rinse hands with water. On 8/27/15 at 1:30 p.m., the surveyor reviewed the Centers for Disease Control guidelines for washing the hands with soap and water. This technique included to wet hands first with water and apply an amount of soap recommended by the manufacturer to the hands, rub hands together vigorously for at least 15 seconds covering all surfaces of the hands and fingers then rinse hands with water. On 8/27/15 at 1:42 p.m., the surveyor interviewed the Director of Nursing (DON) and the Administrator and they confirmed that the facility policy was to rub hands away from stream of running water for at least 15 seconds then rinse soap off under running water. 2. On 8/27/15 between 9:23 a.m., and 9:57 a.m., during the medication pass, the surveyor observed Nurse #1 obtain the blood pressures (BP) of three different residents using the same BP machine and same BP cuff. Nurse #1 did not disinfect the BP cuff between using it on these three residents. Also, Nurse #1 wrapped the cuff around the arms of these three residents at times over clothing and other times directly onto the bare skin. Before using the cuff on the second resident, the cuff was on the floor in the room of the second resident. Nurse #1 did not disinfect the cuff after picking up the cuff from the floor and before wrapping it around the bare skin of this resident. On 8/27/15 at 12:52 p.m., the surveyor interviewed Nurse #1 who stated that he was not trained that he had to disinfect the BP cuff between resident use so that was why he did not do this during the above observation. He also stated that it was not facility policy that the BP cuff had to be disinfected between resident use. He stated that he should have disinfected the BP cuff after picking it up from the floor and using it on the second resident during the above observation. On 8/27/15 at 1:30 p.m., the surveyor reviewed the facility policy titled Epidemiology/ Infection Control Department Policy and Procedures which indicated that the BP cuffs had to be disinfected between resident use. On 8/27/15 at 1:42 p.m., the surveyor interviewed the DON and the Administrator and they confirmed that the facility policy was that the BP cuff had to be disinfected between resident use. NJAC 8:39-19.4(a)

Based on observation, interview and record review, it was determined that the facility failed to provide appropriate pharmaceutical services with respect to dispensing, labeling and administering medication. This deficient practice was observed on the morning medication pass of 8/27/15 for 1 of 6 residents observed, Resident #9, and was evidenced by the following: On 8/27/15 at 10:13 a.m., during the medication pass, the surveyor observed Nurse #1 administer Ciprofloxacin 500 milligrams (mg) by mouth (po), Ferrous Sulfate 325 mg po and Therapeutic Multivitamins with Minerals po to Resident #9. At that time, the surveyor reviewed the electronic Medication Administration Record [REDACTED]. On 8/27/15 at 12:19 p.m., the surveyor reviewed physician orders [REDACTED]. On 8/27/15 at 12:40 p.m., the surveyor interviewed the unit secretary who stated that the Consultant Pharmacist (CRPh) faxed a report from a medication regimen review for Resident #9 to the facility on [DATE] at 7:56 a.m. She then stated that she gave it to the nurse to review at 10 a.m. During this interview, the surveyor reviewed the CRPh report which indicated that Ciprofloxacin should be administered at least two hours before or six hours after Ferrous Sulfate and Multivitamins with Minerals. On 8/27/15 at 12:48 p.m., the surveyor interviewed Nurse #1 who acknowledged that there were no statements on the eMAR or on the medication labels that cautioned not to administer Ciprofloxacin, Ferrous Sulfate and Multivitamins with Minerals at the same time. She then stated that there was medication information available on the computer. Nurse #1 then obtained a computer generated, 26 page document on Ciprofloxacin medication information. On page 7, there was a statement which cautioned that Ciprofloxacin should be taken at least two hours before or six hours after Calcium and Zinc (in Multivitamins with Minerals) and Iron (Ferrous Sulfate). The interview continued with Nurse #1 at 1:02 p.m. Nurse #1 stated that Ciprofloxacin should not have been administered at the same time as Ferrous Sulfate or Multivitamins with Minerals and the Time of Administration should not have been scheduled for these medications to be administered simultaneously. On 8/27/15 at 1:42 p.m., the surveyor interviewed the Administrator and the Director of Nursing. They each stated that the lack of cautionary documentation on the medication labels and on the eMAR contributed to plotting the three above medications' TOA's at the same time. They also stated that the dispensing pharmacy had access to the Times of Administration that the three medications were scheduled. They also stated that the dispensing pharmacy had a responsibility to caution the medication nurses not to administer Ciprofloxacin at the same time as Ferrous Sulfate and Multivitamins with Minerals as part of their dispensing duties. On 8/27/15 at 1:30 p.m., the surveyor reviewed the facility policy titled Medication Administration Using Barcode Technology which indicated that the person who administered medications performed the eight rights of medication administration including the resident's right to get the medications at the right time. On 8/27/15 at 2 p.m., the surveyor reviewed manufacture's literature which indicated that Ciprofloxacin was an antibiotic indicated to treat infection. Further review indicated that Ferrous Sulfate as well as minerals in Multivitamin with Minerals tablets including Calcium and Zinc should not be taken at the same time as Ciprofloxacin because they may interfere with the absorption of Ciprofloxacin and reduce its effectiveness. If possible, it may be best to avoid taking Calcium, Iron and Zinc while taking Ciprofloxacin. Otherwise, Ciprofloxacin should be taken either two to four hours before or four to six hours after Calcium, Iron or Zinc. NJAC 8:39-29.3(a)(1), 29.4(a)(b)(3)